summary: QI Detention - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
St. Lucie Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
1301 Bell Avenue
Fort Pierce, Florida 34982
Review Date(s): February 27- March 1, 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:
Shakela Minns, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
2)
Peter Keelan, Office of Education, Southeast Region Education Coordinator (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Sharon Wong, Office of Accountability and Program Support, Regional Monitor (Interviews)
Program Name: St. Lucie Regional Juvenile Detention Center MQI Program Code: 225
Provider Name: State Operated Contract Number: N/A
Location: St. Lucie County / Circuit 19 Number of Beds: 50
Review Date(s): February 27- March 1, 2024 Lead Reviewer Code: 159
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures) and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 59 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 59 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 59 (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 * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 59 (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 59 (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* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
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 * Satisfactory
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 59 (Revised July 2023)
Program Overview
The St. Lucie Regional Juvenile Detention Center is a state-owned detention center, operated
by the Department, located in Fort Pierce, Florida. The center serves youth in St. Lucie, Martin,
Indian River, and Okeechobee counties in Circuit 19. The St. Lucie Juvenile Assessment Center
(JAC) is situated inside of the center. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-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 St. Lucie County School District.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant, eight juvenile justice detention officer (JJDO) supervisors, and
forty-one JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by one
designated mental health clinician authority (DMHCA), one licensed mental health counselor,
one licensed clinical social worker, one psychiatrist, and one counselor. 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 the availability for substance abuse services for youth
with co-occurring disorders. Medical services are provided by one designated health authority
(DHA), one advance practice registered nurse (APRN), one registered nurse (RN) serving as
the clinical manager, four RNs, one licensed practical nurse (LPN), and one medical clerk. The
medical clinic maintains nursing coverage seven days a week, from 7:00 a.m. to 8:15 p.m., and
on weekends, from 7:00 a.m. to 6:00 p.m. Food services are provided by Department staff and
include menus, meal planning, meal schedules, special diets, nutritional analysis, daily
allowance, food preparation, health certifications, food product standards, sanitation, and
cleaning. Staff are responsible for the custody and control of youth in their care, providing youth
supervision twenty-four hours a day, seven days a week. The center has three living modules
which are divided by male and female. There are sixty-four security cameras at the center, of
which sixty-three were operational. The one camera which was not operational is in an area
where there are no youth. A tour of the center was conducted during the annual compliance
review week and observations found it to be clean with minimal graffiti and free from insect
infestation. Common areas, living modules, bathrooms, classrooms, kitchen, and dining areas
were observed to be clean. The center is an older center and is currently awaiting renovations.
At the time of the annual compliance review, the center had four vacancies, which included four
JJDO I positions.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 59 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures ensuring initial background screenings are
conducted on all newly hired staff, contracted providers, mentors, interns, and volunteers. A
review of the initial background screenings for seventeen newly hired staff, four new contracted
staff, and seven new volunteers found the center received background screening results from
the Department’s Background Screening Unit (BSU)/Clearinghouse prior to each staff’s hire
date. Reviewed documentation validated a criminal history report was reviewed for each staff,
contracted staff, and volunteer prior to being hired. None of the staff, contracted staff, or
volunteers were applicable for a background screening exemption. None of the reviewed staff
were applicable for a break in service. The center utilizes an ergometric pre-employment
assessment tool for all direct care applicants. Fifteen applicants were applicable for being direct
care, and each record included a copy of the pre-employment assessment passing score
maintained in accordance with policy. Reviewed documentation validated the center added all
staff, and volunteers to the Clearinghouse employment roster. The center submitted the Annual
Affidavit of Compliance with Level 2 Screening Standards to the Department’s BSU on January
25, 2024, meeting the annual requirement. The Annual Affidavit of Compliance with Level 2
Screening Standards for school board teachers was submitted to the BSU on January 25, 2024.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures which require staff, contracted staff, and volunteers
to be rescreened every five years from the initial date of employment. A review of the staff roster
found the center had seven staff, three contracted staff, and eight volunteers eligible for a five-
year rescreening. Reviewed documentation confirmed each volunteer’s or staff’s rescreening
was completed and submitted to the Department’s Background Screening Unit
(BSU)/Clearinghouse within the required time frames.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 59 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures regarding staff code of conduct. Staff are required
to adhere to the code of conduct which prohibits any type of abuse, profanity, threats,
harassment, intimidation, horseplay, or personal relationships with youth. Five staff personnel
records were reviewed, and each record contained a signed code of conduct form. All five
personnel records contained disciplinary actions for violations of the code of conduct. Two staff
received an oral reprimand, one staff was terminated, one staff resigned, and another staff
received a written reprimand. Reviewed documentation confirmed retraining was provided to
correct the staff actions when applicable. Three additional personnel records were reviewed for
commendations. Two staff received commendations for employee of the month. One staff
received employee of the year for outstanding work performance and dedication. Five youth
were interviewed, and one of five youth reported never being stopped from reporting abuse to
the Florida Abuse Hotline, and four youth reported they never had to report abuse. Five youth
reported staff were respectful when talking to youth. Three youth stated they never heard staff
use profanity when speaking to the youth, one youth reported once, another youth reported
hearing staff use profanity often. All five youth reported they have never heard staff threaten
youth and they felt safe at the center. Each youth reported they have never exchanged emails,
telephone numbers, or social media information with staff. Five staff were interviewed, and each
staff was able to explain the process for allowing youth to call the Florida Abuse Hotline or the
Department’s Central Communications Center (CCC) to report suspected abuse. Each
interviewed staff reported never hearing a co-worker use threats, intimidation, and/or humiliation
when interacting with youth. Two of the five interviewed staff reported never hearing staff use
profanity when speaking to youth. One staff reported hearing staff use profanity once and two
staff revealed they have occasionally observed staff using profanity when speaking to youth.
This information was shared with the center’s administration staff during the week of the annual
compliance review. Each staff described the working conditions at the center as good. An
interview with the superintendent confirmed staff must act in a professional manner with youth
and peers. The superintendent indicated staff are expected to be role models for the youth in
the center. In addition, the superintendent reported any form of abuse, or the use of profanity is
not acceptable in the workplace.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 59 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures to ensure when a reportable incident occurs the
center notifies the Department’s Central Communications Center (CCC) within two hours of
becoming aware of the incident. The center had seventy reportable incidents for the annual
compliance review period. A review of seven incidents reflected five incidents were reported to
the CCC within two hours as required. Two incidents were not reported within the required time
frame. One incident was reported three hours later, and another incident was reported one-and
one-half hours later. This information was shared with the administration staff during the week of
the annual compliance review. The administration staff provided the staff with retraining
memorandums during the week of the annual compliance review. Each applicable incident was
documented in the center’s CCC logbook. A review of the center’s internal incident/grievance
reports found there were no additional incidents which should have been reported to the CCC.
The interviewed superintendent reported all reportable incidents must be called into the CCC
within two hours of the incident or two hours after gaining knowledge of the incident.
1.05 Protective Action Response (PAR) Satisfactory 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 pertaining to the use of Protective Action
Response/Right Interactions model (PAR/RI). The center had a total of 173 PAR/RI incidents for
the annual compliance review period. A review of nine PAR/RI Reports found each of the nine
reviewed PAR/RI Reports were completed by the end of the staff’s workday. None of the
incidents resulted in serious injury to the youth or staff, required the use of mechanical
restraints, or needed to be reported to the Florida Abuse Hotline. All nine PAR/RI Reports were
reviewed by a supervisor or a PAR/RI instructor. Eight of the nine reports documented a post-
PAR/RI interview which was conducted with the youth within thirty minutes of the incident. One
report documented the post-PAR/RI interview was conducted with the youth ten minutes late.
One youth was applicable for a post-PAR/RI medical review. The appropriate medical staff were
not on-site at the time and the youth was sent off-site for an evaluation. Reviewed
documentation reflected eight of the nine PAR/RI Reports were reviewed by the
superintendent/designee within seventy-two hours, as required. One PAR/RI Report was
reviewed seven days later by the superintendent/designee. The superintendent was made
aware of this issue during the annual compliance review week. A review of internal incident
reports and logbooks indicated there were no additional PAR/RI incidents which should have
been reported. The center’s PAR/RI rate during the previous quarter was 15.85, which is above
the statewide Detention PAR/RI rate of 15.17. Five interviewed staff reported staff try to talk to
youth prior to using PAR/RI or mechanical restraints. The superintendent was interviewed and
indicated when PAR/RI is used by a staff, a PAR/RI Report is entered into the Facility
Management System (FMS) located in the Department’s Juvenile Justice Information System
(JJIS). The superintendent indicated staff receive annual refresher training in PAR/RI and are
only allowed to utilize authorized techniques when it’s reasonable and necessary.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 59 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures addressing the training and certification
requirements for all new staff. Phase One training consists of instructor-led and web-based
courses. Phase Two Training consists of 120 hours of academy instructor-led training. A review
of five staff training records for pre-service training indicated three staff completed all required
trainings within 180-days of hire. One staff received an extension and completed Phase Two
training within the required time frame allotted. One staff was still within the 180-days of
completing training and was awaiting completion of Phase Two training. Reviewed
documentation confirmed each applicable staff completed all trainings required by the
Department prior to having contact with youth. All pre-service trainings were documented in the
Department’s Learning Management System (SkillPro), when applicable. The center did not
have any returning direct care staff applicable for the specified training when returning less than
one year from separation.
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 (FOPs) which require staff to complete twenty-four
hours of in-service training each calendar year after completion of pre-service certification
training. The policy requires supervisors to complete eight hours of supervisory training
annually. The center provides in-service training to staff through a combination of the
Department’s Learning Management System (SkillPro) and instructor-led classes. Five staff
training records were reviewed for in-service trainings including three direct care staff and two
supervisory staff. Three staff training records reflected staff completed the mandatory training
topics. One staff did not complete all required trainings due to going out on medical leave. One
staff did not complete Mental Health and Substance Abuse training. Another staff did not
complete Mental Health and Substance Abuse training and Suicide Awareness and Prevention
training. This information was shared with the administration staff during the week of the annual
compliance review. Two staff were applicable for a minimum of eight hours of supervisory
training. Each staff completed the required eight hours of supervisory training. All trainings were
entered into SkillPro, when applicable. The in-service training plan was approved by the
Department’s regional director on December 15, 2023. The center has an annual in-service
training calendar which is updated as changes occur. An interview with the superintendent
confirmed the center’s practice.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 59 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills.
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures in place related to youth grievances to ensure each
youth has the right to grieve and ensure all youth are treated fairly, respectfully, without
discrimination, and their rights are protected. The center keeps blank grievance forms on the
living modules which are available for youth, upon request. The center’s staff will then input the
grievance into the Department’s Facility Management System (FMS) in the Department’s
Juvenile Justice Information System (JJIS). The process includes an informal phase, formal
phase, and the appeal phase. The informal phase is completed by detention staff whereby the
youth and staff attempt to resolve the youth’s complaint. If the staff is unable to resolve the
issue, the written grievance will be submitted to the supervisor, beginning the formal grievance
process. The written grievance requires a response from the juvenile justice detention officer
supervisor (JJDOS) by the end of the shift if possible or within twenty-four hours. Next, the
appeal phase requires a response from the superintendent or designee. The superintendent will
have seventy-two hours to take the corrective action deemed necessary. Five youth grievances
were reviewed and found three were reviewed in the formal phase by a supervisor within the
two-hour time frame. Two grievances were reviewed after the required time frame. One
grievance was reviewed one day late, and another was reviewed four days late. The center’s
administration staff was made aware of the findings during the week of the annual compliance
review. Three grievances were resolved at the formal phase. Two grievances made it to the
appeal phase and were handled in accordance with policy. An interview with the superintendent
confirmed there are three phases to the grievance process. Five youth were interviewed and
knew the process for submitting a grievance. Four youth indicated they have never filed a
grievance and one youth rated the grievance process as fair. Five staff were interviewed and
each staff was knowledgeable and was able to explain the grievance process and procedures.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 59 (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 outlining the process of entering and sharing alerts.
The center’s practice is to appropriately enter, downgrade, or discontinue alerts in the
Department’s Juvenile Justice Information System (JJIS) by the appropriate staff member on
the date each was identified and no longer applicable. A review of five youth records confirmed
alerts were documented in accordance with the center’s policy. The reviewed youth were
applicable for fifteen separate alerts. A review of youth records, the master control logbook, and
the JJIS alert list found the center is documenting and sharing alert information, as required.
Reviewed documentation indicated alerts were discussed during shift briefings. A printed copy
of the alert report is provided to the supervisory staff on each shift daily, and alerts are reviewed
with all staff during each shift briefing. An interview with the center’s superintendent confirmed
this practice. An observation of a shift briefing meeting during the annual compliance review
week supported youth alert information was consistently discussed with the staff during the
meeting. Five interviewed staff reported being made aware of alerts during shift briefings and
alert print outs. Two staff reported reviewing the center’s logbook. One staff also reported
reviewing JJIS and the alert board.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 59 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a practice in place regarding data trend analysis. An informal interview with the
superintendent in comparison to reviewed documentation found the center captures data
through various reports and changes are made as needed. The superintendent indicated the
center’s practice regarding data trend analysis is to review incident reports, confinements,
Protective Action Response/Right Interactions model (PAR/RI) Reports, the Department’s
Central Communications Center (CCC) reports, staff retention reports, and vacancies. The
center conducts monthly supervisor meetings and shift briefings to ensure all staff are made
aware of imperative information regarding the center. The superintendent indicated the center
shares information with providers and stakeholders during quarterly advisory board meetings,
and the last meeting was held on February 21, 2024. The superintendent also indicated sharing
information with the circuit’s chief probation officer (CPO) who shares the information during the
circuit advisory board (CAB) meetings.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 59 (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 regarding youth admission. Five youth case
management records were reviewed and each record contained an Admission Wizard
documenting an arrest affidavit, Detention Risk Assessment Instrument (DRAI), and Suicide
Risk Screening Instrument (SRSI) were reviewed. Reviewed documentation confirmed the
Admission Wizard documented the completion of a full body search conducted by a staff
member of the same gender. Each record confirmed all youth were offered a phone call to their
parent/guardian. Reviewed documentation confirmed each youth received a meal during the
admission process. Each Admission Wizard documented the completion of a medical/mental
health/substance abuse screening completed upon admission. During the annual compliance
review week, an observation of a youth admission was conducted. All required procedures of
the process were followed, the youth was afforded the opportunity to make a phone call to their
parent/guardian, and a meal was provided.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 59 (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 (FOPs) regarding youth orientation. Five youth
case management records were reviewed, and each youth received an orientation within
twenty-four hours of admission, as required. Reviewed documentation indicated each youth
reviewed and signed an orientation acknowledgement form indicating each youth’s orientation
included center rules and regulations, grievance procedures, visitation, telephone calls, access
to medical, mental health, and substance abuse services, access to the Florida Abuse Hotline
and the Department’s Central Communications Center (CCC), behavior expectations and
related consequences, possible new law violations for destruction of property, youth rights, and
Prison Rape Elimination Act (PREA) information. During the annual compliance review wweek,
an observation of a youth orientation found all required elements as outlined in the center’s
FOPs were covered. Five interviewed youth reported during the orientation process they were
informed of the rules and regulations, daily schedule, education services, visitation, abuse
reporting, and the behavior management system (BMS).
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Office of Accountability and Program Support Page 18 of 59 (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 regarding classification. Five youth case
management records were reviewed and the classification process for each youth included
review of information concerning the youth’s history and status. A review of each classification
confirmed the center takes the youth’s gender, height, weight, age, level of aggression, mental
illness, intellectual disabilities, physical disabilities, history of violent behavior, gang affiliation,
criminal history, history of sexual offenses including sexual battery charges, Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB) screening results, medical, suicide risk
identified or suspected, escape, and security risks into consideration before placing a youth in a
room. Each reviewed record confirmed the youth were assigned a room based on classification.
None of the youth were applicable for being reclassified due to changes in a youth’s behavior.
None of the reviewed youth had a history of committing a sexual offense or were a victim of a
sexual offense. The superintendent remains informed of how to identify local gangs through
trainings with the local police department. The superintendent is also informed of gang activity
and alerts by email. The superintendent was interviewed and indicated youth are assigned a
room based on their classification. The superintendent also reported only the shift supervisors
can make room assignments to ensure the highest level of safety for all youth. If there are any
changes in behavior or status, the youth will be reclassified in accordance with the center’s
policy.
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Office of Accountability and Program Support Page 19 of 59 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures (FOPs) regarding all admitted youth to determine
gang affiliation. The center has chosen the assistant superintendent as the gang representative
for the center. During the annual compliance review week, an informal interview was conducted
with the gang representative for the center. The gang representative reported staff are informed
of youth involved in gangs through shift briefings. The gang representative notifies the juvenile
probation officer (JPO) by way of email if a youth is identified as having suspected gang
involvement and gang related activities. Five youth case management records were reviewed
and none of the youth were applicable for gang involvement. Three additional records were
requested and reviewed to meet the sample size. Each applicable record included an email sent
from the gang representative to the proper JPO containing the required information in
accordance with the FOPs.
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 regarding admission and storage of youth personal
property. All youth personal and valuable property is inventoried and documented in the
Department’s Juvenile Justice Information System (JJIS), maintained securely, and returned to
the youth or the parent/guardian in a timely manner upon the youth’s release. Personal
belongings, such as clothing and shoes, are placed in a brown bag and stored in several secure
lockers at the center. Valuable items are listed and placed in a clear tamper-proof property bag,
identified with the youth’s name and Department identification number (DJJID), then secured in
the center’s property safe which always remains on camera view. Five youth case management
records were reviewed, and each record contained youth and staff signatures on the JJIS
property sheet. Each record contained the letter of acknowledgement regarding unclaimed
property with youth and staff signatures. A review of five youth case management records
displayed each was applicable for personal property and two were applicable for valuable
property. During the annual compliance review week an observation of a youth admission with
property was made. During the observation, the youth’s personal property was stored in a clear
tamper-proof bag, signed by the staff and youth, and then dropped into the property safe on
camera view. Access of the youth’s personal property is limited to shift supervisors and
administration. A review of the Department’s Central Communication Center (CCC) reports
since the last annual compliance review found no incidents regarding youth property. Five
interviewed youth reported when they arrived at the center, staff checked their property and
signed a property sheet ensuring their property was accurate. During an interview, the
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Office of Accountability and Program Support Page 20 of 59 (Revised July 2023)
superintendent reported upon admission all youth valuables are placed in a tamper-proof bag
signed by the youth and staff. The shift supervisor and master control operator are responsible
for logging the property in the logbook and dropping the property in the drop safe which is under
surveillance located in master control. The superintendent further stated the property is not
removed until taken to the property room by an administrator. The property room also has a
safe which is always under surveillance. The center’s supervisors and administrators are the
only staff with access to both safes.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center has facility operating procedures (FOPs) for the release of youth in secure detention.
Three closed youth case management records were reviewed. Each record had a copy of the
Department’s Detention Release form, which documented the supervisor had reviewed all
paperwork related to the youth’s release and court documents. All three youth had their
identification verified prior to release. The parent/guardian identification was verified prior to
release for each youth, with a photocopy of the parent/guardian identification being placed in
each youth’s case management record. None of the reviewed records identified the youth as an
endangered person. Each youth and the person whom the youth was released to were
reminded of future court dates and signed the release forms. The date of admission and the
date of release documented in each youth’s record correlated with the dates documented in the
Department’s Juvenile Justice Information System (JJIS). All three case management records
indicated all required parties signed all applicable release forms. During the annual compliance
review week an observation of a release confirmed the releasing staff was following the FOPs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 21 of 59 (Revised July 2023)
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures (FOPs) regarding the release of youth personal
property, medication, and aftercare instructions. Three case management records were
reviewed. Each record contained a Property Receipt form signed by the youth and
parent/guardian upon release. Each record contained documentation verifying the youth was
released to an appropriate person to include a copy of their identification. Each record was
applicable for a youth being released with medication. The medication receipt was signed by the
person taking custody of the youth and the person was informed of an upcoming appointment
for the youth. The center provided three examples of abandoned property since the last annual
compliance review and all procedures were followed as required. An informal interview with the
supervisor reported when any property is not picked up within thirty days, a notice of impending
disposal of property will be mailed. If the youth or parent/guardian cannot be located the
superintendent or designee shall ensure all money and property are counted and inventoried.
Then a money order shall be sent to the regional fiscal manager (RFM). The RFM will forward
the money order to the headquarters designee. A record shall exist for any property disposed of
or cash forwarded to headquarters. A review of each applicable record confirmed the center
followed the FOPs for disposal of abandoned property. An observation of a youth being
released from the center was conducted during the week of the annual compliance review. The
shift supervisor retrieved the youth’s property from the safe and the youth and parent/guardian
signed the appropriate documentation for taking custody of the property. The
parent’s/guardian’s identification was confirmed by the issued driver’s license and a copy was
made. All of the center’s release procedures were followed during the observation of the youth
release.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures to ensure Detention Reviews are conducted, on a
weekly basis, for proper management of youth in secure detention and information sharing. The
center has an officer assigned as the detention review specialist (DRS). An informal interview
was conducted with the DRS who stated the weekly meeting is held Thursday mornings,
virtually. During the annual compliance review week, an observation of the weekly Detention
Review meeting was conducted, and all required participants were in attendance. Each week,
all youth in the center are discussed during the Detention Review meeting with mental health,
medical, education, and juvenile probation officers (JPOs). A review of the center’s Detention
Review uploaded documents confirmed the center was conducting Detention Review meetings
on a weekly basis with all the required participants attending the meeting. An interview with the
superintendent confirmed Detention Review meetings are conducted on a weekly basis by the
DRS. The superintendent confirmed all required staff who participate in the weekly meetings.
The superintendent also advised youth court dates, release dates, detention hearings,
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Office of Accountability and Program Support Page 22 of 59 (Revised July 2023)
placement information, and other relevant information is discussed during the Detention Review
meetings.
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 regarding the daily activity schedule. During the
annual compliance review week, a center tour was conducted, and the daily activity schedule
was posted on all the youth living modules. Youth were also observed attending school, lunch,
sick calls, breakfast, and open programming. A review of the center’s logbook confirmed
activities such as wake-up/personal hygiene, mealtimes, visitation, recreation, education, shift
change, bedtime, and groups were conducted, as scheduled. Five youth were interviewed and
confirmed the center has a daily schedule and it is being followed. Five interviewed staff
reported the center follows the daily activity schedule.
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 facility operating procedures in place to provide for educational access. The
center’s educational center is directly managed by the Saint Lucie County School District. The
school operates on a year-round basis. The annual calendar indicates 250 days of instruction
distributed over twelve months, with a minimum of twenty-five hours of weekly classroom
instruction. The annual academic calendar also allows up to ten days of teacher training or
professional development. A review of the center’s approved academic calendar provided by
Saint Lucie County School District indicated 243 days of instruction, with three days of teacher
training or professional development. A review of the daily schedule and academic schedule
confirmed the center is following the approved calendar provided by the school district. During
the week of the annual compliance review, the Department of Education was made aware of the
discrepancy. A review of logbook entries showed the daily school schedule was followed with
little deviation. Video footage was reviewed for three days and indicated the youth were bought
to the classrooms on time and the education schedule was followed. An informal interview with
school staff and the superintendent validated classes were occurring in accordance with the
center’s schedule. One of five interviewed youth reported the center prepares the youth for the
high school equivalency diploma (GED), high school, vocational, employment, and/or college
very well. Three youth reported being prepared well, and one youth reported not well and further
reported already having a high school diploma. Four interviewed staff indicated there is minimal
interference with educational instruction and one staff reported there was no interference. The
interviewed superintendent reported the center ensures youth are afforded the opportunity to
participate in education activities and there is minimal interference to the school day.
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Office of Accountability and Program Support Page 23 of 59 (Revised July 2023)
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures in place which support career education provided
by the Saint Lucie County School District. The center provides appropriate career education to
the youth based upon each youth’s age, as well as assessed cognitive and educational abilities.
The center implements a Type 1 career education curriculum to include communication,
interpersonal skills, life skills, and decision-making skills. This classification, which emphasizes
soft skills, includes activities focused upon the youth learning or improving upon their
interpersonal communication skills and their decision-making abilities. This component provides
the youth with the opportunity to establish career choices based upon their capabilities, choices,
and interests. Five youth were interviewed, and each validated they were taking math, science,
history, and reading. Four youth reported they are participating in career-related and life skill
classes while at the center.
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Office of Accountability and Program Support Page 24 of 59 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains facility operating procedures 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 a licensed mental health counselor (LMHC) with a clear and active license in
the State of Florida which expires March 31, 2025. The DMHCA’s job description outlines the
clinical and administrative oversight responsibilities of all contractual requirements. The DMHCA
is scheduled to be on-site Monday through Friday and is on-call twenty-four hours each day for
emergencies and consultations. A review of the DMHCA sign-in and sign-out logs verified the
DMHCA was on-site, forty hours a week, as contractually required. The center has one
designated back-up DMHCA. The back-up DMHCA is a licensed clinical social worker (LCSW)
in the State of Florida. The reviewed license expires March 31, 2025. The center has not utilized
a back-up DMHCA since the last annual compliance review; however, the center has two
additional licensed mental health staff at the center qualified to provide coverage. During an
interview, the DMHCA indicated they are responsible for ensuring youth at the center receive
suicide risk screenings, Crisis Assessments, and mental health treatment. Mental health
services are provided within fourteen days of entering the center. Treatment services are
tracked by the DMHCA, and caseloads are staffed with mental health staff daily. Additionally,
youth receive tele-psychiatry with the psychiatrist for medication management, and treatment
planning.
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 contractually licensed
positions, in addition to the designated mental health clinician authority (DMHCA), include two
licensed mental health staff, a statewide psychologist, and a psychiatrist. Two mental health
staff are licensed clinical social workers (LCSWs). Each of the staff’s licenses were clear and
active in the State of Florida with expiration dates of March 31, 2025. Each staff had the
required credentials and a copy of each license and credentials were on-site for review as
required. The statewide psychologist holds a clear and active license in the State of Florida with
an expiration date of May 31, 2024.
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Office of Accountability and Program Support Page 25 of 59 (Revised July 2023)
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 a contract with VitalCore Health Strategies, LLC. to provide mental health
and substance abuse services to all applicable youth in the center. 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 with the Department of Children and
Families. The center did not have any non-licensed mental health staff since the last annual
compliance review. The center utilizes all licensed clinical staff to fulfill contractual requirements.
During an informal interview, the DMHCA confirmed the center does not have any unlicensed
staff.
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 facility operating procedures 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). Five youth mental health and substance abuse records were
reviewed and confirmed 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 (JAC) and then reviewed by detention staff as a part of each youth’s intake process.
Each of the five 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 five
applicable mental health records contained positive “yes” responses on the SRSI form. Four of
the five mental health records with positive responses were applicable for prior open or closed
suicide risk alerts in JJIS. One record was not applicable. Each applicable youth was placed on
suicide precautions and a mental health referral was generated. Three of the five mental health
records contained an elevated score on at least one domain on the MAYSI-2. Each of the four
youth required a comprehensive assessment, and the center notified mental health staff and the
superintendent, as required. There were no applicable youth with an elevated suicide subscale
on the MAYSI-2. One of the five reviewed youth records was applicable for having all negative
responses on the MAYSI-2, invalidating the screening. Each reviewed mental health records
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Office of Accountability and Program Support Page 26 of 59 (Revised July 2023)
included 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 five youth mental health and substance
abuse records reflected four youth were applicable for referral for mental health and substance
abuse services. All four 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). One youth refused to have a
comprehensive evaluation completed. Two youth mental health records contained an updated
Substance Abuse and Mental Health Assessment (SAMH). One youth’s record included a new
SAMH. Each reviewed SAMH was completed by the center’s on-site mental health provider
within thirty-one days, as required. All treatment recommendations made corresponded to all
diagnosed mental health and substance abuse disorders. Two of the five records documented
the youth were not yet at the center for thirty-one days during the annual compliance review
week, and each record documented a referral was made; however, the update had not yet been
completed. Two youth were applicable for a community provider assessment since the last
annual compliance review. Each of the evaluations were completed within the required time
frames and contained treatment recommendations which corresponded to all diagnosed mental
health or substance-related disorders. 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 leaving 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. Five youth records were reviewed for mental
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Office of Accountability and Program Support Page 27 of 59 (Revised July 2023)
health and substance abuse treatment services. Four 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. One record was not applicable as
the youth had been in the center for less than two weeks. Three of the reviewed youth records
were applicable for treatment with individual or group counseling. One youth was offered
treatment services and refused services. During an informal interview the DMHCA indicated if a
youth refuses services the mental health staff will meet with the youth, develop a treatment plan,
and hold a treatment team meeting where the youth is offered treatment services while at the
center. Each initial treatment plan contained the reason for treatment referral, the initial
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, initial
treatment methods and goals, and psychiatric services. Each applicable treatment plan was
signed and dated by the youth, clinical staff, and treatment team members. Each reviewed
treatment plan had a note regarding the parent/guardian’s presence over the telephone with the
date. Three records had an individualized treatment plan created within thirty-days of the
youth’s admission by mental health staff. One of the three youth refused services, one was not
applicable for treatment, and the remaining youth’s plan was not yet due. Each of the applicable
plans were documented on the Department’s Individualized Mental Health/Substance Abuse
Treatment Plan form. A review of each applicable treatment plan confirmed they identified the
youth’s individual mental health/substance abuse (MH/SA) needs, DSM-5 diagnoses, treatment-
focused symptoms, treatment goals, and strengths/needs. Three youth were applicable for
psychiatric services or pharmacological interventions. Two of the three treatment plans were
signed by the youth, mental health professional, treatment team members, and the
parent/guardian, when applicable. One youth’s treatment plan indicated the youth refused
services. Each applicable record contained progress notes to validate the services included in
the treatment plan were being received. Three of the reviewed youth records contained thirty-
day individualized treatment plan reviews. Two of the applicable individual youth mental health
records contained a completed thirty-day review, as required and one youth record contained a
thirty-day review, although the youth refused services. Each applicable treatment plan review
was signed and dated by the youth, MH/SA clinical staff, and treatment team members. Each
had a note regarding the parent/guardian participation by telephone and each was dated. None
of the youth were applicable for having been an alleged victim of a Prison Rape Elimination Act
(PREA) incident. Three closed mental health records were reviewed for MH/SA treatment
discharge summaries. Each MH/SA 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. The center holds
treatment team meetings on Thursdays, each week. Observations of a treatment team meeting
were conducted during the annual compliance review week and involved all required parties. An
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.
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Office of Accountability and Program Support Page 28 of 59 (Revised July 2023)
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 (MH/SA) interventions are provided to applicable youth to reduce or
alleviate symptoms of MH/SA issues. Five mental health and substance abuse records were
reviewed and four were applicable for receiving initial treatment services; however, one youth
had refused services and the other youth was not applicable. Each applicable 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 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 each
week. Reviewed progress notes validated youth were receiving treatment services as stipulated
on their treatment plans. Three of the youth required substance abuse treatment. Each
applicable record contained the proper Authority for Evaluation and Treatment (AET) and
substance abuse consent forms. Each reviewed record contained treatment notes documented
on the required Department form with all required elements. A review of video surveillance was
conducted for groups held within the last thirty days. Observations of the video confirmed
mental health groups were held in accordance with the program’s policy. Reviewed
documentation validated mental health staff provide groups at a minimum once each week
when there were enough youth receiving treatment. In the event there are only a few youth, the
mental health staff meet with youth individually. A review of the group sign-in sheets and
logbooks validated groups were conducted in accordance with policy. Observations and a
review of the documentation indicated the group was held for twenty-five minutes and the times
noted on the sign-in sheets matched the video review. An interview with the designated mental
health clinician authority (DMHCA) confirmed mental health groups are provided to youth after
they exceed twenty-one days at the center. A treatment team will then be initiated to offer
services to the youth. Additionally, the DMHCA indicated youth services are tracked to ensure
services are provided as required. The DMHCA further stated, the center provides suicide risk
screenings, Crisis Assessments, individual therapy, group therapy, treatment planning, and
discharge planning, as needed. Five youth were interviewed, and two youth rated the center’s
mental health and substance abuse services as very good, and three youth stated they were not
receiving mental health or substance abuse services.
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3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center maintains facility operating procedures which outline the required psychiatric
services to be available to youth. Psychiatric services, include psychiatric evaluations,
consultation, and medication management. Psychiatric services are provided to youth
determined to need services as indicated by symptoms of mental disorder or substance-related
disorders, 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 two hours each week. The psychiatrist’s license was clear and active in the State of
Florida with an expiration date of March 31, 2026, and the back-up psychiatrist, a licensed
medical doctor, holds a clear and active license with an expiration date of January 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, through tele-psychiatry. A review of five 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 individual youth mental health records contained documentation a
psychiatric referral and interview were 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. All
three youth were applicable for the prescription of medications 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, a description of the 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 the 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. No youth were
applicable for a significant change, discontinuation, or new prescription requiring
parent/guardian consent. One youth was applicable for the monitoring of Tardive Dyskinesia
which was documented monthly on the CPPN for the youth. All three 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 tele-psychiatry for medication management, treatment
planning, weekly individualized sessions, psychoeducation, and substance abuse education.
Additionally, the DMHCA confirmed they meet with the psychiatrist on a weekly basis to discuss
youth receiving mental health and psychiatric services.
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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 written Suicide Prevention Plan outlining the requirements 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 15, 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 outlined emergency contact telephone numbers to
include the superintendent, on-call administrator, designated mental health clinician authority
(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 also has an established review process for each serious suicide attempt or
serious self-harming injury. This review process included all required elements. A copy of the
plan is located in administration and on the center’s shared network drive, accessible to all staff.
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 five youth mental health and substance abuse records showed five
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. None of the reviewed records
required a Follow-Up ASR. Reviewed documentation confirmed 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 mental health record contained a completed mental health
referral, Suicide Precautions Observation Log, 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 the center’s logbooks revealed the starting and ending
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time of each youth’s PO period was documented as required. A review of five youth records
reflected there were no youth applicable for secure observation placement. During an informal
interview the superintendent indicated the center does not utilize secure observation for
potentially suicidal youth. During an interview, the designated mental health clinician authority
(DMHCA) confirmed the center’s practice when revising the youth’s supervision levels. Five staff
were interviewed and each confirmed if a youth expresses suicidal thoughts, they are to notify
the mental health staff, search the youth and their room for sharp objects, and document
supervision. Five staff reported having to maintain the youth on constant sight and sound
supervision. Five 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.
Three youth stated they have never been placed on suicide precautions while at the center.
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 written 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 five youth mental health records
showed five were applicable for having been placed on suicide precautions and each had a
Suicide Precautions Observation Log maintained. Each of the five applicable records contained
Suicide Precautions Observation Logs completed on the required Department form, and for the
duration of the youth’s PO placement. 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. None of the youth were 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 the youth were placed
on constant supervision. Observations confirmed proper supervision was maintained for all
three youth.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center maintains a written 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). Five
pre-service and five 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 the two-hour SkillPro training. Reviewed documentation of “mock”
suicide drills conducted since the last annual compliance review showed the center completed
drills on all three shifts at least quarterly, as required. The center exceeded the requirement with
all but one shift in the month of September, by conducting drills on each shift at least once each
month since the last annual compliance review. Reviewed documentation supported the center
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had forty-one applicable staff requiring participation in a suicide drill semi-annually. All forty-one
of the center’s staff participated as required and many exceeded the requirement. 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 the direct care staff participated in at least one drill which included the use of
cardiopulmonary resuscitation (CPR) annually. The center maintains three complete suicide
response kits, co-located with the center’s first-aid kits, which are located in master control, the
medical office, and in the supervisor’s office. An interview with five staff was conducted and all
five staff indicated the suicide response kits were located in master control, medical office, and
in the supervisor’s office.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a written 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 the youth and others while maintaining control and safety of the center. 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 the 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. Additionally, the plan outlines requirements for
response to Prison Rape Elimination Act (PREA) incidents. Copies of the plan are located in the
administration office and in the mental health office. The plan is 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 a written 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 15, 2023. The facility operating procedures (FOPs) and plan were
signed by the superintendent on August 15, 2023, and the designated mental health clinician
authority (DMHCA) on August 18, 2023. The center’s plan includes procedures for immediate
staff response, notifications, communication, supervision, authorization to transport for
emergency Baker Act or Marchman Act, documentation, training, and review. A copy of the plan
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is located in master control, superintendent’s office, mental health office, and the center’s
shared network drive, and is accessible to all staff.
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 stipulate the
response procedures for youth in crisis. Staff response is to be in the least restrictive means
possible to protect the safety of the youth and others while maintaining control and safety of the
center. Any youth presenting with acute and extreme emotional or psychological distress are to
receive a Crisis Assessment to evaluate the severity of the youth’s distress and symptoms, level
of risk to self or others, and recommendations for treatment and follow-up care. A review of five
youth mental health records revealed none were applicable for Crisis Assessments. The
designated mental health clinician authority (DMHCA) provided three additional youth records
which were applicable for Crisis Assessments since the last annual compliance review. A review
of the three records for Crisis Assessments was conducted. 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). Each of the three reviewed assessments confirmed they
were completed by a licensed mental health staff. Each of the assessments reviewed 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 (ASRs), 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 facility operating procedures to address the Emergency Care Plan which
outlined 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 five youth mental health records revealed none were applicable for
requiring Baker Act or Marchman Act procedures. The designated mental health clinician
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authority (DMHCA) provided three 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 conducted within the administration of the Assessment of Suicide Risk (ASR) for all
three 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 with a suicide risk had an alert entered in the Department’s Juvenile Justice
Information System (JJIS), which was updated with the discontinuation of the alert and
precautions based upon the ASR. The center had no Marchman Act proceedings since the last
annual compliance review. An interview with the DMHCA, confirmed the center has had to
transfer approximately ten 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 maintains facility operating procedures to ensure clinical services are provided to
youth who are in the center. Medical services are provided to the center by VitalCore Health
Strategies, LLC. The center has a board-certified physician who is a licensed medical doctor
(MD). The MD holds an unrestricted license and meets all requirements for independent and
unsupervised practice in Florida with a license expiring on January 31, 2026. The MD serves as
the center’s designated health authority (DHA). The physician has specialty training in pediatrics
and demonstrated prior experience in treating the primary healthcare needs of adolescents. The
advanced practice registered nurse (APRN) has a Collaborative Practice Protocol in place with
the DHA. A review of sign-in and sign-out logs since the last annual compliance review
confirmed the DHA was on-site at least once a week for two hours, as contracted. In the event
the DHA is on vacation or has scheduled absences, the center has a contract with a back-up
licensed MD to provide coverage. The back-up DHA holds a clear and active unrestricted
license in the State of Florida with an expiration date of January 31, 2025. The back-up DHA
was not utilized during the annual compliance review period. Documentation supported when
the DHA designated the APRN to provide the clinical services on-site, the center’s DHA
performed the administrative duties. The DHA and/or APRN provide periodic evaluations,
Comprehensive Physical Assessments, sick call referrals, and administrative duties.
Documentation and an interview with the DHA revealed the DHA is on-site two hours each week
and on-site nursing coverage is provided seven days a week from 7:00 a.m. to 8:15 p.m. on
weekdays and 7:00 a.m. to 6:00 p.m. on weekends. At the time of the annual compliance
review, the center had two full-time registered nurses (RNs), three part-time RNs, one full-time
licensed practical nurse (LPN), and one part-time APRN. The interviewed DHA verified their
responsibility for communicating with the center’s staff regarding each youth’s medical needs as
needed. The staff are available for consultation by telephone twenty-four hours a day, seven
days a week for acute medical concerns, emergency care, and coordination of off-site care. At
the time of the annual compliance review, the center had not utilized telehealth services.
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 maintains a written policy and procedures to ensure the creation and use of facility
operating procedures (FOPs) for all utilized health-related procedures and protocols. The
designated health authority (DHA) and superintendent reviewed, signed, and dated all
respective treatment FOPs. The DHA signed the FOPs on May 10, 2023, and the
superintendent signed on May 9, 2023. Written documentation revealed the psychiatrist signed
on May 5, 2023. Nursing staff reviewed, signed, and dated a cover page on medical FOPs,
treatment protocols, and other procedures on May 5, 2023, and May 8, 2023. New policies or
changes in policies made during the year were reviewed, signed, and dated by each nurse on
the individual policy changes occurring between annual compliance reviews. Documentation
supported an annual review of medical FOPs was conducted. All newly employed healthcare
personnel received a comprehensive clinical orientation to the Department’s healthcare policies
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and procedures, given by a registered nurse (RN) or designated healthcare professional. All
treatment protocols or standing procedures at the center were written and authorized by the
DHA.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center maintains facility operating procedures ensuring parents/guardians are afforded the
right to provide or withhold consent concerning the healthcare provided to the youth. A review of
five Individual Healthcare Records (IHCRs) indicated two youth were over the age of eighteen,
one youth was in the custody of the Department of Children and Families, and two youth had a
signed Authority for Evaluation and Treatment (AET). Each youth record with a signed AET had
the word, “copy” stamped on the form. The two IHCRs with AETs revealed the AETs were
signed by a parent/guardian. One reviewed youth reviewed record revealed the contracted DCF
provider consented to provide ordinary medical treatment by executing the limited consent for
evaluation and treatment. The record also contained a court order authorizing all treatment.
Each of the five reviewed youth had an AET and/or court order obtained prior to providing
medical services. Each applicable AET form was signed by a Department representative. Two
of the five youth were eighteen years of age and the IHCR contained a signed Release of
Information form.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains facility operating procedures ensuring requirements for parental/guardian
notification and written consent from the parent/guardian. A review of five youth Individual
Healthcare Records (IHCRs) found three youth were applicable for prescribed over-the-counter
medications not covered by the Authority for Evaluation and Treatment (AET) and two youth
were eighteen years of age or older. Each applicable record included parent/guardian consent.
Reviewed documentation confirmed written notifications were sent utilizing the required
Department forms. At the time of the annual compliance review, the center had two youth taking
psychotropic medications. Documentation revealed staff witnessed all telephone call attempts
and conversations for use of psychotropic medications. One applicable IHCR indicated a new
medication was prescribed and contained documentation of verbal and written notification to the
parent/guardian. One IHCR was applicable for new prescribed psychotropic medications and
parental/guardian consent was documented on the Clinical Psychotropic Progress Note
(CPPN). There were no youth under the supervision of the Department of Children and Families
(DCF) on psychotropic medication. Reviewed documentation indicated vaccines were verified
within thirty days of the five youth’s admissions. An interview with the clinical registered nurse
(RN) manager revealed medical staff notify the youth’s legal parent/guardian if a signed consent
is needed. Medical staff also contact the juvenile probation officer (JPO) if an AET is unable to
be obtained. If the youth is eighteen years of age, staff will place a note in the chronological
progress note section of the IHCR stating the youth is able to consent to treatment.
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4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains facility operating procedures ensuring at the time of admission, each youth
will receive a Facility Entry Healthcare Admission Screening utilizing the Department’s Medical
and Mental Health Admission Screening (MMHS) form in the Department’s Juvenile Justice
Information System (JJIS). A review of five Individual Healthcare Records (IHCRs) found the
MMHS forms were completed on the date of each youth’s admission. Each screening was
completed by a juvenile justice detention officer (JJDO) and reviewed with the youth by a
licensed medical staff within twenty-four hours. Each youth was applicable for notification to the
designated health authority (DHA) which was documented in the youth’s IHCR. None of the
youth were applicable for a rescreening at the time of the annual compliance review. During an
interview, the nurse reported if a youth is provided treatment not listed on the Authority for
Evaluation and Treatment (AET), such as starting a new medication or being sent off-site, the
parent/guardian is notified as soon as possible. In addition, if a follow-up is needed, a written
notification will be sent to the parent/guardian depending on the situation. The nurse also
reported rescreenings and healthcare admission screenings are conducted by the nursing staff
and center staff. The center’s practice is to complete a new healthcare admission screening
form whenever a youth is admitted to the center.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains facility operating procedures (FOPs) ensuring all youth are oriented and
have access to all healthcare services through release. The center’s FOPs included access to
medical care, sick call access, what constitutes an "emergency" and when to notify staff,
medication process to include side effect monitoring, the right to refuse care and how it is
documented, what to do in the case of a sexual assault or attempted sexual assault, the non-
disciplinary role of the healthcare providers, and the review of the list of healthcare contacts to
ensure accuracy. Reviewed documentation indicated each youth received a general healthcare
orientation with health education topics documented on the Department’s 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.
The center maintains facility operating procedures ensuring the designated health authority
(DHA) is notified of all youth admitted with chronic health conditions and/or if a youth needs
emergency care. A review of five Individual Healthcare Records (IHCRs) indicated four of the
five youth had known or suspected chronic conditions with evidence of a referral to the
physician or advanced practice registered nurse (APRN). One reviewed youth was identified as
in-need of emergency care upon admission. In each instance, the DHA was notified within
twelve hours of the youth’s admission and a notification was documented in the IHCR. One
youth was taking psychotropic medications and the psychiatrist notification was documented in
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the IHCR. An interview with the clinical registered nurse (RN) manager confirmed the process
and timeframes for notifying the DHA of youth admissions.
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 maintains facility operating procedures ensuring the process for conducting or
reviewing each youth’s admission history. A review of five Individual Healthcare Records
(IHCRs) found each contained a new Health-Related History (HRH) form with the date of
completion. Each youth’s HRH form was updated and completed within seven calendar days of
the youth’s admission. Each of the HRHs were completed prior to the Comprehensive Physical
Assessment (CPA). Each HRH included signatures and dates for the most current admission
and was completed by a registered nurse. A review of the nursing interview confirmed the HRH
is completed by the medical staff within seven days of each youth’s 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.
The center maintains facility operating procedures ensuring a Comprehensive Physical
Assessment (CPA) will be completed for all applicable youth admitted determining the health
and well-being of the youth. A review of five Individual Healthcare Records (IHCRs) indicated
the youth’s physical assessment was completed on the Department’s CPA form. Each youth
had a new CPA completed within seven days of admission. Each of the five IHCRs documented
an advanced practice registered nurse (APRN) completed the CPA. Two of the five youth had a
Medical Grade of three, two youth had a Medical Grade of two, and the other youth had a
Medical Grade of one. Each CPA was current and completed by the APRN as the youth was
examined. Documentation showed each of the five CPAs were completed with each section
marked with an “O”. One youth refused part of the exam, the clinician wrote “Youth Refused”,
and the youth signed a refusal form. All five youth’s Problem Lists were updated as required.
Each of the five reviewed IHCRs maintained a verified Tuberculosis Skin Test (TST), as
required, and a Tuberculosis (TB) screening was conducted within the required time frame. The
results of the TSTs were documented on the CPAs and Infectious and Communicable Disease
(ICD) forms matched for each youth. Reviewed documentation in comparison with an interview
with nursing staff determined all youth TB testing is completed annually once an Authority for
Evaluation Treatment (AET) is obtained from the youth’s parents/guardians.
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 maintains facility operating procedures ensuring all youth are evaluated and treated,
if necessary, for sexually transmitted infections (STIs). A review of five Individual Healthcare
Records (IHCRs) included documentation two of the five youth indicated they were sexually
active. Both youth were clinically screened and evaluated for STIs. Three of the five youth
refused to complete the STI screening. One youth was referred for further evaluation by the
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advance practice registered nurse (APRN) and the referral was documented on the STI form.
The results of the testing, screening results, clinical evaluation, and diagnosis were documented
on the Infectious and Communicable Disease (ICD) form and filed in the lab section of the
IHCR. One youth was applicable for a gynecological exam and documented consent was found
in the youth’s IHCR. One youth was out of the Department’s physical custody and a rescreening
was completed. Each youth was offered human immunodeficiency virus (HIV) counseling,
testing, and treatment. One of the five youth received HIV testing, with consent and other youth
refused. Reviewed documentation found written consent from the youth was obtained and
testing was completed by an outside provider. The results were maintained in a sealed
envelope marked “Confidential” within the youth’s IHCR and reviewed by a practitioner.
Reviewed documentation of pre-test/post-test counseling was documented on the individual
Health Education Records and/or in the progress notes. The youth’s confidentiality was
protected by not including the youth’s HIV status on the program’s internal alert system. An
interview with five youth indicated they were able to request an HIV test as needed.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains facility operating procedures regarding sick call processes and requests. A
review of five youth Individual Healthcare Records (IHCRs) indicated three of the youth were
applicable for a sick call event. All three sick calls were documented on the Sick Call Referral
Log. Two youth were not applicable for sick call events. There were no instances in which a
youth presented with a similar sick call complaint three or more times within a two-week period
or complained of any severe pain with which staff were unfamiliar. Documentation in all three
applicable records indicated the sick call was conducted by a licensed practical nurse (LPN) and
reviewed the same day by the registered nurse (RN) in person. Each applicable youth’s IHCR
included sick call request forms filed in reverse chronological order and progress notes were
documented in accordance with policy. A review of the daily schedule, posted schedule, and
nurse interview confirmed sick calls are conducted daily. Sick calls are documented in the youth
IHCR on the sick call request form, with documented dates in correspondence with the Sick Call
Index. Reviewed documentation also found approved treatment protocols for both RN and LPN
level staff. Documentation and an interview with the RN revealed sick call care is provided to the
youth as needed, or Monday through Sunday from 9:00 a.m. to 11:00 a.m. and Monday through
Friday 4:00 p.m. to 5:00 p.m. Sick call hours are posted outside the medical office, inside of the
medical office, and on all living modules. All sick calls are conducted by the licensed nurses at
the center. When nursing staff is not on-site, the center has procedures whereby the shift
supervisor reviews all sick call requests as soon as possible and within twenty-four hours after
the request is submitted. A sick call was observed during the annual compliance review week
and the youth verbally consented prior to observation. The youth was escorted to the medical
clinic by a juvenile justice detention officer (JJDO). The medical provider identified themselves
and stated why the youth was there. The youth was seen in a private area with no other youth
present to hear or see the examination. An exam table and equipment was used to perform sick
call, and the youth was examined by the nurse and interviewed. At the time of the observation a
JJDO was present during the exam and the medical staff was able to maintain privacy. The
JJDO was located on the outside of the medical clinic door. An interview with nursing staff
confirmed the sick call process. The nurse reported youth requesting to see a nurse will notify
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direct care staff and a sick call is entered in the Department’s Juvenile Justice Information
System (JJIS). Nursing staff will see the youth within twenty-four hours of the sick call being
placed; however, the center’s practice is to see the youth within an hour or two. The RN clinical
manager will review the LPNs sick calls daily or at the next available opportunity when on-site. If
the designated health authority (DHA) is on-site, the DHA will conduct the sick calls. The
center’s practice is to refer the youth with repeated similar sick call complaints to the DHA or
advanced practice registered nurse (APRN). Five youth were interviewed, and two reported
being seen immediately by medical staff upon a request. Three youth stated being seen within
one day. An interview with five staff indicated the nurse conducts sick calls; however, in the
absence of the nursing staff, a supervisor completes the 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.
The center maintains facility operating procedures ensuring a comprehensive process of
episodic care and first-aid care. The center utilizes an Episodic Care Log to document episodic
care and first-aid treatment. The log documents the date and time of the treatment, nature of the
complaint, person rendering aid, treatment, and whether the youth was recommended for off-
site care. A review of five youth Individual Healthcare Records (IHCRs) revealed one youth was
applicable for on-site first-aid or episodic care; therefore, two additional youth records were
requested. Each of the youth received episodic or first-aid care by a licensed healthcare staff
which was documented in problem-oriented narrative charting. The nature of the complaint was
listed, the findings of the person rendering care were included, with the documented outcome of
the treatment rendered. One of the three youth were referred for off-site care and the youth’s
IHCR included education and instructions. Documentation indicated the plans for follow-up and
future care were documented for the three youth reviewed. One youth was applicable for
placement on the alert list and the alert was entered. One youth required parental/guardian
notification which was made and documented. Documents indicated each of the three youth had
an entry in the Episodic Care Log and each youth received a follow-up evaluation from a
licensed healthcare staff the next time a licensed staff was on-site, or sooner, if warranted.
Documentation revealed the center had fifteen first-aid kits located in master control, the
Juvenile Assessment Center (JAC), each of the three living modules, the medical office, the
supervisors’ office, the foyer of the center, the kitchen, and each of the six transport vehicles.
Documentation from each of the first-aid kits confirmed the first-aid kits were fully stocked with
the designated health authority (DHA) approved contents. An interview with nursing staff
indicated the center’s nurse ensures contents are maintained and monitored by medical staff
monthly in accordance with guidelines to prevent expiration or deterioration. A review of
documentation of the first-aid kits confirmed the kits are monitored by nursing staff monthly and
replenished as needed. The center maintains two automated external defibrillators (AEDs). One
is in the medical clinic and the other is located in master control. Each AED is equipped with
procedures. The nurse checks the AEDs monthly to ensure the devices are operable and an
outside vendor checks the AEDs yearly. The AEDs were last checked on February 2, 2024. At
the time of the annual compliance review, nursing staff checked the expiration dates in front of
reviewer and conducted a self-test of the AED, with no discovered issues. A review of the AED
check logs since the last annual compliance review confirmed the nurse checks the AEDs in
accordance with the center’s policy. The AED batteries have an expiration date of March of
2026. The last date the AED batteries were changed was in March of 2022. The expiration date
of the AED pads was August of 2025 and the last date the AED pads were changed was
January 12, 2021. The center conducts emergency medical drills at least quarterly on each shift
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and emergency drills including cardiopulmonary resuscitation (CPR)/AED demonstration are
conducted at least once a year on each shift. Each reviewed drill simulated an episodic care
event which called for immediate first-aid and/or administration of CPR techniques and the
initiation of the emergency procedures to follow when a life-threatening emergency occurs. The
center maintained documentation for emergency drills. Reviewed documentation confirmed
quarterly emergency drills from May 2023 through February 2024 were conducted, as required.
Announced or unannounced emergency medical drills were conducted at least quarterly on
each shift. Center observations confirmed a list of emergency numbers was posted and
accessible for non-licensed and licensed staff and are inaccessible to youth. Reviewed
documentation confirmed all authorized direct care staff, to include supervisors only were
appropriately trained on the administration of the epinephrine auto-injector. A review of five pre-
service and five in-service staff records indicated staff training requirements were met regarding
episodic care, first-aid, and emergency care. An interview with the medical staff indicated the
center’s policy on the use, access, and inventory of NARCAN®. The center stores NARCAN® in
a locked container inside of the medical cart. If NARCAN® is used, it is disposed of in a medical
bag and placed in a disposable medical container; however, at the time of the annual
compliance review the NARCAN® had never been used. The center reports having NARCAN®
since September 16, 2022. The center’s NARCAN® is a four-milligram nasal spray, with an
expiration date of May of 2025. All medical staff, including two full-time registered nurses (RNs),
three part-time RNs, one licensed practical nurse LPN, and one part-time advanced practice
registered nurse (APRN), were trained on NARCAN® administration by the clinical supervisor.
Documentation revealed NARCAN® inventories were conducted weekly by the clinical
supervisor and confirmed with the clinical staff for accuracy. An interview with nursing staff
confirmed their knowledge of the process for documenting on-site episodic care. An interview
with five staff indicated each staff can call 9-1-1, if needed. Five youth were interviewed and one
youth rated the medical care as poor, one youth rated it as fair, two youth rated it as good, and
one youth rated the medical care as very good.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center maintains facility operating procedures to ensure timely referrals for off-site
healthcare. A review of five youth Individual Healthcare Records (IHCRs) indicated one youth
was applicable for off-site care referrals; therefore, an additional two IHCRs were requested.
Each of the three youth had an indication the youth required off-site care. The Summary of Off-
Site Care Consultation Report form was utilized and filed in each youth’s IHCR. The off-site
emergency care was documented on the Episodic Care Log. Each of the three youth were
applicable for a parental/guardian notification with efforts documented. Each applicable youth’s
IHCR documented the designated health authority (DHA) was notified of an emergency event,
to include the date, time, and manner of notification. The DHA reviewed and signed all off-site
care findings, instructions, and information. One of the three youth required a follow-up test,
referral, and appointment. Documentation revealed a referral was entered on the Sick Call Log,
with evidence indicating the referral was tracked and the youth received appropriate, timely
follow-up care, as needed. An interview with nursing staff indicated the tracking of youth who
are sent off-site for emergency care is documented in the youth’s progress notes and a daily
email with updates of the youth’s condition is sent to the Department’s Office of Health Services
(OHS) and VitalCore Health Strategies, LLC. corporate staff. Additionally, if the youth is required
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to stay off-site for an extended period the Department’s Central Communication Center (CCC) is
notified within the required time frame.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center maintains facility operating procedures ensuring youth identified with chronic
conditions receive regularly scheduled evaluations and necessary follow-up care. A review of
five Individual Healthcare Records (IHCRs) indicated four of the five youth were applicable for
chronic conditions/periodic evaluations. The medical/mental health screening form documented
a current chronic condition for the four applicable youth stating the type of chronic condition.
Two of the four youth were taking prescribed medication on an on-going basis at the time of
admission. All four youth were classified with a Medical Grade between two and four. Three of
the four youth received periodic evaluations at least every ninety days, the fourth youth was not
due for a periodic evaluation at the time of the annual compliance review. Documentation for the
three youth found progress notes supported periodic evaluations were completed and
documented. No youth had an off-site evaluation and no youth required a documented
Summary of Off-Site Care form. The reviewed documentation confirmed there were no
indications of missed or lapsed periodic evaluations. Reviewed records reflected each youth’s
Department Problem List was updated, as required. The Department’s Problem List was
updated in accordance with policy and reviewed documentation confirmed periodic evaluations
were tracked. An interview with the designated health authority (DHA) revealed an evaluation is
conducted on youth with chronic conditions. The DHA reported youth evaluations are tracked
every ninety days unless a chronic medical condition requires an earlier follow-up. All youth
chronic medical conditions are entered on a log by the clinical manager and youth are
scheduled to have their periodic evaluations as directed.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center maintains facility operating procedures (FOPs) for medication management to
ensure all medication and pharmaceutical products are procured, dispensed, administered, and
stored safely. Additionally, the center has FOPs ensuring the standard Department Medication
Administration Record (MAR) is utilized for each youth receiving either prescription medications
on a routine basis or over-the-counter (OTC) medication. A review of five Individual Healthcare
Records (IHCRs) revealed three of the five youth were applicable for medication management.
Each of the three youth were taking medication at admission, and the medication was verified
prior to the youth being admitted into the center. The prescription verification was included in the
chronological progress note in each IHCR. Each reviewed record documented the designated
health authority (DHA) and, when applicable, the psychiatrist was contacted to obtain the order
to resume the specified medications prescribed prior to admission. All medications had a
current, valid order and documentation supported each was administered pursuant to a current
prescription. If current medications were continued, discontinued, changed, or new ones were
ordered, the DHA placed an order on the Practitioner Order form. Reviewed documentation
indicated there was documentation of prescription verification in the chronological progress
notes in the IHCRs as required. The MAR was used to document all medication administration.
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Each of the three applicable youth MARs clearly indicated medication start and stop dates. At a
minimum, the nursing staff documented side effect monitoring weekly on each MAR.
Documentation confirmed the MAR contained all required elements to include the youth’s name,
date of birth, youth allergies, precautions, Medical Grade, medical alerts, and a current picture
of the youth. The nursing staff initialed each administered medication entry. The youth initialed
each provided medication entry. Two of the three applicable youth were prescribed psychotropic
medications and the DHA was notified. One of the two youth entered the center on psychotropic
medications and the psychiatrist conducted an initial diagnostic psychiatric interview as
required. Documentation confirmed the youth received an initial diagnostic psychiatric interview
within fourteen days of admission. One of the two youth on psychotropic medications received a
medication monitoring/review every thirty days as required. The other youth was not applicable
for medication monitoring. None of the youth were applicable for restricted housing. An
observation of a medication administration was conducted during the annual compliance review
week. The youth’s verbal consent was obtained prior to observation. The youth was escorted to
the medical clinic for medication administration by a senior detention staff, and the youth
approached the nursing staff administering medication individually. An observation confirmed
the medical provider identified themself and stated why the youth was there, the same staff
prepared and administered the medications. The nurse verified the youth’s allergy and alert
status, the staff and youth initialed the MAR, observed the youth to make sure medication was
swallowed, and ensured OTC medication administrations were documented. The center did not
have any standing orders for psychotropic medications, no pro re nata (PRN) orders for
psychotropic medications, or emergency treatment orders for psychotropic medications. The
center maintains a list of staff who are required to have access to the clinic and medications.
The list included the superintendent, assistant superintendents, the training coordinator, and
juvenile justice detention officer supervisors (JJDOSs). A review of supervisory training records
verified each of the authorized staff were trained in medication administration. An interview with
nursing staff confirmed, depending on the severity periodic evaluations are conducted every
thirty, sixty, or ninety days and are conducted by the DHA. The process for verification of
medications is to count all medication, fill out a medication receipt for counted medication, and
have the parent/guardian sign. Medication is secured by placing it in the medical cart. It was
also revealed, only supervisors can administer medication in the absence of a nurse. At the time
of the annual compliance review, the interviewed staff were not able to administer medication to
any of the youth. Two of the five interviewed youth revealed only nursing staff has administered
medication to the youth. The other three youth stated they do not take any medications.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center maintains facility operating procedures ensuring medications and any medical
equipment classified as sharps will be secured and inventoried. The center maintains an
inventory of all sharps and medical equipment classified as sharps including syringes, butterfly
needles, scissors, needles, and suture removal kits. An observation of the medical equipment
classified as sharps was conducted and all were secured and inventoried utilizing a routine
perpetual inventory descending count as each sharp was utilized and disposed of. All
medications were identified and secured in the locked area designated for storage of
medications. The observed medication cart was clean and organized with stocked items
separate from youth-specific medications. Observed medications were stored in a separate,
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secured/locked area, inaccessible to all youth and oral medications were stored separately from
the injectable and topical medications. Medications which require refrigeration were stored in a
secured refrigerator, which is used for medication only. Additionally, documentation confirmed
there were perpetual and weekly inventories of all sharps and stocked over-the-counter (OTC)
medications conducted with a shift-to-shift inventory count of all controlled substances and
documented on the youth’s individualized controlled medication inventory record. Non-
healthcare staff were trained in the delivery and oversight of the self-administration of
medication. All trainings were delivered by a registered nurse (RN) to thirteen supervisors. An
observation of three controlled medications and three OTC medications verified the counts were
accurate. A review of three random sharps found the inventory counts were accurate.
Documentation and counts matched the ending inventory numbers. The reporting criteria and
procedures regarding inventory discrepancies is to report any discrepancies to management
and the Department’s Central Communication Center (CCC) as soon as the situation occurs.
Documentation indicated there were no discrepancies. An interview with the clinical nurse
indicated the process for the disposal and destruction of expired and/or discontinued
medications. Medications are destroyed utilizing the chemical medication disposal agent with a
licensed pharmacist and documented.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center maintains facility operating procedures ensuring proper procedures are followed to
prevent the spread of infectious diseases or illnesses and provide staff with the knowledge of
appropriate prevention, containment, treatment, and reporting requirements of infectious
diseases. A review of five Individual Healthcare Records (IHCRs) revealed each documented
the date each youth received infection control training. Each youth received training on infection
control within seven days of admission, which included hand-washing techniques,
universal/standard precautions, prevention/transmission of communicable diseases,
vaccinations, and Center for Disease Control and Prevention (CDC) guidelines for infection
control. The Exposure Control Plan/Infection Control Plan was written in accordance with
Occupational Safety and Health Administration (OSHA) guidelines and included a risk
assessment with a list of all job classifications in which staff have the potential for occupational
exposure, all job classifications in which some staff have the potential for occupational
exposure, and tasks or procedures which would cause the staff in the applicable job
classifications to have an occupational exposure. The methods of compliance included infection
control practices, engineering and work practice controls which discussed the availability of
hand washing at the center, procedures for proper disposal of needles and other sharps,
procedures for maintaining the work-site in a clean and orderly manner, the use of specified
signs and labels to communicate hazards to staff, procedures for handling of contaminated
laundry, procedures for post-exposure evaluation and follow-up, and the system of medical
record keeping for staff with occupational exposure. Additionally, the infection control
procedures in place included prevention, containment, treatment, and reporting requirements
related to infectious diseases, according to OSHA and the CDC guidelines. Documentation
indicated the infection control procedures includes common, infectious diseases of self-limiting,
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episodic contagious illnesses and viral or bacterial infectious diseases. The procedures also
entailed tuberculosis, Hepatitis A, B, C, human immunodeficiency virus (HIV), infectious
diseases caused by blood-borne pathogens, other outbreaks or epidemics caused by any other
infectious agent, whether spread directly or indirectly, the outbreaks of pediculosis and/or
scabies, Methicillin-Resistant Staphylococcus Aureus (MRSA) and other antibiotic-resistant
micro-organisms, food-borne illnesses, bio-terrorist agents, and chemical exposures in the
workplace. An interview with nursing staff confirmed the center’s process for needle stick post-
exposure evaluation. The nurse stated the nurse will wash the site and the clinical staff will send
them to VitalCore Health Strategies, LLC. laboratory for blood work and shots as needed.
Additionally, the Hepatitis B immunization is made available for staff, and staff have access to
protective equipment. Documentation revealed the superintendent maintained a separate file
containing all documents for youth and staff who have experienced a facility/occupational
exposure. All records are maintained as confidential for a ten-year period. A review of five pre-
service and five in-service training records confirmed each staff was trained on the center’s
specific Exposure Control Plan. An interview with nursing staff also confirmed the registered
nurse (RN) conducts the infection control training with staff. There were no exposure incidents
since the last annual compliance review.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center maintains facility operating procedures to ensure the care of pregnant youth
including procedures for medical issues, nutrition, education, and medication. Five youth
Individual Healthcare Records (IHCRs) were reviewed and none were applicable for prenatal
care/education. The center had two pregnant youth during the annual compliance review period
and the two applicable records were reviewed. One youth’s IHCR found the designated health
authority (DHA) conducted a focused medical evaluation at least every thirty days. One youth
was released from the center two days after entry and did not have an evaluation.
Documentation revealed there was daily monitoring for danger signs of pregnancy
complications and a documented plan for post-birth psychological and physical care.
Documentation revealed the youth was added to the internal alert system. An interview with
nursing staff confirmed the youth was provided education material related to the youth’s
pregnancy with topics such as, alcohol and drug use, smoking while pregnant, nutrition, sexual
transmitted infections (STIs), the use of contraception, and prenatal care. In addition, the youth
was given material on the birthing process, postpartum care, basic baby care, child/infant care
development, and parenting skills. There was indication the youth received nutritious food in
quantities appropriate for a pregnant youth, as ordered by the practitioner, and the licensed
healthcare professional staff provided routine monitoring of the pregnant youth’s nutritional and
weight status during the pregnancy. A review of the youth’s IHCR confirmed all education
material was given. A licensed nurse provided in-service education on youth prenatal healthcare
needs annually to all non-healthcare staff involved in the supervision or treatment of youth. An
interview with nursing staff indicated prenatal services are provided to pregnant youth while in
the center. Youth are transported to the obstetrician gynecologist (OB/GYN) appointments,
administered prenatal vitamins, discuss comfort measures such as sleeping mats, and the
increase of calories and additional snacks. Female youth are routinely tested for pregnancy
upon admission and pregnant youth are seen weekly by nursing staff and monthly by the DHA
and will be seen off-site by an OB/GYN as soon as possible. Female youth are also given a
Department approved educational packet for pregnant youth.
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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 which outlines supervision of youth requirements.
Observations were conducted each day of the annual compliance review week of staff
supervising youth. Youth were observed in the classrooms, in the living modules, eating
breakfast and lunch, going to and from school, and during recreation. There was proper
supervision during each of these observations and staff were aware the number of youth they
were supervising. All youth movements were communicated to master control prior to
movements. Master control authorizes each movement and each entry is logged in the master
control logbook. Daily counts are tracked in the master control logbooks, living module
logbooks, and the Department’s Juvenile Justice Information System (JJIS). Five staff were
interviewed, and all stated the center has enough staff to provide safety and security of the
youth and staff.
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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 addressing the behavior management system
(BMS) to ensure the safety and security of youth and staff, which offers rewards, privileges, and
consequences for youth behaviors. Reward calendars were posted throughout the center to
make youth aware of rewards and privileges which can be earned. Youth names and levels
were posted on a dry erase board on the modules for each youth to see their progress.
Observations conducted during the annual compliance review week revealed the center had the
BMS posted in both living modules. Five interviewed staff stated the center’s BMS is a point
system, level system, the BMS is posted throughout the center, listed in the youth handbook,
and discussed during orientation. Five interviewed staff stated the center provides level three
parties, snacks, culinary classes, special level three blankets, longer phone calls, and birthday
celebrations as part of the BMS. Staff also stated levels and points can be taken away as a
consequence. All staff reported the BMS is effective in the center. Each of the five interviewed
staff stated they speak with youth to discuss the consequences being imposed and the youth is
given an opportunity to explain their behavior. Each staff indicated speaking with youth about
alternative, acceptable behaviors. Each of the five staff stated supervisors provide feedback to
staff regarding the implementation of the BMS through coaching and talking to staff. Staff
receive feedback on the implementation of the BMS daily. Each staff stated they have never
seen a co-worker take meals, snacks, clothing, education, or medical care from a youth
because they were acting out or observed any staff encouraging youth to beat up another youth.
Three out of five interviewed youth stated they would rate the center's BMS as fair. Two youth
stated they would rate the center's BMS as good. Each of the five interviewed youth were able
to explain the difference between each level and how youth move from level to level. Each
youth stated they are rewarded in the center with more phone calls, better snacks, better
blankets, and level three parties. Four of the five youth stated all staff use the reward system the
same. One youth stated staff sometimes use the rewards the same. All youth stated youth are
never allowed to punish other youth. Five youth stated they have never been sent to their room
for punishment. One youth stated when they received consequences, they were not fair. One
youth stated the consequences they received were fair. Three of the five youth stated they
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never received consequences. Three of five youth stated when consequences were given
points and levels were taken away and two youth never received consequences. One youth
stated handcuffs or leg irons are not used on out-of-control youth to prevent them from hurting
themselves or others. Four youth stated they have never witnessed the use of handcuffs or leg
irons. During an interview with the superintendent, it was stated the statewide BMS is used to
ensure youth are provided clear and reasonable guidelines and consequences both positive and
negative. The superintendent stated the staff go above and beyond to ensure youth are
provided rewards when good behaviors are exhibited.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures addressing ten-minute checks. Staff utilize the
electronic wand system by tapping on the check point sensors on the outside of each youth’s
room. The juvenile justice detention officer (JJDO) must observe the youth behind the closed
door before the check point sensor is activated. The data from the wand is downloaded daily to
ensure no data is lost. A review of the documentation and surveillance coverage was conducted
for three randomly selected dates, across three shifts, and on two different youth living modules.
The review revealed the ten-minute checks were consistently conducted at intervals of ten
minutes or less. Documentation of logs was reviewed for nine different dates throughout the
annual compliance review period. All dates indicated check times were documented in real time
within ten minutes or less. There was a weekly review of management oversight, which
reflected checks were conducted in the required frequency to ensure the checks were met with
fidelity. Five staff were interviewed, and all five reported room checks are conducted every ten
minutes when a non-suicidal youth is placed in their room. During an interview, the
superintendent reported anytime a youth is placed in their room, ten-minute checks must be
conducted using the wand system. Additionally, if the wands are not available, staff are required
to utilize the Visual Observation Report (VOR) form on each youth placed in their room. Staff
are responsible for providing supervision while youth are inside the rooms. Staff conduct
observations in a manner ensuring the safety and security of each youth and document each
check in real time either 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.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures in place to ensure staff always know the exact
number and location of all youth under their supervision. A review of the master control
logbooks confirmed the census counts of youth are documented at the beginning, randomly
throughout the shift, and at the end of each shift. A review of one full day from each month since
the last annual compliance review confirmed counts were being conducted and documented as
required. Counts were also documented following emergencies, disturbances, and drills.
Census counts were documented upon any change of population, on the master control dry
erase board, and updated on the Department’s Juvenile Justice Information System (JJIS)
census. Living module counts were recorded in the assigned module logbooks by detention
staff. The center also conducts status checks of the areas, during which the counts are also
recorded. An observation of counts was completed during the week of the annual compliance
review, and staff completed counts before and after meals. Five staff were interviewed and all
staff reported counts are conducted at the beginning of shifts, end of shifts, before and after
school, and before and after meals. If the count is not correct, staff will recount, get supervisors
involved, and place everything on lock down until the count is resolved. Emergency counts are
conducted when a youth is believed to be missing, when visibility is hindered such as an
electrical outage, and after a major disturbance.
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5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has facility operating procedures regarding logbooks. The center maintains separate
logbooks in master control and for each living module, as well as one for visitors, and one for
contracted and education staff. A review of logbooks since the last annual compliance review
revealed each logbook was bound with numbered pages, all entries included the date and time
of the event or incident, the name of the staff and youth involved, and the initials of the staff
making the entry. All reviewed entries revealed safety and security of the center, including
medical, special needs, and mental health alerts, were highlighted. Reviewed logbooks reflected
all errors were struck through with a single line and voided and initialed by the person correcting
the error. Reviewed master control logbooks included emergency situations, incidents, fire and
escape drills, population counts at the beginning and end of each shift, group movements,
admissions and releases, presence of law enforcement, name of youth placed in confinement
including the time confinement began and the time confinement ended, name of youth placed
on precautionary/secure observation, including the time precautionary and secure observation
began, and the time precautionary and secure observation was discontinued. A review of the
center’s activity schedule and logbook documented minimal educational instruction interference.
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 facility operating procedures regarding logbooks. The master control and
module logbooks for twelve months were reviewed. The supervisors review the logbooks each
shift, including the master control logbook when accepting the shift, to document they are aware
of current relevant situations in the center. A review of the center’s logbooks confirmed the
superintendent or designee reviewed the logbooks on a weekly basis. The officer assigned to
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the modules conducted reviews of the logbook upon accepting the shift, documenting the pages
reviewed. Logbooks contained documentation to support the superintendent or designee toured
the youth living modules at least once during each shift. Three full days of each month for the
annual compliance review period reflected no issues noted. During an informal interview, the
superintendent reported logbooks are reviewed weekly by the superintendent or designee. The
shift supervisor reviews the master control logbook upon receiving the shift, module logbooks
are signed daily by the juvenile justice detention officer (JJDO) acknowledging review of the
logbook prior to starting their shift.
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.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center maintains facility operating procedures on key control, which includes the issuance
of keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys, and
reporting and replacement of damaged keys. All keys are kept in a locked box in the master
control. The center maintains a master key inventory which accounts for all key rings by ring
number, the number of keys on each ring, the capability of each key, and to whom the keys are
assigned and issued. Emergency keys which provide egress through exterior doors are stored
in master control and the supervisor’s office. All restricted keys are secured in the supervisor’s
key box in master control. The master control operator verified keys are restricted only to staff
authorized to have each key type and all key rings are color coded to maintain control of the
keys. A review of the Key Control Logs and observations of the distribution and collection of
keys during the annual compliance review week confirmed the issuance of keys and key rings
were documented on the center’s Key Control Log. A form is also used to track staff keys. Staff
sign-out the keys at the beginning of the shift and sign-in at the end of the shift. At each shift
briefing the shift supervisor documents the name and initials of the staff, and the time of the
issuance of the key to the staff. A review of the shift reports confirmed they matched the keys in
use. Observations indicated keys were on the staff to whom the keys were issued, and youth
did not have access to center keys. A review of the master control inventory for five random key
rings revealed the inventory report matched the actual key rings in use. A random review of
three staff and their assigned keys matched the key log. A review of the Department’s Central
Communications Center (CCC) reports and internal incident reports found no instances of lost
or missing keys since the last annual compliance review. Personal keys are stored in staff
lockers and visitor keys are stored inside master control on a hook. Once the visitor departs, the
keys are returned. Supervisors, administration, and maintenance mechanic staff have access to
emergency keys. The center has a process in place for reporting lost or missing keys. Five
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interviewed staff reported medical records keys, youth property area keys, and mental health
keys are restricted. Four of the five staff stated case management keys and kitchen keys are
also restricted keys. All staff reported they knew the key control process and were able to
explain the process for reporting missing or damaged keys as outlined in the policy. Three
reviewed staff knew the function of each key on their key ring. The superintendent was
interviewed and confirmed no permanent keys are issued to staff.
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 in place for transportation and operation of
Department vehicles. The center has a total of seven vehicles used to transport youth. Each
transportation vehicle had documentation of an annual maintenance inspection completed by a
certified mechanic. Documentation showed the mechanic inspected the tires, lights, and brakes
ensuring the vehicles were safe to transport youth. Reviewed documentation verified the
center’s maintenance staff conducted monthly visual checks for all transportation vehicles.
During the monthly maintenance checks staff visually checked the vehicle water coolant, lights,
oil, emergency equipment, brakes, horn, interior/exterior, and cleanliness. In addition, the tires,
battery, windshield and wipers, windows, mirrors, and vehicle damage were visually inspected.
The inspections were documented on the Monthly Inspection forms which were maintained
digitally by the maintenance staff. Each inspected vehicle had the appropriate number of
seatbelts and a current fire extinguisher. Transportation staff take the emergency transport kit
prior to transporting youth which included the window punch, first-aid kit, and seatbelt cutter. An
observation of a youth transport was conducted. Prior to transporting youth, staff inspected the
vehicles for contraband, conducted a fuel check, maintained copies of transportation procedures
in the vehicle, verified the seatbelts were operational, ensured the security screen was secure,
confirmed the vehicle folder included the logs, vehicle and mechanical restraint keys, gas credit
card, and vehicle registration. In addition, staff had a center issued cellular telephone,
documented the inspection in the logbook, ensured the vehicle was always secured, ensured
the youth were searched prior to being placed in the vehicle, and ensured youth and staff were
wearing their seatbelts. Documentation supported for each transport the van logbook
documented acknowledgement the vehicle was checked, destination, number of youth being
transported, staff names, the name of the officer riding in the back of the van, and the time the
transport began and ended. A check of four center vehicles found all were locked when not in
use. Five youth were interviewed, and each youth stated they feel staff are driving safely when
they are being transported. Each youth stated 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 has facility operating procedures to ensure all tools and equipment related to
maintenance and the kitchen area are properly maintained, stored, and inventoried. All tools
were secured behind two secure doors accessible to the maintenance staff, supervisors, and
administrators. Tools are stored on a shadow board which can help to easily identify missing
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tools. The center maintains an inventory of tools. A review of the inventory logs confirmed they
included documentation of the issuance and return of tools. Kitchen tools included knives and
other sharps which were stored in a locked box in the kitchen area. An inventory of kitchen tools
is maintained and counts are documented at the beginning of the day, midday, and at the end of
the shift. Observations of the tool room and the kitchen verified all tools were secured when not
in use. A review of five tools and the tool inventory lists verified there were no tools found to be
missing. There were no tools which were not listed on the inventory sheets. Five tools were
randomly selected and each tool was secured, marked for easy identification on the shadow
board, inventoried accurately, and the inventory was signed by the superintendent/designee.
During an informal interview, the assistant superintendent verified service vendors are always
accompanied by center staff when in the secure area of the center. The center’s policy and an
informal interview with the maintenance and kitchen staff stated if tools are lost, they would fill
out a maintenance disposal form, search for the tools, and if it is not recovered call the
Department’s Central Communications Center (CCC). During an informal interview, the
superintendent stated access to tools is limited to the maintenance mechanic and the center’s
administrators, and tools are kept outside on a shadow board away from the building. Five staff
stated the supervisor is notified and all youth are searched when a tool is reported damaged or
missing.
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 in place which prohibit youth from using cleaning
products, medical equipment, and accessing any tools. Youth are allowed to use Class B tools
which include mops, brooms, buckets, and other common household items. When youth are
using these tools, they are under direct supervision. An observation of a youth using a broom,
mop, and bucket was conducted by video. The youth was supervised by staff while sweeping
and mopping the common area of the living module. Five staff were interviewed, and each
stated youth have access to mops and brooms. Five youth were interviewed and stated they are
allowed to use mops and brooms. Four of five youth stated they don’t clean with any type of
cleaning agent such as bleach, laundry soap, window, or toilet cleaners. One youth stated staff
will spray the chemical and the youth will clean the chemicals off the surface.
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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 regarding the inventory of all flammables, toxic,
caustic, and poisonous items. Flammable, toxic, caustic, and poisonous items are maintained in
secure storage areas with limited access. Safety Data Sheet (SDS) logbooks are located where
the chemicals are stored. The center maintains an inventory of all chemicals which includes the
quantity of each chemical. Monthly Inventories of flammable, toxic, caustic, and poisonous items
are maintained by the maintenance staff and reviewed and signed by the superintendent or
designee. The inventories were compared to the items on-site and were found to be accurate
and complete. A review of five SDSs and corresponding items was completed, and all five
chemicals were properly accounted for and stored in a secure place.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous 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 which state flammable, toxic, caustic, and
poisonous fluids and other dangerous substances may only be drawn or acquired by authorized
staff and prohibit youth from using or handling these items. A review of the flammable, toxic,
caustic, and poisonous materials storage area confirmed the area is inaccessible to youth. The
inventory and check out logs were also reviewed and verified only authorized staff are permitted
access to these items. All five interviewed youth stated they did not have access to flammable,
toxic, caustic, and poisonous items. Five staff were interviewed, and each staff stated youth
were not allowed to clean with substances which are toxic, flammable, or poisonous.
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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 states flammable, toxic, caustic, and
poisonous fluids and other dangerous substances may only be drawn or acquired by authorized
staff and prohibit youth from using or handling these items. A review of the flammable, toxic,
caustic, and poisonous materials storage area confirmed the area is inaccessible to youth. The
inventory and sign-out logs were also reviewed and verified only authorized staff are permitted
access to these items. Observations of the storage area showed a list of authorized staff posted
on the interior of the storage door. The kitchen has a container for grease designated for
disposal outside of the center. An interview with the center’s staff confirmed there were no
instances of chemical spills or disposal of any flammable, toxic, caustic, or poisonous items
since the last annual compliance review.
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 which outline the process of placing youth in
confinement under twenty-four hours. The procedure requires staff to 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. During the annual compliance review period the center had a
total of three hundred sixty-seven confinement placements. Twenty confinement youth records
were reviewed. Each of the twenty reviewed youth confinement records contained
documentation which ensured each youth had the right to have three meals a day plus evening
snack, access to mental health care as needed and requested, daily showers, clean clothing,
mattress/bedding, education materials during school hours, and the right to grieve a
confinement placement. Documentation verified the supervisor approved the confinements, staff
placed only one youth in the confinement room, the room was searched, and documentation of
the search was entered in the Department’s Facility Management System (FMS) prior to placing
a youth in confinement for all twenty reviewed records. A review of twenty Visual Observation
Reports (VORs) verified staff were observing youth in confinement at least every five minutes
for the first hour of confinement. After the first hour, youth were observed according to the
Detention Supervision Matrix. None of the reviewed records documented a physical injury was
observed prior to placing youth in confinement. Each of the reviewed confinement records
documented the reason for the confinement, which was explained to the youth. All twenty
reviewed records verified the supervisor conducted an initial confinement review with the youth
within one hour of the incident. A full report was completed before and after the end of shift, the
supervisor conducted additional reviews with the youth at a minimum of every three hours, and
all reviews were entered in FMS. All twenty reviewed confinement reports documented staff and
supervisors continually counseled the youth and considered removing the youth from
confinement as soon as the youth was able to safely rejoin the population and was no longer a
threat to safety. Reviewed documentation verified the confinements did not interfere with
visitation. The center did not have any pregnant youth in confinement under twenty-four hours
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during the annual compliance review period. An observation of the confinement rooms verified
the cameras and plexi-glass windows were free of obstructions. The interviewed superintendent
stated all confinements are entered in the Department’s Juvenile Justice Information System
(JJIS). Superintendents and regional staff are responsible for tracking quarterly reports and
monthly reviews. Five interviewed staff had knowledge of the center's step-by-step process for
placing youth in confinement. Each staff reported completing a confinement report, conducting
and documenting ten-minute checks, searching the confinement room, conducting five-minute
checks for the first hour, and providing youth with 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 Continuity of Operations Plan (COOP) which requires COOP drills to be
conducted and documented, at minimum, twice a year, with one drill being completed prior to
the hurricane season. Reviewed documentation verified the center conducted two drills during
the annual compliance review period, and one was completed prior to hurricane season. Each
reviewed drill had documentation containing the type of drill, time and date, participants, a brief
scenario, findings, recommendations, and was documented on the Emergency Drill Reporting
form. Five staff were interviewed, and each stated they participated in COOP drills during the
annual compliance review period. The superintendent was interviewed and stated the center
conducts COOP drills twice annually, and all staff are trained how and when to respond.
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 regarding developing, implementing, and
maintaining an Escape Prevention Plan. The centers policy requires escape drills to be
completed on a quarterly basis. A review of the center’s Escape Prevention Plan verified it
included the Department’s established policies and procedures regarding escapes. A review of
the center’s drills confirmed escape drills were conducted monthly during the annual compliance
review period. Each drill was documented on the Emergency Drill Reporting form and included
all required elements. Each drill was reviewed and documented in the master control logbook. A
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review of five staff training records confirmed the staff were trained in escape prevention
monthly. Five staff were interviewed and stated they participated in escape drills monthly 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 for the implementation of disaster preparedness
and fire prevention plans. Fire drill documentation was reviewed and found the center
conducted fire drills monthly, on each shift, during the annual compliance review period. Each
drill was documented on the Emergency Drill Reporting forms which included all required
elements and were documented in the master control logbook. The center had an annual fire
extinguisher inspection conducted on January 9, 2024. Observations confirmed the annual
inspection of fire extinguishers was completed as reported. Five interviewed staff reported fire
drills take place at least monthly, and each participated in a fire drill. Five youth were
interviewed and each stated they were instructed on what to do in case of a fire.
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 which address illegal contraband and prohibited
items and how to reduce the introduction of contraband into the center. A review of the center’s
policy and observations verified prior to admission, a full body search and electronic search is
completed. In addition, searches are conducted when deemed appropriate by the shift
supervisor, when there is a reasonable suspicion the youth is harboring contraband, and during
center-wide initiatives to reduce the introduction of contraband. An observation of a room search
verified staff wore gloves during the search. An informal interview with the assistant
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superintendent verified an incident report is completed for any full body search conducted at any
time other than admission. A review of the center’s policy and observations verified staff and
visitors were electronically searched when entering the secured area of the center. All bags,
cases, jacket pockets, and shoes were searched. All personal keys, personal cellular
telephones, and other contraband items were prohibited in the secured area of the center. A
review of random shift reports for one day for each month of the annual compliance review
period during each awake shift verified youth room searches were documented and completed
as required. In an informal interview, the assistant superintendent stated there was one instance
which may have compromised the safety and security of the center throughout the annual
compliance review period. The incident was called into the Department’s Central
Communications Center (CCC). A review of the CCC reports since the last annual compliance
review found there were three instances of contraband found at the center. The contraband and
the calls to the CCC were documented in the master control logbook. Documentation verified
incident reports were completed identifying findings and disposition of the contraband found.
Confiscated items were secured and hand delivered to the supervisor. Reviewed documentation
showed the shift supervisor documented the chain of custody for the contraband items and the
regional director was notified. Local law enforcement was contacted for the items considered
illegal as defined by Florida Statute. The center has search dogs check the center quarterly for
contraband. An interview with the superintendent stated all youth brought in by law enforcement
are frisk searched prior to the arresting officer’s departure. During admission each youth is
searched, all valuables are secured, and the youth is taken through the electronic scanner.
Detained youth will have a full body search by a certified detention staff of the same gender.
Two staff will be present at the time of the full body search. The center has zero tolerance for
introducing contraband, law enforcement will be immediately contacted, and corrective actions,
including possible dismissal, for staff will be applied.
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report_type: QI Detention

file_name: St. Lucie Detention Center-FINAL-FY2324.pdf