facility_name: Pinellas Juvenile Detention Center

summary: QI Detention - FY25-26 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Pinellas Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
5255 140th Avenue North
Clearwater, Florida 33760
Review Date(s): December 9-12, 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)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Co-lead,
Interviews, Video Review)
Evan Hald, Office of Educational Services, Education Coordinator (Standard 2)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Pinellas Regional Juvenile Detention Center MQI Program Code: 364
Provider Name: Department of Juvenile Justice Contract Number: NA
Location: Pinellas County/ Circuit 6 Number of Beds: 95
Review Date(s): December 9-12, 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
Overall Rating Summary
Limited Ratings Failed Ratings
1.05 Right Interactions (RI)
2.10 Educational Access*
This monitoring report reflects the Department’s assessment of program compliance with applicable standards during the established review period. Monitoring reports represent a snapshot
of program operations and documentation at the time the review was conducted. When areas of limited or failed compliance are identified, the Department works with the provider through
established processes to address those issues and ensure corrective actions are implemented as outlined in FDJJ 2000. Follow-up monitoring, verification activities, and corrective action
processes are used to confirm identified deficiencies are addressed and programs return to compliance with applicable standards.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 58
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
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) Limited
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in
a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 58
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Youth Management
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Representative 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 Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 58
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
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 Evaluation Satisfactory
3.06 Treatment and Discharge Planning Satisfactory
3.07 MH/SA Treatment Satisfactory
3.08 Suicide Prevention Plan * Satisfactory
3.09 Suicide Prevention Services * Satisfactory
3.10 Secure Observation* Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates below
Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in a
program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 58
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
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 & 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 Psychiatric Services* Satisfactory
4.17 Medication/Sharps Inventory and Storage Process Satisfactory
4.18 Infection Control/Exposure Control/Education Satisfactory
4.19 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 58
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth* Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58
Program Overview
The Pinellas Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Clearwater, Florida. The center serves youth in Pinellas County in
Circuit 6. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the ninety-five-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 Pinellas County School Board. The center’s
management team includes one superintendent, three assistant superintendents, two
administrative assistants, nine juvenile justice detention officer (JJDO) supervisors, and fifty-six
JJDOs. Mental health and healthcare services are provided through the contracted provider,
VitalCore Health Strategies, LLC. Mental health services are provided by three licensed clinical
social workers (LCSW), five licensed mental health counselors (LMHC), one designated mental
health clinician authority (DMHCA), one regional mental health director, one psychiatrist, and
two master’s-level interns. Clinical services provided by the center include mental health and
substance abuse evaluations, mental health treatment planning, individual, group and family
therapy, mental health crisis intervention services, on-site psychiatric services, and availability
for substance abuse services for youth with co-occurring disorders. Medical services are
provided by one designated health authority (DHA), one advanced practice registered nurse
(APRN), eleven registered nurses (RN), one RN manager, and one medical records clerk. The
medical clinic maintains nursing coverage Monday through Friday, from 7:00 a.m. to 7:00 p.m.,
and on weekends, from 7:00 a.m. to 5:00 p.m. Food services are provided by Department staff
and include menus, meal planning, meal schedules, special diets, nutritional analysis, daily
allowance, food preparation, health certifications, food product standards, sanitation, and
cleaning. Staff are responsible for the custody and control of youth in their care, providing youth
supervision twenty-four hours a day, seven days a week. The center has five living modules
which are divided by male and female. There are 109 security cameras at the center, of which
109 were operational. During the tour, the facility was found to be generally clean with no major
security issues. Module B4 is currently closed due to construction on the module. The grass and
landscaping were mowed and manicured. At the time of the annual compliance review, the
center had twelve vacancies. The vacancies are as follows: one food service worker, five JJDO
Is, and six JDDO IIs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 58
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures (FOPs) for volunteers, mentors, and interns who
work with youth less than ten hours a month requiring sight and sound supervision. All
volunteers and mentors must complete an application for service which requires them to sign a
code of ethics, Prison Rape Elimination Act (PREA) document, and submit to a background
screening. The center submitted their Annual Affidavit of Compliance with Level 2 Screening
Standards on January 28, 2025. The school board submitted their annual Affidavit of
Compliance with Level 2 Screening Standards also on January 28, 2025. A total of twenty-four
staff, eleven contracted staff, and two volunteers were reviewed for initial background screening
requirements. Reviewed personnel records for twenty-four staff indicated each staff had a
completed background screening and documented criminal history report reviewed prior to their
hire date in the Department’s Background Screening Unit (BSU). Twenty-three reviewed staff
were rated as eligible for hire with no exceptions, the remaining staff had an exemption obtained
prior to working with youth. All twenty-four staff were applicable for the pre-employment
assessment tool. Two volunteers were not applicable to take the assessment. Eleven
contracted staff hired were not applicable to take the assessment. Twenty- four applicable staff
had evidence of a passing assessment score in their personnel record. The contracted provider,
VitalCore Health Strategies, LLC, did add eight contracted staff, and two volunteers to the
Clearinghouse employee roster, but three contracted staff were not added.
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 had a total of five staff applicable for five-year rescreening requirements. All five staff
personnel records had a completed rescreening. Each rescreening was completed within the
twelve-month requirement, and none of the five personnel records were submitted late. The
contracted provider, VitalCore Health Strategies, LLC, did not have any staff eligible for a five-
year rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 58
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.
Three staff records were reviewed for violations of the staff code of conduct. Each staff
personnel record contained evidence which confirmed management took action with each staff
due to allegations and/or findings in direct violation of the center’s code of conduct. All three
staff personnel records included a signed code of conduct form. Each violation resulted in
termination or a voluntary resignation. Three staff records were reviewed which contained
commendations and/or awards during the annual compliance review period. Each staff received
commendations for staff of the month during the annual compliance review period. The center’s
superintendent was interviewed and explained the center’s employee code of conduct. The
superintendent stated all staff should adhere to the code of conduct which prohibits any form of
abuse, profanity, threats, harassment, intimidation, or personal relationships with youth. Nine
staff were interviewed, and eight stated youth are allowed to make a call to the Florida Abuse
Hotline or the Department’s Central Communications Center (CCC), and one staff stated a
supervisor makes the call. Nine staff stated they notify their supervisor and the superintendent if
a call needs to be made to the Florida Abuse Hotline or CCC, and staff can make the call. When
asked if they have heard a staff member use profanity when speaking with youth, eight staff
stated they never have. The remaining staff stated they have occasionally observed a coworker
using profanity when speaking to youth. When asked to clarify, the staff stated they have not
observed a coworker cursing towards a youth. When asked if they have heard staff use threats
or intimidation when interacting with youth, each staff stated they never have. Nine staff were
asked about working conditions at the center in the past year, one staff member stated they
were fair, five staff stated the conditions were good, and three staff stated they were very good.
Nine youth were interviewed, seven youth confirmed they have never been stopped from
reporting abuse to the Florida Abuse Hotline since they have been at the center. Two youth
stated they have never had to report abuse. All nine interviewed youth confirmed staff are
respectful when talking with all youth at the center. Five youth stated they have never heard
staff use curse words when speaking with them or other youth; however, four youth stated they
occasionally hear staff use curse words when speaking with youth. Each youth said they have
never heard a staff threaten any youth at the center. Each youth said they feel safe at the
center. Each youth said they have never exchanged emails, telephone numbers, or social
media contact information with staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58
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 had a total of 134 incidents reported to the Department’s Central Communications
Center (CCC) during the annual compliance review period, ten of which were reviewed. All ten
reports were documented as reported to the CCC within the two-hour required time frame. All
ten reports were documented in the center’s master control logbook. The center’s
superintendent was interviewed and explained the center’s incident reporting process. The
superintendent said when there is a reportable incident, it shall be reported to the CCC within
two hours of gaining knowledge of the incident. The incident shall also be reported to the
superintendent.
1.05 Right Interactions (RI) Limited 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 had 340 documented Right Interaction (RI) incidents during the annual compliance
review period. Nine RI incidents were reviewed for reporting and documenting requirements.
Five of the reports were not completed by the end of the staff’s workday and four were. Four
reports did not include statements from all staff involved and five did. None of the incidents had
evidence there were injuries to either the youth or staff involved. None of the reports had
evidence the youth made allegations requiring notification to the Florida Abuse Hotline. All nine
reports were reviewed by a juvenile justice detention officer supervisor (JJDOS) or RI certified
supervisor. All nine reports documented a post-RI interview was conducted with the youth by
the administrator, or designee, as soon as possible, but no longer than thirty minutes after the
incident. Eight youth did not require a medical review; however, one did. A medical review was
conducted for the youth, and it was documented in the youths Individual Healthcare Record
(IHCR). None of the youth were sent off-site for an evaluation. None of the incidents involved
mechanical restraints. All nine RI incidents had evidence the superintendent/designee reviewed
the report within seventy-two hours of the date/time of the incident. The center’s RI rate during
the previous quarter was 9.48, which was below the statewide detention RI rate of 13.67. There
was no additional RI incidents noted in internal incidents, grievances, or logbooks which were
not documented by a RI Report. Nine interviewed staff stated they try to talk to a youth prior to
using physical restraints. The superintendent was interviewed and stated the physical and
mechanical restraints are tracked by utilizing the mechanical restraint log and the Department’s
Juvenile Justice Information System (JJIS)/Florida Model Jail Standards (FMJS). The
superintendent explained the process for monitoring RI incidents and use of force which are
documented in JJIS is to conduct supervisory and administrative reviews which include
reviewing the RI Report, and video to ensure compliance.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 58
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.
Nine staff training records were reviewed for pre-service training requirements. Each staff
record confirmed pre-service training and certification requirements were completed within 180
days of hire. Each staff completed a new staff orientation within thirty days of being hired. Each
reviewed staff completed Phase Two training at the Department’s academy, which consisted of
120 hours of training for each staff. None of the reviewed staff were a rehire, thus they were not
applicable for annual update requirements. All training was documented within the Department’s
Learning Management System (SkillPro) for each staff.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
Nine staff training records were reviewed for annual in-service training requirements. One
reviewed staff was an assistant superintendent, two were juvenile justice detention officer
supervisors (JJDOS), one was a juvenile justice detention officer (JJDO), and five were JJDO
IIs. Each staff exceeded the required number of hours for in-service training and completed
between fifty-eight and ninety-five hours of in-service training. Each staff received training in
Right Interactions (RI), as well as cardiopulmonary resuscitation (CPR), first-aid, and automated
external defibrillator (AED) training. Each staff received the required hours for suicide prevention
annual training. Each staff had active shooter, human trafficking training, emergency care plan,
infection control training, information security awareness, mental health/substance abuse,
Prison Rape Elimination Act (PREA), professionalism, interpersonal communication, and ethics
including standards of conduct, sexual harassment, trauma response practices, exposure
control plan, and escape prevention and fire prevention plan/disaster procedures training. All
three supervisory staff received between eight and eleven additional hours of supervisory
specific training. All training was documented in the Department’s Learning Management
System (SkillPro). The center has a licensed nurse who provides in-service education on girls’
healthcare annually to all non-healthcare staff involved in the supervision or treatment of girls.
The center maintains an annual in-service training calendar, which is updated as changes
occur. The center’s annual in-service training calendar was approved by the superintendent, the
director of the Department’s Office of Talent, Leadership, and Culture (TLC), and the assistant
secretary of detention which was evident by a signature. The superintendent was interviewed
and elaborated about the management training they received which consists of tier one and tier
two leadership training, as well as supervisor for success training.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 58
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.
A review of grievances during the annual compliance review period found a total of zero
grievances completed by youth. Grievance forms are available for youth access and are
maintained on each module in a staff drawer. Nine staff were interviewed, and all were able to
summarize the center’s grievance process. Nine youth were interviewed concerning the center’s
grievance process, seven youth stated it is good and two have never filed a grievance. Each
youth summarized the grievance process. The center’s superintendent was interviewed
regarding the grievance process and stated youth are given the opportunity to submit a
grievance. Youth shall not be denied the opportunity to file a grievance or get punished for doing
so. A juvenile justice detention officer (JJDO) will attempt to resolve complaints using effective
communication, and if it is not resolved a youth can submit a written grievance to the juvenile
justice detention officer supervisor (JJDOS) on duty which must be entered into the
Department’s Juvenile Justice Information System (JJIS) within two hours. The findings are to
be documented on the grievance form and forwarded to the superintendent. It is then reviewed
and responded to within seventy-two hours. The superintendent explained grievance forms are
uploaded into JJIS/Facility Management System (FMS) and each grievance remains in JJIS.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 58
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.
Nine youth were reviewed for alerts entered by the center. A total of forty-two alerts were
entered for the nine reviewed youth. All forty-two alerts had evidence the alert was entered
and/or closed on the date required. All current alerts were documented in module logbooks,
which is required by the center’s Facility Operating Procedures (FOP). The Department’s
Juvenile Justice Information System (JJIS) alert reports were reviewed daily by juvenile justice
detention officer supervisors (JJDOS) and administrators. The assistant superintendent stated
JJDOSs review alert reports during daily debriefs. Information regarding youth alerts being
shared with all staff occurs during shift briefing which is held in the training room with
supervisors and floor staff. JJDOSs hand out the alert sheet and talk with staff about recent
events at the center and staff assignments. The center’s shift briefing minutes were reviewed for
identification of youth with alerts. A shift briefing was observed in the training room with
JJDOSs, floor staff, and the assistant superintendent. During the shift briefing the JJDOS on
shift provided floor staff with a copy of the shift report. The JJDOS went over each youth’s alerts
with staff. There were no additional alerts found which should have been entered into the alert
system, as specified in the center’s procedures. The superintendent was interviewed regarding
the center’s medical alert process and stated the admitting juvenile justice detention officer
(JJDO) will bring it to the attention of medical staff if a youth has any alerts to make sure they
are up to date. Medical will then confirm with the parent/guardian. A nursing interview confirmed
nursing staff is responsible for updating the medical alerts system at the time a qualifying event
occurs. Nine staff were interviewed regarding how they are informed of alerts, and all stated
they are written in the logbook, on alert forms, and they are informed during shift briefings.
Furthermore, staff also receive emails regarding alerts. Each staff was asked how management
informs staff about issues within the center and eight staff stated logbooks, nine staff stated staff
debriefings, eight staff stated alerts, nine staff stated meetings, and four staff stated they receive
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 58
emails. Each staff was asked how effective they believe this process is for communicating
information. Five staff stated very good, four staff stated good.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a practice regarding data trend analysis. The center utilizes information
gathered from various reports found in the Department’s Juvenile Justice Information System
(JJIS) and the information is disseminated. The center shares the information either in person,
or by email on a quarterly basis with stakeholders. Furthermore, the information is disseminated
during the superintendent’s monthly meetings, education meeting, mental health and medical
meeting, safety meeting, youth focus group, and treatment team. The center’s management
team reviews the reports, and any trends noticed are discussed during these management
meetings. Monthly meetings are held with administration and center staff during which specific
topics are discussed. The meeting is open for staff to discuss issues and ask questions.
Documentation of monthly meetings was provided for the annual compliance review period and
found data trend analysis topics were discussed. The superintendent provided documentation of
the data reviewed which included Right Interactions model (RI), behavior management reports,
and all staff reports.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 58
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) outlining the process of youth being
admitted to the center. Nine youth case management records were reviewed for the admission
process. Eight youth records included documentation showing detention staff reviewed the
arrest affidavit/custody order, Detention Risk Assessment Instrument (DRAI), and Suicide Risk
Screening Instrument (SRSI). The remaining youth was admitted to the center due to a
residential commitment program closure. Each youth had a completed full-body search,
telephone call, meal, and medical, mental health, and substance abuse screening. An
admission could not be observed during the annual compliance review week, as no intakes took
place 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);
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 (FOPs) outlining the process of orientation being
conducted within twenty-four hours of admission. Nine youth records were reviewed for the
orientation process. Nine youth were interviewed and each reported someone advising them of
the rules and regulations, daily schedule, education services, visitation, abuse reporting, and
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behavior management system when they entered the center. Each of the nine youth records
included documentation the youth was provided an orientation, containing all required elements,
within twenty-four hours of admission. Each of the nine youth signed an orientation
acknowledgement to document the contents were discussed with the youth and a copy was in
each youth record. An orientation was not observed during the annual compliance review week,
as no admissions took place while the review team was on-site.
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) outlining the classification process for youth
entering the center. Nine youth records were reviewed for the classification process. The
center’s classification process included all required elements for each youth. The classification
process included all required topics prior to making room assignments. There was
documentation the superintendent is informed of how to identify and address local youth gangs
through emails with law enforcement, education, and probation. The superintendent reported
the center utilizes several screening forms and interviews prior to assigning youth to a room.
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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 (FOPs) outlining the process of notification of youth
presenting with gang involvement. Nine youth records were reviewed, and none of the youth
had suspected gang involvement. The center did not have any additional youth which were
appliable since the last annual compliance review. The gang liaison reported an email is sent to
the juvenile probation officer, law enforcement, and education advising of placement or any
issues. This information is sent even if a youth was identified prior to placement or after
placement.
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 (FOPs) outlining the process of the storage of
youth personal property. Nine youth records were reviewed. Each youth and a staff signed an
itemized personal Property Receipt Form and valuable Property Receipt Form, if applicable.
Each youth signed a letter of acknowledgement regarding unclaimed property. Four of the nine
youth entered the center with valuable property. Each appliable youth’s valuable property was
verified and secured in a clear tamper proof property bag. Each bag included the date, youth’s
name, identification number, and a list of items in the bag. Each of the four valuable property
bags were placed in a drop safe. A review of the logbook confirmed each of the four youth’s
property was logged with required information. None of the youth refused to sign the Property
Receipt Form. Each youth’s other personal property was placed in an assigned locker as
documented on the Property Receipt Form, which is also placed in a locker. A valuable Property
Receipt Form was placed in each of the four applicable youth records. Youth personal property
is stored in a secure area and the drop safe is under video surveillance. Access to youth
personal property is limited to supervisory staff. Observation of the receipt of youth property
could not be observed during the annual compliance review, due to no admissions taking place
during the annual compliance review week while the review team was on-site. There were no
reported incidents regarding youth property to the Department’s Central Communications
Center (CCC) during the annual compliance review period. The superintendent confirmed the
process of securing youth property which includes documentation, storage, and disposal of
property. Youth property is documented on each youth’s property log sheet. Property is then
sealed in a bag with the youth’s name, Department of Juvenile Justice identification number
(DJJID), date of admission, and listed items. Each bag is logged in the valuable’s logbook by
the date, youth’s name, DJJID, and bag number. Finally, the property is placed in the locked
property cabinet. Personal property is stored in the safe located in the intake and release area.
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Property for youth no longer in detention is stored in a safe for thirty days after a property letter
is sent to the parent/guardian. When the thirty days have ended the property is donated or
thrown away. Any money will be placed in the form of a money order and sent to the regional
office. Nine youth were interviewed and confirmed staff checked their personal property and had
them sign a personal property form when they arrived at the detention center.
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) outlining the process of releasing youth
from the center. Three closed records were reviewed. Each closed record included
documentation showing the on-duty juvenile justice detention officer supervisor (JJDOS)
reviewed all paperwork related to release prior to the youth’s release. A JJDOS reviewed the
release paperwork received from court in each of the three records. A juvenile justice detention
officer (JJDO) verified youth identification prior to each release. AJJDO verified the identification
of the parent/guardian prior to release with an identification which is photocopied and placed in
each of the three youth records. None of the youth had an Endangered Person Alert. The JJDO
reminded the youth and parent/guardian of any future court dates for each of the three youth. A
JJDO had all required parties sign all applicable release forms. A review of the Department’s
Juvenile Justice Information System (JJIS) and youth records confirmed the date of admission
and date of release correlated for each of the three youth records. One youth release was
observed during the annual compliance review and confirmed the process of youth release from
the center.
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 (FOPs) outlining the process of releasing youth
personal property, medication, and aftercare instructions. Three closed records were reviewed.
Each applicable youth and their parent/guardian signed the receipt of property form upon
release. There was documentation in each record verifying the youth was released to an
appropriate person with a copy of their identification. One of the three youth was released with
medication and the Department’s receipt of medications form was signed by the person
receiving the youth. The youth and the person to whom the youth was released were reminded
of any health or welfare issues, including medical, mental health, and/or substance abuse needs
and any pending appointments. One youth release was observed during the annual compliance
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review; it confirmed the release of youth property process. A review of three properties held for
more than thirty days was conducted since the last annual compliance review. The review
confirmed the center followed the disposal process according to the FOP.
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 has facility operating procedures (FOPs) outlining the Detention Review process.
Observation of a Detention Review for youth in secure detention was conducted, and it
confirmed probation, detention, education, medical, and residential staff were in attendance and
discussed the status of each youth placed in secure detention. A review of weekly Detention
Review documentation confirmed the meeting occurs weekly and all required parties attend.
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 (FOPs) which outline what is included in the
center’s daily activity schedule. During the annual compliance review, observations of
education, meals, recreation, transportation, and art class found activities were being held as
scheduled. A review of the center’s daily schedule found activities including wake up and
personal hygiene, mealtimes, visitation, recreation and physical activities, indoor activities which
promote education, problem solving, and life skills, bedtimes, groups, and open center time are
provided regularly. The daily schedule was posted in all living areas. Each of nine interviewed
youth and nine interviewed staff reported the daily schedule is followed.
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 (FOPs) to ensure educational access and
education services are provided through the Pinellas County School District. A review of the
daily school schedule confirmed the center offers six fifty-minute class periods each day,
meeting the required twenty-five hours of weekly instructional time. The facility’s activity
schedule aligned with the education schedule and daily activity times. A review of video footage
from three randomly selected days confirmed education classes were held as scheduled. A
review of the past twelve months of logbook entries, using one randomly selected day each
month, identified inconsistencies in the documentation of education time, and the inability to
verify youth were transitioned to and from education classes at the correct time. Nine
interviewed youth reported attending school Monday through Friday. Five youth stated the
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school was preparing them very well, while two responded well, and two responded not well for
the high school equivalency diploma (GED), vocational training, employment, or college. Nine
interviewed staff reported minimal interference with educational services. The superintendent
also confirmed minimal interference of education instruction.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has established facility operating procedures (FOPs) to deliver career education to
youth, 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. Nine interviewed youth reported participating in core classes such as
math, science, history, reading, social studies, 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 a contract with VitalCore Health Strategies, LLC. to provide mental health
services at the center. The center has a designated mental health clinician authority (DMHCA)
who coordinates services and provides coverage at the center for forty hours each week. The
DMHCA is a licensed mental health counselor (LMHC) and has an active license through the
State of Florida, which expires on March 31, 2027. The center has a back-up DMHCA whose
license expires on March 31, 2027. The DMHCA provides oversight and coordination of mental
health services, including the completion of Assessments of Suicide Risk (ASR), supportive
services, and individual therapy. The DMHCA also provides supervision of non-licensed staff. A
review of the mental health logbook sign-in confirmed the DMHCA at a minimum, was on-site
weekly as required by contract. Copies of the DMHCA’s agreement and position description
were reviewed during the annual compliance review week. During an interview, the DMHCA
confirmed overseeing the coordination and implementation of mental health and substance
abuse services. Members of the mental health team are oriented to Facility Operating
Procedures (FOP), practice standards, and receive regular supervision from the DMHCA. The
DMHCA and the superintendent are responsible for overseeing and consistent implementation
of mental health services to youth in detention. Mental health staff at the center provide crisis
management, counseling, group counseling, and family counseling as needed/requested. The
DMHCA communicates with clinical staff daily and weekly, 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 has a contract with VitalCore Health Strategies, LLC to provide licensed mental
health staff who deliver mental health and substance abuse services at the center. The center
had seven licensed mental health counselors (LMHC) and six licensed clinical social workers
(LCSW), since the last annual compliance review. All were working under the direction of the
designated mental health clinician authority (DMHCA), who is also an LMHC. All seven LMHC’s
and six LCSW’s have clear and active licenses in the State of Florida with expiration dates of
March 31, 2027. All licenses were posted in the mental health office and copies were provided
to the review team while on-site. Each licensed mental health staff was licensed under the
appropriate Florida Statutes chapter. The clinical supervisor ensures all licensed clinical staff
under their supervision are providing services they are qualified to provide based on education,
training, and experience.
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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 has facility operating procedures (FOPs) to ensure mental health and substance
abuse services are provided by staff with the appropriate qualifications. The designated mental
health clinician authority (DMHCA) must ensure clinical staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience.
The center had two non-licensed master’s-level clinical staff during the annual compliance
review period. Both staff are registered clinical social work interns. The center is not required to
provide a specific amount of non-licensed clinical staff hours as stipulated in the provider
contract. A review of documentation confirmed each non-licensed mental health clinical staff
working under the direct supervision of the DMHCA received a minimum of one hour a week of
on-site, face-to-face direct supervision, by a licensed mental health professional, for the purpose
of overseeing and directing the mental health services provided in the center during the annual
compliance review period. The center does not have Chapter 397 license; therefore, all
substance abuse services are provided by licensed clinical staff. A review of substance abuse
group sign-in logs and nine youth mental health and substance abuse records confirmed this
practice. Documentation confirmed both non-licensed clinical staff have completed twenty hours
of training and supervised experience in assessing suicide risk, mental health crisis intervention,
and emergency mental health services. Both non-licensed clinical staff hold a master’s-level
degree from an accredited university or college. There were no vacancies since the last annual
compliance review.
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) regarding the assessment of youth for
mental health and substance abuse needs upon admission. Nine youth mental health records
were reviewed, and each youth was screened using the Suicide Risk Screening Instrument
(SRSI), which was entered into the Department’s Juvenile Justice Information System (JJIS) at
intake. Eight of the nine youth were screened using the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2) and each was entered in JJIS at intake. The remaining
youth did not have a MAYSI-2 completed due to being transferred in from a residential program
due to program closure. A nurse and mental health staff completed all required sections on
each SRSI, and all completed entries included an accurate referral selection in the “Screening
Results” section. Six of the nine youth had positive responses on the SRSI, the remaining two
youth did not have any positive responses. Each of the six applicable youth were then placed on
suicide precautions and a mental health referral was completed, which documented each
youth’s need for an Assessment of Suicide Risk (ASR). Each applicable SRSI screening
included “yes” responses when youth had any open or closed suicide risk alerts in JJIS, as
prompted within the JJIS SRSI navigation screen in red font. Two youth’s MAYSI-2s were
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marked “invalid” due to all negative responses, and both were referred for a comprehensive
assessment. Three of the nine youth’s MAYSI-2s indicated an elevated suicide risk subscale,
each youth was placed on suicide precautions and referred for an ASR. Five of the youth’s
MAYSI-2 assessment indicated the need for a comprehensive assessment and each were
referred to mental health staff within the center. The superintendent was notified for each of the
eight applicable youth who required further assessment based on the SRSI and/or MAYSI-2.
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) regarding mental health and substance
abuse evaluations. Eight youth were applicable and were identified after admission as in need
of and referred for a Substance Abuse Mental Health (SAMH) evaluation. Four youth were
appliable for a new SAMH evaluation which was completed by the youth’s thirty-first day by the
center provider, VitalCore Health Strategies, LLC. One youth had a comprehensive evaluation
completed by a community provider one day after the youth’s admission into the center. The
community evaluation contained all required elements and the signature of the licensed staff
completing the evaluation. SAMH evaluations for the remaining three identified youth were not
completed, as each youth was still within thirty days of admission the week of the annual
compliance review. Treatment recommendations were made which corresponded to all
diagnosed mental health or substance related disorders for all five youth records. Each
comprehensive SAMH evaluation consisted of the SAMH in the Department’s Office of Health
Services (OHS) electronic medical record or a comparable Department approved instrument.
During an interview, the designated mental health clinician authority (DMHCA) described the
process for obtaining a comprehensive SAMH assessment. 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 Community Assessment Tool
(CAT) above the state approved cut off score. Youth are also referred if there is other
information regarding the youth’s behavior or history which indicates the need for further mental
health assessment. Mental health staff reviews documentation on all youth entering the center,
which includes a review of preliminary screening conducted by the Office of Probation and
Community Corrections. If a need for a comprehensive assessment is identified by detention
staff screening, and not by the Juvenile Assessment Center (JAC) screening, a referral for a
comprehensive assessment is sent to the assigned JPO by e-mail and is marked confidential.
The process for obtaining a comprehensive mental health and/or substance abuse assessment
based on behavior was explained. In the event a youth exhibits behavior, or information is
obtained which indicates a youth needs further mental health assessment, information will be
provided by a mental health professional. A referral is created, and it is tracked on the
comprehensive assessment log.
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3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The provider’s contract requires the superintendent and designated mental health clinician
authority (DMHCA) or mental health/substance abuse clinical staff to ensure the development
and review of an initial and/or individualized treatment plan for each youth receiving mental
health/substance abuse treatment in the center. Nine youth mental health and substance abuse
records were reviewed. Eight of nine youth were applicable for requiring a mental health
orientation and received an orientation within fourteen days. One youth was not applicable
because the youth was still within fourteen days of admission. Five of the nine youth required a
treatment plan, and four youth were not applicable since the youth were recently admitted in the
center at the time of the annual compliance review. Two of the five applicable youth had an
initial treatment plan in place within seven days of the onset of treatment with one exception.
One youth’s initial treatment plan was one day late. Both applicable youth were admitted with
psychotropic medications. The remaining youth did not require an initial treatment plan. Both
initial treatment plans documented the reason for the referral, initial Diagnostic and Statistical
Manual of Mental Disorders-5 (DSM-5) diagnosis/symptoms, initial treatment methods including
counseling and frequency, initial treatment goals, psychiatric services including psychotropic
medication and frequency, medication the youth was admitted with in order to compare with the
initial treatment plan, and the clinical staff signature signed by a licensed clinical supervisor.
Each of the initial treatment plans contained the youth signature and mini-treatment team
assignment. All mini-treatment team members were involved in the development of each initial
treatment plan. Five youth were applicable for an individualized treatment plan. The remaining
four had been at the center less than 30 days. Each applicable record documented the
individualized treatment plan was developed for youth receiving mental health and/or substance
abuse treatment in the center by the thirty-first day of the youth’s admission. All five youth
individualized treatment plans included DSM-5 diagnosis, symptoms which are treatment
focused, treatment goals including mental health services if the youth had a mental illness,
substance abuse services if the youth had a substance related diagnosis, and the youth’s
strengths and needs. Two of the five youth had psychotropic medications listed in each of their
initial treatment plan which matched the psychotropic medications the youth was prescribed at
the time the individualized treatment plans were developed. Three youth were not applicable for
psychotropic medication. Four youth records documented in progress notes youth were
receiving treatment services as stipulated on the treatment plan. The remaining youth declined
services. A review of the five youth records confirmed the individualized treatment plan was
signed by the youth, mental health substance abuse professionals, treatment team members,
and parent/guardian. Four youth were applicable for treatment plan reviews. The remaining
youth was not applicable for a thirty-day review for thirty days had not passed since the
treatment plan was developed. Two youth had one thirty-day individual treatment plan review,
one youth had two thirty-day individual treatment plan reviews, and one youth had four thirty-
day individual treatment plan reviews. Each review was completed and documented on the
Department’s Individualized Mental Health/Substance Abuse Treatment Plan Review form and
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revisions were documented on the forms. Modifications were documented on each review form
for all four youth. A review of the four youth Individualized treatment plan reviews indicated they
were signed and dated by the clinical staff, youth, licensed mental health professional, treatment
team members, and parent/guardian. Each treatment plan review documented treatment and
services were provided by a licensed psychiatrist. None of the youth were an alleged victim of a
Prison Rape Elimination Act (PREA) event; therefore, it was not required to be included in the
plan. None of the reviewed youth were eligible for Mental Health/Substance Abuse Treatment
Discharge Summaries; therefore, the center provided three additional youth mental health
records for review. Each of the three youth records included a completed Mental
Health/Substance Abuse Treatment Discharge Summary form which was documented on the
Department’s approved form. A copy of each discharge summary was provided by mail to the
juvenile probation officer (JPO), parent/guardian, and youth. Each youth was released prior to
clinical staff having each youth sign the discharge summary. The discharge summary was
completed on the day of each youth’s discharge, signed by the licensed mental health
professional, and the upload of additional documentation was completed within fourteen days
for the applicable youth records reviewed. A mini-treatment team meeting was observed during
the annual compliance review week. The treatment team meeting was conducted with a medical
doctor, nurse, DMHCA, and youth. The team talked with the youth about his current feelings
and possible treatment options. During an interview, the DMHCA explained to ensure services
are provided at the center, the DMHCA and medical team ensures coordination of ongoing
treatment with existing community provider if a youth is active in treatment when admitted to the
detention center. Short term individual therapy is provided in the center where each youth
receives individual sessions as determined by their individual needs reflected in their treatment
plan. Crisis counseling is used to focus on identification of specific event(s) precipitating a crisis,
alleviating a youth’s specific distressing symptoms, and restoring youth’s level of functioning. A
review of the Individualized Mental Health/Substance Abuse Treatment Plan is conducted every
thirty days by mental health staff. Any modifications or updates are recorded on the
Individualized Mental Health/Substance Abuse Treatment Plan Review form located in the
Office of Health Services (OHS) Electronic Medical Record, developed by the Florida
Department of Juvenile Justice. The DMHCA meets with the superintendent on a daily or
weekly basis as needed.
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) to provide mental health and substance
abuse treatment planning to provide interventions which will reduce each youth’s symptoms of
mental disorder or substance abuse. Nine youth mental health records were reviewed for
mental health and substance abuse treatment, and eight youth required mental health
treatment. The remaining youth did not require treatment. Each applicable youth was assigned
to a mini-treatment team which consisted of mental health clinical staff, staff from a different
service area, youth, and parent/guardian, if available. An individual treatment plan was
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developed for five of the applicable youth; three of the youth had been at the center less than
thirty days. Of the five individual treatment plans, four included individual, group, or family
therapy prescribed at least weekly. The remaining youth declined services; therefore, did not
include weekly prescribed treatment. Mental health staff checked in with the youth periodically
to remind the youth of the mental health services and this information was documented in
progress notes. A review of progress notes revealed each of the four youth received counseling
according to the frequency required by the plan. One youth required substance abuse treatment
and did receive individual, group, or family counseling according to the frequency of their plan.
Each youth had an Authority for Evaluation Treatment (AET) form signed. Only one youth
received substance abuse services while at the center and had the proper consent for
substance abuse treatment obtained through the signed Mental Health Substance Abuse form.
All treatment notes were documented on the Department’s Counseling/Therapy Progress Notes
form. A review of group sign-in sheets confirmed group therapy was limited to ten or fewer youth
for mental health and limited to fifteen or fewer youth for substance abuse treatment groups. A
review of group sign-in sheets confirmed groups did not have more than the required number of
youth and were held on the modules for the required time. Mental health staff have adequate
access to youth and confidential space to provide treatment services. A video review of one
group, during the last thirty days confirmed the group was conducted as scheduled, with four
youth involved in the group. During an interview, the designated mental health clinician authority
(DMHCA) explained the process used for individualized substance abuse treatment planning. A
youth with a substance dependence goal will have an individualized treatment plan including
substance abuse goal and treatment. Services are provided by the DMHCA and/or a licensed
mental health staff as needed for each youth, if they accept substance use services.
Intervention strategies within each plan are based upon best practices and effective treatment
models appropriate to the individual characteristics and needs of each youth, including
psychiatric services when applicable. A review of each Individualized Mental Health/Substance
Abuse Treatment Plan is conducted by a mini-treatment team every thirty days. Modifications of
each Individualized Mental Health/Substance Abuse Treatment Plan is recorded on the
Individualized Mental Health/Substance Abuse Treatment Plan. Therapists will provide
individual counseling for mental health areas as indicated in each plan. Mental health staff
provide crisis management, individual counseling, group counseling, and family counseling as
needed or requested at the center. Nine youth were interviewed and asked to rate the mental
health and substance abuse services at the center. Six youth stated good, one youth stated
very good, one youth stated fair, and one youth stated they are not receiving services.
3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a Suicide Prevention Plan detailing their suicide prevention procedure which is
reviewed and signed by the designated mental health clinician authority (DMHCA) and
superintendent annually. The plan includes identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and review process. The center has an
established review process for every serious suicide attempt or serious self-inflicted injury and a
mortality review for a completed suicide, including all required elements. The multidisciplinary
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review includes circumstances surrounding the event, center procedures, all relevant training
received by involved staff, medical and mental health services involving the victim, precipitating
factors, and recommendations.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has a Suicide Prevention Plan in place which outlines the procedures for youth
identified as at-risk, which includes a review process for any instances of a serious suicide
attempt, self-inflicted injury, or completed suicide. Nine youth mental health records were
reviewed, and eight youth were applicable for receiving suicide prevention services. Eight youth
were identified as a suicide risk during admission screening. All eight youth had alerts entered in
the Department’s Juvenile Justice Information System (JJIS) and were placed on precautionary
observation (PO) upon their suicide risk being identified. Each youth was referred for a suicide
risk assessment. Each Assessment of Suicide Risk (ASR) document had an assessment
documented on the day of service for each youth. Each youth was on constant supervision prior
to the ASR completion. Each PO log was completed in its entirety for each youth, and all alerts
were closed appropriately following each youth’s removal from PO. Clinical staff were involved
in the process for each youth. None of the youth were released prior to receiving an ASR or
while on PO. An ASR was completed for all eight youth. Each youth had documentation staff
consulted with the designated mental health clinician authority (DMHCA) or licensed mental
health professional on the mental health substance abuse referral summary. The
superintendent and clinical staff were notified immediately of suicide risk for each youth. Each
youth’s ASR documented the date and time a referral was made to the mental health
professional, the date and time the youth was placed on PO, and each ASR was completed
within twenty-four hours. Seven youth were placed on standard supervision following their ASR.
The remaining youth required two follow-up ASRs prior to being released to standard
supervision. The DMHCA and the superintendent consulted regarding each youth being placed
on and stepped down from PO. Staff entered the date and time each youth was placed on and
discontinued from PO in JJIS. The discontinuation of close supervision was documented in
accordance with the center’s suicide prevention plan for each youth. An ASR was administered
by licensed mental health staff for seven youth. The remaining youth’s ASR was completed by a
non-licensed mental health staff and it was confirmed the staff had the required ASR training.
Each ASR included the results of the assessment including recommendations for supervision
and follow up. A review of logbooks and ASRs confirmed each youth had an entry about being
placed on and stepped down from PO, which included instructions on what staff were to do
while each youth was on PO. Each applicable ASR was documented on the Department’s form
which included all required elements. A review of JJIS confirmed alerts were appropriately
entered and removed following removal from PO for each youth. A review of logbooks
confirmed beginning and ending times were documented for youth placed on precautionary
observation. During an interview, the DMHCA explained the process of conducting suicide risk
screenings. The initial screening process begins at the Juvenile Assessment Center (JAC) with
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the administration of the Massachusetts Youth Screening Instrument – 2 (MAYSI-2) to assess
mental health and substance abuse issues, and the Suicide Risk Screening Instrument (SRSI)
to assist in identifying youth at-risk of suicide. The JAC determines if a youth is a suicide risk,
then places the youth on suicide precautions. Each youth is maintained on a minimum of
constant supervision when entering the detention center. A juvenile justice detention officer
(JJDO) immediately reviews all screening instruments and forms upon a youth’s admission to
the detention center. The intake JJDO reviews the MAYSI-2 and the SRSI. If an assessment
suggests a youth is a potential suicide risk, the youth is placed on suicide precautions and
maintained on a minimum of PO constant supervision until an ASR is completed by a mental
health professional. The process for a referral following a screening consists of trained staff
using screening tools to identify youth entering the facility at risk of suicide. Staff are also trained
in verbal and behavioral warnings which suggest suicide risk. Both aforementioned results in
mental health referrals to assess a youth’s potential for suicide. Furthermore, a detention officer,
either observing indications of suicide risk upon admission from screening tools or observing
warning signs, immediately notifies a JJDO supervisor (JJDOS) of any potential risk. A JJDOS
places the youth on PO constant supervision and initiates suicide precautions. Mental health
professionals are notified through JJIS when an SRSI indicates any issues, and the DMHCA is
on call twenty-four hours a day seven days a week. When a youth is potentially suicidal staff are
notified in writing through a log entry, they receive a PO log form, verbally through staff
meetings and during a relief of on-duty JJDOs in the modules. Mental health staff communicate
with the on-duty JJDOS in the administration office or interview room to discuss youth
supervision levels. The information is documented in the ASR, module logbook, and master
control. The procedure for notification of the superintendent, parent/guardian, and other
applicable agencies of a potentially suicidal youth consists of the on duty mental health
professional notifying the parent/guardian by telephone, and the juvenile probation officer (JPO)
through email. If a mental health professional is not on duty, the JJDOS will notify the
parent/guardian by telephone, and a mental health referral is submitted in JJIS. If necessary, a
report to the Department’s Central Communications Center (CCC) will be completed, and an
email and telephone call will be used to notify the DMHCA, superintendent, and JPO. Nine staff
were interviewed about their responsibilities if a youth expresses suicidal thoughts. All nine staff
indicated they would notify mental health, maintain sight and sound supervision, search the
youth, and conduct room searches. One staff indicated they would place the youth in a locked
room. Nine youth were interviewed. Eight youth stated they have never been placed on suicide
watch at the center. One youth stated yes to being placed on suicide watch while at the center
and indicated staff watched the youth all the time.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures (FOPs) to ensure youth placed on suicide
precautions may be maintained on secure observation when less restrictive means are not
effective. Nine youth mental health and substance abuse records were reviewed. None of the
youth were applicable for having been placed in secure observations. The center had no youth
placed on secure observation since the last annual compliance review.
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3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures (FOPs) for youth placed on suicide precautions.
Nine youth mental health records were reviewed for the completion of Suicide Precaution
Observation (PO) Logs, and eight were applicable. All eight youth were placed on PO and were
applicable for the completion of Suicide Precaution Observation Logs. The center used the
Department’s Suicide Precaution Observation Logs for each youth. Each youth had Suicide
Precaution Observation Logs for the duration of their placement. The appropriate level of
supervision and observations of each youth’s behavior was documented in real time and did not
exceed thirty-minute intervals. A video review of three youth on three different days confirmed
the center placed each youth on PO during intake/admissions and provided constant
supervision. Each of the three youth were observed sleeping in the middle of the day room area
on a mat while on constant supervision. Two of the three youth were stepped down to close
supervision and then standard supervision once mental health met with the youth. The
remaining youth was Baker Acted and had not returned to the center when the video
observation was being conducted. The superintendent was interviewed and confirmed the
center will use secure observation for potentially suicidal youth only if the youth has been placed
on confinement, A youth is placed on secure observation, and a juvenile justice detention officer
(JJDO) is assigned to sit at the youth’s door to always maintain a visual of the youth.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Nine in-service and nine pre-service staff training records were reviewed and confirmed suicide
prevention training was completed as required. The center conducted suicide drills monthly, and
at least quarterly on each shift. All mock mental health drills were in response to a suicide
attempt or a simulated incident of serious self-injury. The center did not use youth during any
drill simulations related to mental health or substance abuse care. The center provided semi-
annual training on emergency response procedures which include “mock” training in emergency
response to a suicide attempt or incident of serious self-inflicted injury. Staff who are not present
during a quarterly drill have the opportunity to review each drill scenario and procedures in an
effort to understand the process and receive the necessary training to respond to an incident of
a suicide attempt or incident of serious self-inflicted injury in the center during meetings. The
center has a total of six suicide response kits located on each of the five modules and one in
master control. Each suicide kit is co-located with a first-aid kit. A review of one suicide drill
simulation was conducted and the video footage matched documentation. All nine interviewed
staff stated the Knife-for-Life, wire cutters, and needle nose pliers are kept in master control.
One staff member stated they are kept in the medical office, and eight staff stated they are kept
in the staff bathroom, and each in each module.
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3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a written combined crisis intervention and emergency services plan which
details the response procedures for youth in crisis. The plan includes a notification and an alert
system, means of referral, youth self-referral, communication, supervision, documentation, and
review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures (FOPs) regarding the process for emergency
mental health and substance abuse services. The center’s Emergency Care Plan was signed
and approved on July 18, 2025. The plan includes immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services, transport for emergency mental health evaluation and treatment,
transport for emergency substance abuse assessment and treatment, documentation, training,
and review. The plan is accessible to all staff in the briefing room, superintendent office, and
medical office.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures (FOPs) to ensure any youth demonstrating acute
psychological distress receives a detailed evaluation or Crisis Assessment, by a licensed mental
health professional. Nine youth mental health records were reviewed, and none of the youth
were applicable for a Crisis Assessment. The center provided three youth mental health records
which were applicable for having a Crisis Assessment completed. A review of the three records
for Crisis Assessments was conducted. The Crisis Assessments included the reason for the
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assessment, mental status examination and interview, determination of danger to self or others,
initial clinical impressions, supervision recommendations, treatment recommendations, and
recommendations for a follow up or further evaluation for all three youth. A mental health alert
was entered into the Department’s Juvenile Justice Information System (JJIS) for all three
youth. All three youth records indicated after the Crisis Assessment; the youth remained on
standard supervision. All three youth were identified by direct care staff or clinical staff as having
acute emotional or behavioral problems, or acute psychological distress. All three youth records
documented the Crisis Assessments were conducted by a licensed mental health professional,
or by a non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional. All three youth records documented the Crisis
Assessments were conducted immediately or within two hours for emergencies, or within
twenty-four hours based on the needs of each youth; none of the Crisis Assessments were late.
Two of the three youth records indicated the youth was an alleged victim in a Prison Rape
Elimination Act (PREA) event, and each youth was offered ongoing mental health treatment
services.
3.16 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 any youth believed to be an
imminent danger to themselves or others because of mental illness or substance abuse
impairment is provided emergency services. Nine youth individual mental health records were
reviewed; one was applicable for a Baker Act. The center provided two more youth records
applicable for a Baker Act. Each of the three incidents indicated while pending an off-site
transportation for Baker Act, a suicide risk alert was opened, each youth was placed on one-on-
one supervision, with documentation on a precautionary observation (PO) log of staff
maintaining PO until the youth’s release, as required. Upon re-admission to the center after a
Baker Act, documentation confirmed each applicable youth was placed on suicide precautions
and a referral was made to mental health. A Mental Status Examination (MSE) was completed
by or under the direct supervision of a licensed mental health professional for all three Baker Act
incidents. Documentation of each incident found each youth was maintained on a minimum of
constant supervision until properly transitioned to a lower level of supervision, determined by an
assessment completed by a mental health professional, and mental health staff conferring with
a licensed staff and superintendent or designee. All three youth records documented the suicide
risk alert in the Departments Juvenile Justice Information System (JJIS) was discontinued due
to an Assessment of Suicide Risk (ASR) and Crisis Assessment. During an interview, the
designated mental health clinician authority (DMHCA) stated there were ten youth required to
be transferred to the Crisis Stabilization Unit during the past year for Baker Act services. There
were no youth transferred to the Crisis Stabilization Unit during the past year for Marchman Act
services.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has a contract with VitalCore Health Strategies, LLC, and they have an agreement
with a medical doctor (MD), who serves as the center’s designated health authority (DHA). The
MD has an unrestricted license and meets all requirements for practice in the State of Florida.
The DHA specializes in pediatrics, and has an active license, which expires on January 31,
2027. The center also has an advanced practice registered nurse (APRN), who has an active
license in the State of Florida, with an expiration date of July 31, 2026. The APRN has a
Collaborative Practice Protocol in place with the DHA, which was renewed on April 5, 2025, and
copies are maintained on-site. The APRN provides clinical services, and the DHA performs all
administrative duties. The center does not utilize a physician assistant (PA). The DHA is
required by contract to be on-site for a minimum of four hours weekly. A review of the center’s
DHA sign-in logs for the annual compliance review period found the DHA was on-site as
required. The center has a back-up DHA through their contract with VitalCore Health Strategies,
LLC who has an active license in the State of Florida, with an expiration date of January 31,
2027; however, the back-up DHA was not used during the annual compliance review period.
The center did not utilize tele-medicine during the annual compliance review period. During an
interview, the DHA advised duties include the review laboratory studies, radiographic results,
performing physical exams, and taking care of chronically ill youth. The DHA is also in charge of
reviewing and updating some of the protocols for the center. The DHA confirmed she is at the
center for a minimum of four hours each week and is available by telephone as needed. The
DHA provides on-site clinical services as well as working with the APRN. The nurse manager
will assist with making sure all off-site care findings, instructions, and information is reviewed
either by the DHA or designee. All documentation is theoretically electronic, but there are also
paper charts for the DHA to review and sign. The DHA is on-site weekly, and discussions take
place with nursing staff weekly to review important medical issues pertaining to each youth.
Arrangements for coverage when the DHA is out are made when requested. The DHA
confirmed there are no concerns with healthcare at the center.
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 facility operating procedures (FOPs) covering all health-related procedures and
treatment protocols which are or may be used at the center. The designated health authority
(DHA) and superintendent signed and dated all respective treatment protocols, policies, and
procedures, and conducted an annual review of all treatment protocols as required; with the
superintendent signing them on January 31, 2025, and the DHA on July 18, 2025. Nursing staff
signed and dated a review of all nursing protocols throughout the year. Any new policies or
updates in policies which took place during the year were reviewed, signed, and dated by each
nurse on a signature page, as well as an annual review of medical policies, procedures, and
protocols conducted by all required individuals. All healthcare personnel hired from the time of
the last annual compliance review received a comprehensive clinical orientation to the
Department’s healthcare policies and procedures. This orientation was provided by a registered
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nurse (RN). All treatment protocols or standing procedures were approved, written, and
authorized by the DHA.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures (FOPs) which require the completion of the
Authority for Evaluation and Treatment (AET) or Limited Consent for Evaluation and Treatment
authorizing specific treatment for youth. Nine youth Individual Healthcare Records (IHCRs) were
reviewed, and five were applicable for requiring an AET. The remaining four youth were over the
age of eighteen; therefore, did not require an AET. Four of the five applicable youth had a AET
form with the word “COPY” stamped on the form filed in each IHCR which were signed by a
parent/guardian. The remaining youth’s father passed away and the stepmother did not have
court ordered parental/guardian rights yet, but the center had a limited consent signed by the
superintendent and a completed affidavit of diligent effort. All AETs were obtained prior to each
youth receiving medical services, and all were signed by a Department representative. All AETs
were valid. The four youth over the age of eighteen each had a documented release of
information in their IHCR. During an interview, the nurse advised youth parents/guardians are
contacted during the admission process to obtain a new or current AET. If the parent/guardian is
unable to be reached after several attempts the juvenile probation officer (JPO) is contacted for
assistance with obtaining a signed AET. Youth who are over eighteen years of age sign the AET
using the Authority for Evaluation and Treatment for Youth Over 18 years of age form during the
admission process.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center has facility operating procedures (FOPs) to ensure they inform each youth’s
parent/guardian of any significant change in youth’s condition and to obtain consent when new
medication and treatments are prescribed. Nine youth Individual Healthcare Records (IHCRs)
were reviewed, and five were applicable for requiring parental notification and consent. The
remaining four youth were over the age of eighteen; therefore, did not require parental
notification and consent. All five applicable IHCRs had consent provided by the parent/guardian.
Three youth were taking psychotropic medication when they were admitted, and one IHCR
contained notes verifying staff witnessed all telephone call attempts and conversations for
psychotropic medications. The remaining two youth were over the age of eighteen and did not
require parental consent for taking psychotropic medications. All youth had current records for
vaccinations/immunizations, and all were verified within thirty days of admission. None of the
youth had new medication ordered during admission. During an interview, the nurse said
parental notifications are initiated for medications not covered in the Authority for Evaluation and
Treatment (AET) form, off-site medical appointments, initiation of off-site emergency medical
care, and as notification of missing or incomplete vaccinations. Parental notifications occur
verbally or in writing within twenty-four hours of a qualifying event occurring. Parents/guardians
are notified by telephone whenever a youth is transported off-site and upon their return. Each
youth is evaluated by a nurse upon return to the center as well as an evaluation by the
designated health authority (DHA). Immunization records are obtained from the Florida Shots
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Immunization portal. Vaccinations are not provided on-site. Medical records are reviewed within
twenty-four hours of admission. If youth are prescribed new psychotropic medications,
discontinued on psychotropic medication, or there are psychotropic medication adjustments,
each parent/guardian is contacted by the psychiatrist with any changes. Consent is obtained
from each parent/guardian to initiate the changes. If a parent/guardian is unable to be
contacted, the CPPN documentation and the Acknowledgement of Receipt of CPPN or the
practitioner form is mailed to the parent/guardian. Youth are sent off-site to the health
department to receive vaccinations. The process for documenting parental/guardian exemption
from immunizations is the parents’/guardians’ responsibility for obtaining the immunization
exemption form from the health department. The form must be completed and returned to the
center.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures (FOPs) requiring youth to be screened upon
admission for healthcare concerns which may need a referral for further assessment by
healthcare staff. Nine youth Individual Healthcare Records (IHCRs) were reviewed, and all had
a Department Medical and Mental Health Admission Screening form completed by a juvenile
justice detention officer (JJDO) or JJDO supervisor (JJDOS) on the date of admission. All were
reviewed by a nurse within twenty-four hours. The center notifies the designated health authority
(DHA) for all admissions. Three of nine IHCRs were applicable for rescreening.
In all three applicable IHCRs there was a change in physical custody, and the center completed
healthcare admission rescreening for each. The three rescreenings were completed by a JJDO
or JJDOS on the date of admission and reviewed by a nurse within twenty-four hours. One
youth received a qualitative urine pregnancy screening test, and the chronological progress
notes included documentation of consent. The nurse was interviewed and said all newly
admitted youth are seen by nursing staff within twenty-four hours. Intake packets are provided
to nursing staff from the intake department as they receive notification of new intakes. New
intakes are also updated in the Department’s Juvenile Justice Information System (JJIS) by
detention staff. Each admission screening is completed by nursing staff. The nurse also advised
when a change in physical custody occurs, a new intake packet is provided to the medical
department to be reviewed, signed, and dated prior to completing the 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 facility operating procedures (FOPs) which require all youth to be oriented in the
process of healthcare delivery at the center. A review of the FOPs confirmed the orientation
covers 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 healthcare
providers, and general infection control/hygiene. Nine youth Individual Healthcare Records
(IHCRs) were reviewed, and all contained documentation which verified youth are receiving
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orientation, as required. All health education topics were documented on Form HS013. In
addition, youth with chronic conditions were educated on their medical condition.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures (FOPs) governing the notification of the designated
health authority (DHA) when a youth admitted requires emergency care or any routine
notification. The center notifies the DHA on all admissions. Four of the nine reviewed youth
Individual Healthcare Records (IHCRs) were applicable for youth having a known chronic
condition. Documentation confirmed the DHA was notified within twelve hours of all admissions.
None of the youth were identified as requiring emergency care upon admission. Three of the
nine youth were taking psychotropic medication upon admission, and the psychiatrist was
notified. The nurse was interviewed and said the admitting nurse contacts the DHA by
telephone as soon as a youth with a chronic condition is seen in the clinic. This notification is
documented on the intake log as well as the admission chronological notes 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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed, and all had a Health-Related
History (HRH) form which was completed by a nurse within seven days of admission on the
Department’s form. All HRHs were completed prior to the Comprehensive Physical Assessment
(CPA), which was evidenced by signature and date. The designated health authority (DHA)
reviewed each HRH as indicated by a check mark on the CPA. The nurse was interviewed and
said an HRH is completed by a nurse within seven days of admission for all youth
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures (FOPs) which require a Comprehensive Physical
Assessment (CPA) form to be completed for all youth admitted into the center. Nine youth
Individual Healthcare Records (IHCRs) were reviewed, and all had a complete CPA. Five youth
were applicable for a current CPA on file at admission. The remaining four had a new CPA
completed within seven calendar days of admission. All the CPAs were completed by a medical
doctor (MD) or an advanced practice registered nurse (APRN). All youth had a Medical Grade
documented on their CPA, and none were missing any elements. The five current CPAs had no
changes in the youth’s condition and were reviewed as each youth was examined and signed
off as reviewed by the MD or APRN. A focused evaluation was completed with each
readmission where a new CPA was not initiated, and a current CPA was used. All sections of
each CPA were clearly marked with an O or an X. No part of any exam was refused by any
youth. In each of the nine IHCRs reviewed, the Department’s Problem List was updated. Each
youth had at least one verified tuberculosis skin test (TST) which was within a year or
completed within seven days of admission, and the results were documented on the CPA. None
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required further evaluation. A review of the FOPs was completed for appropriate documentation
of when any part of the exam is not conducted and/or refused by the youth, as well as the
Tuberculosis screening and rescreening process, and both were contained in the FOPs. The
nurse was interviewed and said a new CPA and TST is completed within seven days of
admission, if applicable. The nurse also said the center does not conduct routine 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.
The center has facility operating procedures (FOPs) requiring all youth to be evaluated and
treated for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) risk
factors, if necessary. Nine youth Individual Healthcare Records (IHCRs) were reviewed, and all
contained documentation which confirmed seven youth were clinically screened and evaluated
for STIs. Two were not sexually active; therefore, did not require clinical screening. Two of
seven applicable youth required further evaluation, and the designated health authority (DHA)
reviewed the STI screening tool and documented a referral on the form. The two IHCRs
documented testing and screening results on the Department’s Infectious Communicable
Diseases (ICD) form, and the testing was filed in the lab section of the IHCR.
None of the youth received a gynecological exam. None of the youth were out of the
Department’s physical custody. All nine IHCRs had evidence each youth was offered counseling
and testing for HIV. Three of the nine youth consented to testing and received the testing. The
pre and post-test counseling was documented in each IHCR, and the test results were placed in
a sealed envelope marked confidential with a practitioner having reviewed the results in each
IHCR. Each youth’s confidentiality was protected by not including the HIV status or any other
STI diagnosis on the center’s internal alert system. The nursing interview stated the STI
screening form is completed with each youth during the admission process. If the screening
indicated a need for further evaluation, the nurse would complete the STI Screening Form with
the youth within twenty-four hours of admission. The DHA reviews the STI Screening form
during the completion of the Comprehensive Physical Assessment (CPA) and determines if a
youth requires additional testing. STI screenings, evaluations, referrals, and testing are
documented and filed in section one under Infectious and Communicable Diseases in the IHCR,
and the laboratory results are filed in section five under Laboratory Report section. If a youth
has been out of custody for more than thirty days, a new intake is completed. HIV test results
are kept in the Laboratory Testing section of the youth IHCR. Youth can consent to testing using
the HIV Youth Consent form completed during the admission process. Once the consent form is
completed, the DHA is informed, and the HIV testing and counseling is completed on-site. The
DHA is the person conducting HIV pre-counseling, testing and post-counseling. The process is
documented on the HIV Consent Form. The date of the HIV testing and results are documented
on the Infectious and Communicable Disease Form. Pre-counseling and post-counseling are
documented on the Health Education Form. Nine youth were interviewed, and all nine said they
can ask for an HIV test.
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4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures (FOPs) which require all youth to be able to make
sick call requests and have their complaints treated appropriately through the sick call system,
to include a sick call process for youth to receive regular medical care while in confinement.
Nine youth Individual Healthcare Records (IHCRs) were reviewed, and four had evidence of a
sick call event. All reviewed sick call events were documented on the Sick Call Referral Log.
None of the youth presented with similar sick call complaints three or more times within a two-
week period, and none had complaints of severe pain with which staff treated as emergencies
and required an immediate referral to a licensed healthcare professional. Each youth and
registered nurse (RN) completed the Department’s Sick Call Request form, and they were filed
in each IHCR in reverse chronological order. All sick call requests were documented on the
Department Sick Call Index and the dates listed on the Sick Call Index corresponded to the
completed Sick Call forms located in the IHCR. None of the reviewed youth were in restricted
housing. A review of the daily schedule and RN interview indicated sick calls are conducted
daily, and youth are seen within twenty-four hours of submitting a sick call request. The center
has approved treatment protocols for the RNs. Sick calls are provided Monday through Friday,
from 7:00 a.m. through 6:00 p.m., and on Saturday and Sunday, from 7:00 a.m. through 5:00
p.m., and as needed. The sick call hours are posed in each of the housing modules and in
medical. Only licensed nurses conduct sick calls, but the center has procedures in place
whereby a juvenile justice officer supervisor (JJDOS) will review all sick call requests as soon as
possible and within four hours after a request is submitted if there are no licensed nurses on-
site. Youth in restricted confinement are assessed and evaluated for medical complaints every
twenty-four hours. This is documented on an episodic progress note. If distress is noted while
medical staff are not on-site, the designated health authority (DHA) is contacted. One sick call
event was observed during the annual compliance review. Consent was obtained from the youth
to have the sick call event observed. The medical provider identified themself and confirmed
why the youth was there. The youth was seen in a private area where no other youth was
present to hear or see the examination. The examination table was utilized, and a juvenile
justice detention officer (JJDO) was present and positioned in the medical lobby/vestibule, with
the door slightly open. The nurse was interviewed and confirmed the sick call process and
hours. Sick Call is routinely completed by a RN or licensed practice nurse (LPN). The clinic
manager reviews the LPNs sick call documentation daily utilizing the Sick Call Review section of
the Department’s Juvenile Justice Information System (JJIS) electronic medical record (EMR).
Once the documentation is reviewed, it is signed by the clinical manager or designated RN. Sick
calls are conducted in the medical clinic. The nurse said they respond to the sick calls within
twenty-four hours and said the DHA will conduct sick call if there is a sick call while they are on-
site. The nurse also said if youth submit a sick call three times within a two-week period for the
same health related complaint, they are referred to the DHA for further evaluation. The center
does have Designated Health Authority (DHA) treatment protocols in place. Youth in restricted
housing are assessed daily by nursing staff when nursing staff are on-site. Youth in restricted
housing are monitored by detention staff during room checks when nursing is not on-site. Nine
youth were interviewed, and three said they are seen immediately when they request sick call.
Four said they are seen within one day, and two said they have never requested a sick call. All
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youth said sick calls are conducted by a nurse or doctor. Nine staff were interviewed, and all
said nurses review sick call requests and conduct 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 facility operating procedures (FOPs) requiring a comprehensive process for the
provision of episodic and first-aid care. Nine youth Individual Healthcare Records (IHCRs) were
reviewed, and four were applicable for having an on-site episodic or first-aid event. All episodic
care events were conducted by a registered nurse (RN) and documented in the problem-
oriented subjective, objective, assessment, and plan (SOAP) format. All contained the nature of
the complaint, findings of person rendering care, treatment rendered, education or instruction to
the youth, and plans for follow-up or future care. None required off-site care, and none were
required to be placed on an alert list. Three required parental notification, and the remaining
youth was over eighteen years of age; therefore, did not require parental notification. All had an
entry documented in the Episodic Care Log. The center has seventeen first-aid kits located in
the housing modules, kitchen, master control, administration, intake, and transport vehicles.
Three random first-aid kits were checked, and all were fully stocked with the designated health
authority (DHA) approved contents. First-aid kits are inventoried monthly and replenished as
needed by nursing staff. In addition, if a first-aid kit is used, medical is notified, and the first-aid
kit is replenished and resealed. The center provided documentation which confirmed the first-aid
kits are checked and inventoried monthly. The center has three automated external defibrillators
(AEDs), which are stored in master control, the clinic, and in the B4 module. All AEDs contain a
copy of the procedures. On-site nursing staff check the AED pads and batteries monthly. The
AEDs are checked annually by an outside provider and were last checked on September 10,
2025. Observations of the three AEDs during the tour confirmed they were functioning
appropriately. Each of the three AED batteries expires on September 28, 2026, and the pads on
January 28, 2028. The batteries were changed on August 19, 2022, and the pads were changed
on September 10, 2025. A review was conducted of the emergency medical drills from the time
of the last annual compliance review, which confirmed each drill 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. Announced and unannounced medical drills were
conducted monthly on each shift. The center tried to ensure staff can participate in at least one
emergency drill annually. A review of video footage for one medical drill indicated the drill was
visible on camera and was simulated. A list of emergency numbers was posted in the clinic,
accessible to staff and inaccessible to youth. A review of documentation indicated select
authorized direct care staff were trained on the administration of the epinephrine auto-injector by
a RN. A review of nine in-service and nine pre-service staff training records indicated they all
received training regarding episodic, first-aid, and CPR. The center has a policy and procedures
regarding access, use, and inventory of Narcan. Medical staff conduct a perpetual and monthly
inventory of Narcan, which is stored in the locked medication cart. The nurse was interviewed
and confirmed the location of all first-aid kits. The nurse said when on-site episodic care is
provided by a licensed healthcare professional, documentation should be in SOAP note form.
When care is provided by non-licensed staff, documentation of the care provided is completed
by utilizing the Report of On-Site Health Care by Non-Health Care Staff. The nurse also said if
youth are sent off-site for care, this is documented in the Off-Site and Episodic Care logs. The
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nurse went on to confirm nursing staff check all AED pads and batteries monthly. The AEDs are
in the medical clinic, master control, and module B4 B. Furthermore, the AED procedures are in
the medical clinic. A list of emergency telephone numbers is in the medical clinic and master
control and are inaccessible to youth. Emergency drills are conducted monthly on each shift.
Nine staff were interviewed, and all said they could call 9-1-1- if needed. Nine youth were
interviewed, and six said they rated healthcare good at the center. Two said it was very good,
and one said they did not need healthcare at the center.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures (FOPs) which require they complete timely referrals
and coordination of medical services to an off-site healthcare provider. A review of nine youth
Individual Healthcare Records (IHCRs) revealed four required off-site care. The Summary of
Off-Site Care Consultation Report form was filed in each IHCR. All the off-site care referrals
were documented on the Episodic Care Log. The parental/guardian notification efforts were
documented in two IHCRs, and the remaining two were not required because both youth were
over the age of eighteen. Discharge and other applicable documents were filed in each IHCR.
The designated health authority (DHA) reviewed and signed all off-site care findings,
instructions, and information. The nurse was interviewed and said all off-site referrals are
documented on the Episodic Care and the Off-Site Care Logs. The nurse also said hospital
orders are reviewed by the receiving nurse when a youth returns to the center, and all orders
are also reviewed and signed by the DHA. The nurse also advised lab requisitions and radiology
testing are tracked using an on-line portal. Youth referrals and appointments are tracked using
an appointment calendar and by email to arrange transportation.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures (FOPs) to ensure youth who have chronic
conditions receive regularly scheduled evaluations and follow-up, if necessary. Four of nine
reviewed youth Individual Healthcare Records (IHCRs) were applicable for chronic
conditions. Each of the applicable IHCRs had the chronic conditions documented on the
Department’s Medical/Mental Health Screening form. None of the youth had a communicable
disease and none were taking prescribed medication on an on-going basis for any reason. One
of the four applicable youth was undergoing treatment for a physical health condition. All the
youth had an appropriate Medical Grade of two through five, and all were placed on the center’s
chronic conditions list. One youth was applicable for a ninety-day periodic evaluation, and it was
completed timely, and the progress notes were reviewed for documentation of the completed
periodic evaluation. All periodic evaluations are tracked using the Chronic Physical Health
Conditions Roster. None of the youth were pregnant or taking anti-tuberculosis medication at
the time of the annual compliance review. The Department’s Problem List was updated as
required for each youth. The designated health authority (DHA) was interviewed and advised
youth who have chronic medical issues and are at the center over ninety days receive a periodic
evaluation within ninety days. The clinic manager assists in keeping track of who needs to be
seen and when they are scheduled. The DHA said the clinic manager provides weekly updates
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as to any new youth with chronic conditions, and any youth who are approaching a ninety-day
evaluation. The nurse was interviewed, and said youth with chronic medical conditions are seen
by the DHA every ninety-days and the DHA follow-ups are managed using the Physician List.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures (FOPs) which require medication to be received,
stored, inventoried, and provided in a safe, effective manner. Nine youth Individual Healthcare
Records (IHCRs) were reviewed, and five indicated youth were taking
medication at the time of admission. All medications were verified prior to being
admitted into the center and documented on the chronological progress notes and the
Department’s Medication Receipt Transfer Disposition form. In the five applicable IHCRs, the
designated health authority (DHA) and, the psychiatrist, as applicable, were contacted to
obtain the order to resume the specified medications. All medications had a current, valid order
and were administered pursuant to a current prescription. The DHA placed an order on a
Practitioner Order Form for any current medications which were continued, discontinued,
changed, or new ones ordered. No youth were in restricted housing; therefore, nursing staff did
not have to complete daily visits and other required services and documentation. Over the
counter (OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form
were administered according to approved protocols. The Department Medication Administration
Record (MAR) was used to document all medication and treatment, including start and stop
dates for the five applicable youth. No medication administration was conducted by non-
healthcare staff and there were no lapses or errors in medication administration. None of the
youth had any refusals for receiving medication. Nursing staff documented side effect
monitoring each week on each MAR. Each MAR included youth name, Department
Identification Number (DJJID), date of birth, youth allergies, precautions, Medical Grade, and
medical alerts. Each MAR also contained a picture of the youth. A nurse and youth initialed
each medication administration entry. No youth required parenteral medication. The center did
not have any standing orders, emergency treatment orders, or pro re nata (PRN) orders for
psychotropic medications. An observation of medication administration for one youth was
observed during the annual compliance review. The youth was individually escorted to the clinic
by a juvenile justice detention officer (JJDO). The nurse identified themselves and stated why
the youth was in the clinic. The same nurse prepared and administered the medication. The
nurse verified the youth’s allergy and alert status, and both the youth and nurse initialed the
MAR. The nurse observed the youth to ensure the medication was swallowed. The nurse was
interviewed and verified the process for nursing staff to verify a youth’s medication when a youth
is admitted with medications and described the nursing protocol for non-medical staff to verify
medication upon admission. The nurse said nurses verify youth medications using the
Medication Receipt, Transfer, and Disposition Discharge Form, contact with the prescribing
pharmacy or physicians’ office, and parental/guardian contacts. All medications are verified
against the form to ensure the right medication, dosage, and amounts are correct. The nurse
also explained there is a training curriculum utilized by the non-licensed healthcare staff to
administer medications in the absence of a nurse. The clinic manager provides training to
supervisory non-healthcare staff. The list of non-healthcare staff who are approved to administer
medications is listed in the medical clinic. The nurse was able to provide the dates and times
when medication pass is administered. The nurse described the medication procurement
process as the prescribing physician writes an order which is then provided to the contracted
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pharmacy. The pharmacy mails the medications to the center. The medication is verified by
nursing staff before administering it to a youth. The center also has a backup pharmacy in the
event a medication is needed immediately. The center does utilize a psychiatrist who comes on-
site and is on call twenty-four hours a day and seven days a week. The psychiatrist prescribes
new and continues medication orders for youth on psychotropic medications. All youth are seen
for an initial comprehensive evaluation within fourteen days of admission. Medication
management is provided every thirty days for youth on psychotropic medications. Nine staff
were interviewed, and all said they do not give medication to youth. Nine youth were
interviewed, and seven said nurses give medication, while two said they do not take medication.
4.16 Psychiatric Services [Contract Provider] 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) governing psychiatric services. The
center’s psychiatric services are provided by a physician licensed pursuant to Chapter 458 or
459, Florida Statute, who is board certified in Child and Adolescent Psychiatry. The psychiatrist
has an active and clear license, with an expiration date of January 31, 2026. The center has a
backup psychiatrist, with equal education to the psychiatrist, who also has an active and clear
license, with an expiration date of March 31, 2026. The designated mental health clinician
authority (DMHCA) was interviewed and advised they meet weekly with the psychiatrist to
discuss youth receiving psychiatric services. Nine youth Individual Healthcare Records (IHCRs)
were reviewed, and three were applicable for entering the center on psychotropic medication.
All were referred for a psychiatric interview and an initial diagnostic interview which was
completed within fourteen days of admission to the center. The diagnostic psychiatric interview
included the reason for referral, history, mental status examination, Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, treatment recommendations,
prescribed medication, the name of the medication, the need for psychotropic medication, and
the frequency of medication monitoring. The in-depth diagnostic interviews were all conducted
within thirty days of admission and included the stated reasons and factors leading to the
referral, developmental history, history of psychiatric illness, mental status examination,
individual, family, or environmental factors, DSM-5 diagnosis, treatment recommendations,
prescribed medications, and the most recent therapeutic serum drug levels. Clinical
Psychotropic Progress Notes (CPPN) were completed for each youth. Each youth had
psychotropic medication administered. The administration of medication included identifying
data for each youth, diagnosis, target symptoms for each medication, side effects, youth
adherence to the medication regimen, vitals for each youth, and signatures of the psychiatrist.
Consent for psychotropic medication was obtained for one youth. The remaining two youth were
over the age of eighteen and did not require parental consent.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center has facility operating procedures (FOPs) requiring any medical equipment and stock
medications to be secured and inventoried. During a visual tour of the center’s medical
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department, medical equipment classified as sharps was secured and inventoried utilizing a
routine perpetual inventory descending count as each sharp was utilized and disposed. The
medication cart was clean and organized with stock items separate from youth-specific
medications, and all controlled substances also had a perpetual inventory and were stored
behind two locks, separately from other medications. At the time of the annual compliance
review, the center did not have any youth taking oral medications. The center’s medical
department has a dedicated refrigerator for the storage of medications which require
refrigeration. Documentation was provided which confirmed the center conducts perpetual and
weekly inventories of all sharps and stock over the counter (OTC) medications. Documentation
also confirmed a shift-to-shift inventory was conducted for all controlled substances and
documented on each youth’s individualized Controlled Medication Inventory Record.
Supervisory non-healthcare staff are trained in the oversight of medication self-administration.
This training is delivered by a registered nurse (RN), and an annual refresher is provided to
these staff. Three controlled medications, three OTC medications, and three sharps were
reviewed and compared with the inventories. All inventories matched the number of medications
and items reviewed, with no discrepancies. In the event of an inventory discrepancy, the nurse
advised a recount is conducted of the item in question, then a search will be conducted of the
area. If the discrepancy is not resolved, the superintendent is notified, as well as the pharmacist
in the event it is missing medication. Controlled medications are disposed between nurses and
the pharmacy consultant. Other medications are disposed of between nurses. The pharmacist is
on-site monthly and will dispose and destroy medication. The nurse was interviewed and
advised any unused medications are either returned to the pharmacy for credit or destroyed
using medication destroyer solution. Destroyed medications are documented on the medication
disposal log and are signed, dated, and witnessed. Controlled medications are secured in a
double locking system. The medications are secured in the lock box within the medication cart.
A separate key is utilized to open the lock box. The center has an agreement with a consulting
pharmacist who conducts site visits monthly to check the medication cart and re-stock the
medication cabinet, removing any medications with expiration dates, monitoring controlled
medications, reviewing the destruction log, and reviewing medication administration records
(MAR). The pharmacist also conducts temperature checks for the refrigerator used to store
refrigerated medications. The center maintains a copy of the pharmacy license on-site which is
a Consultant Pharmacy license.
4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures (FOPs) which require the implementation of
infection control procedures. These procedures include prevention, containment, treatment, and
reporting requirements related to infectious diseases, as according to the Occupational Safety
Health Administration (OSHA) federal regulations and the Centers for Disease Control (CDC)
and Prevention guidelines. The plan includes pre-service and in-service training for all staff, in
addition to training for youth on infection control. Nine youth Individual Healthcare Records
(IHCRs) were reviewed, and all had documentation which confirmed each youth received
infection control training within seven days of admission. Training included hand washing
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techniques, universal precautions, prevention of communicable diseases, vaccinations, and
CDC guidelines for infection control. The center’s exposure plan was reviewed and was found to
be in accordance with OSHA guidelines, which included risk assessments and methods of
compliance. The infection control procedures include common, infectious diseases of childhood,
episodic contagious illnesses, viral or bacterial infectious diseases, tuberculosis (TB), Hepatitis
A, B, and C, human immunodeficiency virus (HIV), infectious diseases caused by bloodborne
pathogens, other outbreaks or epidemics caused by any other infectious agent, outbreaks of
pediculosis and/or scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and other
antibiotic-resistant micro-organisms, foodborne illnesses, bio-terrorist agents, and chemical
exposures in the workplace. The center has a process for needle stick post-exposure. If staff
incur a needle-stick, it must be reported to a juvenile justice detention officer supervisor
(JJDOS). The staff is offered post-exposure evaluation and follow up in accordance with OSHA
standards. The staff will be referred to a nearby provider for post exposure evaluation and/or
post exposure prophylaxis, using the worker's compensation process. The staff will be provided
with appropriate counseling concerning precautions to take during the period after exposure
incident. The center makes Hepatitis B immunization available for staff, and staff have access to
protective equipment. The center did not have any instances in which infectious diseases and
sexually transmitted infections (STIs) were reported to the local health department, nor did they
have instances in which incidents reported to the local health department needed to be reported
to the Department’s Central Communications Center (CCC). The center also did not have three
or more cases of any reportable infectious diseases for which the local health department
and/or CDC had to be notified. The center did not have any youth or staff who had experienced
occupational exposure since the last annual compliance review. A review of nine pre-service
and nine in-service staff training records indicated all staff completed training on the center’s
specific exposure control plan. The nurse was interviewed and said a copy of the Exposure
Control Plan is in the medical clinic and provided it to the team during the annual compliance
review. The nurse confirmed infection control training is provided to youth by nursing staff during
admission, as well as providing training to staff on the center’s exposure control plan. The nurse
also indicated the county health department is routinely used for dental and prenatal services.
4.19 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures (FOPs) requiring they provide access to prenatal
care for all pregnant youth, in addition to providing health education to both youth and staff.
Nine youth Individual Healthcare Records (IHCRs) were reviewed, and one was applicable for
prenatal care/education. The center provided two additional applicable IHCRs for review of
youth who were at the center during the annual compliance review period. A review of the three
applicable IHCRs revealed each youth received prenatal care immediately upon determination
of pregnancy, which continued until the youth was discharged. The designated health authority
(DHA) provided routine, focused medical evaluations of each youth’s pregnancy every thirty
days at a minimum. Each youth was placed on the Department’s Juvenile Justice Information
System (JJIS) alert system for vital nutrition, health awareness, and sleeping arrangements.
None of the youth complained about issues related to pregnancy while they were at the center.
Each IHCR contained documentation which confirmed each youth received education related to
pregnancy including alcohol and drug use, smoking, nutrition, sexually transmitted diseases
(STDs), contraception, prenatal care, birthing process, postpartum care, basic baby care, child
development, and parenting skills. Each youth received nutritious food in quantities appropriate
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for pregnant youth. Nursing staff provided routine monitoring of nutritional and weight status for
each youth while at the center. All required topics were documented on the Health Education
Form. A review of nine in-service and nine pre-service staff training records was conducted and
confirmed all non-healthcare staff involved in the supervision or treatment of youth have
received training on youth prenatal healthcare, which includes observation and monitoring of
emergency care needs and symptoms of possible miscarriage. The center’s nursing protocols
include treatment plans for pregnant youth. The nurse was interviewed and said the center
provides off-site gynecological appointments, nutritional support, prenatal vitamins, daily
observations for complications, weekly weight checks, a double mat for sleeping, mental health
services, and aftercare planning for pregnant youth. The nurse further advised a urine
pregnancy test is completed for all female youth upon admission, regardless of reported
participation in sexual activity. The nurse confirmed the DHA provides a routine, focused
medical oversight evaluation of each youth's pregnancy every thirty days until the eighth month
of pregnancy, every two weeks in the eighth month, and weekly thereafter. The nurse also said
pregnant youth are provided with a special diet. Nine youth were interviewed and asked if they
received prenatal, obstetrical, or gynecological services when needed at the center. One said
yes, one said no, and seven said it wasn't needed.
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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 (FOPs) governing the supervision of youth. The
FOPs require staff to be constantly aware of the location of youth assigned to their supervision.
Observations of staff supervising youth were conducted each day of the annual compliance
review. Staff were observed actively supervising youth in the housing modules while engaged in
indoor activities, on the recreation field while youth were involved in outdoor activities, in the dining
hall during lunch, and while being escorted to and from each location. Staff were randomly
questioned regarding the number of youth they were supervising, and all staff were aware of the
total number of youth under their supervision, the breakdown of how many youth were currently
being supervised, and the location of the remaining youth. Positive interactions between staff and
youth were observed each day of the annual compliance review, and supervision was appropriate
each day of the annual compliance review with staff stationed strategically to properly supervise
all youth. During the annual compliance review, all movements were heard announced and
authorized by master control. These announcements included the housing module, number of
youth being moved, the location of transition, and a conclusion of the movement. Nine staff were
interviewed and each stated they believe there are enough staff to provide for the safety and
security of youth and staff at the center.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
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The center has facility operating procedures (FOPs) which require the center to establish a
behavior management system (BMS). The BMS offers rewards and privileges for good
behavior, and consequences for negative behavior. These are designed to motivate youth to
meet and exceed the center’s expectations. Postings of the BMS were observed in all living
areas, the dining hall, and in all common areas where youth are. The postings specified
appropriate and inappropriate behaviors, rules, and expectations. A review was conducted of
youth point cards which confirmed youth are receiving their rewards for good behavior and are
also held accountable for any negative behavior. All rewards and consequences observed were
in accordance with the BMS postings. A review of documentation verified the center prohibits
the use of group punishment and there were no instances of inappropriate use of restrictions or
group punishment displayed during the annual compliance review period. Nine staff members
were interviewed and asked about the BMS system. Each of the nine staff stated youth are
given canteen, extra phone calls, and are able to go to the art room as a reward for good
behavior Each staff indicated they believe the centers BMS is effective. All nine interviewed staff
were able to explain the center’s BMS. All nine staff indicated the center’s BMS is a level
system, is posted throughout the center, and is included in the youth handbook. Nine staff
stated they all speak with youth to discuss the consequences being imposed. Each of the staff
stated youth are given the opportunity to explain their behavior and they speak with youth about
alternative behaviors. Nine staff were asked to explain how supervisory staff provide feedback
to staff regarding the implementation of the BMS. Seven of the nine staff stated supervisory staff
conduct formal and informal coaching to help them understand the BMS. The remaining two
staff stated supervisory staff will talk to staff on the side before dropping a level. Each of the
nine staff stated staff receive feedback on implementation of the BMS from informal and formal
coaching from shift supervisors, during their daily debriefing, and supervisors will also train staff.
Each of the nine staff stated levels can be taken away as a consequence. One staff stated a
snack can be taken away and another staff stated points can be taken away as a consequence;
however, each of the nine staff stated they have never seen a coworker take meals, snacks,
clothing, education, or medical care from a youth because they were acting out. Each of the
nine staff stated they never observed staff encouraging youth to beat up another youth. Nine
youth were interviewed about the center’s BMS, and seven youth stated the BMS is good. One
youth stated it was fair, and the remaining youth stated it was very good. Each youth was able
to explain the difference between each level in the BMS system. Each youth stated the BMS
consists of three levels. Eight of the youth stated they move up a level for good behavior and
the one remaining youth was new to the center. All nine youth also stated they can receive extra
telephone calls and canteen for good behavior and receive more incentives and an art program
when they are rewarded in the center for good behavior. Each youth stated all staff use rewards
the same and youth are never allowed to punish other youth. Each youth stated they have never
been sent to their room for punishment. Seven youth stated they felt consequences were fair
when received and the remaining two youth stated they never received consequences. Five
youth stated nothing was taken from them when consequences were given. Two youth stated
their levels were taken away and the remaining youth never received consequences. Two youth
stated the center does not use leg irons or handcuffs to prevent youth from harming themselves
and the remaining seven youth stated they have never witnessed this. The superintendent was
interviewed and stated the BMS is a three-level system which rewards positive behavior.
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5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures (FOPs) requiring staff to visually check on youth at
least every ten minutes while they are in their rooms for any reason. The center has a total of
190 cameras, and at the time of the annual compliance review, all were operational. The center
currently has two shifts, 7:00 a.m. to 7:00 p.m., and 7:00 p.m. to 7:00 a.m. Video recordings are
stored for thirty days. The center had a deficiency for ten-minute checks which was recently
closed on June 6, 2025. A review of ten-minute check logs for thirty-minute increments from
each shift and each housing module each month from July 2025 through December 2025 was
conducted and compared with the ten-minute check wand reports. Out of a total of seventy-two
reviewed checks, all but six were completed within ten minutes, with all six being between one
and two minutes late. A video review of thirty-minute increments for three random days for a
total of forty-three ten-minute checks was conducted; on December 3, 2025, on B1 module, one
ten-minute check was missed, and on December 9, 2025, one ten-minute check on G1 module
was one minute late. Nine staff were interviewed and each stated each check is completed
every ten minutes while youth are in their room for sleeping purposes. The superintendent was
interviewed and stated the ten-minute check process occurs when a youth is placed behind a
door, and juvenile justice detention officers (JJDO) are to conduct ten-minute visual checks to
maintain supervision of each youth.
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) which require staff to always know the
exact number and location of all youth under their supervision. A security count was observed
during the annual compliance review week when all youth arrived at their classrooms. An
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informal count was called by master control. When the count was conducted, all eight staff
assigned to supervise youth in each of the three classrooms counted each youth and verified
the total count with each other before calling in the count to master control. Staff were aware of
the total number of youth assigned to them, and the actual number of youth present. Master
control verified the location of all youth with all staff supervising youth. A review of logbooks for
one full day from each month during the annual compliance review period was conducted.
Counts were consistently conducted at the beginning and end of each shift, prior to and
following group movement, anytime a population change occurred, and randomly at least once
on each shift. A total of nine code blues were noted on the reviewed logbook entries, with a
count being conducted after each of the nine codes. Nine staff were interviewed and were able
to explain counts are conducted before and after every movement. Staff will stop all movement
if a count is incorrect. Furthermore, emergency counts are conducted when a youth is believed
to be missing, there is an electrical outage, or major disturbance.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) governing logbooks. The center maintains
logbooks in master control, each module, and for each transport vehicle. A review of logbooks
for one day each month since the last annual compliance review revealed logbooks were bound
with numbered pages and displayed the date at the top of each page. All entries had the times
of the events displayed in a.m./p.m., the name of the staff and youth involved, a brief description
of the event, and the initials of the staff who made the entry. Any entry impacting the safety and
security of the center was highlighted. Any errors were struck through with a single line, had
void written after the error, and included the staff’s initials. Logbook reviews included the
superintendent’s weekly review, juvenile justice detention officer supervisor (JJDOS) reviews
when assuming center responsibility, daily JJDOS reviews of logbooks maintained in each living
area, juvenile justice detention officer (JJDO) reviews of each living area logbook when
beginning their shift, and superintendent, assistant superintendent, or JJDOS reviews during
their daily tour of each living area. The superintendent was interviewed and stated logbooks are
to be reviewed by management while conducting weekly safety and security inspections of the
facility, notations are logged in each logbook as well as the master control logbook. A review of
master control logbooks for one full day each month during the annual compliance review period
was conducted which confirmed all emergency situations, incidents, drills, receipt of medication
and mental healthcare, population counts at the beginning and end of each shift, counts, group
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movements, admissions and releases, presence of law enforcement, searches, and youth on
precautionary or suicide observation with the beginning and ending times were consistently
documented.
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) requiring the center to be responsible for
maintaining inventory and control of all center keys. The FOP includes key assignments, usage,
restrictions on usage, inventory and daily tracking of keys, secure storage of keys, procedures
to follow when keys are missing or lost, and the reporting and replacement of lost or damaged
keys. A review of the key storage area revealed master control has a locked key box where
keys are maintained, along with a lock box in the juvenile justice detention officer supervisor
(JJDOS) office and superintendent office. An inspection of each area was conducted during the
annual compliance review, and each key box was found to be secured. An observation was
conducted of staff arriving and departing the center. Staff were observed turning in personal
keys and receiving a tag so they could retrieve their personal keys at the end of their workday.
This was also the case with the annual compliance review team for each day of the review.
Restricted keys are only issued to approved staff from each department. The key box contains a
list of staff authorized to check out a particular key ring. Each staff must turn in their personal
keys to retrieve a facility key ring. Emergency key rings are in the superintendent's office and
only the superintendent and assistant superintendents are authorized to access them. The
master key inventory was reviewed and included each key ring number, number of keys on
each ring, which lock each key accessed, and who each key ring was issued to. All facility key
rings contained a color-coded marker which coincided with each department. Documentation of
each key issuance included the date and time of issue, name of staff issuing the key ring, name
of staff who the key ring was issued to, and the time the key ring was returned. The issuance of
keys and key rings was documented on each shift report. Staff carrying keys were observed to
always carry their keys on their person and in their pockets. Staff did not allow youth to handle
facility keys. Keys are not allowed to be removed from the facility without prior authorization
from the superintendent. During the annual compliance review, the key box was found to be
secured in an area which is not easily accessible. During the annual compliance review period,
there were no incidents reported to the Department’s Central Communications Center (CCC)
related to key control concerns. A sample of five key rings was observed and compared to the
inventory and key log. All key rings matched the key ring inventory. Three staff were informally
interviewed about the number of keys on their key rings and the function of each key, and all
were aware of how many keys were on their key rings and which doors each key accessed. An
informal interview was conducted with the assistant superintendent, who advised keys are only
issued to authorized staff. Nine staff were interviewed and stated restricted keys consist of
medical records, youth property area, mental health records, case management records, and
the kitchen area. Each staff was able to articulate staff keys are given to master control,
personal keys are securely stored, visitor keys are given to master control upon entry, a chit or
token is provided to visitors, daily tracking of keys, facility keys assigned to staff, inventory of
keys, youth do not have access to keys, the facility is searched for missing keys, youth are
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searched for missing keys, and keys are replaced for any damages. An interview was
conducted with the superintendent, who stated all staff keys are kept in the lock box in the
JJDOS office. The interview also indicated staff are assigned keys during briefing by a JJDOS.
Mental health, medical, kitchen, and education staff keys are maintained by master control and
are signed in and out on the key log and kept in the key book located in master control.
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 (FOPs) designed to ensure any vehicle used by the
center to transport youth is properly maintained, and the center is required to maintain
documentation on the use and maintenance of each vehicle. During the annual compliance
review, center staff advised they had eight transport vehicles. Documentation reviewed
indicated each of the eight transport vehicles underwent an annual vehicle inspection by a
certified mechanic as required from the time of the last annual compliance review. A review of
documentation revealed maintenance staff conducted monthly visual checks of all transport
vehicles. These monthly checks include tires, battery, and windshield wipers. All transport
vehicles were found to have the appropriate number of functioning seat belts, a seatbelt
cutter/window punch tool, and a current fire extinguisher. The center has first-aid kits for each
transport vehicle, which are stored in the intake office, and are checked out whenever staff go
on a transport. Each transport vehicle has a corresponding logbook. Each logbook was
reviewed, and each entry contained an acknowledgement the vehicle was checked for
contraband and required equipment prior to and after the transport, the destination of the
transport, number of youth and staff names, name of the juvenile justice detention officer
(JJDO) riding in the back of the van, and the time the transport began and ended. A transport
was observed during the annual compliance review. Transport staff were observed to inspect
the vehicle for contraband, ensure the vehicle had sufficient fuel, verify the equipment, to
include seatbelts, were present and functioning, ensure they had the proper documentation and
logs for the transport, ensure they had a cellular telephone for the transport, and document the
vehicle inspection in the logbook before they departed the facility. Transportation staff
conducted searches of youth prior to youth being placed in the vehicle, and ensured youth were
secured with a seatbelt prior to departing. All eight vehicles were inspected and confirmed all
were locked when not in use. Nine youth were interviewed and each youth stated they have
never seen anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures (FOPs) which require they ensure all tools and
equipment used for maintenance and in the kitchen are properly maintained and accounted for.
The center’s tool FOP requires all tools to be stored on a shadow board, in a secure area,
accurately identified, numbered, and inventoried. All tools must be checked in and out as they
are used and returned, and this shall be noted on a tool checkout form. Knives are to be
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secured in a separate locked box. An observation was conducted of the tool room and kitchen
area where tools are stored. All tools were properly stored and there were no tools missing.
Documentation confirmed kitchen staff conducted an itemized inventory of all equipment,
including knives, upon reporting for duty. During an informal interview, the assistant
superintendent confirmed all service vendors were accompanied by center staff when they were
in a secure area of the center. The assistant superintendent also advised if a tool is lost or
missing, the facility is locked down, and a search is conducted to find the tool. If a tool is lost or
damaged, a report is submitted, and a replacement tool is ordered. Once a replacement tool
arrives, it is marked and added back to the active inventory. Youth do not use tools to include
kitchen and medical equipment. Youth are allowed to use cleaning items such as mops,
brooms, and other common household items, under direct staff supervision. A random sample
of ten tools from the center’s inventory was conducted. All ten tools were secured, had a
marking which was easily identifiable, the inventory was accurate, and signed by the
superintendent or designee. Nine youth were interviewed and seven youth stated they can use
mops and broom while being supervised by staff and the remaining two youth stated they do not
use any tools. Nine staff were interviewed and asked about the center’s process for damaged or
missing tools. All nine staff stated they would notify the on-duty juvenile justice detention officer
supervisor (JJDOS), conduct a search, and document it in the logbook. One staff stated they
notify maintenance staff as well. Eight staff stated all youth can use mops and brooms while
staff are supervising them and the remaining staff stated youth are not allowed to use any tools.
The superintendent was interviewed and stated JJDOSs, assistant superintendents, and
superintendents are the only staff who have 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.
The center has facility operating procedures (FOPs), which name the superintendent as the
person responsible for the implementation of a safety plan addressing proper use, storage, and
disposal of chemicals, including flammable, toxic, caustic, and poisonous items. A review was
conducted of the center’s Safety Plan which requires flammable, toxic, caustic, and poisonous
items to be maintained in a shed with limited staff access and no youth access. Safety Data
Sheet (SDS) must be located where any chemicals are stored. During an observation of the
flammable, toxic, caustic, and poisonous storage area, five random flammable, toxic, caustic,
and poisonous items were inspected. All items were properly inventoried and stored with the
appropriate SDS sheet for each item. This area is restricted to authorized personnel, and in an
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area inaccessible to youth. Nine youth were interviewed and five youth stated they do not use
any type of cleaning agent such as bleach, laundry soap, window, or toilet cleaner. Four youth
stated staff can control the spraying of chemicals and then youth are able to clean in front of
staff. Each of the nine-youth stated they do not have access to flammable, toxic, caustic, and
poisonous items. Nine staff were interviewed and each of the nine staff stated youth are not
allowed to clean with substances which are toxic, flammable or poisonous items.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) which designate the maintenance staff as
the person responsible for diluting, handling, and disposing of hazardous items and toxic
materials in accordance with Occupational Safety and Health Administration (OSHA) standards.
From the time of the last annual compliance review, there have been no instances of a chemical
spill or the need to dispose of any flammable, toxic, caustic, or poisonous items. During an
informal interview with the center's assistant superintendent, it was stated the center uses a
vendor monthly to remove kitchen grease from the appropriate storage area. The assistant
superintendent also advised any flammable, toxic, caustic, and poisonous items are either used,
or a vendor is called to come pick them up from the facility to be disposed of should the need
arise of such items.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains facility operating procedures (FOPs) which govern the requirements for
behavioral confinement for less than twenty-four hours. The center had 504 instances of youth
placed in confinement for less than twenty-four hours since the time of the last annual
compliance review. All confinements are documented in the Department’s Facility Management
System (FMS). A sample size of fifteen confinements under twenty-four hours were reviewed.
Documentation confirmed all fifteen youth had access to mental healthcare as
requested/needed, and all received notice of their right to grieve a confinement placement. All
were provided with three meals a day, plus snacks, as required depending on the amount of
time they were in confinement. Each youth was applicable for being afforded a daily shower,
based on the time they were placed on and released from confinement. Thirteen youth were
applicable for needing education materials based on the time they were placed on and released
from confinement, and each received educational materials. All confinements were approved by
a juvenile justice detention officer supervisor (JJDOS) prior to the youth being placed in
confinement, and only one youth at a time was placed in a confinement room at any given time.
Documentation confirmed each room was searched prior to placing a youth in confinement.
Each of the fifteen reviewed youth for confinement under twenty-four hours contained a Visual
Observation Report (VOR) which documented visual supervision at a minimum of every five
minutes for the first hour in confinement. None of the fifteen youth were applicable for having a
physical injury; therefore, assessments and treatment were not needed. All fifteen youth were
explained the reason for confinement, as documented on the VORs. A JJDOS conducted an
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initial confinement review for all youth within one hour of each incident occurring, and thirteen
confinement reports were completed in full before the end of the shift, and two were not. FMS
contained documentation which a JJDOS conducted additional reviews at a minimum of every
three hours for any youth remaining in confinement longer than three hours. None of the
confinements interfered with visitation; therefore, notifications for potential visitors were not
needed. Fourteen confinement reports were reviewed by the superintendent within forty-eight
hours, and one was six days late. The superintendent was interviewed and stated confinements
are tracked in FMS, and youth confinements are reviewed by a JJDOS every two hours and
reviewed by administration once each confinement has ended. Regional detention management
reviews the use of confinement, lockdown, and restraints monthly. Nine staff were interviewed
and asked to explain the center’s step by step process for placing youth in confinement. Nine
staff stated confinement rooms are searched, and ten-minute checks are conducted every ten
minutes; however, five-minute checks are conducted for the first hour. Each staff stated all
youth are given education material if they are in confinement during education hours. During a
tour of the facility, windows and doors to youth rooms and cameras were free of obstruction, so
each youth may be visually observed. It was also noted several windows had been scratched
and needed to be replaced, but visual observation of youth is not impeded because of the
scratches.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures (FOPs) in place requiring the establishment of a
Continuity of Operations Plan (COOP) and for COOP drills to be conducted at a minimum of
twice a year. The center conducted two drills from the time of the last annual compliance review.
One was conducted May 7, 2025, and one was conducted August 20, 2025. A review of
documentation determined both drills contained the type of drill, date and time, participants,
brief scenario, findings, and recommendations, as required. The superintendent was
interviewed and stated the COOP is the process for relocation and continued operations of a
facility during an emergency or disaster.
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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) which require the center to develop and
implement an escape prevention plan. The center has an escape prevention plan which
includes the Department’s policies and procedures regarding escapes. In addition, the center is
required to conduct escape drills at least quarterly on each shift. All escape drills were reviewed
since the time of the last annual compliance review. The center conducted monthly escape drills
on each shift, which exceeds the quarterly requirement. A review of nine staff training records
was conducted and revealed all staff were trained in escape prevention annually. A review of
logbooks confirmed the documentation of each drill. Eight of nine interviewed staff stated they
participated in quarterly escape drills, and one did not.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has facility operating procedures (FOPs) requiring the implementation of a disaster
preparedness and fire prevention plan. In addition, the center is required to conduct monthly fire
drills on each shift. The center’s plan was reviewed and approved by a local fire official who also
conducted an annual inspection of all fire extinguishers. A review of fire drill documentation since
the time of the last annual compliance review revealed fire drills were conducted monthly on each
shift. Logbooks were reviewed and each fire drill was properly documented. Nine staff were
interviewed, and each staff said the center conducts fire drills every month on each shift. Nine
youth were interviewed and seven youth stated they have been instructed on what to do in case
of a fire, the remaining two youth stated they have not been instructed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 58
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) designed to stop illegal contraband and
prohibited items from entering the facility. The center shall delineate items and materials
considered to be contraband and provide youth and staff with this list. The center must also have
a FOP on contraband and searches and 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. Any contraband found must be documented, as well as
the confiscation of any illegal contraband and the manner of disposition. The center must
complete an incident report identifying findings for all recovered illegal contraband, notify the
regional director, and report all incidents to the Department’s Central Communications Center
(CCC) within two hours. In all instances involving confiscation of illegal or prohibited contraband,
the center must turn the item over to local law enforcement and a criminal report must be filed.
The center received a deficiency during the annual compliance review period related to search
and contraband procedures. The deficiency was closed on July 25, 2025. A review of the
Department’s Facility Management System (FMS) revealed searches are being documented
electronically. During the annual compliance review week, a transport of one youth was observed,
and staff conducted a thorough pat search. An observation of nineteen youth leaving the dining
hall was observed and staff searched each youth before heading back to the module. Staff wore
gloves during each search and verbalized the search with each youth. Since the time of the last
annual compliance review, there were no reported strip searches, other than during admission.
During the annual compliance review week, members of the review team were subjected to
electronic searches. These were conducted anytime a staff, visitor, or volunteer entered the
secure part of the facility. All personal keys and cellular telephones are prohibited from entering
the secure area of the facility. A review of logbooks for one day each month from the time the
deficiency was closed found room searches are conducted on each awake shift, prior to placing
a youth in a room, and whenever a youth is released. Since the time of the deficiency being
closed, there have been no instances which may have compromised the safety or security of the
center. All visitors entering the facility are required to complete a contraband attestation
statement. A review of nine newly hired staff training records was conducted, and all contained a
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 58
signed contraband attestation. There was one reported instance of contraband entering the center
since the deficiency was closed. The confiscation of the contraband and notification to the CCC
was documented in the logbook. A review of FMS confirmed all incident reports regarding
contraband were entered into the system. Confiscated items were handed to the on-duty juvenile
justice detention officer supervisor (JJDOS). The one contraband incident did not require law
enforcement to be contacted for illegal contraband entering the center, and appropriate
notifications were made. The superintendent was interviewed and stated searches of youth rooms
are conducted daily on each shift and electronic frisk searches are conducted when youth are
introduced to the detention center. The superintendent also stated the CCC is notified, and law
enforcement is contacted if there are any instances of illegal contraband being found. The
superintendent stated all staff and visitors are searched when entering the facility and staff are
searched before every reentry to the secure area of the facility. The center also uses a trained
canine from the Pinellas County Sheriff’s Office to conduct searches throughout the facility.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 58

source: DJJ

report_type: QI Detention

rule: Indicator 1.05

excerpt: Right Interactions (RI)

rating: Limited Compliance

rule: Indicator 2.10

excerpt: Educational Access (Critical)