state: FL

summary: QI Detention - FY23-24 - 6 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Manatee Regional Juvenile Detention Center
"Department of Juvenile Justice"
(State-Operated)
1803 5th Street West
Bradenton, Florida 34205
Review Date(s): March 5 - March 8, 2024
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Kara Brown, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor (Standard
1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Youth
Interviews)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Evan Hald, Office of Education, Southwest Region Education Coordinator (Standard 2)
Melissa Johnson, Office of Accountability and Program Support, Regional Supervisor (Youth
and Staff Interviews)
Jamal Martin, Pinellas Regional Juvenile Detention Center, Assistant Detention Superintendent,
(Standard 5)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Staff Interviews)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Manatee Regional Juvenile Detention Center MQI Program Code: 298
Provider Name: State-Operated Contract Number: State
Location: Manatee County / Circuit 12 Number of Beds: 60
Review Date(s): March 5-8, 2024 Lead Reviewer Code: 184
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
1.08 Grievances 1.05 Protective Action Response (PAR)
3.12 Suicide Prevention Training * 5.03 Ten-Minute Checks*
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * 5.05 Logbook Maintenance
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 61 (Revised July 2023)
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 Protective Action Response (PAR) Failed
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Limited
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 61 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
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 61 (Revised July 2023)
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 Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Limited
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 61 (Revised July 2023)
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 Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 61 (Revised July 2023)
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* Failed
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Failed
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Limited
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 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 61 (Revised July 2023)
Program Overview
The Manatee Regional Juvenile Detention Center is a state-owned detention facility, operated
by the Department, located in Bradenton, Florida. The center serves youth in Manatee,
Sarasota, and DeSoto counties in Circuit 12. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
sixty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Manatee County School Board.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant, seven juvenile justice detention officer (JJDO) supervisors, and
forty-eight JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by one licensed
mental health counselor who serves as the center’s designated mental health clinician authority
(DMHCA), one additional licensed mental health counselor, one psychiatrist, five pro re nata
licensed staff, and one non-licensed staff. Clinical services provided by the center include
mental health and substance abuse evaluations, mental health treatment planning, individual,
group, and family therapy, mental health crisis intervention services, on-site psychiatric
services, and availability for substance abuse services for youth with co-occurring disorders.
Medical services are provided by one medical doctor (MD) who serves as the center’s
designated health authority (DHA), one advanced practice registered nurse (APRN), two full-
time registered nurses (RNs), one part-time RN, and one full time licensed practical nurse
(LPN). The medical clinic maintains nursing coverage seven days a week, from 7:00 a.m. to
7:30 p.m. Monday through Friday, and from 7:00 a.m. to 5:30 p.m. on Saturdays and Sundays.
Food services are provided by Department staff and include menus, meal planning, meal
schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has four living modules which are divided by male and female.
Three living modules were in use at the time of the annual compliance review, two for boys and
one for girls. There are sixty-four security cameras at the center, of which all were operational.
Observations of the facility found the exterior was landscaped and free of debris. The common
day room area, classrooms, and cafeteria were clean and in good repair. Youth and staff
restrooms, each living module, and youth rooms appeared dirty. Debris was located in the sinks
in youth restrooms and a mattress was located in a youth shower. Graffiti was observed in youth
rooms, confinement rooms, the intake room, on doors throughout the facility, and down the
hallway in one of the living modules. Peeling paint and paint splatters on the floor were
observed throughout the facility. The floor in the mental health area was peeling and water was
observed all over the floor in one of the living modules. At the time of the annual compliance
review, the center had twenty vacancies, which included one administrative assistant, one food
service worker, six JJDO Is, ten JDDO IIs, and two JJDO supervisors.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 61 (Revised July 2023)
Strengths and Innovative Approaches
• The center has faith-based volunteers who come into the center six days a week and
provide mentorship, community outreach, and spiritual guidance. The volunteers arrange
for and provide different activities for youth, including holiday parties, games, and arts
and crafts.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 61 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures ensuring a background screening is conducted for
all Department staff, contracted staff, volunteers, mentors, and interns with access to youth and
confidential youth records. The center did not have any contracted grant providers, volunteers,
mentors, or interns who assisted or interacted with youth on an intermittent basis for less than
ten hours a month who did not need to be background screened, as the center conducts
background screenings on all volunteers. The center provided an Annual Affidavit of
Compliance with Level 2 Screening Standards for the center, which was signed by the
superintendent on January 26, 2024, and an Annual Affidavit of Compliance with Level 2
Screening Standards for the school board, which was signed by a school board representative
on January 12, 2024. The center was unable to provide documentation showing the affidavits
were sent to the Department’s Background Screening Unit (BSU) prior to January 31, 2024.The
center indicated the affidavits were sent; however, the BSU was unable to locate the affidavits
and the staff who should have sent them was no longer with the Department. The affidavits
were sent to the BSU on March 6, 2024, during the annual compliance review week. The center
had two new volunteers and fifteen newly hired staff since the last annual compliance review. All
newly hired staff and volunteers had an initial background screening completed prior to contact
with youth or confidential youth records and a criminal history report was reviewed for each.
Each staff and volunteer received an eligible rating; therefore, no exemptions were needed.
Sixteen of seventeen staff and volunteers did not have a break in service as indicated in the
Department’s Staff Verification System (SVS). The remaining staff had a break in service and a
new background screening was completed. A pre-employment assessment tool was
administered to fifteen of the seventeen individuals and a passing score was documented for
each. The remaining two were not applicable for a pre-employment assessment tool, as they
were not direct care staff.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures ensuring all staff, contracted staff, and volunteers
are rescreened every five years. The center had four staff and one contracted staff require a
five-year rescreening since the last annual compliance review. All four Department staff had a
five-year rescreening completed every five years, calculated from their agency hire date. None
of the rescreenings were completed more than twelve months prior to or less than ten days prior
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 61 (Revised July 2023)
to the staff’s five-year anniversary date. The remaining staff was a contracted staff and a five-
year rescreening was completed every five years, calculated from the agency hire date.
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures ensuring all staff adhere to a code of conduct.
Seven staff code of conduct violations during the annual compliance review period were
reviewed. All seven reviewed staff records included a signed code of conduct form which was
signed upon hire. Reviewed documentation indicated management responded to each code of
conduct violation. Four staff received re-training, one staff received a written reprimand, one
staff received a verbal reprimand, and one staff resigned for an unrelated reason prior to
disciplinary action being imposed.
Seven youth were interviewed, and six indicated they have never had to report abuse at the
center. The remaining youth stated they have never been stopped from reporting abuse since
being at the center. All seven youth stated staff are respectful when speaking with them and
other youth. One youth indicated they have never heard staff use profanity with speaking with
them or other youth, one youth stated they have heard staff use profanity once, and five youth
stated they have heard staff use profanity occasionally in general conversation. All seven youth
stated they have never heard staff threaten them or other youth. Each youth stated they feel
safe at the center. All seven youth stated they have never exchanged contact information or
social media contact information with staff. Seven staff were interviewed and all were able to
explain the process for allowing youth and staff to call the Florida Abuse Hotline or the
Department’s Central Communications Center (CCC), if age eighteen or older, to report
suspected abuse. Two staff indicated they have never observed a coworker using profanity
when speaking to youth, three staff indicated they have observed it once, and two staff stated
they have observed it often. Three of the staff who have observed staff using profanity indicated
the staff is no longer at the center, one staff indicated the staff they observed was having a bad
day and talking to themself, and the remaining staff did not provide an explanation. All seven
staff stated they have never observed a coworker using threats, intimidation, or humiliation
when interacting with youth. During an interview, the superintendent confirmed staff must
adhere to a code of conduct which prohibits any form on abuse, profanity, threats, harassment,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 61 (Revised July 2023)
intimidation, or personal relationships with youth. Staff sign the code of conduct at the time of
hire. The superintendent indicated violations of the staff code of conduct result in disciplinary
action up to and including dismissal or criminal prosecution.
The center provided staff commendations for two staff who received commendations during the
past year. One staff received a certificate for perfect attendance, hard work, and dedication, as
well as earning Detention services staff of the month for July 2023. The other staff received a
certificate for heartfelt work and dedication.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures indicating they will notify the Department’s Central
Communications Center (CCC) within two hours of a reportable incident occurring, or within two
hours of becoming aware of the incident. The center had seventy-eight CCC incidents reported
during the annual compliance review period. Seven incidents were reviewed, and six were
reported within two hours of the incident occurring, or the center becoming aware of the
incident. The remaining incident was reported four days late. Five of the incidents were
documented in the center’s logbook, as required. The center was unable to locate the logbook
which included documentation from the date one of the incidents occurred, and the remaining
incident was not documented in the logbook. No additional incidents which should have been
reported to the CCC were discovered during the annual compliance review week. During an
interview, the superintendent stated all staff at the center are aware they are mandated
reporters and must report any incident to the CCC within two hours.
1.05 Protective Action Response (PAR) Failed Compliance
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 PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center has facility operating procedures indicating they must use physical intervention
techniques in accordance with Florida Administrative Code. Anytime a physical intervention
technique is used, a Protective Action Response Right Interactions model (PAR/RI) Incident
Report must be completed. The center had 139 PAR/RI incidents reported during the annual
compliance review period, of which nine were reviewed. Seven of the nine reviewed PAR/RI
Reports were completed by the end of the staff’s workday. One report was completed the day
after the incident, and the remaining report showed a revision had been made, which replaced
the date the report was completed with the date of the revision; therefore, the date the report
was completed was unable to be determined. Seven PAR/RI Reports included statements from
all staff involved. The remaining two reports were each missing statements from one involved
staff. None of the reviewed incidents resulted in serious injuries to the youth or staff or required
a call to the Florida Abuse Hotline of the Department’s Central Communications Center (CCC).
Three of the reviewed PAR/RI Reports were not reviewed by a supervisor or a PAR/RI
instructor. The remaining four PAR/RI Reports were signed indicating a supervisor or PAR/RI
instructor reviewed them. There was no documentation of a post-PAR/RI interview being
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Office of Accountability and Program Support Page 13 of 61 (Revised July 2023)
conducted for six of the nine reviewed incidents. One post-PAR/RI interview was conducted an
hour and forty-seven minutes after the incident, and the remaining two youth both received a
post-PAR/RI incident within thirty minutes of the incident, as required. None of the reviewed
PAR/RI Reports indicated a need for a PAR/RI medical review and mechanical restraints were
not used in any of the incidents. There was no documentation of the superintendent or a
designee reviewing five of the reports. The superintendent or designee reviewed two reports
prior to involved staff completing the reports, and the remaining two reports were reviewed by
the superintendent or designee as required. No additional PAR/RI incidents which were not
documented by a PAR/RI Report were discovered during the annual compliance review week.
The center’s PAR/RI rate during the previous quarter was 7.28, which is below the statewide
Detention PAR/RI rate of 15.17. Seven staff were interviewed, and each stated staff try to talk
with youth prior to using physical restraints. During an interview, the superintendent stated
regional management receives an alert when a confinement or PAR/RI Report is generated,
which allows them to track the use of physical restraints. The superintendent indicated
mechanical restraints are only used for transports outside of the facility. The superintendent
indicated supervisors are required to review and sign all PAR/RI Reports during their shifts and
administrators must review them within forty-eight hours.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures indicating all staff are trained in accordance with
Florida Administrative Code. Pre-service/certification requirements shall be satisfied within 180
days of hire. Seven staff records were reviewed for pre-service training. Each staff completed a
new staff orientation within thirty days of hire. All seven staff completed Phase One of training
and five staff completed Phase Two of training within 180 days of hire. One staff did not require
Phase Two training, as they were not direct care staff. The remaining staff was completing
Phase Two training at the time of the annual compliance review and received an extension for
completing their required pre-service and certification requirements. Each staff’s trainings were
documented in the Department’s Learning Management System (SkillPro), as required.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures in place to ensure all center staff receive twenty-
four hours of in-service training, including mandatory topics specified in Florida Administrative
Code, each calendar year. Seven staff training records were reviewed for in-service training.
Each staff completed at least twenty-four hours of required training in calendar year 2023. Five
staff completed trainings in all mandatory topics throughout the year. One staff completed all
required trainings except for mental health and substance abuse training. The remaining staff
completed all required trainings with the exception of two of the six required hours of suicide
awareness and prevention training. The center only had one supervisory staff applicable for in-
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Office of Accountability and Program Support Page 14 of 61 (Revised July 2023)
service training at the time of the annual compliance review. The one supervisor completed at
least eight additional hours of training in leadership and personal accountability. Each staff’s
trainings were documented in the Department’s Learning Management System (SkillPro), as
required, with the exception of two trainings each for three staff. The center had a list of in-
service trainings which included course names, descriptions, objectives, and training hours for
any instructor-led trainings which was approved by the Department’s regional director on
November 29, 2022. The center maintains an annual in-service training calendar which is
updated as changes occur. During an interview, the superintendent described the management
trainings they have received and confirmed staff are required to complete twenty-four hours of
annual in-service training, with an additional eight hours required for supervisory staff.
1.08 Grievances Limited Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures in place addressing the center’s grievance
procedures. Grievance forms are available to youth on each living module; however, at the time
of the annual compliance review, grievance forms were only located on one of the three living
modules in use. Grievance forms were placed on the other two living modules during the annual
compliance review week. The center had six grievances filed during the annual compliance
review period. Four grievances were responded to, signed, and resolved the same day they
were submitted and the other two were responded to, signed, and resolved the day after they
were submitted. The appeal phase was not necessary for any of the grievances. Three of the
six grievances were not documented in the Department’s Juvenile Justice Information System
(JJIS) Facility Management System (FMS) module; the other three were. Two grievances were
not responded to within the appropriate time frames. Two grievances within phase two where a
supervisor reviews the grievance, documents the action taken, and notifies the youth of the
decision were completed beyond the twenty-four hour requirement, five minutes late for one,
and two hours late for the other. Phase three where the superintendent or designee reviews the
grievance within seventy-two hours, was not completed for either. The remaining four
grievances were responded to within the specified time frames. Seven youth were interviewed
and two stated they are able to ask for a grievance form, three youth stated they have never
used the grievance process, and two youth stated they were not sure about the grievance
process. One youth indicated the grievance process is good and the other six stated they have
never filed a grievance. Seven interviewed staff were able to explain the grievance process.
During an interview, the superintendent stated if a youth requests a grievance, staff will provide
them with a form to complete. The superintendent stated staff, supervisors, and administrators
are required to review each grievance with the youth who fills it out in the different phases and
the youth has the opportunity to appeal. The superintendent indicated the forms are signed by
all involved individuals and uploaded in FMS.
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Office of Accountability and Program Support Page 15 of 61 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures ensuring all critical and special alerts are entered in
the Department’s Juvenile Justice Information System (JJIS), reviewed, and responded to
appropriately. Seven youth records were reviewed for alerts, with a total of thirty-seven alerts. A
review of the center’s logbooks found each applicable alert was documented as required. Each
alert was placed on the alert list on the same day it was entered in JJIS, or when the youth
entered the facility, if the alert was previously placed in JJIS, as the center utilizes the JJIS alert
list as their internal alert system. All alerts matched in JJIS and the internal alert system. A
review of youth records found one youth had one alert which was entered sixteen days late. An
observation of a shift briefing while on-site found alerts were reviewed with staff during shift
briefings. Alert lists are given to the lead staff on each module, who then documents them in the
logbook. Medical and mental health staff are responsible for updating alerts in their areas.
During an interview, the superintendent stated alerts are entered by juvenile justice detention
officers and medical staff based on assessment, observation, and/or information provided by the
youth or parent/guardian. The alerts are reviewed during each shift briefing and dining hall staff
receive a copy of alerts for dietary needs and allergies. Seven staff were interviewed and six
staff stated they are informed of alerts in shift briefings, five staff stated they are informed by
looking in the logbook, two staff indicated they are informed by the alert board, and one staff
each stated they are informed through JJIS and through the alert report. All seven staff
indicated management informs staff about issues within the center during staff debriefings and
meetings. Three staff also stated they are informed through the logbook, one staff said through
alerts, and one staff said they are notified through email. Two staff indicated the process is for
communicating information is fair and five indicated it is good.
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a process in place for including the review and analysis of data in decision-
making practices. The detention center has a quarterly report card based on data pulled from
Tableau and from the Department’s Juvenile Justice Information System (JJIS). An example of
the center’s report card was provided. The regional director will pull reports from JJIS monthly,
including the Department’s Central Communications Center (CCC) reports and Protective
Action Response Right Interactions model (PAR/RI) reports. They will review factors including
staff involved in incidents, the time of day incidents occurred, and youth involved. An email is
then sent to the superintendent which includes the findings and identified issues.
Superintendent meetings are held quarterly, and conference calls are held monthly to discuss
updates. Information is shared with staff and administration monthly through emails, monthly
staff meetings, and regular meetings with the department heads. Regional management staff
attend cross branch calls with residential and probation to share information. Management
meets monthly with probation and with the Juvenile Assessment Centers through a video
meeting held quarterly where this information is shared. These meetings include members from
community providers. The center provided an agenda from a leadership meeting which included
data trend analysis.
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Office of Accountability and Program Support Page 17 of 61 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual 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 his/her
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 in place to ensure proper screening, evaluation,
and documentation of each youth, ensuring all youth are admitted into the center in accordance
with Florida Administrative Code. A review of seven Admission Wizard forms from the
Department’s Juvenile Justice Information System (JJIS) found documentation of a Detention
Risk Assessment Instrument (DRAI), Suicide Risk Screening Instrument (SRSI), and an arrest
affidavit or order to retain the youth in custody for each youth. Reviewed documentation
confirmed all seven youth had a full body visual search and/or electronic search. Each youth
record documented all youth received a telephone call and were evaluated for medical, mental
health, and substance abuse needs upon admission. An observation of a youth admission
process was not able to be completed during the annual compliance review week due to no
youth admission occurring while the annual compliance review team was on-site.
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Office of Accountability and Program Support Page 18 of 61 (Revised July 2023)
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 old 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 to ensure each youth admitted into the center is
informed of the center rules and regulations, grievance procedures, visitation, telephone calls,
expectations for behavior, related consequences for failing to meet behavior expectations, and
youth rights within twenty-four hours of admission. Seven youth case management records
were reviewed, and each included an orientation packet which was completed within twenty-four
hours of admission. All seven reviewed records had documentation to validate the orientation
was explained verbally and in writing by the juvenile justice detention officer (JJDO). Each of the
seven orientation packets included information on rules and regulations, youth rights, dress
code, personal hygiene, visitation, telephone calls, education, daily schedule, mental health,
grievance procedures, access to medical, mental health, and substance abuse services, access
to the Florida Abuse Hotline, access to the Department’s Central Communications Center
(CCC), the behavior expectations, the behavior-related consequences, and Prison Rape
Elimination Act (PREA) related information. Each of the seven reviewed case management
records had an orientation acknowledgement form and handbook cover page signed by the
youth. Seven youth were interviewed regarding the orientation process and three of the seven
youth indicated they had been provided information regarding the center’s rules and regulations,
daily schedule, education services, visitation, abuse reporting, and behavior management
system. Four of the seven youth stated they did not receive information regarding the center’s
rules and regulations, daily schedule, education services, visitation, abuse reporting, and
behavior management system; however, each of the four youth had a signed orientation
acknowledgment form and handbook cover page at admission. An observation of a youth
admission process was not able to be completed during the annual compliance review week
due to no youth admission occurring while the annual compliance review team was on-site.
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Office of Accountability and Program Support Page 19 of 61 (Revised July 2023)
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;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
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 ensuring all youth admitted into the center are
classified to ensure the highest level of safety and security. The center’s policy listed all the
required elements, including human trafficking information. All youth are given a room
assignment based upon their classification and may be reclassified if there are any changes in
their status or behavior. No youth required a reclassification. The center reviews several factors
prior to placing the youth into a room inclusive of height, weight, age, gender, level of
aggression, mental illness, developmental disabilities, physical disabilities, history of violence,
gang affiliation, criminal history, history of sexual offenses, vulnerability to victimization,
identified or suspected suicide risk, medical, and security and escape risk. Youth with a history
of committing sexual offenses, victims of a sexual offense and/or abuse, or youth determined to
be physically or sexually aggressive are not to be placed in a room with any other youth.
Additionally, the policy requires a review of the Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) results documented by staff when making a youth’s room
assignment. All room assignments are documented in the Department’s Juvenile Justice
Information System (JJIS). All youth requiring a single room shall have an alert entered in JJIS.
Seven youth case management records were reviewed for classification. Each reviewed record
contained a copy of the JJIS Admission Wizard documentation, which included the classification
results and the VSAB. Each reviewed youth case management record contained the Suicide
Risk Screening Instrument (SRSI). Seven reviewed youth records contained a classification
form which identified the module or room classification of where the youth was placed. An
interview with the superintendent confirmed any youth who may have concerns such as mental
health, physical health, cognitive, and/or prior victimization, will have an appropriate alert
entered into JJIS, and will be housed accordingly. This may include a single room, a detention
alert, or a call to the Department’s Central Communications Center (CCC).
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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 in place to ensure all information regarding
suspected youth gang affiliation is shared with the circuit gang representative. The center’s
superintendent has been designated to serve as the gang representative for the center. It is the
center’s superintendent who then corresponds with the chief probation officer (CPO) regarding
all suspected gang activity. The center is required to enter suspected gang affiliation alerts into
the Department’s Juvenile Justice Information System (JJIS) if there is a youth suspected to
have gang affiliation. Staff are notified of all updates and alerts during shift briefings and on the
daily alert sheet. An informal interview with the superintendent confirmed the center’s practice.
Seven youth case management records were reviewed, in which none of the records were
applicable for gang affiliation. There were no additional applicable youth records available. The
informal interview with the center’s gang liaison revealed there has been no suspected gang
activity at the center during the annual compliance review period to warrant communication with
the circuit gang representative.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures in place ensuring the proper safe handling and
security of personal property, including valuables, which are collected and secured at the time of
each youth’s admission. Each youth’s personal and valuable property is inventoried, maintained
securely, and returned to the youth or parent/guardian in a timely manner upon the youth’s
release. Personal items, such as clothing and shoes, are placed in a mesh bag and secured in
the center’s inventory locker room. Valuable items are listed and placed in a clear tamper-proof
property bag, identified with a youth’s name and Department identification number (DJJID), then
secured in the drop safe located in the admission office. The center maintains a drop safe
logbook to document the time, youth’s name, name of the juvenile justice detention officer
(JJDO) securing the property, and the JJDOs initials. Seven youth case management records
were reviewed, and each contained documentation of a letter of acknowledgement of unclaimed
property signed by the youth and staff. Each record contained a Property Receipt form
documenting the assigned locker for personal items. An observation of all seven personal
property bags was conducted and each contained an inventory form. One reviewed record
contained a Property Receipt form for valuable items. The drop safe bound logbook contained
all required elements for the applicable reviewed youth record. The applicable youth with
valuable items had the items in a clear tamper-proof bag and securely stored in the drop safe.
An admission was unable to be observed during the annual compliance review week, as one did
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Office of Accountability and Program Support Page 21 of 61 (Revised July 2023)
not take place while the annual compliance review team was on-site. A review of the
Department’s Central Communications Center (CCC) reports since the last annual compliance
review found no incidents regarding youth property. All seven interviewed youth stated staff
check their property inventory and each youth signed the inventory was correct. The
superintendent interview confirmed the center’s property storage practice.
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 in place to ensure all releases from the center
occur promptly and accurately. Three closed youth case management records were reviewed.
The on-duty juvenile justice detention officer supervisor (JJDOS) verified each youth’s release
by reviewing the court order and signing the secure detention release form. Each of the closed
youth records had the appropriate documentation including a copy of photo identification of the
person taking custody, youth and parent/guardian notifications of any future court dates, and all
parties signed all required release forms. None of the released youth had an alert reflecting an
endangered person. The release date in the Department’s Juvenile Justice Information System
(JJIS) corresponded with the youth’s correct release date in each reviewed record. A youth
release was unable to be observed during the annual compliance review week, as there were
none released while the annual compliance review team was on-site.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures in place to ensure all youth personal property is
released to the proper youth or the youth’s parent/guardian. The parent/guardian, youth, and
staff must sign a receipt acknowledging all property was returned upon each youth’s release. A
review of three closed youth case management records revealed each youth record contained
the required information with all required signatures of receipt of youth’s personal property.
Each record contained identification documentation verifying the youth was released to an
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appropriate person. One closed case management record was applicable for the youth and
person the youth was being released to being reminded of any health or welfare issues
including medical, mental health, and/or substance abuse needs, and any pending
appointments. The youth and parent/guardian were reminded, as required. One case
management record was applicable for a receipt of medications to be signed by the person
receiving the youth and the document was signed as required. The center did not have any
inventory of unclaimed property held more than thirty days during the annual compliance review
period. An interview with the superintendent confirmed any property which is not retrieved after
thirty days is considered to be abandoned and a notice will be mailed to the last known address.
A record shall exist for any property disposed of and cash is forwarded to the regional fiscal
manager. A release was not observed during the annual compliance review week, as no release
took place while the annual compliance review team was on-site.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures ensuring detention reviews are conducted
weekly for youth in secure detention, placed on home detention, or placed on electronic
monitoring to ensure proper management of each youth and the sharing of information.
Detention reviews are conducted on a weekly basis to address the status of each youth. The
center’s superintendent has been appointed to coordinate weekly detention reviews. An
observation of a weekly detention review found updates are provided regarding each youth’s
next court date, behavior while in detention, residential placement status, and release status.
Reviewed documentation found reviews were conducted with the center’s staff including
medical, education, mental health, commitment, and representatives from probation. Attendees
from outside the center participated virtually utilizing video conferencing. Video conferencing
attendance logs were maintained for each meeting. An interview with the superintendent
confirmed detention reviews are conducted weekly by video call to share each youth’s status
updates and are attended by all required participants.
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 addressing the daily activity schedule. The center’s
daily activity schedule includes daily expectations in accordance with the behavior management
system (BMS), education, mealtimes, visitation, indoor and outdoor recreation, shift changes,
bedtimes, groups, and open program time. The center provides and maintains weekday,
weekend, and holiday schedules. Observations during the annual compliance review week
revealed schedules are posted throughout the center along with a monthly activity calendar.
Visitation is held twice a week for youth. During the morning and early afternoon hours, youth
are participating in education. Reviewed documentation reflected activities included behavior
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management incentive parties and a variety of recreational activities. A review of the center’s
logbook and observations throughout the annual compliance review week confirmed the center
adheres to the daily activity schedule. Youth hygiene and wake up were not consistently
documented in the logbook. Seven youth were interviewed, and each youth indicated the center
has a daily schedule which is followed. Seven staff were interviewed, and all reported the daily
schedule is followed unless circumstances do not permit.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has a facility operating procedure ensuring educational instruction is integrated into
their daily schedule. Interviews, a review of three days of logbooks, and reviews of video
footage for three days confirmed the center is providing five-hour daily instruction periods,
reliable school schedules with no cancellations of school, and 250 days of instruction per year,
including 10 dedicated teacher training days. Minimal disruptions were documented, with
classes running on time and youth arriving and departing as scheduled. Interviews with seven
staff and seven youth further confirmed this, with all seven youth and six of the staff interviewed
verifying adherence to the daily schedule and minimal interference with learning. The remaining
staff stated they try not to disrupt the classrooms but will if they need to call for a youth. Four
youth stated the center is preparing them for a high school equivalency diploma (GED), high
school, vocational school, employment, and/or college very well, two stated well, and one stated
not well. The superintendent’s interview results verified 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 a facility operating procedure indicating they have a career competency
development program. The center offers career education programming which meets the
requirements of a Type 1 program which incorporates communication, interpersonal, and
decision-making skills, as well as life skills and activities through career-related instruction in
class. Three of seven interviewed youth confirmed they have participated in a career course
while at the center. The remaining four youth indicated they do not.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains a facility operating procedure requiring a single licensed mental health
professional to serve as the designated mental health clinician authority (DMHCA). The DMHCA
is responsible for the coordination and implementation of mental health and substance abuse
services. The Department maintains a contract with VitalCore Health Strategies, LLC to provide
mental health and substance abuse services to all applicable youth in the center. The contract
requires a full-time licensed professional to serve as the DMHCA for forty hours each week. The
center’s DMHCA is provided through VitalCore Health Strategies, LLC. The DMHCA is a
licensed mental health counselor (LMHC) who holds a clear and active license in the State of
Florida, under Chapter 491, with an expiration date of March 31, 2025. The DMHCA is
scheduled to be on-site Monday through Friday and is on-call twenty-four hours each day for
emergencies and consultation. The mental health provider had a previous minor deficiency
which was closed on December 22, 2023. The minor deficiency was related to mental health
staff not being on-site for the required hours. A review of mental health staff sign-in logs since
the date of closure was conducted and showed the DMHCA was on-site as required. The
DMHCA’s job description outlines the clinical and administrative oversight responsibilities of all
contractual requirements. The center has one back-up DMHCA, who works for VitalCore Health
Strategies, LLC as the regional director of mental health programs. The back-up DMHCA is a
licensed clinical social worker (LCSW) under Chapter 491 in the State of Florida, with an
expiration date of March 31, 2025. The back-up DMHCA was utilized during the annual
compliance review period, as evidenced by the DMHCA sign-in logs. In an interview the
DMHCA confirmed the center’s process for coordination and implementation of mental health
and substance abuse treatment services. The DMHCA indicated they are responsible for
ensuring youth at the center receive mental health services which include individual, group, and
psychiatric services. The DMHCA reported the youth receive tele-psychiatry with the psychiatrist
for medication management and treatment planning. Additionally, the DMHCA indicated
communication between the DMHCA and clinical staff occurs on a frequent basis, and the
DMHCA is available twenty-four hours, seven days a week.
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 contracts with VitalCore Health Strategies, LLC to provide mental health and
substance abuse services to all applicable youth in the center. The center’s contract with
VitalCore Health Strategies, LLC requires a full-time designated mental health clinician authority
(DMHCA), one full-time licensed mental health counselor (LMHC), and a part-time psychiatrist.
The center’s full-time LMHC position became vacant as of February 16, 2024. In an informal
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interview, the regional DMHCA indicated they are in the process of filling the position. The
regional DMHCA has been providing coverage at the center. In addition to the DMHCA, the
center has five licensed pro re nata (PRN) mental health staff. All five mental health staff hold a
clear and active license in the State of Florida. Each staff has the proper credentials (education,
training, and experience); and a copy of each license and credentials were on-site for review
and were verified. The psychiatrist holds a clear and active license in the State of Florida with
an expiration date of January 31, 2026. The back-up psychiatrist holds a clear and active
license in the State of Florida with an expiration date of March 31, 2026.
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 maintains facility operating procedures for the supervision of non-licensed mental
health staff by a licensed mental health professional. All mental health services must be
provided by a licensed mental health professional or a non-licensed mental health clinical staff
person who is working under the direct supervision of the licensed mental health professional.
The contract does not specify the center must have non-licensed staff; however, it does specify
minimum qualifications and supervision for any non-licensed clinical staff employed. The center
does not have a Chapter 397 license. The designated mental health clinician authority
(DMHCA) is the clinical supervisor, who ensures the clinical staff working under their
supervision are performing services they are qualified to provide based on education, training,
and experience. The center has five part-time licensed mental health professionals (LMHPs)
and one non-licensed staff working under the DMHCA. All five licensed health staff work pro re
nata (PRN). A review of the LMHP’s credentials verified their licenses are clear and active in the
State of Florida. Reviewed documentation showed only the LMHPs conduct the substance
abuse treatment. The non-licensed mental health staff works under the direct supervision of the
LMHPs. The non-licensed mental health staff holds a master’s-level degree in social work from
an accredited university. Documentation reflected the non-licensed staff received twenty hours
of training and supervised experience in assessing suicide risk, mental health crisis intervention,
and emergency mental health services. The non-licensed mental health staff works PRN. A
review of supervision logs during the annual compliance review period confirmed the non-
licensed staff received at least one hour each week of on-site, face-to-face supervision provided
by the DMHCA, as required, which was documented on the Department’s Licensed Mental
Health Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision
Log form.
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3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center maintains a facility operating procedure requiring the identification of youth mental
health and substance abuse needs through a comprehensive screening process and referrals to
be made when youth are identified with mental health and/or substance abuse needs or are
identified as a possible suicide risk. Upon admission, a juvenile justice detention officer (JJDO)
will review each youth’s Massachusetts Youth Screening Instrument, Second Version (MAYSI-
2), face sheet, and alerts. The JJDO then completes their assigned section of the Suicide Risk
Screening Instrument (SRSI). A review of seven youth mental health and substance abuse
records showed each youth had a completed SRSI and a MAYSI-2 during the youth’s admission
process. Each reviewed document was completed by the Juvenile Assessment Center, and
then reviewed by detention staff as a part of each youth’s intake process. Each of the seven
SRSIs were reviewed by a mental health clinical staff and included their documented
recommendation. Each of the SRSIs had completed entries which also had a summary and
recommendations included in the screening results section. Each form was completed in the
Department’s Juvenile Justice Information System (JJIS). Four of the seven reviewed individual
youth mental health records contained a positive “yes” response on the SRSI form and each
record indicated the need for further assessment based on the screening results. Four of seven
individual youth mental health records with positive responses were applicable for prior open or
closed suicide risk alerts in JJIS; the remaining three records were not applicable. Four of seven
individual youth mental health records contained an elevated score on at least one domain on
the MAYSI-2. Four of the seven youth contained an elevated suicide subscale on the MAYSI-2.
Each applicable youth was placed on suicide precautions, and a mental health referral was
generated. Reviewed documentation confirmed each applicable youth was placed on
precautionary observation (PO) and remained on PO until the Assessment of Suicide Risk
(ASR) was completed by the center’s clinical staff. Two of the seven reviewed youth records
were applicable for having all negative responses on the MAYSI-2, invalidating the screening.
Each of the applicable youth required a comprehensive assessment, and the center notified
mental health staff and the superintendent, as required. All seven individual youth mental health
records had screenings completed by trained staff, according to the Department’s Learning
Management System (SkillPro).
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center maintains facility operating procedures outlining a process for identifying the mental
health and substance abuse needs of youth through a comprehensive screening. The center
utilizes the Department’s Mental Health and Substance Abuse Referral Summary form. Youth
who are identified at the Juvenile Assessment Center (JAC) as needing further assessment are
referred for a comprehensive assessment. A review of seven youth mental health and
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substance abuse records reflected one youth was applicable for referral for mental health and
substance abuse services. The remaining records reflected four youth had been in the center
less than thirty days, one youth refused mental health/substance abuse services, and one
record was not applicable for the community provider assessment. Two additional records were
provided for review of a community provider assessment. A review of the three applicable
records showed each youth was screened, and a referral was made for each youth to receive a
comprehensive mental health evaluation based on the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2). Two of the three individual youth mental health records
contained a new Substance Abuse and Mental Health (SAMH) Assessment completed by the
center’s on-site mental health provider within thirty-one days, as required. The remaining record
contained an updated SAMH Assessment, which contained all required elements. All treatment
recommendations made corresponded to all diagnosed substance abuse and mental health
disorders for each youth. An interview with the designated mental health clinician authority
(DMHCA) validated the center’s practice regarding obtaining mental health and/or substance
abuse assessments.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures to ensure each youth needing treatment services
has an initial and/or individual treatment plan created and has a discharge summary completed
when youth leave the center. The provider’s contract requires the 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. Seven youth records were
reviewed for mental health and substance abuse treatment services. Three of the seven youth
records reflected they were applicable for requiring an initial treatment plan. The remaining
records reflected two youth had been in the center less than thirty days, one youth refused
mental health/substance abuse services, and one record was not applicable for treatment
services. A review of the documentation confirmed each applicable youth was assigned to a
mini-treatment team and each was referred for services utilizing the Department’s Mental Health
and Substance Abuse Referral Summary form. All three youth records had an initial treatment
plan in place within seven days of initiation of treatment which was developed on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Three of the
reviewed youth records were applicable for treatment with individual or group counseling. Two
of the three reviewed youth records were applicable for treatment with psychotropic medication
management and frequency of monitoring by the psychiatrist. Each initial treatment plan
contained the reason for referral for treatment, the initial Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) diagnosis, initial treatment methods and goals, and
psychiatric services. All the treatment plans were signed and dated by the youth, mental
health/substance abuse clinical staff, and treatment team members; each had a note regarding
the parent/guardian’s presence over the telephone, and each was dated. One of the three youth
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records showed an Individualized Mental Health and Substance Abuse Treatment Plan was
developed and completed within thirty-one days of the youth’s admission. The remaining two
youth did not have an Individualized Mental Health and Substance Abuse Treatment Plan, as
the youth had not been at the center for thirty-one days. The applicable reviewed plan was
documented on the Department’s Individualized Mental Health/Substance Abuse Treatment
Plan form. A review of the applicable individualized treatment plan confirmed it identified the
youth’s DSM-5 diagnoses, treatment-focused symptoms, treatment goals, and strengths/needs.
A review of the applicable record indicated the youth was not applicable for psychiatric services
or pharmacological interventions. The treatment plan was signed by the youth, mental health
professional, and treatment team members. The parent’s/guardian’s participation by telephone
was documented. The applicable youth record was not due for a thirty-day review at the time of
the annual compliance review; therefore, the review was not yet completed. There were no
applicable records for having been an alleged victim of a Prison Rape Elimination Act (PREA)
incident. Three closed individual youth mental health records were reviewed for mental
health/substance treatment discharge summaries. Each treatment discharge summary was
completed on the required Department form, and each record indicated a copy of the summary
was provided to the youth, juvenile probation officer, and parent/guardian, if applicable. Weekly
treatment team meetings are conducted on Wednesdays for each youth receiving mental health
services. The psychiatrist is updated each Wednesday on youth behaviors and medications are
discussed. During the annual compliance review week, a treatment team meeting was
observed, and involved all required parties. A discussion of youth goals and progress was
conducted with all participants. In an informal interview with the back-up DMHCA, it was stated
the psychiatrist is usually on-site, although the center has a tele-psychiatry authorization. The
interview with the DMHCA, validated the process for ensuring services are provided to the youth
when admitted at the center and the process used to review and update individual treatment
plans.
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’s mental health and substance abuse treatment planning ensures mental
health/substance abuse interventions are provided to applicable youth to reduce or alleviate
symptoms of mental health/substance abuse issues. Seven mental health and substance abuse
records were reviewed and three were applicable for receiving initial treatment services, one
youth refused services, and the three remaining youth were not applicable. Each applicable
reviewed record contained the properly executed consents for mental health and/or substance
abuse treatment services and each youth was assigned to a mini-treatment team as required.
Each applicable record contained documentation of the youth receiving mental health treatment
in the form of individual, group, and/or family counseling as outlined in the treatment plan, at
least a minimum of once a week. An interview with the designated mental health clinician
authority (DMHCA) confirmed mental health services are provided to youth at the center and a
treatment team is initiated to offer services to each youth. The DMHCA confirmed mini
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treatment team meetings are conducted every thirty days. Reviewed progress notes validated
youth were receiving treatment services as stipulated on their treatment plan. None of the youth
required substance abuse treatment. Each individual youth mental health record contained the
proper Authority for Evaluation and Treatment (AET) consent form, and each contained
treatment notes documented on the required Department form with all required elements. A
review of three separate samples of video was conducted and observations showed each
mental health group was conducted, as required. A review of group sign-in sheets and logbooks
validated groups were conducted. Each group had the appropriate number of youth in the
group, not exceeding the maximum number allowed. Observations and a review of
documentation indicated groups were held from twenty or twenty-five minutes and the times
noted on the sign-in sheets matched the video review. The mental health staff at the center
provide groups a minimum of one time each week when there are enough youth receiving
treatment. In an informal interview with the DMHCA and regional DMHCA, it was stated if the
center has a higher capacity of youth requiring treatment services, mental health staff will
provide more than one group a week, depending on the need. Additionally, in the event there
are only a few youth, mental health staff meet with youth individually. Seven youth were
interviewed, and three youth rated the center’s mental health and substance services as very
good, one stated it was good, one stated it was poor, and two youth stated they were not
receiving mental health or substance abuse services.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center maintains facility operating procedures which outline the required psychiatric
services to be available to youth. Psychiatric services include psychiatric evaluation,
consultation, and medication management. Psychiatric services are provided to youth
determined to need services, as indicated by symptoms of mental disorder or substance-related
disorder, or to youth who are treated with psychotropic medication after their admission to the
center. The center maintains a contract with VitalCore Health Strategies, LLC., for the provision
of a licensed psychiatrist to provide psychiatric services for applicable youth in the center.
VitalCore Health Strategies, LLC., provides a part-time psychiatrist who is contracted to provide
services for a minimum of two hours each week. The psychiatrist’s license was clear and active
in the State of Florida with an expiration date of January 31, 2026. The back-up psychiatrist is a
licensed medical physician, and holds a clear and active license with an expiration date of
March 31, 2026. The contract was reviewed and confirmed the inclusion of tele-psychiatry. A
review of the center’s Tele-Psychiatry Log and observations validated the psychiatrist is
providing weekly services, as required. A review of seven youth mental health and substance
abuse records found two youth were applicable for entering the center on psychotropic
medication; therefore, the center provided one additional applicable record for review. Each of
the three reviewed individual youth mental health records contained documentation of a
psychiatric referral and interview completed within fourteen days of admission. All three youth
had an initial psychiatric interview which included the reason for referral, the youth’s history, a
Mental Status Examination, the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis, treatment recommendations, applicable prescribed medication,
explanation of the need for psychotropic medication, and the frequency of the medication. Each
youth record documented the psychiatric evaluation was completed within thirty days of the
youth’s referral/admission. All three youth were applicable for the prescription of medications
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and each psychiatric interview documented the most recent applicable therapeutic serum drug
levels, signature of the practitioner, page three of the Clinical Psychotropic Progress Note
(CPPN), target symptoms of each medication, evaluations and description of effect of
prescribed medication on target symptoms, normal dosage range, ordered dosage, frequency
and route of administration, side effects, adherence to medication regime, and whether there
was telephone contact with the parent/guardian to discuss medication. Each youth’s evaluation
was documented on the Department’s CPPN and completed within the required time frame. All
three youth records contained a current Authority for Evaluation and Treatment (AET) form. Two
youth were applicable for the monitoring of Tardive Dyskinesia which was documented monthly
on the CPPN for the youth, and one did not require monitoring. All three reviewed youth were
applicable for receiving tele-psychiatry, and there was documentation of consent from the youth
and parent/guardian in each case. An interview with the designated mental health clinician
authority (DMHCA), confirmed youth receive psychiatric services, individual, and group
counseling. Additionally, the DMHCA confirmed they meet with the psychiatrist on a weekly
basis to discuss youth receiving mental health and psychiatric services.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a suicide prevention plan to safely screen, refer, assess, monitor, and
protect youth with elevated risk of suicide in the least restrictive means possible. The policy and
plan were signed by the designated mental health clinician authority (DMHCA) and the center’s
superintendent on August 17, 2023. The plan identifies the center’s procedures for required
suicide prevention training, suicide precautions, levels of supervision, referrals, communication,
notification, documentation, immediate staff response, and a review process as referenced in
Florida Administrative Code. Mental health staff assist in training detention officers in suicide
prevention, including verbal and behavioral cues indicating a suicide risk. The plan also outlines
emergency contact telephone numbers to include the superintendent, on-call administrator,
DMHCA, local police department, designated health authority, licensed mental health
professional, psychiatrist, a local emergency room, the crisis stabilization unit, and Poison
Control. The center has an established review process for each serious suicide attempt or
serious self-harming injury. This review process includes all required elements. A copy of the
plan is located in the administration office and in the mental health office and is accessible to all
staff.
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3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center maintains facility operating procedures to address supervising, observing,
monitoring, and housing youth identified through screenings, documentation, and observation
as being at risk for suicide, and protect youth with elevated risk of suicide in the least restrictive
means possible. A review of seven youth mental health and substance abuse records showed
four youth were applicable for having been placed on precautionary observation (PO) at the
time of admission until an Assessment of Suicide Risk (ASR) was completed. Each youth began
on constant supervision based upon the Suicide Risk Screening Instrument (SRSI) results and
after the completion of the ASR, each youth was placed on standard supervision. Each youth’s
ASR was completed within twenty-four hours, as required, and none of the reviewed records
required a Follow-Up ASR. Each youth was removed from PO after being evaluated by the
licensed clinical staff and notification was made to the superintendent. All reviewed forms were
completed by a licensed clinical staff and contained all required elements. Each applicable
individual youth mental health record contained a completed mental health referral, PO log,
Assessment of Suicide Risk (ASR), and the Department’s Juvenile Justice Information System
(JJIS) alert. Each applicable JJIS suicide alert was observed to be open and closed
appropriately. A review of all four youth’s Suicide Precaution Observation Logs confirmed each
was completed in their entirety to include documented safe housing areas and all required
signatures. A review of the center’s logbooks revealed the start and end time of each youth’s
precaution period was documented in the logbook. A review of the four youth records reflected
there were no youth applicable for secure observation placement. In an interview with the
center’s superintendent, it was indicated the center does utilize secure observation for
potentially suicidal youth; in which the DMHCA is notified, and if secure observation is approved
the juvenile justice detention officer will maintain constant sight and sound supervision while
maintaining the Suicide Precaution Observation log. Additionally, a youth’s level of supervision
can only be authorized by the DMHCA. In an interview, the DMHCA confirmed the center’s
practice when a youth appears to have suicide ideation and indicated the process for revising a
youth’s supervision level. Seven staff were interviewed and each confirmed if a youth expresses
suicidal thoughts, they are to notify the DMHCA, five staff stated they will search the youth and
his/her room for sharp objects, six staff stated they would document supervision, and two
indicated they would keep youth at constant sight and sound. Seven youth were interviewed,
two youth indicated they have been placed on suicide precautions while at the center, and
stated they were watched the whole time while on PO. The remaining five youth stated they
have never been placed on suicide precautions while at the center.
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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 maintains a suicide prevention plan to address precautionary observation (PO) and
the process to safely screen, refer, assess, monitor, and protect youth with elevated suicide risk
in the least restrictive means possible. A review of seven youth mental health records showed
four were applicable for having been placed on suicide precautions and each had a Suicide
Precaution Observation Log maintained. Each of the four applicable records contained Suicide
Precaution Observation Logs completed, on the required Department form, and for the duration
of the youth’s PO. The appropriate level of supervision was maintained, and checks were
documented in real time, at a minimum of every thirty-minutes as required, for each youth. No
youth was applicable for having warning signs documented on the logs. All logs were signed by
the shift supervisor and reviewed by the mental health clinical staff. Each log documented safe
housing requirements. Observations of video surveillance footage on three dates and
corresponding documentation of youth on PO confirmed each youth was placed on constant
supervision. The review confirmed proper supervision was maintained for each youth
3.12 Suicide Prevention Training [Detention Staff] (Critical) Limited Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center maintains a suicide prevention plan to safely screen, refer, assess, monitor, and
protect youth with elevated risk of suicide in the least restrictive means possible. The plan
requires all staff who work with youth to receive six hours of annual training on suicide
prevention and implementation of suicide precautions. Suicide prevention trainings are
completed and documented in the Department’s Learning Management System (SkillPro).
Seven pre-service and seven in-service staff training records were reviewed. All reviewed staff
records documented staff completed suicide awareness and prevention training, with the
exception of one staff who was missing two hours of suicide training. In an informal interview,
the superintendent indicated the center was operating with two, twelve-hour shifts until February
2024. The reviewed documentation of “mock” suicide drills conducted since the last annual
compliance review, showed the center had not completed all drills on each shift at least
monthly, as required by policy. The center conducted drills on each shift during the months of
May, July, September, and October. One of the two shifts was missing a drill during the months
of June, August, November, December, and January, and no drills were conducted the month of
February. The center had an open deficiency assigned by the Department’s Office of Health
Services for missing drills at the time of the annual compliance review. Reviewed
documentation supported the center had thirty-seven applicable staff requiring participation in a
suicide drill semi-annually. All thirty-seven of the center’s staff participated as required, in the
first six months and approximately ten staff had completed a drill for the first quarter of the
second six-month period. Staff who are not present during a drill have the opportunity to review
each drill scenario, procedures, and critique 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. Documentation supported approximately thirty-two direct care staff participated in
at least one drill since the last annual compliance review period, which included the use of
cardiopulmonary resuscitation (CPR) annually; however, not all staff have not had the
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opportunity to participate. The center maintains seven complete suicide response kits which are
located in master control, medical office, in the youth modules, and in the administration’s office.
An interview with seven staff was conducted and all indicated the suicide response kits were
located in the medical office, and five indicated they were located in master control and in the
youth modules.
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 Crisis Intervention Plan which details the response procedures for youth in
crisis. Staff response must be in the least restrictive means possible to protect the safety of
youth and others while maintaining control and safety of the center. The plan was last reviewed
and approved on August 17, 2023. The center’s procedures require the completion of a Crisis
Assessment to evaluate any youth presenting with acute emotional or psychological distress
which is extreme and does not respond to ordinary interventions. Assessments are to be
completed by a mental health clinician to determine the severity of a youth’s distress,
symptoms, level of risk to self or others, and recommendations for treatment and follow-up care.
The plan details crisis intervention procedures including a notification and alert system, means
of referral including youth self-referral, communication, supervision, documentation, and review.
The center utilizes a local mental health center as their crisis stabilization unit. Copies of the
plan are located in the administration office and in the mental health office and are accessible to
all staff.
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 an Emergency Care Plan outlining mental health and substance abuse
emergency procedures for youth who are believed to be an imminent danger to themselves or
others because of mental illness or substance abuse impairment. The plan was last updated
and approved on August 17, 2023. The facility operating procedure and plan were signed by the
superintendent and the designated mental health clinician authority (DMHCA) on August 17,
2023. The center’s plan includes procedures for immediate staff response, notifications,
communication, supervision, authorization to transport for emergency Baker Acts or Marchman
Acts, documentation, training, and review. A review of seven pre-service and seven in-service
staff training records documented each was trained on the center’s Emergency Care Plan, with
the exception of two staff who had not completed the Emergency Care Plan training at the time
of the annual compliance review. Copies of the plan are located in the administration office, and
in the mental health office, and are accessible to all staff.
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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 to address Crisis Assessments and stipulating the
response procedures for youth in crisis. Staff response is to be in the least restrictive means
possible to protect the safety of youth and others while maintaining control and safety of the
center. Any youth presenting with acute and extreme emotional or psychological distress is to
receive a Crisis Assessment to evaluate the severity of their distress and symptoms, level of risk
to self or others, and recommendations for treatment and follow-up care. A review of seven
youth mental health records revealed none were applicable for Crisis Assessments. The
designated mental health clinician authority (DMHCA) provided three additional records which
were applicable for Crisis Assessments since the last annual compliance review. A review of the
three closed records for Crisis Assessments was conducted. A review of documentation showed
each assessment was completed the same day the youth was determined to be in crisis and
was documented on the Department’s Crisis Assessment form. The assessments included the
reason for assessment, a Mental Status Examination, a determination of the youth’s danger to
self/others, initial clinical impressions, supervision and treatment recommendations,
recommendations for follow-up, and notification to the parent/guardian. The assessments
indicated a potential safety or security risk; therefore, a mental health alert was warranted and
was entered into the Department’s Juvenile Justice Information System (JJIS) for each youth.
Each of the three reviewed assessments confirmed they were completed by a licensed mental
health staff. Each of the reviewed assessments were related to an allegation of a Prison Rape
Elimination Act (PREA) event; therefore, each youth was offered ongoing mental health
treatment services, as required. An examination of Assessments of Suicide Risk, logbooks, and
the Department’s Central Communications Center (CCC) incidents did not reveal any events
where a Crisis Assessment should have been completed and was not.
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 a facility operating procedure to address mental health and substance abuse
emergency procedures for youth believed to be an imminent danger to themselves or others
because of mental illness or substance abuse impairment. A review of seven youth mental
health records revealed one was applicable for requiring Baker Act procedures. The designated
mental health clinician authority (DMHCA) provided two additional youth records which were
applicable for a Baker Act since the last annual compliance review. Each youth reviewed was
placed on suicide precautions upon re-admission following the Baker Act placement. A Mental
Status Examination (MSE) was completed by a licensed mental health professional within the
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administration of the Assessment of Suicide Risk (ASR) for the applicable youth. All three youth
were maintained on constant supervision until properly transitioned to a lower level of
supervision. Documentation showed supervision levels were lowered for each youth after an
appropriate assessment was conducted by a licensed mental health professional and mental
health staff conferred with the licensed supervisor and superintendent or designee. Each youth
had a suicide risk alert entered in the Department’s Juvenile Justice Information System (JJIS)
which, along with precautions, was discontinued based upon the ASR. An interview with the
DMHCA, confirmed the center has had to transfer approximately eleven youth to the crisis
stabilization unit for Baker Act services, and there were no youth requiring to be transferred for a
Marchman Act, since the last annual compliance review.
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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 board-certified physician who holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida serving as the
designated health authority (DHA). The DHA’s license expires on January 31, 2025. The DHA’s
specialty is pediatrics. The DHA has an advanced practice registered nurse (APRN) to provide
clinical services on-site who has a Collaborative Practice Protocol in place with the DHA
performing all administrative duties. A review of DHA sign-in logs during the annual compliance
review period indicated the DHA was on-site at least once a week, as contractually required.
The VitalCore Health Strategies, LLC contract indicates one APRN will be on-site, in the clinic,
at least weekly. In reviewing the sign-in logs, it appears the APRN was not on-site for seven
weeks during the annual compliance review period. The center has a back-up DHA who is a
licensed physician, holds an unrestricted license, and meets all requirements for independent
and unsupervised practice in the State of Florida. The back-up DHA’s license expires on
January 31, 2025. The back-up DHA was not utilized during the annual compliance review
period. The center has facility operating procedures (FOPs) in place regarding tele-medicine;
however, tele-medicine was not used during the annual compliance review period. The DHA
was interviewed and indicated their duties include completing Comprehensive Physical
Assessments, continued stay reviews, sick calls, addressing outside labs/appointments, and
assisting with the development of medical FOPs and policies. The DHA also indicated they are
available on-site two hours weekly to provide on-site medical services and available by cellular
telephone twenty-four hours a day, seven days a week for both medical and non-medical staff.
The DHA communicates with the registered nurse manager daily about youth with medical
issues, including off-site physician/dentist recommendations and lab results. The backup DHA
provides coverage for the DHA during vacation or scheduled absences. The DHA indicated they
have ongoing concerns about the number of Baker Acts at the center and the supervision from
staff. They added the staff are doing their best, but staffing can be an issue.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center has facility operating procedures (FOPs) for all medical and health-related protocols.
The designated health authority (DHA) conducted an annual review and signed all respective
treatment FOPs on April 7, 2023, the superintendent reviewed and signed on April 5, 2023, and
the psychiatrist reviewed all FOPs related to psychiatric services and psychotropic medication
on January 30. 2024. The DHA authorized and approved all treatment protocols and standing
procedures. The nursing staff reviewed, signed, and dated a cover page on which all FOPs,
treatment protocols, and other procedures were listed, as required.
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures regarding the Authority for Evaluation and
Treatment (AET). A review of seven youth Individual Healthcare Records (IHCRs) revealed
three youth had a valid AET maintained in their IHCR, all of which were obtained prior to
providing medical services. Each of the three IHCRs had either the original AET or one which
had the word “copy” stamped on the form, and all were signed by the parent/guardian and a
Department representative. One youth was under the custody of the Department of Children
and Families and one youth required treatment and the parent/guardian could not be located;
therefore, a court order was obtained for all treatment procedures and maintained in the IHCR,
as required, for both youth. Two of the seven reviewed youth were eighteen years of age or
older; however, neither IHCR contained a documented release of information.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and four IHCRs were
applicable for parent/guardian notification/consent. The written notifications were sent in each of
the four applicable records utilizing the required Department forms. Two of the IHCRs were
applicable for parent/guardian notification regarding over-the-counter medications, which were
not covered by the Authority for Evaluation and Treatment (AET), and consent was provided for
both. Four youth were applicable for psychotropic medication and each IHCR documented a
staff witness for all telephone call attempts and conversations for psychotropic medications.
None of the youth required parent/guardian notification for vaccinations or immunizations or
received new medications while at the center. None of the youth were applicable for new
psychotropic medications, discontinuation of psychotropic medication, or a significant change of
drug dosage for psychotropic medications. Immunization records were verified in all seven
reviewed IHCRs within thirty days of each youth admission, as required. None of the seven
youth required immunizations/vaccinations after admission to the center.
Nursing staff were interviewed and indicated an AET is required prior to providing medical
services. The AET is to be signed by the parent/guardian and witnessed by a Department
representative. The AET is valid as long as the youth has remained under any type of
supervision, custody, or other form of legal control by the Department; or, for one year after it
was signed by the parent/guardian, whichever comes later; or until the youth’s eighteenth
birthday. The program’s process is to notify the juvenile probation officer (JPO) if a new AET is
required to enlist their assistance. They also send an AET to court with each youth for their
parent/guardian to sign if they are present. If a youth is in Department of Children and Families
(DCF) custody, then the case worker is contacted to obtain a limited AET. Youth eighteen years
of age or older are responsible for authorizing their healthcare and authorizing release of their
healthcare information and records. They are also responsible for accepting care and providing
consent for care. Youth give verbal consent and sign/initial for any treatment and/or medications
rendered. Parent/guardian notification should be made to inform parents/guardians of significant
changes in each youth’s condition and obtain consent when new medications are ordered,
medications are stopped, when a youth is sent off-site for treatment, whether scheduled or
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emergency, and when treatments are prescribed. These notifications are first done verbally and
followed with a letter. The nurse contacts parents/guardians by telephone as soon as a change
occurs or when an order is obtained when notification is required. Then a letter is sent out
explaining the medication or treatment rendered. The nursing interview also stated all staff shall
have immediate access to contact Emergency Medical Services (EMS) by calling 9-1-1 under
any circumstances which require immediate medical attention or evaluation, and then the
designated health authority (DHA) is notified of the youth needing to be sent to the Emergency
Room. The nursing interview confirmed vaccinations are not provided on-site, records are
verified through a website and are reviewed during the admission process. If a parent/guardian
presents certified documentation of exemption for a youth, the documentation is reviewed by the
DHA and nursing and uploaded into the IHCR.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed. Each IHCR included a
Medical and Mental Health Admission Screening form completed on the date of admission by a
juvenile justice detention officer (JJDO) or juvenile justice detention officer supervisor (JJDOS).
Each admission screening was reviewed by medical staff within twenty-four hours of the
screening, as required. All seven youth were applicable for notification to the designated health
authority (DHA) and notifications to the DHA were documented in all seven IHCRs. None of the
seven reviewed IHCRs were applicable for healthcare admission rescreening; therefore, three
additional applicable records were requested and reviewed for healthcare admission
rescreening. Reviewed documentation validated the center completed a rescreening in all three
applicable IHCRs each time a change of custody occurred. Each rescreening was completed by
a JJDO or JJDOS and reviewed by medical staff within twenty-four hours of the screening.
None of the youth required a qualitative urine pregnancy screening test. An interview of nursing
staff indicated youth are first seen by the center’s nursing staff on the day of admission. Youth
are seen the following morning by nursing staff if they arrive at the center after nursing staff are
gone for the day. JJDOs or JJDOSs complete the Medical and Mental Health Admission
Screening forms and nursing staff review and sign the form on the third page. JJDOSs or
master control notify medical of newly admitted youth. If there is a change in physical custody
since the admission of a youth, the youth will be assessed for any changes in medical condition
since the last physical custody. Vital signs are obtained, and health-related history is reviewed
with the youth; any changes would be documented on the Health-Related History form.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures for all required health education topics including
access to medical care, sick call, what constitutes an emergency and when to notify staff,
medication process with side effect monitoring, the right to refuse care and how it is
documented, what to do in case of sexual assault or attempted sexual assault, the non-
disciplinary role of healthcare providers, and review of the list of healthcare contacts to ensure
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accuracy. A review of seven Individual Healthcare Records indicated each youth received a
general healthcare orientation which was documented on the required Department form.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed, and three records were
applicable for designated health authority (DHA) notification for known or suspected chronic
conditions. Each youth was referred to the DHA, as required. The center’s practice is to notify
the DHA of all admissions. The DHA was notified within twelve hours of admission for each
youth. None of the youth required emergency care upon admission. Four youth were taking
psychotropic medication and the psychiatrist notification was documented in the IHCR for each.
Nursing staff were interviewed and indicated nursing staff are responsible for DHA notifications
and they contact the DHA by telephone for youth with chronic conditions or serious issues,
which is documented on the intake log as well as on the admission form.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures indicating a Health-Related History (HRH) form
must be completed for all youth admitted into the program. Seven youth Individual Healthcare
Records (IHCRs) were reviewed for HRH form completion. Each youth’s HRH form was
updated or completed within seven calendar days of admission. The HRH form was completed
or updated prior to the Comprehensive Physical Assessment (CPA) for each youth, which was
evident by a signature and date from the nurse who completed each form. Each HRH form was
completed by a licensed nurse. The designated health authority (DHA) or advanced practice
registered nurse (APRN) reviewed each HRH form, and the checkbox was marked on each
CPA indicating they were reviewed. A review of each HRH form confirmed signatures and dates
were from the most current admission for each youth. Nursing staff were interviewed and
confirmed a nurse is responsible for completing each youth’s HRH form within seven days of
admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and each IHCR included
the Department’s Comprehensive Physical Assessment (CPA) form. Two of the seven IHCRs
had a current CPA maintained from a prior admission with no changes in medical condition,
both current CPAs were reviewed by the designated health authority (DHA) or advanced
practice registered nurse (APRN), and the focused medical evaluations were completed for
both. The remaining five IHCRs had a new CPA completed within seven calendar days of
admission, as required. Each of the seven reviewed IHCRs documented the youth’s Medical
Grade, each CPA was completed by the DHA or designee, and all sections of each CPA were
marked with “O” or an “X,” as required. Three youth refused part of the exam, the clinician wrote
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“Youth Refused” on each CPA, and each youth signed a refusal form. The Department’s
Problem List was updated for each IHCR. Each of the seven reviewed IHCRs maintained a
verified Tuberculosis Skin Test (TST), as required, and a tuberculosis (TB) screening was
conducted within the required time frame for each. The results of the TST documented on the
CPA and Infectious and Communicable Disease (ICD) form matched for each youth. None of
the youth required further evaluation, isolation, or hospitalization. The center has facility
operating procedures (FOPs) documenting when any part of the CPA is refused by a youth, the
clinician will write “youth refused”, or a similar term. The FOPs also include a TB screening and
rescreening process.
An interview with nursing staff indicated a CPA is completed for each youth within seven
calendar days of admission. A new CPA is needed every two years if youth have Medical Grade
of one. A new CPA is created if a youth’s Medical Grade changes from one. Additionally, a TB
screening shall be completed within seventy-two hours of admission if one is not documented in
the youth’s IHCR within the past year. Youth are given a test one time a year and results are
documented on the CPA, ICD form, and on the TB tracking log. Lastly, the nursing interview
indicated female youth do not receive 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 a facility operating procedure ensuring all youth are evaluated and treated, if
necessary, for sexually transmitted infections (STIs). Seven youth Individual Healthcare
Records (IHCRs) were reviewed for STI and human immunodeficiency virus (HIV) screenings.
Each youth was clinically screened and evaluated for STIs. Two of seven reviewed youth
required further evaluation, and both were further evaluated by the designated health authority
(DHA). Both youth were referred, and both referrals were documented on the Department’s STI
Screening form. Testing was ordered for both youth and was performed within seven days of
admission. Testing, screening results, clinical evaluations, and diagnosis were documented on
the Infectious Communicable Diseases (ICD) form for both youth. The documentation was then
filed in the lab section of each youth’s IHCR.
None of the seven youth received or required a gynecological exam. None of the seven youth
were out of the Department’s physical custody or required a rescreen. All seven youth were
offered counseling and HIV testing; however, none of the youth consented to or received HIV
testing. Seven youth were interviewed, and each youth indicated they can ask for a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and three youth IHCRs
were applicable for sick call, for a total of four sick calls. Each of the three applicable youth’s
sick calls were documented on the Sick Call Referral Log. None of the three applicable youth
presented with similar sick call complaints three or more times within a two-week period or with
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complaints of severe pain with which medical staff were unfamiliar. The center utilized an
electronic Sick Call Request form for all three applicable youth and nursing staff completed the
Sick Call Request forms for each youth. A licensed practical nurse (LPN) conducted two of the
four sick calls and the remaining two sick calls were conducted by a registered nurse (RN). The
two sick calls conducted by a LPN were not reviewed with the designated health authority
(DHA), advanced practice registered nurse (APRN), or RN daily, rather one sick call was
reviewed five days later, and one sick call was reviewed six days later. Each Sick Call Request
form was filed in the appropriate IHCR in reverse chronological order in accordance with Florida
Administrative Code. None of the three applicable youth were in restricted housing of any kind.
All sick call events were documented on the Sick Call Index and corresponded with the Sick Call
Request forms. A review of the sick call hours posted on the clinical door and an informal
interview with nursing staff revealed sick call is conducted daily, as required, and as needed.
Sick calls are conducted by nursing staff and the center has treatment protocols addressing
different levels of nursing staff. The center also has procedures in place for shift supervisors to
review all sick call requests as soon as possible and within four hours if licensed nursing staff
are not on-site. The shift supervisor will discuss with youth about medical issues for youth in
confinement. For non-emergency issues, the shift supervisor will input the sick call request for
the youth to be seen at the next scheduled sick call time. Nursing staff are required to make
daily visits for youth in confinement. All youth in confinement will receive all prescribed
medication. The nursing staff will evaluate youth every two hours if a youth in confinement has
an active medical condition. A sick call was observed during the week of the annual compliance
review. The youth was escorted to the sick call and the youth’s verbal consent was obtained
prior to observation. The nursing staff identified themselves and stated why the youth was there.
The youth was seen in a private area with no other youth present and the youth’s privacy was
maintained. An exam table was not used to perform the sick call and the youth was examined
by the nursing staff. Nursing staff complete all sick calls.
An interview with nursing staff indicated a LPN or RN complete all sick calls. A RN reviews each
sick call within twenty-four hours if the sick call is conducted by an LPN. In the event an RN will
not be on-site within twenty-four hours, the LPN will call the DHA to review the sick call. Sick call
is conducted in medical daily from 8:00 a.m. to 10:00 a.m., as needed. Youth presenting with
similar sick call complaints three or more times within a two-week period are referred to the
DHA or APRN, and the youth is added to the list to be seen by a provider. The DHA has
approved treatment protocols. Youth in restricted housing or on confinement are assessed
every twenty-four hours and if they have any medical complaints or distress it is documented in
an episodic note. Any distress noted when medical is not on-site will result in contact to the DHA
or through telehealth. Seven youth were interviewed, two youth indicated nursing staff conduct
sick call and once they make a sick call request, it takes more than three days to be seen, and
the remaining five youth indicated they have not had any sick calls. Seven staff were
interviewed, and each staff indicated nursing staff review and conduct sick call.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and one IHCR indicated the
youth had an on-site first-aid or episodic care event. Two additional youth IHCRs were
requested and reviewed to obtain the required sample size of three records. All three youth
received episodic or first-aid care by licensed healthcare staff, which was documented in
problem-oriented charting, and included the nature of the complaint, findings, treatment
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rendered, education/instruction provided, and plans for follow-up/future care. None of the
episodic care events were handled by non-healthcare staff or required placement on the
center’s internal alert list. One episodic event was applicable for off-site care and
parent/guardian notification, and the off-site care and parent/guardian notification were
documented as required. The youth received a follow-up evaluation from a licensed healthcare
staff the next time a licensed healthcare staff was on-site. The episodic care events were
documented in the Episodic Care Log for each of the three applicable IHCRs.
The center has a total of seventeen first-aid kits, nine of which are used for transportation. The
center’s first-aid kits are strategically located in master control, kitchen, maintenance,
intake/release, the modules, and the vans. Observations of three first-aid kits during the week of
the annual compliance review revealed each was fully stocked with designated health authority
approved contents. The center has a process to ensure all first-aid kit contents are maintained
and stored in accordance with guidelines to prevent expiration. All first-aid kits are inventoried
and restocked monthly, and when necessary, by nursing staff. If a first-aid kit seal is broken,
nursing staff restock and seal it. A review of first-aid kit checks during the annual compliance
review period validated the checks were conducted monthly, as required.
The center has two automated external defibrillators (AEDs) located in master control and in
medical. The AED procedures are located with each AED. Nursing staff conduct monthly checks
for both AEDs and an outside provider completes battery checks. Reviewed AED check
documentation during the annual compliance review period validated nursing staff conducted
monthly AED checks, as required. A review of both AEDs indicated all batteries expire on May
20, 2026, and pads expire on November 28, 2024. The AED batteries and AED pads were last
changed on January 28, 2023. A self-test was conducted for each AED and each AED was
operational with no issue.
Emergency drills for the last year were reviewed. The use of cardiopulmonary resuscitation
(CPR) or AED demonstration during emergency drills was confirmed to have taken place during
drills on two shifts; therefore, meeting the annual requirement. The center maintains all
completed emergency drills in a drill binder. A review of all emergency medical drills for the last
year confirmed a drill was completed on each shift, at least quarterly. A list of emergency
numbers was posted and accessible for non-licensed and licensed staff and inaccessible to
youth. A review of training documentation revealed supervisory level staff were trained on the
administration of the epinephrine auto-injector by a registered nurse (RN). A review of seven
pre-service and seven in-service staff training records indicated each staff completed the
required training in episodic, first-aid, and emergency care. The center has facility operating
procedures (FOPs) detailing the use, access, and inventory of Naloxone (NARCAN). The FOP
indicates the center will maintain at least one prescribed stock nasal spray kit for emergency
purpose of accidental overdose for use for youth. NARCAN should not be ordered for each
individual youth. The center maintains NARCAN in the medical office and nursing and
supervisory staff have access to NARCAN. A review of training documentation revealed each
staff with access to NARCAN received training on the use of NARCAN. The nursing staff
conduct a weekly count of NARCAN, and reviewed documentation validated the nursing staff
conducted a weekly count of NARCAN during the annual compliance review period.
An interview with nursing staff indicated first-aid kits are located in all modules, classrooms,
intake, kitchen, master control, staff lounge, supervisors’ office, and in all vehicles. Episodic
care by licensed staff will be documented in the Electronic Medical Record (EMR), in an
Episodic Care Progress Note, and will cover all elements of a subjective, objective, assessment,
and plan (SOAP) note. Any episodic care provided by non-licensed staff shall be documented
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on a Report of On-Site Care by Non-Healthcare Staff form. Youth who received episodic care by
non-licensed staff must have a follow-up evaluation by licensed staff when they return to the
building. An off-site care log is used to track youth who are sent off-site for emergency care. The
interview with nursing staff indicated the center's AEDs are located in medical and master
control. The AED procedures are located in a binder with each AED. Nursing staff check to
ensure AED batteries and pads are operable. The list of emergency numbers is available in the
medical office. Nursing staff indicated the center does emergency medical drills monthly on
each shift. Seven youth were interviewed, three youth said the medical services at the center
are very good, two youth said good, one youth said fair, and the remaining youth said they are
not currently receiving medical services. Seven staff were interviewed, and each staff said they
can call 9-1-1 if needed.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and one IHCR was
applicable for off-site care; therefore, two additional youth records were requested and
reviewed. Reviewed documentation indicated each of the three applicable youth required off-
site care, the Department’s Summary of Off-Site Care Consultation Report form was utilized for
each, and the off-site care events for each youth were documented on the off-site referral
tracking log/Episodic Care Log. Parent/guardian notifications, discharge documents, and other
applicable documents were filed in the IHCR for each of the three applicable youth. Progress
notes in each youth’s IHCR indicated the designated health authority (DHA) was notified of each
event. The DHA or designee reviewed and signed all off-site care findings, instructions, and
information in each IHCR. None of the three IHCRs were applicable for follow-up appointments.
Nursing staff were interviewed and indicated off-site care is tracked on the off-site care log.
Nursing staff review all hospital orders with the DHA and the DHA gives orders to follow in the
center. The DHA reviews off-site care findings when on-site because nursing staff place them in
a folder for the DHA to review each visit to the center. Nursing staff track follow-up testing,
referrals, and appointments on a calendar and send email communication to staff; additionally,
the Summary of Off-Site Care form is utilized if a youth is sent off-site for follow-up testing,
referrals, or additional appointments requested by a provider.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and three IHCRs were
applicable for chronic conditions. Each of the three applicable youth were identified on the
Department’s Facility Entry Physical Health Screening form with a current chronic condition, had
a documented Medical Grade of two through five, and two of the three were taking prescribed
medication on an on-going basis. Each of the three applicable youth were placed on a chronic
conditions list, as required. None of the three applicable youth stayed at the center for at least
ninety days for periodic evaluations, were taking tuberculosis medication, had a communicable
disease, were pregnant, needed evaluation prior to renewing an expired medication, or required
off-site evaluation. The Department’s Problem List was updated, as required, for each of the
three applicable youth and there was no indication of lapses in care for any youth. An interview
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with nursing staff indicated the designated health authority (DHA) is notified of and sees all
youth with chronic conditions, and chronic conditions are listed in the chronic condition binder.
The DHA was interviewed and indicated youth with chronic medical conditions are seen for
periodic evaluations a minimum of every ninety days. The registered nurse (RN) manager keeps
track of when periodic evaluations are due, and the DHA sees the youth when on-site.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication
management. Six youth were taking medication at the time of admission; however, medications
were only brought to the center for two youth, both of which were verified prior to being admitted
to the center. The prescription verification was included in the chronological progress notes for
both youth. The designated health authority (DHA), and when applicable the psychiatrist, were
contacted to obtain an order to resume medications prescribed prior to admission for all six
youth. The remaining youth was not prescribed any medication. None of the youth were
prescribed new medication after being admitted to the center. All medications for five of the six
youth had a current, valid order, and were administered pursuant to a current prescription. One
youth had an order placed which stated the incorrect dose. An order with the correct dose was
placed the next day; however, the incorrect order was not discontinued until three days later.
The youth received the correct dose every day despite the order being incorrect and the
Department’s Office of Health Services confirmed the youth received their medication as
intended. The DHA/designee placed an order on the Practitioner Order form for each current
medication which was continued, discontinued, or changed. The prescription verification for
each youth was documented in the chronological progress note in their IHCR. None of the six
applicable youth were in restricted housing. Two youth required over-the-counter medications
not listed on the Authority for Evaluation and Treatment (AET), and both were administered
according to approved protocols. The Medication Administration Record (MAR) was utilized for
each youth to document all medication and treatment including start and stop dates. Each MAR
contained all required elements, with the exception of one MAR which did not include a current
picture of the youth. The nursing staff documented weekly side effect monitoring on each MAR,
and nursing staff initialed each provided medication entry. There were no lapses or errors noted
for any medication. None of the medications were administered by non-healthcare staff. None of
the youth required parenteral medications or were applicable for refusal of medication. Four
youth were prescribed psychotropic medication prior to admission and the DHA and psychiatrist
were notified of each youth’s admission. Initial psychiatric interviews were conducted within
fourteen days of admission for three of the four youth. One youth was released from the center
prior to fourteen days; therefore, no psychiatric interview was conducted. None of the youth
remained at the center for thirty days to receive a thirty-day medication review.
The center has a facility operating procedure (FOP) for medication disposal which indicates a
registered nurse shall be responsible for the disposal of medications in conjunction with the
pharmacy consultant. Controlled and non-controlled medications must be disposed of by
utilizing the Drug Enforcement Agency (DEA) approved Drug Buster disposal system in
accordance with state board of pharmacy and DEA disposal plan. The center did not have any
standing orders, emergency treatment orders, or pro re nata orders for psychotropic
medications.
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One medication pass was observed during the annual compliance review week. The youth was
escorted to the medical clinic. The youth approached the nursing staff individually, the nursing
staff identified themselves, and indicated why the youth was there. The nursing staff verified the
youth’s allergy and alert status, prepared, and administered the medication, did not pre-pour the
medication from original packaging, and observed the youth to ensure the medication was
swallowed. Both the youth and nursing staff signed the MAR, and the medication administration
was documented as required.
Nursing staff were interviewed and indicated if a youth arrives with medication, a medication
receipt is filled out and the nurse reviews the medication to ensure it is from a licensed
pharmacy with a patient specific label intact on the original medication container in order to
accept it. Medications shall have a current, valid order and are given as ordered on current
prescription or Practitioner Order form. The DHA or psychiatrist shall be contacted to obtain the
order to resume the specified medications prescribed prior to admission. The center utilizes a
standard Department MAR. Juvenile justice detention officer supervisors at the center are
trained to pass medications. The approved list is in the front of the medication book. Medication
pass is daily as required by orders. At the time of the annual compliance review the center had
med pass at 8 a.m., 5 p.m., and 7 p.m. The center has a modified Class II permit. Seven youth
were interviewed. Three youth said they do not currently take medication and the remaining
youth said the nurses provide the medication to youth. Seven staff were interviewed, and all
said they do not provide medication to youth.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has facility operating procedures regarding stock medications and medical
equipment classified as sharps. An observation of the center’s medical area was completed
during the annual compliance review week. The center maintains all sharps in a locked cabinet
in medical. Sharps are inventoried utilizing a perpetual inventory, which descends as sharps are
utilized and disposed. All medications are maintained in medical, and all are locked in
designated storage areas. The medication cart is clean and organized with stock items separate
from youth-specific medications. All injectable, topical, and liquid medications are securely
maintained, separated, and inaccessible to youth. The oral medications were stored separate
from injectable and topical medications. The center’s controlled medications had a perpetual
inventory and were stored separately from other medication. The nurse indicated the center’s
practice is to store all narcotics and controlled medications behind two locks in the medication
cart. An observation of the medication cart confirmed the separate box inside the cart with an
additional lock. The center maintains two small refrigerators in medical, which are utilized for
medication only. An observation confirmed only medication was in the refrigerators. A review of
the medical binders for sharps and over-the-counter (OTC) medications confirmed a perpetual
inventory is maintained for OTC medications. The supervisory floor staff were trained by the
center’s registered nurse (RN) on the delivery and oversight of medication administration. An
observation of counts of three different controlled medications, sharps, and OTC medications
was completed during the annual compliance review week. All the controlled medications,
sharps, and OTC medication counts matched the center’s inventory counts. An informal
interview was conducted with the RN regarding reporting criteria and procedures regarding
inventory discrepancies and the disposal and destruction of expired and/or discontinued
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medications. The RN stated it would be confirmed if the missing medication was used and not
documented and a review of youth information would be completed. Medical staff would be
asked to determine if the medication was administered, and they forgot to document it. If unable
to determine the location of the missing medication, a report would be submitted to the medical
supervisor and a report would be submitted to the Department’s Central Communications
Center notating the medication error. The RN stated the medical staff utilize destroyer solution
to dissolve medications. If a controlled substance is being destroyed, the controlled substance is
dissolved when the pharmacist is on-site. The destruction of a controlled substance is
documented in the pharmacy book. An interview with nursing staff confirmed all controlled
medications are disposed of by nursing staff and the pharmacy consultant. The nurse stated all
controlled substances such as narcotics are kept in a locked compartment in the medication cart
which is also locked. The nurse stated the center has a current agreement with a consultant
pharmacist, who is on-site monthly. The pharmacy consultant reviews the center’s medication
cart, medication cabinets, medication refrigerator, destroys medications, ensures all items are
labeled appropriately, reviews Medication Administration Records (MARs) and sharps, as well
as ensures licenses are up to date. Nursing staff confirmed the center maintains a copy of the
pharmacy consultant’s license on-site and it is a Consultant Pharmacy License, not a
Registered Pharmacy Consultant License.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
Seven youth Individual Healthcare Records (IHCRs) were reviewed, and each youth received
infection control training within seven days of admission, including hand-washing techniques,
vaccinations, universal precautions, prevention/transmission of communicable diseases, and
the Centers for Disease Control and Prevention (CDC) guidelines on infection control. A review
of the center’s Exposure Control Plan revealed the plan was written in accordance with
Occupational Safety and Health Administration (OSHA) standards and included all required
elements of risk assessment and methods of compliance. A review of the center’s infection
control procedures revealed they included prevention, containment, treatment, and reporting
requirements related to infectious diseases, according to the OSHA and CDC guidelines, and
included all required elements. The center has facility operating procedures addressing needle
stick post-exposure evaluation, and for staff to have access to personal protective equipment
and Hepatitis B immunizations. The procedures for needle stick post-exposure evaluation
include identification and status of the source of the individual, testing of the blood of the
individual, documenting route of exposure and circumstances related to incident, referring the
individual for medical attention, offering post-exposure prophylaxis and counseling, informing
the individual on potential illnesses to be alert for, and assuring the process is effectively carried
out. An informal interview with the nursing staff revealed the center did not have any infectious
diseases or sexually transmitted infections during the annual compliance review period which
had to be reported to the local health department, the CDC, and the Department’s Central
Communications Center (CCC). The superintendent indicated the center has not had any
instances of occupational exposure. A review of seven pre-service and seven in-service staff
training records revealed each staff received training on the center’s Exposure Control Plan.
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Nursing staff were interviewed and indicated Infection and Exposure Control Plans are available
to staff and the registered nurse manager conducts exposure control training for staff. Youth
receive training during admission. The center uses county health department services for
immunizations, dental care, and pre-natal care.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed, and none were applicable
for prenatal care/education. The center had no pregnant youth during the annual compliance
review period. Seven reviewed IHCRs revealed each youth received education related to
pregnancy including all required topics which were documented on the Health Education
Record. Reviewed training documents validated the center’s licensed nursing staff provided
education on prenatal healthcare annually to all non-healthcare staff involved in the supervision
or treatment of youth. A review of seven in-service staff training records revealed each staff
received training in youth healthcare including observation and monitoring of emergency care
needs and symptoms of possible miscarriage. The center has standing orders for pregnant
youth. Nursing staff were interviewed and indicated prenatal care is set up for pregnant youth
who receive scheduled gynecology appointments, pregnancy diets, and are educated on
pregnancy. Female youth are tested for pregnancy upon admission and as ordered by the
designated health authority. The registered nurse (RN) provides non-licensed healthcare staff
education on girls’ healthcare. Each youth is given a handout and they review shaken baby
syndrome, the difference of breast feeding and bottle feeding, what to expect with body
changes, dietary needs, and post-partum expectations. Seven youth were interviewed, and
none needed prenatal care.
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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 addressing active supervision of youth. Staff
supervision of youth was observed each day of the annual compliance review. Staff were
observed actively supervising youth on the living modules, in the classrooms, in the cafeteria, in
the transportation area, and during line movements throughout the center. Positive interactions
were observed with youth and staff. Youth were always in sight of at least one juvenile justice
detention officer (JJDO), youth were accompanied by staff at all times, and master control
authorized movements of youth prior to youth being moved. A review of center logbooks found
youth counts were consistently conducted. The center tracks the daily census through logbooks
and the Department’s Juvenile Justice Information System (JJIS). Seven staff were interviewed
and four indicated there are enough staff at the center to provide for the safety and security of
all youth. One staff indicated there are enough staff, but the schedule is not done right, one
stated the center needs more staff, and the remaining staff stated there is enough staff some
days.
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5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures requiring a uniform behavior management system
(BMS) which offers rewards, privileges, and consequences based on youth behavior. The
center’s BMS includes rewards for positive behavior, which are given to match the center’s BMS
incentive calendar, and consequences for inappropriate behavior. Postings of the BMS, which
clearly specified appropriate and inappropriate behaviors, rules, norms, and expectations, were
observed throughout the center. A review of BMS documentation, including youth point cards,
did not find any instances of inappropriate use of restrictions or group punishment. Seven staff
were interviewed, and each staff was able to explain the center’s BMS process, indicating it is a
level system related to youth behavior. Six staff indicated the BMS is included in the youth
handbook or orientation process, five staff indicated the BMS is posted throughout the center,
and three staff indicated it is a point system. Interviewed staff indicated rewards provided by the
center include snacks, extra phone calls, outdoor activities, games, movie nights, and outside
meals. One interviewed staff indicated things cannot be taken away from youth as a
consequence. The remaining six staff indicated things can be taken away from youth as a
consequence; however, they each indicated the youth’s level can be dropped, they can lose
points, and they won’t earn rewards. Six interviewed staff indicated they feel the BMS is
effective. The remaining staff indicated it is only effective when it is done properly. Each
interviewed staff indicated staff speak with youth to discuss consequences being imposed,
youth are given an opportunity to explain their behavior, and staff speak with youth about
alternative acceptable behaviors. The interviewed staff indicated supervisors provide feedback
to them regarding the implementation of the BMS through debriefings, trainings, meetings, and
talking to them one on one. Three staff indicated they receive feedback daily, two weekly, two
as needed, and one indicated they never receive feedback on the implementation of the BMS.
All seven staff indicated they have never seen staff take meals, snacks, clothing, education, or
medical care from a youth because they were acting out and they have never observed any
staff encouraging youth to beat up another youth. Seven youth were interviewed, and three
youth indicated they would the rate the BMS as very good. Three youth indicated they would
rate the BMS as good, and the remaining youth indicated they would rate it poor. Each youth
was able to explain the BMS and indicated youth can move levels based on your actions. The
interviewed youth indicated rewards at the center include snacks, free time, outside time, being
able to get their hair done, group projects, and extra phone calls. One youth indicated the center
is supposed to be doing a “corner store” but they have not done it in the three months they have
been there. Five interviewed youth indicated all staff use rewards the same. One youth stated
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they were not sure, and the remaining youth indicated it depends on the staff. Each youth
indicated youth are never allowed to punish other youth. Five youth indicated they have never
been sent to their room for punishment reasons. The remaining two youth indicated they have;
however, one stated it was confinement when refusing school. Two youth indicated
consequences at the center are fair and the remaining five stated they have never received
consequences. One youth stated their level was taken away as a consequence, the remaining
six youth did not report anything being taken away as a consequence or stated they have never
received consequences. Two youth said handcuffs or leg irons are not used on out of control
youth to prevent them from hurting themselves or others, and the remaining five youth stated
they have never witnessed it. The center’s superintendent was interviewed and indicated the
center’s BMS includes a partnership with all staff working toward a three-level system for
rewarding positive behavior. The superintendent indicated as a youth’s level progresses, they
earn extra privileges such as extra phone calls, family dinners, television, games, and extra
snacks.
5.03 Ten-Minute Checks (Critical) Failed Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures indicating staff shall visually observe youth at least
every ten minutes while they are in their sleeping room. The center has sixty-four cameras, all of
which were operational at the time of the annual compliance review. The center maintains video
recordings for a period of thirty days. A review of video security tapes and corresponding logs
was conducted to verify ten-minute checks for the last thirty days. The sample of security tapes
and corresponding logs included three samples of thirty-minute increments from each shift on
each living module. The reviewed video footage and wand reports revealed staff conducted two
checks one minute late, three checks two minutes late, one check three minutes late, two
checks four minutes late, one check five minutes late, one check nine minutes late, one check
eleven minutes late, one check thirteen minutes late, one check twenty-two minutes late, and
one check twenty-three minutes late.
A review of wand logs for ten-minute checks from May 2023 until March 5, 2024, was
conducted. One thirty-minute increment on each shift for each month was reviewed, with the
sample including all living modules. The center was unable to locate ten-minute check wand
records for the months of May, June, July, and August 2023. A review of wand logs found one
check was conducted one minute late, two checks were conducted two minutes late, one check
was conducted four minutes late, four checks were conducted seven minutes late, one check
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was conducted eleven minutes late, two checks were conducted twelve minutes late, one check
was conducted sixteen minutes late, one check was conducted eighteen minutes late, one
check was conducted twenty minutes late, and one check was conducted one hour and forty-
five minutes late. Seven staff were interviewed, and each staff stated room checks are
conducted every ten minutes when a youth is placed in their room for sleeping or non-
punishment reasons. The center’s superintendent was interviewed and indicated ten-minute
checks are conducted for all youth utilizing the wand at bedtime and utilizing a room check form
while in their room for shift change.
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 in place to ensure staff always know the exact
number and location of all youth under their supervision. Observations while on-site found
counts were conducted prior to and following all group movement. Seven staff interviews were
conducted, and each staff stated counts are conducted at the beginning and end of each shift.
Two staff also indicated counts are conducted before and after school and before and after
every meal. A review of one day each month during the annual compliance review period in the
master control logbooks confirmed census counts of youth are documented at the beginning
and end of each shift, prior to and following routine group movement, anytime a population
change occurs, randomly, and at least once on each shift. Head counts and youth movements
are both documented in the center’s logbooks.
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5.05 Logbook Maintenance Failed 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 center has a facility operating procedure ensuring they maintain a chronological record of
events, incidents, and activities. The center maintains separate logbooks in master control and
for each living module, as well as one for visitors, and one for contracted staff. The center’s
master control logbook includes emergency situations, incidents, all drills, the receipt of medical
and mental health alerts, population counts at the beginning and end of each shift and
throughout shifts and count changes, youth counts following emergency situations, group
movement, admissions and releases, presence of law enforcement, the names of youth placed
in confinement with the time it began and ended, and youth placed on precautionary
observation along with the time initiated and ended. The center was unable to locate their
master control logbook from June 20, 2023 through July 26, 2023. Each logbook was bound
with numbered pages and the date documented at the top of each page. A review of three full
days each month for the annual compliance review period found logbook entries included the
time of each event in a.m. or p.m., the name of the staff and youth involved, a brief description
of each event, and the initials of the staff making each entry. Entries impacting the safety and
security of the center were highlighted and all errors were struck through with a single line, with
“void” written after the error followed by the staff’s initials. Documentation found the juvenile
justice detention officer (JJDO) supervisors reviewed the master control logbook when
accepting responsibility for the center and reviewed the living area logbooks daily and JJDOs
reviewed logbook entries from the previous shift when accepting responsibility for the living
area. All reviews documented the name and position of the reviewer, as well as the date and
time the review was completed.
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5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) 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 a facility operating procedure regarding logbook reviews. The superintendent or
designee is required to review all logbooks on a weekly basis and provide recommendations as
to the completeness and accuracy of the information recorded. Juvenile justice detention officer
(JJDO) supervisors are required to review the master control logbook when assuming
responsibility of the center and review the logbook maintained in each living area daily. JJDOs
are required to review the logbook in their assigned module when accepting responsibility for
the living area at shift change. The superintendent, assistant superintendent, or staff in charge
of the center is required to tour the youth living areas at least once during each shift and
document their visit in each area’s logbook. A review of three full days each month for the
annual compliance review period found reviews were conducted and documented as required.
During an interview, the superintendent stated JJDO supervisors are required to document their
reviews and security checks in the center’s logbooks a minimum of two times during their shift
and administrators are required to document their reviews and security checks at a minimum of
once a week on each shift. The superintendent stated only blue or black ink can be used, no
white out is allowed, and no scribbling is allowed. The superintendent indicated they conduct
reviews of admissions, releases, supervision level changes, confinements, and more.
5.07 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 stating they will maintain inventory and control of all
facility center keys. The center’s policy includes the control and use of keys including key
assignment and usage, inventory, daily tracking, and reconciliation of keys, secure storage of
keys not in use, procedures addressing missing or lost keys, and reporting and replacement of
damaged keys. Facility keys are secured within a locked room in a locked box. Staff keys are
kept in a locked room in the administration area. Restricted keys are only available to staff in the
respective areas. An observation of shift debriefing found keys are assigned to staff during
debriefing by a juvenile justice detention officer (JJDO) supervisor. Emergency key rings are
located in master control and are included in the facility key inventory. A review of the master
key inventory found it includes each key ring number, the number of keys on each key ring, the
capability of each key, and to whom the key ring was issued. Each key ring was numbered and
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indicated the number of keys on it. All facility keys were placed on a key ring hubs system and
all key ring hubs were color-coded with the appropriate color of hub on each ring. The issuance
of keys and key ring numbers were documented, with the documentation including the date and
time of issue, name of staff issuing the key ring, name of staff receiving the key ring, and the
time the key ring was returned. Observations while on-site found staff carried their issued keys
on their person at all times, youth were not allowed to handle keys, and no keys were removed
from the facility or facility grounds. A review of incidents reported to the Department’s Central
Communications Center (CCC) found the center had one incident reported to the CCC during
the annual compliance review period related to key control. Staff did not return keys to a facility
vehicle upon their return to the facility. The incident was reported as required and the staff
received a re-training. A sample of five key rings was observed and compared to the inventory
and key log. All five key rings were present on the key log and matched the center’s inventory.
Three staff were informally interviewed, and each staff knew the number of keys on their ring
and the function of each key. Seven staff were interviewed and each indicated medical record,
mental health record, and kitchen keys are restricted. Six staff indicated case management keys
are restricted. Five staff indicated youth property area keys are restricted, and one staff
indicated administration keys are restricted. Each interviewed staff was able to explain the key
control process. Six staff indicated personal keys are securely stored, visitor keys are given to
master control, and they are provided with a chit or token, and youth do not have access to
keys. Five staff indicated a key log is utilized and program keys are assigned to staff. Three staff
indicated damaged keys are replaced. Two staff indicated they would notify master control if a
key was missing, and one staff indicated staff keys are given to master control upon entry, there
is an inventory of keys, and if a key is missing a search of the facility and of youth is conducted.
Two staff also indicated if a key is missing the CCC is notified. The superintendent was
interviewed and indicated they are in charge of permanent assignment issued keys and
administration staff have permanent issued keys.
5.08 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 ensuring any vehicle used to transport youth is
properly maintained. The center has six vehicles they utilize for transporting youth. A review of
documentation found each vehicle underwent an annual vehicle inspection by a certified
mechanic to ensure the tires, lights, and brakes were safe. A review of monthly visual vehicle
checks since the last annual compliance review found maintenance staff or a designee
conducted monthly visual checks of each vehicle which included a check of the water coolant,
lights, oil, emergency equipment, brakes, horn, interior/exterior, cleanliness, tires, battery,
windshield and wipers, mirrors, and damage. Each inspection was documented on the
mandatory inspection form and maintained by the center. An observation of each center vehicle
found each vehicle contained the appropriate number of seatbelts, a seatbelt cutter, a window
punch, a current fire extinguisher, and a first-aid kit. A review of the van logbook found each
transport was documented and documentation included acknowledgement the vehicle was
checked, the number of youth and staff names, the name of the officer riding in the back of the
vehicle, the time transport began, and the time transport ended. An observation of a transport
during the annual compliance review week found prior to the transport a transport staff
inspected the vehicle for contraband, ensured the vehicle had sufficient gasoline to reach the
destination, ensured a copy of transportation procedures was in the vehicle, verified seatbelts
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were anchored, tested the security cage, confirmed the vehicle folder contained vehicle logs,
vehicle and mechanical restraint keys, a gas credit card, and the vehicle registration, ensured a
cellular telephone was assigned, was charged, and was turned on prior to departure, ensured
the inspection was documented in the vehicle logbook, ensured the vehicle was secured,
ensured all youth were searched prior to being placed in the vehicle, and ensured all youth and
staff were wearing seatbelts. An observation following a transport during the annual compliance
review week found transport staff searched the vehicle for contraband, locked the vehicle, and
conducted a search of the youth. During the annual compliance review week, eight vehicles
were checked to ensure they were locked when not in use. One staff personal vehicle was
found to be unlocked. The center was notified the vehicle was unlocked. The vehicle was
checked again later in the day and was unlocked again. Seven youth were interviewed, and
each youth indicated they feel staff drive safely when transporting youth. Each youth indicated
they have never seen anyone place contraband in a transport vehicle.
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center maintains facility operating procedures to ensure all tools are properly maintained,
stored, and inventoried. The center’s policy indicates all tools will be stored in a secure,
designated area with a shadow board for each tool. Tools are to be inventoried monthly, and a
tool logbook is to be utilized to document any time a tool is taken on the secure floor. Kitchen
tools are to be kept in a locked cabinet with a shadow board and inventoried weekly. Daily
inventories are also to be kept of kitchen tools, in the morning, mid-day, and evening.
Observations while on-site found all tools were secured in the locked maintenance workshop,
which is accessible by maintenance staff and the superintendent or designee. Kitchen tools
were located within a locked cabinet in the kitchen. All tools are stored on shadow boards and
are marked with a number to identify them as property of the Department. A review of the tool
inventory and observations of tools found there were no tools listed missing or tools not listed on
the inventory. Eight tools were reviewed, and each tool was secured and had a marking for easy
identification. A review of the inventory compared to the tools found the inventory was accurate
and was signed by the superintendent or designee. A review of the kitchen tool inventory found
staff conducted an itemized inventory of all equipment, including knives, upon reporting for duty.
Documentation found tool replacement was verified and documented by the superintendent or
designee. During an informal interview, maintenance staff indicated service vendors are
accompanied by designated center staff at all times when in a secure area of the center and
areas are cleaned and inspected for contraband prior to allowing youth access following a work
project. During an interview, the superintendent stated maintenance staff have access to facility
tools. Seven staff were interviewed, and each staff indicated they would notify their supervisor
or master control if there was a damaged or missing tool. Five staff also indicated a search
would be conducted.
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5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
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 ensuring youth do not have access to any tools.
The center’s policy indicates youth do not use tools, including kitchen and medical equipment.
Youth have access to mops, brooms, buckets, and cleaning towels under direct staff
supervision. An observation of youth cleaning during the annual compliance review week found
the policy was being followed, as youth were observed mopping under staff supervision. Six of
seven interviewed youth indicated they use mops and brooms at the center. One youth also
stated they use scrub brushes. The remaining youth indicated they do not use any tools. Five
interviewed youth indicated they clean with cleaning agents such as bleach, laundry soap,
window, or toilet cleaner; however, each stated only staff handle the items. The remaining two
youth indicated they do not use any cleaning agents. Seven staff were interviewed, and six
indicated youth use mops and brooms. The remaining staff indicated youth to not utilize any
tools.
5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
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 Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS 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.
The center has facility operating procedures addressing the inventory of flammable, toxic,
caustic, and poisonous items. A review of chemical inventories found the center maintained an
inventory of all flammable, toxic, caustic, and poisonous items. Five chemicals were observed
and matched to the chemical inventory. The actual count matched the count on the inventory
form for each chemical with no discrepancies. Each reviewed item had a Safety Data Sheet
(SDS) present for the item. SDSs were located in a logbook, posted near the items, and
available to staff.
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5.12 Access to all Flammable, Toxic, Caustic, and Poisonous
Limited Compliance
Items (Critical)
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 indicating youth are not permitted to use or handle
flammable, toxic, caustic, and poisonous items. Youth are not to be permitted access to any
materials which are flammable, toxic, caustic, and/or poisonous. Observations on-site found all
flammable, toxic, caustic, and poisonous materials were not stored in secure areas inaccessible
to youth with only authorized personnel permitted access, as chemicals were observed to be
unsecured by the staff desk and on a chair within one of the youth living modules. Seven youth
were interviewed, and six youth indicated they do not have access to flammable, toxic, caustic,
or poisonous items. The remaining youth stated they do have access. Six of seven interviewed
staff indicated youth do not have access to flammable, toxic, caustic, or poisonous items. The
remaining staff stated they do; however, staff always handle and spray the chemicals for youth.
5.13 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 which addresses proper use, storage, and disposal
of flammable, toxic, caustic, and poisonous items. The plan addresses what procedures to
follow in the event of a chemical leak or spill. The center did not have any instances of chemical
spills or disposal of any flammable, toxic, caustic, or poisonous items during the annual
compliance review period. The center maintains a container in the kitchen for grease designated
for disposal. An interview with maintenance staff found if there are materials needing disposed
of, they are disposed of by evaporation, compaction, or taken to a local recycling facility.
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures addressing the requirements for behavioral
confinement for less than twenty-four hours. The center had 109 confinements lasting less than
twenty-four hours since the last annual compliance review. Thirteen confinements under twenty-
four hours were reviewed. Each youth was provided three meals a day plus school and an
evening snack, access to mental healthcare as requested/needed, a daily shower, clean
clothing, a mattress and bedding, and education materials, if confined during education hours.
Each youth was notified of their right to grieve their confinement placement. Each confinement
was approved by a juvenile justice detention officer (JJDO) supervisor prior to placement. Each
room was searched prior to placing a youth in confinement and only one youth was placed in
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each confinement room. Each youth was supervised while in confinement, and supervision was
documented on a confinement Visual Observation Report (VOR) for each youth at the proper
time intervals. No physical injuries were observed and none of the youth complained of injury or
illness. The reason for confinement was explained to each youth and a JJDO supervisor
conducted an initial confinement review with each youth within one hour from the incident. Each
confinement report was completed before the end of the shift. A JJDO supervisor conducted
additional reviews with twelve of the youth at a minimum of every three hours. The remaining
youth had a review conducted two hours late. Each youth was continually counseled, and staff
considered removing each youth from confinement as soon as they were able to safely rejoin
the population. None of the reviewed confinements interfered with visitation. Each confinement
report was reviewed by the superintendent or designee within forty-eight hours. The center did
not have any pregnant youth in confinement during the annual compliance review period. The
superintendent was interviewed and indicated administrators are required to review and sign all
confinement reports and review video surveillance for accuracy. Seven interviewed staff were
able to explain the process for placing a youth in confinement. Each staff was able to explain
supervision requirements and stated a confinement report must be completed. Each interviewed
staff stated youth placed in temporary confinement are provided education materials.
5.15 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.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has a facility operating procedures indicating Continuity of Operations Plan (COOP)
drills shall be conducted at least twice a year. A review of drill documentation found the center
conducted at least two drills a year including severe weather, major disturbances, hostage
situations, chemical spills, flooding, or terrorist threats, with one drill being completed prior to
hurricane season, which starts June 1. The center completed two COOP drills, both of which
were weather related, and the documentation for both included the type of drill, date and time,
participants, a brief scenario, findings, and recommendations. Seven staff were interviewed and
six staff indicated they participated in fire drills, five staff indicated they participated in an escape
drill, and one staff stated they participated in a weather, major disturbance, bomb threat,
hostage situation, chemical spill, flooding, and terrorism drill. The superintendent indicated
specific emergency medications and rescue tools are available for use in the event of an
emergency. The superintendent stated all staff coming in contact with youth shall know the
location of all emergency response equipment and be trained on their use.
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5.17 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 indicating they will conduct and document quarterly
mock escape drills. The center maintains an Escape Prevention Plan which includes the
Department’s policies and procedures regarding escapes. A review of drill documentation found
escape drills were conducted quarterly, and documented in the logbook, as required. A review
of seven pre-service and seven in-service staff records found each staff was trained in escape
prevention. Five of seven interviewed staff indicated they participated in an escape drill since
the last annual compliance review.
5.18 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 indicating monthly fire drills will be conducted under
varied conditions and on each shift. A review of drill documentation since the last annual
compliance review found the center has conducted monthly fire drills on each shift with the
exception of first shift in June 2023 and first and second shift in August 2023. Each completed
drill was documented in the center’s master control logbook. A review of documentation found
the fire extinguishers at the center were inspected annually. Seven staff were interviewed and
six staff stated fire drills take place at least monthly. The remaining staff stated they do not. Two
of seven interviewed youth stated they have been instructed on what to do in the case of a fire.
The remaining five youth stated they have not.
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Office of Accountability and Program Support Page 60 of 61 (Revised July 2023)
5.19 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 regarding contraband and searches. A review of
search documentation found frisk searches are conducted prior to admission, as well as an
electronic search and a strip search. All searches are documented both in the logbook and
electronically. A room search was observed during the annual compliance review week and staff
were wearing gloves during the search. A review of search documentation found strip searches
were not conducted any time other than at admission. Two staff of the same gender of the youth
were present when conducting each strip search and each strip search was conducted
individually and not in a group setting. Observations while on-site found electronic searches
were conducted on all persons entering the facility. All bags and other items were searched and
personal keys, personal cell phones, and all other contraband items were prohibited from
entering the secure area. A review of room search documentation found rooms were searched
upon a youth’s release and prior to placing a new youth in a room. A review of room search
documentation from one day each month during the annual compliance review period found
room searches were documented and completed on each awake shift. A review of incidents
reported to the Department’s Central Communications Center (CCC) found two incidents during
the annual compliance review period which may have compromised the safety or security of the
center. Both incidents were reported to the on-duty supervisor and reported to the CCC as
required. A review of the two incidents found both instances were documented in the logbook,
incident reports were completed, law enforcement was contacted, and items were confiscated.
The chain of custody of confiscated items was documented and the regional director or
designee was notified. An interview with the superintendent found all contraband must be
documented in the master control logbook and an incident report be completed. Law
enforcement is to be notified of contraband, the item is to be confiscated, and the CCC and
regional director are notified.
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Office of Accountability and Program Support Page 61 of 61 (Revised July 2023)

source: DJJ

report_type: QI Detention

rule: Indicator 1.05

excerpt: Protective Action Response (PAR)

rating: Failed Compliance

rule: Indicator 1.08

excerpt: Grievances

rating: Limited Compliance

rule: Indicator 3.12

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.05

excerpt: Logbook Maintenance

rule: Indicator 5.12