state: FL

facility_name: Palm Beach Youth Academy

summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Palm Beach Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
1100 45th Street Building A
West Palm Beach, Florida 33407
Review Date(s): December 2-5, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Serena Brown, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Dedilia Finlayson, South Region Detention Operations Consultant (Standard 5)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Peter Keelan, Office of Education, Central Education Coordinator (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Interviews)
Danielle Penn, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Allisa Spearman, Collier Detention Assistant Superintendent (Standard 5)
Program Name: Palm Beach Regional Juvenile Detention Center MQI Program Code: 207
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Palm Beach County / Circuit 15 Number of Beds: 60
Review Date(s): December 2-5, 2025 Lead Reviewer Code: 226
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 59
A ll in d ic a to rs h a ve b e e n ra te d
O v e
S a tis
ra ll R a tin g S u m
fa c to ry a n d n o c o
m a
rre c
ry
tive a c tio n is n e e d e d a t th is tim e .
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
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
In d ic a to r R a tin g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g *
F iv e -Y e a r R e s c re e n in g /R e n e w a l
S ta ff C o d e o f C o n d u c t
In c id e n t R e p o rtin g (C C C ) *
R ig h t In te ra c tio n s (R I)
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts *
In -S e rv ic e T ra in in g
G rie v a n c e s
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n *
D a ta T re n d A n a ly s is
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
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g ra m o p e ra te s
d o s o w ill re s u lt
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
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
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* T h e D e p a rtm e n t h a s id e n
b e lo w D e p a rtm e n t s ta n d a rd
in a p ro g ra m a le rt fo rm b e in
In d ic a to r R a tin g s
S ta n d a r d 2 - Y o u th M a n a g e m e n t
A d m is s io n
O rie n ta tio n
C la s s ific a tio n
N o tific a tio n o f J P O C irc u it G a n g R e p re s e n ta tiv e
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty
R e le a s e
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s
R e v ie w o f Y o u th in S e c u re D e te n tio n
D a ily A c tiv ity S c h e d u le
E d u c a tio n a l A c c e s s *
C a re e r E d u c a tio n
tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
s e in d ic a to
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Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Evaluation Satisfactory
3.06 Treatment and Discharge Planning Satisfactory
3.07 MH/SA Treatment Satisfactory
3.08 Suicide Prevention Plan * Satisfactory
3.09 Suicide Prevention Services * Satisfactory
3.10 Secure Observation* Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
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
Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 59
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
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In d ic a to r R a tin g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e *
F a c ility O p e ra tin g P ro c e d u re s
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t
P a re n ta l N o tific a tio n /C o n s e n t
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n
D H A /D e s ig n e e A d m is s io n N o tific a tio n
H e a lth -R e la te d H is to ry
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g
S ic k C a ll P ro c e s s
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re
O ff-S ite C a re /R e fe rra ls
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s
M e d ic a tio n M a n a g e m e n t
P s y c h ia tric S e rv ic e s *
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n
P re n a ta l C a re /E d u c a tio n
tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m
s . A p ro g ra m m u s t th e re fo re a c h ie v e a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e
g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio
e d ia te a tte
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Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth* Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will
result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 59
Program Overview
The Palm Beach Regional Juvenile Detention Center is a state-owned detention center,
operated by the Department, located in Palm Beach, Florida. The center serves youth in Palm
Beach County in Circuit 15. All youth are processed through the Juvenile Assessment Center
(JAC), which is co-located within the detention center. Male and female youth who are detained
pending adjudication, disposition, or placement in a residential commitment program are housed
in the sixty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Palm Beach County School
District. The center’s management team includes the superintendent, two assistant
superintendents, two administrative assistants, one chaplain, seven juvenile justice detention
officer (JJDO) supervisors, and forty-eight JJDOs. Mental health and healthcare services are
provided through the contracted provider, VitalCore Health Strategies, LLC. Mental health
services are provided by a licensed designated mental health clinician authority (DMHCA), as
well as four licensed clinical social workers. The center had no non-licensed staff during the
annual compliance review period. Clinical services provided by the center include mental health
and substance abuse evaluations, mental health treatment planning, individual, group, and
family therapy, mental health crisis intervention services, on-site psychiatric services, and
availability for substance abuse services for youth with co-occurring disorders. Medical services
are provided by one medical doctor (MD) who serves as the designated health authority (DHA),
one advanced practice registered nurse (APRN) and five registered nurses (RN). The medical
clinic maintains nursing coverage Monday through Friday, eight hours each day, with staff
available twenty-four hours a day, seven days a week by telephone or in person for
consultation. 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 101 security cameras at the center, of which eighty-nine were operational.
The center has completed work orders and the regional maintenance staff were working to
repair the cameras. A tour of the center was conducted during the annual compliance review
week and observations found it to be clean, the exterior was free from debris, the grass was
manicured, and the center was free from insect infestation. The observed lobby area was clean
and had no broken furniture. The youth living areas and bathrooms were observed to be clean
and the bathrooms were functional. There was no graffiti observed at the center. The
classrooms, kitchen, and dining area were found to be clean and well organized. At the time of
the annual compliance review, the center had six vacancies, which included three JJDO I’s,
other personal services (JJDO I-OPS), one food support worker, one JJDO, and one juvenile
justice detention officer supervisor (JJDOS). Additionally, the assistant superintendent was
serving as the acting superintendent for a period of six months during the annual compliance
review period.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 59
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 maintains a written policy and procedures which states a background screening is
required for all Department staff, contracted providers, grant recipient staff, volunteers, mentors,
and interns with access to youth and confidential youth records. The program has a background
screening policy and procedures for volunteers, mentors, and interns who work with youth less
than ten hours a month requiring sight and sound supervision. The Annual Affidavit of
Compliance with Level 2 Screening Standards was completed and submitted to the
Department’s Background Screening Unit (BSU) on January 20, 2025. A review of sixteen staff,
and seven applicable volunteers indicated a background screening and criminal history report
were reviewed by the center for each. None of the staff were applicable for having exemptions
obtained prior to working with youth. The direct care staff pre-employment assessment tool was
administered and a passing score was documented in each staff record. An informal interview
with the center’s administrative assistant confirmed the volunteers do not have a pre-
employment assessment tool administered.
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 maintains a written policy and procedures for background rescreening and renewal
to be conducted for all Department staff, all contracted provider and grant recipient employees,
volunteers, mentors, and interns with access to youth and confidential youth records. The
center’s policy requires the staff and volunteers to have a five-year rescreening completed
through the Department’s Background Screening Unit (BSU)/Clearinghouse. There were no
staff applicable for a five-year rescreening during the annual compliance review period.
Documentation review of an email from the center’s superintendent confirmed none of the
employees, volunteers, mentors, and interns were applicable for the five-year rescreening
during the annual compliance review period.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 59
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 maintains a written policy and procedures requiring center staff to adhere to a code
of conduct prohibiting any form of abuse, profanity, threats, harassment, intimidation, horseplay,
or personal relationships with youth. The center’s policy and procedures require staff to
communicate and interact with youth in a manner which acts as a role model. A total of six staff
records were reviewed. Three of six staff records reviewed had disciplinary actions for a
violation of the code of conduct with management implementing an oral and written reprimand.
Three direct care staff were acknowledged with commendations for employee of the month. A
formal interview with the center’s superintendent confirmed the code of conduct policy is to
ensure staff communicate and interact with youth in a manner which provides a role model for
socially accepted behaviors. A formal interview with seven staff confirmed youth and staff are
allowed to contact the Florida Abuse Hotline or the Department's Central Communications
Center (CCC) to report suspected abuse. Five of the interviewed staff stated they will notify the
supervisor and allow the youth to make the call. Six of the seven staff confirmed they notify the
superintendent for a call to the Florida Abuse Hotline. All seven staff agreed they had never
heard staff using profanity when speaking to the youth or use a threat or intimidation toward the
youth. Five of the seven staff stated the working conditions at the center were good. One staff
stated the conditions were very good. The last staff member stated the center’s working
conditions were fair. A formal interview with seven youth confirmed four of the seven youth
stated they never needed to call the Florida Abuse Hotline. Three of the seven youth stated they
were never stopped from calling abuse. All seven youth agreed staff are respectful when talking
to them or other youth and they never heard staff using profanity or threaten other youth. Each
of the youth stated they feel safe at the center. None of the youth stated they have ever
exchanged social media contact information, email, or telephone numbers with the staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 59
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 maintains a written policy and procedures where the center shall notify the
Department’s Central Communications Center (CCC) within two hours of an incident occurring,
or within two hours of any center staff becoming aware of a reportable incident. The center’s
policy requires incidents to be reported to the CCC and documented. The center had sixty
incidents reported to the CCC during the annual compliance review period. Six reported
incidents were reviewed. All six incidents were reported within the two-hour reporting time
frame. The incidents reported and documented in the logbook and/or shift reports included two
medical transports, one mental health Baker Act, one complaint against staff, a program
disruption, and a youth behavior incident. The center did not have any additional grievances and
incidents which required reporting to the CCC. A formal interview with the center’s
superintendent confirmed the center notifies the CCC of any incidents disrupting or having the
potential to disrupt normal operations within the required timeframe. The superintendent
additionally added youth and staff have unimpeded access to call the CCC or Florida Abuse
Hotline.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center maintains a written policy and procedures regarding the center using physical
intervention techniques in accordance with Florida Administrative Code. The center’s policy
requires reports to be completed on the same day and to be reviewed by a Right Interactions
(RI) certified instructor, and superintendent or designee. Additionally, a post RI interview is to be
conducted. Documentation review in the Department's Juvenile Justice Information System
(JJIS) confirmed a total of 132 RI incidents were reported during the annual compliance review
period. A total of nine incidents were reviewed. All nine incidents had RI Reports completed for
each use of countermoves, control techniques, takedowns, or mechanical restraints. Each
report was reviewed by a supervisor or RI certified instructor. Each of the nine reports were
completed on the same day as the incident and included a statement from all staff involved.
None of the incidents reported serious injury to the youth or staff requiring immediate contact
with the Florida Abuse Hotline. Documentation confirmed each post RI interview was conducted
with the youth by the administrator or designee within the required timeframe. None of the RI
Reports indicated the need for a RI medical review. Mechanical restraints were not used during
any of the reviewed RI incidents. The center had no additional RI incidents noted in internal
incidents, grievances, or logbooks. The center’s RI rate during the previous quarter was 10.74,
which is below the statewide Detention RI rate of 13.67. The interviewed superintendent stated
the center monitors and reviews RI incidents by reviewing the closed-circuit television
recordings and reports. In an instance where physical or mechanical restraints are used the
center uses a Mechanical Restraint Tracking Log. Seven interviewed staff stated staff try to talk
to youth prior to using RI or mechanical restraints.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 59
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 maintains a written policy and procedures requiring detention staff to complete pre-
service/certification requirements specified by Florida Administrative Code within 180 days of
hire. The center’s policy requires two phases of training and consists of 120 hours of workplace
training during the first phase. Second phase staff complete 120 hours of training at the
academy. A review of seven staff training records in the Department’s Learning Management
System (SkillPro) confirmed all the staff completed the pre-service requirements, new staff
orientation, and 120 hours of academy training within 180 days of hire.
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 maintains a written policy and procedures requiring all direct care staff 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. The center’s policy requires both in-service and instructor led training to be completed
annually and documented in the Department’s Learning Management System (SkillPro).
Supervisors are required to complete eight additional training hours. A review of three
supervisors and four direct care staff training records confirmed all the staff completed the
required in-service trainings which were documented in SkillPro. Trainings included active
shooter preparedness, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking intervention, information security awareness, mental health
and substance abuse, Prison Rape Elimination Act (PREA), Right Interactions (RI) update,
professionalism and ethics, sexual harassment, trauma responsive practices, and suicide
awareness and prevention. A review in SkillPro for the three supervisors’ training records
indicated the minimum of eight-hours of annual training in coaching, leadership, and personal
accountability were completed in addition to the twenty-four hours of required in-service training.
On April 16 and 17, 2025, the licensed nurse provided in-service education on girls’ healthcare
and emergency care of the pregnant youth to all the non-healthcare staff involved in the
supervision or treatment of girls. Provided documentation confirmed the center maintains an
updated annual in-service training calendar located in the training office, which was approved by
the center’s superintendent, assistant secretary of Detention services, and the director of the
Department’s office of Talent, Leadership, and Culture. An interview with the superintendent
indicated they were required to complete RI instructional training, CPR, first-aid, and leadership
training, and all trainings were entered into SkillPro. Additionally, required management level
trainings were completed.
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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 maintains a written policy and procedures stating all youth have the right to grieve
the actions of center staff and conditions and circumstances in the center related to the violation
or denial of basic rights. The center’s procedures require a grievance form and a pencil to be
issued to any youth wishing to file a grievance. Grievance forms are available for youth to
access. Grievance forms and deposit boxes were observed on the living modules. A review of
the Department's Juvenile Justice Information System (JJIS) and the center’s grievance binder
confirmed two grievances were filed during the annual compliance review period. Both youth
grievances were documented in the Department’s Facility Management System (FMS), signed,
and resolved within the twenty-four-hour timeframe. A review of seven youth interviews
indicated each youth was knowledgeable of the grievance process and how to obtain the
grievance forms from the living unit’s dayroom area. Youth stated once forms are filled out the
supervisor receives the grievance and has a conversation with the youth and staff. Four of the
seven youth stated they never had to file a grievance. Two youth stated the grievance process
is good. One youth stated the process is very good. Seven staff were interviewed regarding the
center’s grievance process. Each staff explained the informal, formal, and appeal processes.
The staff reported the youth can fill out and submit the grievance form to the supervisor if the
staff cannot resolve the issue. Staff will receive the handwritten grievance and complete the
grievance process in JJIS. According to the formal interview with the superintendent, youth are
encouraged to file a grievance if they feel they have been mistreated. The grievance process
has three phases, which include the informal, formal, and appeal phases. The center uploads
the written grievances, which are maintained in FMS for a year.
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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 maintains a written policy and procedures outlining the process of entering and
sharing alerts. The center’s policy requires alerts for youth to be appropriately entered,
downgraded, or discontinued in the Department’s Juvenile Justice Information System (JJIS).
Seven youth alert records were reviewed in JJIS. All the alerts were updated, removed, or
entered by a registered nurse (RN), center admitting direct care staff, shift supervisors, or the
designated mental health clinician authority (DMHCA). Each alert entered was documented in
the shift report and the center’s module logbooks. A review of the center’s module logbook
indicated the supervisors and administrators were reviewing the alerts as indicated with a
signature by the highlighted note. An informal interview with the assistant superintendent
indicated staff are given updated alerts daily in shift briefings. Reviewed shift reports indicated
the alerts are discussed during the shift briefing. A shift briefing was not observed during the
annual compliance review week. An informal interview with the master control operator
confirmed during the shift briefing staff are provided with alerts daily. The center’s process for
updating alerts was discussed during an informal interview with the shift supervisor, who stated
alerts are updated by medical or mental health staff, and/or during the admission process. Alerts
are updated with new information as changes occur. The center had no additional information
found which should have been placed on the alerts. A formal interview with the center’s
superintendent indicated the alert process is to ensure accuracy, consistency, and be a quick
reference for information pertaining to a youth. Alerts are reviewed daily and placed in the
Facility Management System in JJIS. Seven interviewed staff agreed updated youth alert forms
are received during the shift briefings. Two of the seven staff stated youth alerts are in the
center’s logbooks and JJIS. All seven staff agreed management notifies staff of issues at the
center through staff debriefings and meetings. One staff stated emails were sent when
management needed to inform staff of issues in the center. Five of the seven staff agreed the
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process of communicating information is very good at the center. One staff stated the
communication process is fair. The last staff stated management’s communication process is
good. An interview with the center’s registered nurse (RN) confirmed the licensed healthcare
staff are responsible for updating medical alert systems.
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 maintains a written policy and procedures for reviewing and analysis of data in
decision-making practices. The center’s practice regarding data trend analysis includes utilizing
attendance and tardy slips to monitor staff attendance. The center has a time clock for staff to
clock-in and out for work and a copy of the report is given to the supervisors and administration
to assist with completing staff time sheets. The center uses a wand to track ten-minute checks.
Video observation reviews are conducted by supervisors and administration to ensure staff are
providing a safe and secure environment for the youth. Administration attends shift briefings to
share information with the direct care staff. Monthly supervisory meetings were held to discuss
pertinent information. Additional information was passed on through email, shift reports, face-to-
face contact, and logbooks. Documentation review of shift reports, incident/confinement reports,
logbooks, and alerts confirmed the center’s administration was reviewing and communicating
with direct care staff and providers. The center shares information with providers and
stakeholders during the Department head meetings, safety meetings, and weekly south region
superintendent meetings. In addition, administration attends and participates in meetings with
the advisory board, juvenile division meetings, and the school board meetings. Provided
documentation confirmed an advisory board meeting was held on October 23, 2025. The center
retrieves the collected data and uses the data to help improve staff morale with attendance. The
collection of ten-minute check information helps improve the center’s safety and security
measures with the youth.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center maintains a written policy and procedures to ensure all youth are admitted to the
center in accordance with Florida Administrative Code. A review of seven youth case
management records indicated each record included an arrest affidavit/custody order, a
Detention Risk Assessment Instrument (DRAI), and a Suicide Risk Screening Instrument
(SRSI). Each of the seven-youth records showed an Admission Wizard documented the
completion of a youth full-body and/or electronic search by a juvenile justice detention officer
(JJDO) of the same gender as the youth, a provided telephone call, and a meal was provided.
Each youth received medical, mental health, and substance abuse screenings upon admission.
At the time of the annual compliance review, an observation was conducted of an admission.
The observation verified all the required procedures were completed. The one applicable youth
was full body and electronically searched by an officer of the same gender. The youth was
provided breakfast and a phone call to their parent/guardian.
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2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center maintains a written policy and procedures to ensure youth are oriented to the
center’s rules and regulations, expectations for behavior and related consequences for failing to
meet those expectations, and youth rights within twenty-four hours of a youth being admitted
into the center. A review of seven youth case management records indicated the center
provided each of the seven-youth with an orientation within twenty-four hours of admission to
the center and each youth signed an orientation acknowledgement to document the contents
were discussed. Each of the seven reviewed youth records indicated the orientation was
provided verbally and in writing. All orientation checklists were located in section three of the
case management record and included 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) related information. At the time of the
annual compliance review, an observation of an orientation was conducted. The one applicable
orientation included all elements as outlined in the center’s policy. During an observation of the
orientation process, the youth watched a PREA video upon admission. An interview with seven
youth confirmed they were informed of the rules, regulations, daily schedule, education
services, visitation, abuse reporting, and the behavior management system.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center maintains a written policy and procedures regarding classification and orientation to
ensure each youth is protected from harm, violence, and/or victimization. A review of seven-
youth case management records indicated each record contained information concerning the
youth’s history and status including all required documentation. Each of the seven reviewed
records contained documentation which confirmed the classification for the youth included
mental illness, intellectual disabilities, physical disabilities, history of violent behavior, gang
affiliation, criminal behavior, history of sexual offenses including sexual battery charges which
were reduced to a lesser offense, Vulnerability to Victimization and Sexually Aggressive
Behavior (VSAB) screening results, medical status, identified or suspected suicide risk, escape
risk, security risk, and history of human trafficking. A review of documentation indicated the
classification process included all the required topics to be considered prior to making room
assignment, which included the youth’s gender, height, weight, age, and level of aggression.
Each youth was assigned a room based on their classification. None of the seven reviewed
youth were reclassified due to changes in their behavior or observed status. None of the
reviewed youth had a history of committing a sexual offense or were a victim of a sexual
offense. The interviewed superintendent stated the center has a designated gang liaison, and
the local Sheriff’s office informs them on how to identify and address local youth gangs.
Additionally, it was stated classifications are used to assign a youth to an appropriate room.
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2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center maintains a written policy and procedures to ensure the center has a screening
process for newly admitted youth to determine if the youth is a gang member or gang affiliated.
A review of seven youth case management records indicated none were applicable for
suspected gang affiliation; therefore, additional records were requested. The center reported
only having two-youth applicable for being gang identified or affiliated since the last annual
compliance review. Reviewed documentation indicated each of the two applicable youth’s
information regarding suspected gang involvement was shared by an email with the juvenile
probation officer (JPO), who is designated as the circuit gang representative, indicating
suspicions of gang activity such as youth flashing gang signs, gang tattoos, gang-related
drawings, or related activity. Additionally, detention staff included in the email all pictures, copies
of written statements, drawings, graffiti, and a description of what gang signs the youth was
flashing. The center’s captain serves as the gang representative. An informal interview with the
captain indicated the process for sharing information. The process is for verbal communication
to be conducted and emails are sent to the local sheriff’s office.
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 maintains a written policy and procedures related to ensuring the proper safe
handling and security of each youth’s personal property including valuables, which are collected
and secured at the time of a youth’s admission. A review of seven youth case management
records indicated the itemized personal Property Receipt form and valuable Property Receipt
forms were maintained for each youth. Additionally, youth and staff signed the form, and a letter
of acknowledgement regarding unclaimed property was signed by each youth. Two of the seven
applicable youth had money and personal items of value, which were verified and secured in a
clear tamper proof property bag. The bags included the date, youth’s name, Department
identification number (DJJID) and a listing of items in each of the two applicable bags. The
tamper-proof bags were placed in a drop safe. Additionally, the drop safe bound logbook
included the date, time, youth’s name, DJJID, printed name of the officer who secured the
property, and the officer’s initials. The other personal property for the seven-youth reviewed,
including clothing, was placed in an assigned locker/bag as documented on the Property
Receipt form and the personal Property Receipt form was placed in the youth’s active record.
The valuable Property Receipt form was placed in the youth’s active record for the two-youth
applicable for valuable property. A review of the Department's Central Communications Center
(CCC) reports since the last annual compliance review indicated there were no reported
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incidents regarding youth property valued over fifty dollars. An observation of youth property
processing was not possible the week of the annual compliance review. An interview was
conducted with seven youth and each stated staff checked their personal property and the youth
signed a form stating the personal property was correct. An interview was conducted with the
superintendent who stated youth’s personal property is inventoried and recorded on the
Property Receipt form in the Department’s Juvenile Justice Information System (JJIS), during
the booking process, and placed in the storage room. This process is completed by a supervisor
and administration. After thirty days the unclaimed property is donated to charity, and a receipt
is received. If the property is money, a money order of the amount is received, and it is sent to
the Department’s financial department.
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 maintains a written policy and procedures regarding all youth releases. A review of
three closed youth case management records indicated each closed record showed the on-duty
supervisor reviewed all paperwork related to release prior to each youth’s release. Each of the
three applicable closed records indicated the juvenile justice detention officer (JJDO) supervisor
reviewed the release paperwork received from the court and the youth’s identification was
verified prior to release. Each reviewed closed case management record showed the
identification of the parent/guardian or responsible adult was verified prior to release with an
identification card which was photocopied and placed in the youth’s record. One of the three
youth had an endangered person alert, and the staff verified the parent/guardian and/or
responsible adult did not have pending or historic child abuse investigations related to
trafficking, charges of child abuse, drug trafficking, or prostitution. Additionally, the Department
staff documented efforts to contact the child protection investigator prior to releasing the youth.
Each of the applicable youth, and the person to whom each youth was being released, were
reminded of any future court dates and all required parties signed all applicable release forms.
The date of admission and the date of release documented in the case record correlated with
the Department's Juvenile Justice Information System (JJIS) for each youth. At the time of the
annual compliance review an observation was conducted of a youth being released and
confirmed the center’s practice.
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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 maintains a written policy and procedures ensuring upon the youth’s release from
detention and retrieval of personal property, the releasing officer, the youth, and the youth’s
parent or legal guardian shall review and sign the Property Receipt form and account for all
youth’s personal property. The center’s policy outlines procedures regarding release of youth
with prescription medications. A review of three closed youth case management records
showed each youth and parent/guardian signed the Property Receipt form upon release and
there was documentation verifying the youth was released to an appropriate person with a copy
of their identification. One of the three closed records were applicable for the youth being
released from the center with prescription medications and documentation showed the receipt of
medications was signed by the person receiving the youth. Each of the three reviewed records
indicated the youth, and the person to whom the youth was released to were reminded of any
health or welfare issues, including medical, mental health, and/or substance abuse needs, and
any pending appointments. At the time of the annual compliance review, the center had three
applicable youth’s property held for more than thirty days. An interview with the superintendent
confirmed the center’s process for disposal includes donating the items to charity after thirty-
days, and a receipt is received. If the property is money, a money order in the amount is
received, and sent to the Department’s Bureau of Finance and Accounting. An observation of
the release process was conducted during the annual compliance review week and confirmed
the center’s process.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains a written policy and procedures ensuring Detention Reviews are
conducted by the center on a weekly basis for youth securely detained to ensure proper
management of youth and the sharing of information. At the time of the annual compliance
review, an observation of the weekly Detention Review meeting for youth in secure detention
was conducted. The Detention Review meeting discussed thirty-six youth. The detention review
specialist conducted the meeting, and all participants attended the meeting in person and
through virtual communication. The Detention Reviews are held every Wednesday at 10:00 a.m.
to address the status of each youth. A review of documentation during the annual compliance
review period confirmed all required participants attended the Detention Review meetings in
person and/or telephonically. Additionally, there was a review of the weekly Detention Review
meetings, which were documented in the Department’s Facility Management System.
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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 maintains a written policy and procedures ensuring youth are provided the
opportunity to participate in constructive activities which will benefit the youth and the program.
At the time of the annual compliance review, observations of youth engaged in various activities
throughout the week were conducted which included educational instruction, indoor recreation
times, open programming times, and canteen times. Observations confirmed the center followed
the center’s schedule. The schedule included times for wake-up and personal hygiene,
mealtimes, visitation, recreation and physical activities, indoor activities which promote
education, problem solving and life skills, bedtimes, groups, and open program time. The daily
activity schedule was posted throughout the center. An interview was conducted with seven
youth and seven staff, and each indicated the center has a daily schedule which is followed.
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’s education services are directly supervised and administered by the Palm Beach
County School District. Services operate on a year-round basis providing the assigned youth
with 242 days of education distributed over twelve months with a minimum of twenty-six and a
half hours of instruction each week. A review of the weekly/daily education schedule and the
weekly/daily center’s schedule confirmed both schedules were aligned with the start and end
times for the educational classes and the center’s daily activities. Video observation review of
three random days of educational instruction confirmed the youth arrived and exited from the
classes at the scheduled times. A review of the center’s logbooks during the annual compliance
review period confirmed the youth were being escorted to and from class according to the
established schedules. Seven youth were interviewed and stated the center was preparing them
to earn a high school equivalency diploma (GED), attend a vocational school, or college, or for
employment. Two of the youth stated the center was preparing them very well. Five youth stated
the center was preparing them well. Seven staff were interviewed and all reported classes were
being conducted with minimal interruptions. During an interview with the center’s superintendent
it was stated classes were being conducted with minimal interruptions.
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 provides the youth with the opportunity to participate in a career themed curriculum.
This course of study is categorized as Type 1 Life Skills Curriculum and is based upon the age
of the youth as well as their individual intellectual and educational abilities and levels. This
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course classification, which stresses soft skills, has activities which include learning
development and improvement of effective communication skills as well as focusing upon the
development of interpersonal and decision-making skills. An informal interview with the
education program’s transition counselor, indicated a virtual vocational platform is used for the
career-based curriculum. Seven youth were asked to identify the classes they were taking while
in the center. In response, the seven-youth indicated they were enrolled in both math and
science. Six of the seven youth responded they were taking social studies and history classes.
Lastly, four of the seven youth stated they were taking a reading class.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains a written policy and procedures identifying a single licensed mental health
professional designated as the mental health clinician authority (DMHCA) to oversee
appropriate 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 DMHCA is
available seven days a week, twenty-four hours a day, by way of telephone for consultation. The
DMHCA is a full-time staff and scheduled to be on-site forty hours each week and is on-call
seven days a week. The DMHCA is a licensed clinical social worker (LCSW) with a clear and
active license in the State of Florida, with an expiration date of March 31, 2027. A review of the
mental health sign-in logbook for the annual compliance review period confirmed the DMHCA
was on-site, as required. The center did not have a back-up DMHCA during the annual
compliance review period. During an interview, the DMHCA reported the requirement is for the
DMHCA to be on-site at least once a week for a sufficient time period to ensure appropriate
coordination and implementation of mental health and substance abuse services. The DMHCA
reported the clinical services provided included ongoing engagements with youth by providing
support services, trainings, and individual or group counseling. The DMHCA reported the level
and frequency of communication with the center's staff is daily and consistently to discuss and
review daily and weekly mental health tasks.
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 maintains a written policy and procedures for ensuring mental health and substance
abuse services are provided by individuals with appropriate qualifications. The center’s policy
requires the clinical supervisors to ensure the clinical staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The center requires
mental health and substance abuse services to be provided by individuals with appropriate
qualifications. The clinical supervisor ensures the licensed clinical staff working under their
supervision are performing services they are qualified to provide based on education,
experience, and training. A review of the licensed clinicians’ credentials confirmed four had an
active license in the State of Florida as a licensed mental health counselor (LMHC), with an
expiration date of March 31, 2027, and four staff were licensed clinical social workers (LCSW)
with an active license in the State of Florida expiring on March 31, 2027.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center maintains a written policy and procedures for ensuring mental health and substance
abuse services are provided by individuals with appropriate qualifications. The center’s policy
requires the clinical supervisor to ensure clinical staff working under their supervision are
performing services they are qualified to provide based on education, experience, and training.
The Department maintains a contract with VitalCore Health Strategies, LLC, ensuring mental
health and substance abuse services are provided to all applicable youth in the center. All
mental health services are provided by licensed mental health professionals and the center
does not have any non-licensed mental health clinical staff. The center does not have a Chapter
397 license with the Department of Children and Families. Reviewed documentation confirmed
only the licensed mental health counselors were facilitating all substance abuse treatment and
groups.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center maintains a written policy and procedures ensuring the mental health and substance
abuse needs of youth are identified through a comprehensive screening process. The center’s
policy requires referrals to be made when youth are identified with mental health and/or
substance abuse needs or are identified as a possible suicide risk in accordance with Florida
Administrative Code. A review of seven youth mental health and substance abuse records
confirmed initial screening documents were completed by a probation officer/screener. Each
screening document was reviewed by detention staff. Reviewed documentation confirmed the
Suicide Risk Screening Instrument (SRSI) was completed during intake and documented in the
Department’s Juvenile Justice Information System (JJIS) for each youth. Reviewed
documentation confirmed the Massachusetts Youth Screening Instrument, Second Version
(MAYSI-2) was completed in JJIS for each youth. The nurse and/or mental health staff
completed the required sections of the SRSI for each screening and completed entries, which
included the accurate referral selections in the “Screening Results” section. Five of seven
reviewed screenings confirmed each youth had positive “YES” responses on the SRSI and
youth were placed on suicide precautions and a mental health referral was completed, which
documented the youth's need for an Assessment of Suicide Risk (ASR). Four of five SRSIs
were applicable for a “YES” response when youth had an open or closed suicide risk alert
entered in JJIS. None were applicable for all negative responses resulting in an invalid MAYSI-
2. Each reviewed screening indicated a need for further assessment and a referral was made.
Each assessment confirmed the superintendent was notified. None of the reviewed MAYSI-2s
indicated an elevated suicide risk subscale. Two of seven MAYSI-2 results indicated the need
for a comprehensive assessment and confirmed the screener referred the youth to mental
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health clinical staff for a comprehensive assessment/Society for Adolescent Health and
Medicine (SAMH) assessment.
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 a written policy and procedures regarding the process to identify the
mental health and substance abuse needs of youth through a comprehensive screening. The
center’s policy requires the youth with identified needs to be referred for a further, in-depth
mental health and/or substance abuse evaluation. Seven reviewed youth records confirmed
each were identified after admission and referred for an evaluation. Three of seven youth were
applicable for a comprehensive mental health evaluation, while four had not been at the center
for thirty days. Two were applicable for a new Society for Adolescent Health and Medicine
(SAMH) assessment. One was applicable for an updated mental health and substance abuse
assessment. Each assessment’s treatment recommendations were made which corresponded
to all diagnosed mental health or substance-related disorders. The center’s comprehensive
mental health/substance abuse evaluation consists of the SAMH assessment completed in the
Department’s electronic medical record (EMR). None of the youth received a comprehensive
assessment through a community provider. During an interview with the designated mental
health clinician authority (DMHCA), it was confirmed if a detained youth whose intake screening
did not indicate the need for a comprehensive assessment, exhibits behavior indicating the
need for an assessment, the detention provider shall complete a comprehensive mental health
evaluation and/or comprehensive substance abuse evaluation within thirty days of referral. The
comprehensive mental health/substance abuse evaluation may consist of the SAMH in the
Department’s EMR, or a comparable Department approved instrument, which will be uploaded
into the youth’s Individual Healthcare Record.
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 maintains a written policy and procedures for mental health and substance abuse
treatment and discharge planning. The provider’s contract requires the superintendent and
designated mental health clinician authority (DMHCA), or mental health/substance abuse
clinical staff to ensure the development and review of an initial and/or individualized treatment
plan for each youth receiving mental health/substance abuse treatment in the center. Seven
youth mental health and substance abuse records were reviewed, and one record was
applicable for mental health and substance abuse treatment services. Two additional youth
records were requested for review. Each youth received a mental health orientation held within
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fourteen days of admission. Each youth required a treatment plan. Reviewed documentation
confirmed the initial treatment plans were in place within seven days of the onset of treatment.
Each plan was developed on the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form. Each plan documented the reason for referral for treatment, initial
Diagnostic and Statistical Manual, Fifth Edition (DSM-5) diagnosis/symptoms, initial treatment
methods including counseling and frequency, initial treatment goals, psychiatric services
including psychotropic medication and frequency of monitoring, the medication the youth was
admitted with, a mental health/substance abuse professional’s signature, and the youth’s
signature. Each youth was assigned a mini-treatment team who were involved in the
development of the initial treatment plan. Each youth was applicable for an individualized
treatment plan. The individualized treatment plan was developed for youth receiving mental
health and/or substance abuse treatment in the center by the thirty-first day of the youth’s
admission. The plan included the DSM-5 diagnosis, symptoms which are treatment-focused,
treatment goals including applicable mental health services and substance abuse services, and
strengths/needs. Each psychotropic medication listed in the initial treatment plan matched the
psychotropic medications the youth were prescribed at the time the treatment plan was
developed. The individualized treatment plan was signed and dated by the youth, the mental
health/substance abuse professionals, treatment team members, and the parent/guardian. The
applicable youth had one thirty-day period requiring individual treatment plan reviews. A review
of the documentation reflected the individualized treatment plan reviews were signed and dated
by the clinical staff, youth, licensed mental health professional, treatment team members, and
the parent/guardian. Each treatment plan included treatment and services provided by a
licensed psychiatrist. Three records were reviewed for discharge summaries. All three reviewed
mental health/substance abuse treatment discharge summaries were documented and
completed on the Department’s Mental Health/Substance Treatment Discharge Summary form
upon the youth’s discharge and a copy of the treatment discharge summaries were provided to
the youth, parent/guardian, as allowed, and assigned juvenile probation officer (JPO). Each
discharge summary included the completion day of service, signature of the licensed mental
health professional and was uploaded with additional documentation within fourteen days.
During the week of the annual compliance review, a mini treatment team meeting was
observed. Mental health, medical, and education staff were all present. During the treatment
team meeting, the youth’s overall behavior in the center, medication management, and
education goals were all discussed. During an interview with the designated mental health
clinician authority (DMHCA), it was confirmed the process for ensuring services are provided is
through initial treatment plans. The DMHCA confirmed initial treatment plans are developed on
the Department’s form or on a form which contains all information. Initial treatment plans are to
be developed within seven days of the onset of treatment, or for youth receiving psychotropic
medication, within seven days of the Initial Diagnostic Psychiatric Interview. The DMHCA
confirmed initial treatment plans are to be signed by the mental health or substance abuse
clinical staff completing the form, and if completed by a non-licensed staff, by the licensed
clinical supervisor, within ten days of completion. The plan is signed by mini-treatment team
members who participated in the development of the plan, youth, and parent/guardian, as
allowed. The DMHCA confirmed psychiatric services, including psychotropic medication and
frequency of monitoring, are included in the initial treatment plan for youth receiving
psychotropic medication. The DMHCA confirmed mental health staff will meet with each youth
not engaged in treatment services by their fourteenth day in the center to introduce, educate,
and explore mental health and substance abuse treatment services.
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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 provider’s contract has a written policy and procedures ensuring mental health and
substance abuse treatment planning focuses on treatment provisions to reduce or alleviate
youth’s symptoms of mental disorder or substance abuse impairment and enable youth to
function adequately in the juvenile justice setting. A review of seven youth mental health and
substance abuse records confirmed one youth required treatment; therefore, two additional
youth records were requested for review. Each youth was assigned to a mini-treatment team,
which consisted of a mental health clinical staff, one staff from a different service area, the
youth, and when possible, the youth’s parent/guardian. Each youth received individual, group,
and/or or family counseling according to frequencies required by their plan. Each reviewed plan
included individual, group, and or family therapy prescribed at least weekly. Each youth was
applicable for substance abuse treatment. Reviewed documentation confirmed each youth had
an Authority for Evaluation and Treatment (AET). Reviewed documentation confirmed the
proper consent for substance abuse treatment was obtained through the signed mental health
and substance abuse form. Reviewed treatment notes were documented on the Department’s
Counseling/Therapy Progress Notes form which contained all required elements. During the
week of the annual compliance review, videos were observed and confirmed groups were
conducted, as scheduled. Observations confirmed mental health staff had adequate access to
youth and confidential space to provide treatment services. Reviewed records confirmed group
therapy was limited to ten or fewer youth with mental health diagnoses for mental health
treatment groups. Reviewed records confirmed group therapy was limited to fifteen or fewer
youth with substance abuse diagnoses for substance abuse treatment groups. Seven youth
were interviewed and four rated the mental health and substance abuse services they were
receiving as good, and three youth rated the services they were receiving as very good. During
an interview with the designated mental health clinician authority (DMHCA), the center’s
process used for individualized mental health treatment planning and individualized substance
abuse treatment planning was confirmed. The DMHCA confirmed mental health treatment is
provided based on the youth’s symptoms and diagnostic and statistical manual diagnosis
identified by a comprehensive assessment, comprehensive mental health evaluation, or
updated comprehensive mental health evaluation. The goal is to reduce the youth’s symptoms
of mental disorder and the negative effects of symptoms on the youth’s behavior and
accomplish the measurable goals and objectives specified in the youth’s initial or individualized
mental health treatment plan.
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3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center follows a Suicide Prevention Plan to safely assess and protect youth with an
elevated risk of suicide in the least restrictive means possible, in accordance with Florida
Administrative Code. The center has facility operating procedures and a Suicide Prevention
Plan. The center has a written plan detailing suicide prevention procedures, which is reviewed
and signed by the designated mental health clinician authority (DMHCA) and superintendent
annually. The plan includes the identification and assessment of youth at risk of suicide, levels
of supervision, immediate staff response, staff training requiring at least six hours of training
annually on suicide prevention and implementation of suicide precautions, which includes
quarterly mock suicide drills for all staff who come in contact with youth on each shift, suicide
precautions, communication, notification, referral, documentation, and a review process. The
center has an established review process for every serious suicide attempt or serious self-
inflicted injury requiring hospitalization or medical attention, and a mortality review for a
completed suicide. The multidisciplinary review includes center procedures relevant to the
incident, circumstances surrounding the event, pertinent medical and mental health services
involving the victim, all relevant training received by involved staff, possible precipitating factors,
recommendations, if any, for changes in policy, training, physical plant, medical or mental health
services, and/or operational procedures.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center maintains a written policy and procedures regarding suicide prevention services.
Four of seven reviewed youth mental health and substance abuse records were applicable for
having been placed on precautionary observation at the time of admission until an Assessment
of Suicide Risk (ASR) was completed. A review of the Department's Juvenile Justice Information
System (JJIS) confirmed alerts were initiated. Three of the four reviewed youth mental health
and substance abuse records confirmed a suicide risk referral was initiated, and one youth was
discharged on the same day; therefore, was unable to be assessed. Reviewed records
confirmed each ASR documented an assessment of the youth on the day of service. Each youth
had a constant level of supervision prior to the completion of the ASR. Each required Suicide
Precautions-Observation Log was completed in its entirety to include documented safe housing
areas and required signatures. Each ASR involved a qualified mental health professional. Each
record confirmed the staff documented a consultation with the designated mental health
clinician authority (DMHCA) or licensed mental health professional on the mental
health/substance abuse referral summary. Each record confirmed the superintendent, or
designee was notified immediately of suicide risk. Each ASRs documented the date and time
the referral was made to the mental health professional. Each of the ASRs documented the date
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and time the youth was placed on precautionary observation. Each of the ASRs were completed
within twenty-four hours. Each youth had a Follow-Up ASR completed prior to their removal
from precautionary observation. Reviewed documentation confirmed a conference was held by
the superintendent and licensed mental health professional to reduce the level of supervision for
each youth. A review of the center’s logbooks confirmed the date and time of discontinuation of
suicide precautions was documented. Each Follow-Up ASR was completed by a licensed
mental health professional. Each assessment result included recommendations for supervision
and follow-up. Reviewed documentation confirmed evidence in the center’s logbook and on the
suicide risk assessment indicating administration or supervisory staff provided specific
instructions related to the suicide risk assessment findings and suicide precaution decisions, if
applicable. A review of JJIS determined alerts were appropriately entered and were removed
following youth removals from precautionary observation. A review of logbooks determined the
beginning and ending times were documented for youth placed on precautions. During an
interview with the DMHCA, it was confirmed all mental health staff conduct suicide risk
screenings once youth are admitted into the secure side of the center. It was confirmed
instruments used for screenings are the Suicide Risk Screening Instrument (SRSI), ASR, and
the Follow-Up ASR. The DMHCA confirmed the center’s process for a referral following a
screening and measures taken for referral/assessment by a mental health professional for a
youth who appears to be acutely suicidal. The DMHCA confirmed mental health professionals
are notified through email and have access to emails twenty-four hours a day. The DMHCA
confirmed the center’s procedures for notification of the superintendent, parent/guardian, and
other applicable agencies regarding potentially suicidal youth or youth who have attempted
suicide. The DMHCA confirmed meeting with the psychiatrist once a week for two hours to
discuss youth receiving psychiatric services. Seven interviewed staff confirmed if a youth
expresses suicidal thoughts, staff are responsible to notify the mental health authority,
document supervision, and maintain constant site and sound supervision. One of seven
interviewed youth confirmed they were placed on suicide watch while at the center and staff
watched them all of the time.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center maintains a written policy and procedures regarding secure observation. The policy
allows youth placed on suicide precautions to be maintained on secure observation when less
restrictive means are not effective. Seven youth records were reviewed, and none were
applicable for placement in secure observation; therefore, three additional records were
requested. During the time of the annual compliance review, there was only one youth
applicable for placement in secure observation for the review period. The placement was
authorized by the superintendent and the designated mental health clinician authority (DMHCA).
The secure room was designated in writing. The reviewed record contained a Health Status
Checklist which was completed prior to placement in secure observation. A review of the
Suicide Precautions-Observation Log confirmed completion in its entirety. Reviewed
documentation confirmed within eight hours of placement, a new Assessment of Suicide Risk
(ASR) was completed, and the youth’s parent/guardian was notified of the youth’s potential
suicide risk as indicated by the ASR. Reviewed documentation confirmed the youth’s assigned
juvenile probation officer (JPO) was notified of the youth’s potential suicide risk. Documentation
confirmed the youth did not remain on secure observation beyond twenty-four hours. Reviewed
documentation confirmed mental health staff provided supportive counseling services during
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secure observation status and the observation log documented supervision. Reviewed
documentation confirmed the youth’s supervision level was reduced only after a conference with
the superintendent and licensed mental health professional. The discontinuation of secure
observation and step-down to close supervision was documented in the center’s logbook and
documented in the youth’s mental health record by mental health clinical staff.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center maintains a written policy and procedures for the process to safely screen, refer,
assess, monitor assigned, and protect youth with elevated suicide risk in the least restrictive
means possible. Seven youth mental health and substance abuse records were reviewed, and
three were applicable for having been placed on suicide precautions. Reviewed documentation
confirmed the Suicide Precautions-Observation Logs were maintained for the duration the youth
were on suicide precaution. Reviewed documentation confirmed the appropriate level of
supervision and observations of the youth’s behavior were documented in real time and not
exceeding thirty-minute intervals. When warning signs were observed, notification to the
superintendent or designee and mental health clinical staff were documented on the Suicide
Precautions-Observation Logs. Reviewed documentation confirmed each log was reviewed and
signed by each shift supervisor and the mental health clinical staff. Reviewed documentation
confirmed logs documented safe housing requirements. Observations of video footage and
corresponding documentation of youth on precautionary observation confirmed the youth was
placed on constant supervision and supervision was maintained.
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 policy and procedures to address suicide prevention training.
The policy requires all staff who work with youth to be trained to recognize verbal and
behavioral cues indicating suicide risk, suicide prevention, and implementation of suicide
precautions. Seven in-service and seven pre-service staff training records were reviewed. Each
reviewed staff record confirmed trainings, to include suicide drills held no less than quarterly on
each shift, were completed as required. The center has a total of twenty-one suicide response
kits located in master control, each module sub control, medical, administration hallway, kitchen,
intake unit, transportation office, school portable, annex, second classroom, maintenance shop,
training room, and six vehicles. The suicide response kits are co-located with the first-aid kits.
Reviewed documentation confirmed trainings included mock suicide drills held no less than
quarterly on each shift, for all staff who come in contact with youth including kitchen and
maintenance staff. All mock mental health drills were in response to a suicide attempt and/or
incident of serious self-injury, were simulated, and did not include any youth. The program
provides semi-annual trainings on emergency response procedures which includes mock
training in emergency response to a suicide attempt or incident of serious self-inflicted injury to
include the use of cardiopulmonary resuscitation (CPR). Staff who were not present during a
quarterly drill have the opportunity to review each drill scenario and procedures in an effort to
understand the process and receive the necessary training to respond to an incident of a suicide
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attempt or incident of serious self-inflicted injury in the center. Seven interviewed staff confirmed
the location of the rescue tools, wire cutters, and needle nose pliers as being in each sub
control.
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 maintains a written policy and procedures ensuring crisis intervention services and a
Combined Emergency Services Plan. The policy requires the center’s staff to respond to youth
in crisis in the least restrictive means possible and to protect the safety of the youth and others
while maintaining control and safety of the center. The Combined Emergency Services Plan
included a notification and alert system, communication, supervision, means of referral,
including self-referral, documentation, and review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center maintains a written policy and procedures to address the Emergency Services Plan
which stipulates the response procedures for youth in crisis. The center’s Emergency Services
Plan includes immediate staff response, communication, supervision, notifications, authorization
to transport for emergency mental health or substance abuse services, transport for emergency
mental health evaluation and treatment under Chapter 394, Baker Act, and the transport for an
emergency substance abuse assessment and treatment under Chapter 397, Marchman Act,
documentation, training, and review. The Emergency Services Plan was approved and updated
on July 15, 2025. A copy of the approved plan is located in each module, the procedures binder,
and in master control. The Emergency Services Plan is accessible to all staff.
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3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center maintains a written policy and procedures regarding Crisis Assessments. The policy
requires a Crisis Assessment for any youth demonstrating acute psychological distress. Three
youth records were reviewed for a Crisis Assessment. Each of the three assessments were
completed the same day the youth was determined to be in crisis. The Crisis Assessments
included a reason for assessment, a Mental Status Examination and interview, determination of
danger to self/others, including imminence of behavior, intent of behavior, clarity of danger,
lethality of behavior, initial clinical impressions, supervision recommendations, treatment
recommendations, recommendations for follow-up or further evaluation, and notification to the
parent/guardian regarding follow-up treatment. A mental health alert was entered into the
Department’s Juvenile Justice Information System (JJIS) when the youth was placed on
precautions after completion of a Crisis Assessment. Each youth was identified by direct care
staff or clinical staff as having acute emotional or behavioral problems, or acute psychological
distress. Each Crisis Assessment was conducted by a licensed mental health professional
immediately or within twenty-four hours based on the needs of the youth. None of the reviewed
youth were an alleged victim in a Prison Rape Elimination Act (PREA) event.
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 maintains a written policy and procedures for Baker and Marchman Acts. The policy
requires youth who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment receive emergency mental health or substance
abuse services. Three youth records were reviewed for requiring Baker or Marchman Act
procedures. A review of the records for all three applicable youth confirmed while pending off-
site transport, a suicide risk alert was opened, Suicide Precautions-Observation Logs were
maintained, and each youth was placed on one-to-one supervision. Supervision was
documented on the observation logs until the youth’s authorized release. Each youth was
placed on suicide precautions upon re-admission. Each youth’s supervision level was
maintained until an appropriate assessment was conducted and mental health staff conferred
with the licensed supervisor and superintendent or designee. Each youth was maintained on a
minimum of constant supervision until properly transitioned to a lower level of supervision. Each
youth had a completed mental health referral for a Mental Status Examination (MSE) completed
by or under the direct supervision of a licensed mental health professional. Each youth had a
suicide risk alert in the Department’s Juvenile Justice Information System (JJIS), and the
discontinuation of the alerts and precautions were based upon an Assessment of Suicide Risk.
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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 a written policy and procedures requiring a contractual agreement with a
licensed physician to serve as the designated health authority (DHA). The center maintains a
contract with VitalCore Health Strategies, LLC, who subcontracts with a medical doctor (MD) to
serve as the center’s DHA. The DHA holds an unrestricted, clear, and active license which
meets all requirements for independent and unsupervised practice in the State of Florida which
expires January 31, 2026. A review of the Florida Department of Health records documentation
revealed the DHA did not have any disciplinary cases or public complaints on record at the time
of the annual compliance review. The center utilizes a part-time advanced practice registered
nurse (APRN) whose license expires July 31, 2026. The APRN had a clear and active license in
the State of Florida with no disciplinary cases or public complaints on records at the time of the
annual compliance review. The APRN and DHA both signed the Collaborative Practice Protocol
agreement on April 19, 2025. The DHA is contracted to be on-site at least once a week, with a
week defined as the seven-day period beginning on Sunday and ending on Saturday. The DHA
is on-call twenty-four hours a day, seven days a week. The DHA is on-site every Wednesday.
Reviewed documentation confirmed the DHA was on-site as required. In the event, the DHA
should go on vacation or on a scheduled absence, the center has a back-up licensed MD
designated by VitalCore Health Strategies, LLC. to provide clinical services. The back-up DHA
had an active and clear license in the State of Florida with an expiration date of March 31, 2026.
The center reported the back-up DHA was not utilized since the last annual compliance review.
A review of the medical policy and procedures indicated there was an inclusion and approval
from the Department’s Office of Health Services for telemedicine/telehealth services. The DHA
at the center was interviewed. The DHA indicated they perform Comprehensive Physical
Assessments (CPAs), conduct periodic evaluations, perform sick call, and complete policy and
procedures development. The CPAs are completed on youth after intake and a review of their
health history. The nurses at the center are on call for urgent questions and issues to evaluate
youth when they are sick, for urgent medical issues, and to review protocols and make
recommendations. The DHA is on-site at least once a week and communication is provided by
staff through telephone calls and emails. The DHA is available through on-call services, twenty-
four hours a day, seven days a week. A review of documentation revealed the sign-in and sign-
out of the telemedicine practitioner was utilized. The telemedicine was used for one out of every
four weeks with the Department’s approval. All off-site care findings, instructions, and
information are reviewed by the DHA and all orders and notes are reviewed once on-site
through the Department’s electronic medical records (EMR). The DHA reviews the important
medical issues pertaining to the youth at the center with the healthcare staff. The center has
formalized procedures for many different health-related complaints and issues, which are
printed and kept in a folder for staff. Additionally, they are reviewed yearly. Periodic evaluations
for youth with chronic conditions are completed and tracked depending on the condition, and
usually every thirty days at a minimum. All youth with chronic conditions receive a periodic
evaluation as required. The DHA arranges for coverage when on vacation or during scheduled
absences by contacting the supervisor who will find a DHA from another campus for coverage.
The interviewed DHA did not have any concerns with healthcare at this center.
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4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center maintains a written policy and procedures and facility operating procedures (FOPs)
for all health-related protocols utilized. The center’s designated health authority (DHA) and
superintendent signed and dated all respective FOPs and conducted an annual review of all
healthcare protocols. The reviewed documentation indicated the DHA reviewed, signed, and
dated FOPs on May 21, 2025, the psychiatrist signed on May 21, 2025, and the superintendent
signed on June 4, 2025. The nursing staff reviewed, signed, and dated the cover page
acknowledging review of all FOPs and healthcare protocols on May 21, 2025. The FOPs were
renewed on June 26, 2024. VitalCore Health Strategies, LLC, has an established
comprehensive clinical orientation for all newly employed healthcare staff, which includes a
review of the Department’s healthcare policies and procedures, which is provided by a
registered nurse (RN). Reviewed documentation confirmed all newly hired healthcare personnel
received a comprehensive clinical orientation to the Department’s healthcare policies and
procedures by an RN. The approval of treatment protocols or standing procedures was 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 a written policy and procedures requiring each parent/guardian to be
afforded the right to give or withhold consent regarding the healthcare provided to the youth,
which ensures the completion of the Authority for Evaluation and Treatment (AET) for all youth
admitted into the center. A review of seven Individual Healthcare Records (IHCRs) revealed five
records had an AET which was signed by the parent/guardian and a Department representative.
Each AET was obtained prior to providing medical services for each youth. Reviewed
documentation revealed the original AET form was filed in all five youth’s IHCRs, with an
original AET and/or was stamped “copy” on the applicable AET. There were two youth
applicable for being under the care and custody of the Department of Children and Families
(DCF). The two youth records were applicable and contained a limited consent, which was
signed by the DCF representative. Additionally, both youth required a court order to be
obtained. Both court orders were obtained and maintained in the IHCRs. All seven youth were
under the age of eighteen. An interview with the nurse revealed the original AET shall be filed in
the IHCR. The AET shall be signed by the parent/guardian and witnessed by a Department
representative. It is the responsibility of the Department representative obtaining the signatures
to verify the form is completed with all required documentation. In the event a parent/guardian
refuses to sign the AET, or if the legally assigned guardian is not a parent/guardian there shall
be a court order, and the court order shall be filed in the youth’s IHCR. The AET is valid for as
long as the youth is under any type of supervision, custody, or other form of legal control by the
Department, or, for one year after it was signed by the parent/legal guardian, whichever comes
later. An AET is valid until the youth’s eighteenth birthday. Youth who are eighteen years of age
or older can consent for medical care. If a youth reaches eighteen years of age while in the
center and is not incapacitated or is otherwise emancipated, the youth is responsible for
authorizing their healthcare and authorizing release of their healthcare information and records.
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These youth are responsible for accepting care and providing consent for care at the time of
service.
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 a written policy and procedures outlining parental notifications/consent.
The center’s policy requires the parent/legal guardian to be notified of significant changes in the
youth’s condition and to provide consent when new medications and treatments are prescribed.
A review of seven youth Individual Healthcare Records (IHCRs) indicated four of the seven
youth records were applicable and included notifications of documented parental notifications
for over-the-counter (OTC) medications beyond those covered by the Authority for Evaluation
and Treatment (AET). Each of the four records contained the required consents. Each IHCR
had written notifications sent utilizing the Department’s Parental Notification of Health-Related
Care form. Four of the seven youth were taking psychotropic medications at admission, and
reviewed documentation indicated staff witnessed all telephone call attempts and conversations
for psychotropic medications. The parent/guardian consent for psychotropic medications was
documented on page three of the Clinical Psychotropic Progress Note (CPPN) in each
applicable record. Each record confirmed parental/guardian verbal consent was received for
psychotropic medication whenever a new psychotropic medication was prescribed,
discontinued, or the dosage was significantly changed. One youth was applicable for being in
the care of the Department of Children and Families (DCF) and consent was not required, since
a court order was on record. None of the seven youth were applicable for new medications
ordered. Each of the seven reviewed IHCRs documented the center verified vaccinations within
thirty days of the youth's admission. One youth was applicable for needing additional
immunization and consent was requested from the parent/guardian. None of the seven
reviewed youth were applicable for a religious exemption. During an interview with the center’s
registered nurse (RN) it was confirmed the parental notifications are required to be made for
appropriate consent/notification forms and shall be utilized when a practitioner has ordered
medication, treatment, or medication changes. For new non-psychotropic medication, verbal
attempts/contacts/consents shall be documented in the chronological progress notes in the
IHCR by the staff attempting and/or contacting the parent/guardian. For psychotropic
medications, verbal attempts/contacts/consents shall be documented on the third page of the
CPPN or on an informed consent chronological progress note. The nurse documents parental
notifications in real time, including a documented witness, if consent is obtained. The
parent/guardian and the Department's Central Communications Center (CCC) are contacted
when a youth’s illness or injury requires emergency medical services. The center’s RN added,
only Tuberculosis testing is provided at the center. Immunization records are obtained from the
Florida Shots website and the Department of Health. The designated health authority (DHA) will
review the youth records during the next scheduled on-site visit. Religious Exemptions for
Immunization forms are signed and authorized by the parent/guardian and filed in the youth’s
IHCR.
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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 has a written policy and procedures to ensure each youth receives a screening for
health concerns upon admission. The center’s policy requires each youth, at the time of
admission, to receive a Facility Entry Physical Health Screening (FEPHS) utilizing the
Department’s Medical and Mental Health Admission Screening form. A review of seven youth
Individual Healthcare Records (IHCRs) indicated a FEPHS form was completed on the date of
admission. Each reviewed form was completed on the date of admission by a juvenile justice
detention officer (JJDO) and reviewed by a licensed medical staff within twenty-four hours. Each
youth’s screening form was completed in the Department’s Juvenile Justice Information System
(JJIS), as required. Reviewed documentation validated four of the seven records were
applicable and contained documentation indicating the designated health authority (DHA) was
notified of the youth’s admission in the youth’s IHCR. Three reviewed records were applicable
for having a change in physical custody. A healthcare admission re-screening was completed
for each youth for every change in custody. Each re-screening conducted by a JJDO or JJDO
supervisor was reviewed by a registered nurse (RN) within twenty-four hours. None of the youth
were applicable for a pregnancy screening test. During an interview with the center’s nurse, it
was reported newly admitted youth are usually seen within twenty-four hours or less from
admission time. The nurses are notified by the center’s admitting staff who provide the medical
staff with the FEPHS or electronic communications. Admission screenings are completed by
direct care staff. The nurse reviews and updates the admission screening. Each form is signed
and dated by the youth and licensed medical staff within twenty-four hours. When there is a
change in physical custody the youth are re-screened upon return to the center. The nurse will
review and update alerts, chronological notes, review the health-related history, review the
infection form, and obtain new practitioner orders, when needed.
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 a written policy and procedures for youth orientation to healthcare
services. A review of seven youth Individual Healthcare Records (IHCRs) revealed each youth
received a general healthcare orientation on the day of admission to the center. Each record
contained a completed Department Health Education Record form documenting the youth’s
orientation to the center’s healthcare services within twenty-four hours of admission to the
center. Each youth’s orientation included topics addressing access to medical care, sick call,
what constitutes an emergency and when to notify staff, the 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 standard universal precautions. The center has an education and orientation binder to
ensure all required orientation topics are reviewed. Additional topics included seatbelt usage,
alcohol and drug related problems, sexually transmitted diseases/infections, tobacco products
including smoking cessation, dental hygiene and dental care, basic personal hygiene,
immunizations, infection control, prevention of sexual and other physical violence, nutrition,
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physical fitness, breast and testicular examinations, parenting skills, prenatal, postpartum, and
parenting education as applicable.
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 a written policy and procedures to ensure the designated health authority
(DHA) is notified when youth are admitted to the center. It is the center’s practice to notify the
DHA of all new admissions regardless of a youth’s medical condition and the notification is
documented in the chronological admission progress note. A review of seven Individual
Healthcare Records (IHCRs) reflected five youth were applicable for a known or suspected
chronic condition upon admission. One reviewed youth was identified as in need of emergency
care upon admission into the center. Each of the five reviewed applicable youth records
documented the DHA was notified of each youth’s admission. The notifications were
documented in the youth’s chronological progress notes. Four youth records were applicable for
the youth having been admitted while taking psychotropic medication. Reviewed documentation
confirmed the psychiatrist was notified of each youth’s admission. During the interview with the
nurse it was confirmed the nurse is responsible for notifying the DHA of youth admitted with
serious or chronic conditions. The notifications to the DHA are documented in the chronological
notes.
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 a written policy and procedures regarding health-related history. The
center’s policy requires the nursing staff to complete the Department’s Health-Related History
(HRH) form prior to the Comprehensive Physical Assessment (CPA). A review of seven youth
Individual Healthcare Records (IHCRs) indicated each had an HRH form completed/updated
within seven calendar days of admission. Reviewed documentation indicated the center’s best
practice is to complete the HRH form on the day of admission for each youth. Each of the seven
reviewed records indicated the HRH forms were completed prior to the Comprehensive Physical
Assessment (CPA). Each HRH form was completed by a licensed nurse and reviewed by the
designated health authority, as indicated by the checkbox on the CPA. A review of the center’s
nursing interview indicated the HRH form shall be updated/completed within seven days of
admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains a written policy and procedures regarding the Comprehensive Physical
Assessment (CPA) and Tuberculosis (TB) screenings. The center’s policy requires each
admitted youth to receive, and/or have on record, a current CPA and Health-Related History
(HRH) form completed no later than seven calendar days of admission into the center. A review
of seven youth Individual Healthcare Records (IHCRs) showed each youth’s CPA was
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completed on the Department’s CPA form. Each CPA was completed within seven calendar
days of admission by the designated health authority (DHA). Each youth’s Medical Grade was
documented on their CPA. There were no indications of any missing or incomplete elements on
any of the reviewed CPAs. Each reviewed CPA had all sections complete in full utilizing “O”
and/or X” markings. All seven reviewed records showed the youth refused a portion of the
exam, and documentation supported each youth signed a refusal form. Additionally, the
physician documented “not medically indicated” on portions of each CPA. The Department’s
Problem List was updated as required for each of the seven youth. Each youth had at least one
verified TB Skin Test (TST)/formerly purified protein derivative (PPD) test documented in the
IHCR within the last year. Each youth’s result was documented on their CPA and on the
Infectious and Communicable Disease (ICD) form. An interview with the nurse indicated the
DHA completes a new CPA within seven calendar days of admission, every year for youth with
chronic conditions, and every two years for youth without chronic conditions. The center’s nurse
indicated TB screenings are completed yearly and gynecological exams are not routinely
completed.
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 a written policy and procedures for sexually transmitted infections (STIs)
and human immunodeficiency virus (HIV) screenings. The center’s policy requires all youth
entering the center to be clinically screened, evaluated, and treated, if necessary, for STIs and
HIV. A review of seven youth Individual Healthcare Records (IHCRs) reflected all were clinically
screened and evaluated for STIs utilizing the STI Screening form. Documentation confirmed
only four youth were identified as being sexually active. None of the youth required further
evaluation or additional STI testing. One IHCR indicated the youth refused HIV and STI testing.
Four youth consented to HIV testing, and the results were documented on the Department’s
Infectious and Communicable Disease (ICD) form. None of the youth were applicable for
needing rescreening. Each of the four IHCRs confirmed youth were offered counseling, testing,
and consent for treatment/referral for HIV. The designated health authority (DHA) or advanced
practice registered nurse (APRN) reviewed and signed the test results in the youths electronic
IHCR and results were maintained in a sealed envelope. The HIV pre-test, post-test, and
counseling services were documented in the progress notes of each youth’s IHCR. Each
youth’s HIV status or any other STI diagnosis were kept confidential and not included in the
center’s alert system. Seven youth were interviewed and each youth indicated they can ask for
an HIV test. During the center’s nurse interview it was confirmed youth are screened for STIs by
completing the STI form. If testing is indicated based on the youth’s answers, the youth will be
advised. If the youth agree to be tested, an order will be obtained, and urine will be collected.
The DHA will review results during their next visit. In addition, the nurse reported STI
screenings, evaluations, and referrals are documented on the STI form. Testing is uploaded in
the IHCR after the DHA reviews, signs, and dates the received lab results. Youth who are out of
the center or Department’s custody requiring a rescreening with symptoms present will have a
new STI testing order obtained. Testing will be completed and testing results will be shared with
the youth and DHA. HIV test results are on the youth’s ICD form and located in the IHCR. The
nurse stated youth are provided with general information on HIV during the intake assessment,
where each youth is presented with consent. If youth consent, pre-and post-test counseling is
done. Youth are provided pre-counseling, testing, and post-counseling by a certified HIV
counselor or licensed nurse under the direction/order of a practitioner. Additionally, counseling
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may be conducted by a practitioner. Documentation of pre/post-test counseling is documented
on the IHCR in the chronological progress notes.
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 a written policy and procedures for the sick call process. The center’s
policy requires all youth to have access to make sick call requests and have their complaints
treated appropriately through the sick call system. Sick call care, including dental care, is
available to all youth. A review of seven Individual Healthcare Records (IHCRs) revealed four
were applicable for sick calls. Each youth’s sick call was documented on the Sick Call Referral
Log. None of the youth presented with similar sick call complaints three or more times within a
two-week period, requiring a referral to the medical doctor. None of the youth had complaints of
severe pain in which staff was unfamiliar with. Documentation confirmed each youth and
nursing staff completed a Sick Call Request form, which was found filed in the IHCRs in reverse
chronological order. Each was documented in accordance with Florida Administrative Code.
None of the youth required restricted housing. The dates listed on the Sick Call Index
corresponded to the completed Sick Call Request forms in each IHCR. An observation of the
center confirmed sick call hours were posted in medical and in each of the youth’s living units. A
review of the daily schedule, posted schedule, and nursing interview indicated sick calls were
conducted daily, as pursuant to contract requirements and there were approved treatment
protocols for the registered nurse (RN). Documentation revealed sick call care is provided to
youth Monday through Friday from 9:00 a.m. to 11:00 a.m. and 4:00 p.m. to 6:00 p.m., and on
Saturday and Sunday from 9:00 a.m. to 11:00 a.m. Sick calls are conducted by nursing staff.
When there is not a licensed nurse on-site, the center has procedures whereby the shift
supervisor reviews all sick call requests as soon as possible and within four hours after the
request is submitted. A sick call observation was made during the annual compliance review
week. The youth was escorted to the medical clinic by the juvenile justice detention officer
(JJDO). The registered nurse identified themself and stated why the youth was there. The
youth’s consent was obtained prior to the observation. The youth was interviewed in a private
area and privacy was maintained throughout the observation. An interview with nursing staff
confirmed the nurse conducts open sick calls on Monday through Friday from 9:00 a.m. to 11:00
a.m. and from 4:00 p.m. to 6:00 p.m. Weekend sick calls are conducted from 9:00 a.m. to 11:00
a.m. The designated health authority (DHA) does not conduct sick calls while on-site. Youth
presenting with similar sick call complaints three or more times within a two-week period will be
referred to the DHA. The nurse confirmed the DHA approves treatment protocols. In any
instance where a youth is in restrictive housing, the nursing staff will visit youth while in
restricted housing, accompanied by detention staff, to assess each youth. Seven youth were
interviewed and asked how quickly they could be seen after submitting a sick call request. One
youth reported they have never submitted a sick call, three reported immediately, and three
reported within one day. Seven interviewed staff stated nursing staff conduct and review the
sick calls.
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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 a written policy and procedures for episodic, first-aid, and emergency
care. The center’s policy requires a written plan to provide twenty-four-hour emergency medical,
mental health, and dental care to youth as needed. Seven youth Individual Healthcare Records
(IHCRs) were reviewed, and none were applicable for episodic care. An additional three records
were requested for review. A review of the three records indicated on-site care was provided by
licensed healthcare staff for each youth. Each event was documented in the required subjective,
objective, assessment, and plan (SOAP) format. All events were documented on the Episodic
Care Log, which corresponded with the on-site event documentation within the IHCRs. The
nature of the complaint and findings of the person rendering care and treatment rendered was
documented in each IHCR. None of the three youth were referred to off-site care. Each youth
was placed on the center’s alert list. None of the youth were applicable for episodic, or first-aid
care needing a follow-up. Parental notification was required, made, and documented for two
applicable youth. The center has twenty-one first-aid kits located in master control, sub controls,
medical, the administration area, kitchen, intake, transportation office, school portable, annex,
maintenance shop, training room, and the center’s transport vehicles. The center’s process for
ensuring contents were maintained and stored in accordance with guidance, to prevent
expiration or deterioration, and replenished as needed, is for medical staff to conduct monthly
checks. Monthly inventories of contents were kept, expiration dates were documented, and
contents were replenished as needed. Reviewed documentation supported the first-aid kits
were inventory and monitored. An observation of three first-aid kits revealed each kit was fully
stocked with contents approved by the designated health authority (DHA). The center has two
automated external defibrillators (AEDs). One is located in medical and the other in master
control. During the annual compliance review, the nurse conducted a self-test of the AED and
there were no discrepancies. The expiration date for both AED batteries is November 12, 2028.
On September 22, 2025, both AED batteries were replaced. The expiration date for both of the
AEDs’ pads is October 28, 2027. A list of emergency numbers was observed posted and
accessible for non-licensed and licensed staff, and inaccessible to all youth in the center.
Reviewed documentation indicated authorized direct care staff were appropriately trained in the
administration of the epinephrine auto-injector. A review of seven staff training records
confirmed requirements were met in reference to episodic, first-aid, and emergency care. A
review of the center’s emergency medical drills reflected drills were conducted on each shift
monthly during the annual compliance review period. The emergency medical drills consisted of
both announced and unannounced drills. A review of the center’s logbooks showed direct care
staff had the opportunity to participate in at least one “man-down” drill which included the use of
cardiopulmonary resuscitation (CPR) annually. Video observation review of drills confirmed drills
simulated episodic care events 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 currently has a policy and procedures in place for the use of
NARCAN®. The center’s policy on the use, access, and inventory of NARCAN® is used for the
usage of medication overdose. The center stores the NARCAN® in a locked box behind a
locked medication cart. The nursing staff and trained supervisors have access to NARCAN®.
Each staff with access to NARCAN® has been trained on when and how to use NARCAN® by
the nurse. The center’s medical staff conducts inventory of NARCAN® weekly. Seven staff were
interviewed, and each stated they are personally allowed to call 9-1-1 if a youth has a medical
emergency. Seven youth were interviewed, and each youth stated they can see a dentist and
doctor if needed. An interview with the nurse confirmed the center has a total of twenty-one first-
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aid kits. The nurse indicated on-site episodic care is documented in the progress notes and on
the episodic log. If non-healthcare staff provide emergency care the non-healthcare form is
reviewed by the nurse. Additionally, the Summary of Off-Site Care Consultation Report form is
utilized for all emergency care needs.
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 a written policy and procedures for the provision of off-site emergency and
non-emergency referrals for medical care and treatment. The center’s policy requires
evaluations conducted off-site to be recorded on the Department's Summary of Off-Site Care
Consultation Report form. The designated health authority (DHA) reviews, signs, and dates the
off-site care instructions. Seven youth Individual Healthcare Records (IHCRs) were reviewed;
however, only three were applicable for requiring off-site care. The Summary of Off-Site Care
Consultation Report forms were utilized and filed within each of the youth’s IHCRs. One youth
was applicable for having discharge documents filed. The DHA or designee reviewed and
signed each of the youth’s off-site care findings, instructions, and/or information. Each reviewed
record indicated the youth required follow-up testing, referral, and/or an appointment. A review
of the Sick Call Log indicated referrals were documented for each youth. An interview with the
nurse indicated all routine off-site medical or off-site emergency care will be documented on the
Summary of Off-Site Care Consultation Report form. The center ensures all hospital orders are
followed by the nursing staff reviewing all Summary of Off-Site Care Consultation Report forms,
returning off-site orders, and progress notes for all events, and are conducted upon the youth's
return. The DHA is notified and new orders are written through the electronic medical record. To
ensure the DHA is reviewing and initialing all off-site care findings, instructions, and information,
all documents are placed in the DHA binder for review and signature. The nursing staff tracks
follow-up testing, referrals, and appointments.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center maintains a written policy and procedures ensuring youth who have been identified
with chronic illnesses receive regularly scheduled evaluations and necessary follow-up
treatment. A review of seven youth Individual Healthcare Records (IHCRs) indicated three youth
were identified with a chronic condition as documented on the Facility Entry Physical Health
Screening (FEPHS) form. Additionally, the three youth were identified on the Medical/Mental
Health Screening form as having a current chronic condition. None of the youth were identified
as having a communicable disease. One youth was applicable for taking prescribed medication
on an ongoing basis. Two youth were undergoing treatment for a physical health condition.
Each youth was classified with a Medical Grade of two through four, or a Medical Grade of five
for youth taking psychotropic medications. All three youth were placed on the center's Chronic
Conditions List. A review of progress notes revealed all three youth were still within the time
frame to receive their ninety-day periodic evaluations. None of the youth were applicable for
taking anti-Tuberculosis medications. Two youth were applicable and had an evaluation
completed prior to a prescription renewal, change, or expiration. One youth was applicable for
an off-site evaluation and the care was documented on the Department's Summary of Off-Site
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Care Consultation Report form. There were no indications of lapses in care or missed periodic
evaluations in any of the reviewed records. The Department’s Problem List for each youth was
updated in accordance with Florida Administrative Code. The interviewed designated health
authority (DHA) reported periodic evaluations are completed every ninety days and they are
tracked through the chronic condition tracker log and medical alerts. The health services
administrator was interviewed and stated youth with chronic conditions are placed on the
chronic condition tracker. Periodic evaluations for youth with chronic conditions are completed
and tracked depending on the condition; however, usually every ninety days at a minimum.
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 a written policy and procedures which outlines the process for how
medications are to be received, stored, inventoried, and administered in a safe and effective
manner. A review of seven youth Individual Healthcare Records (IHCRs) indicated three of the
seven youth were admitted on prescribed medications. Documentation revealed the three
youth’s medications were verified prior to being admitted into the center utilizing the
Department’s Prescription Medication Verification Checklist form. The prescription verification
was included in the chronological progress notes for each youth. The designated health
authority (DHA) and the psychiatrist were contacted to obtain orders to resume the specified
medications prescribed prior to admission. All medications for each youth had a current, valid
order, and were administered pursuant to a current prescription. Each youth was applicable for
current medications being continued, discontinued, changed, or newly ordered, and the DHA
placed an order on the Practitioner Order form. None of the youth were applicable for restricted
housing and for having over-the-counter medications not listed on the Department’s Authority
for Evaluation and Treatment (AET) form. The center utilizes a pre-printed Medication
Administration Record (MAR) to document all medication and treatment. All reviewed MARs met
all requirements outlined within the Florida Administrative Code. The programs trained non-
healthcare staff assisted in the delivery of medications when healthcare staff were not on-site.
Documentation indicated staff initialed each administered medication entry. There were no
undocumented explanations for a lapse or errors in medication administration for any of the
reviewed youth. For the three records reviewed, the nursing staff documented side effect
monitoring at a minimum of weekly on each MAR. None of the reviewed MARs were applicable
for refusals. The MAR contained all the required elements, including the youth’s name,
Department identification number, date of birth, youth allergies, precautions, Medical Grade,
medical alerts, and a current picture of the youth. The youth initialed each provided medication
entry. An observation of medication pass was conducted during the annual compliance review.
Consent was obtained before observing the medication administration. Medication delivery was
the sole responsibility of the nurse during the time of medication administration. The youth was
escorted to medication administration by the juvenile justice detention officer (JJDO). The
nursing staff asked the youth their name and allergies. The nurse identified themselves,
reviewed the MAR, and provided a brief overview as to why the youth was there. The youth
provided their name, date of birth, what medications they were prescribed, and if they had any
allergies. The registered nurse (RN) verified the Six Rights of Medication Administration for the
youth. No medications were observed to be pre-poured. Upon administering the youth's
medication, the RN swiped the youth’s mouth and searched under the youth’s tongue. Seven
youth were interviewed and four youth stated a nurse dispenses their medication. Three youth
stated they do not take medication. One youth stated they received medication from the staff. In
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addition, two youth reported the medical treatment is very good at the center. Four youth stated
the treatment is good. One youth reported the medical treatment is fair at the center. An
interview with the nurse indicated nursing staff verify a youth’s medication regimen when a
youth is admitted with medications by completing the prescription verification form, and through
verifying with a pharmacist and prescribing doctor. The nursing staff reviews medications upon
admission and documents the verification on the chronological progress notes in the IHCR or
utilizing the prescription medication verification checklist. According to the nurse, the center
uses the standard Department MAR. During an interview with the nurse, it was stated there is a
training curriculum to train non-healthcare staff on administering medication. The nurse trains
non-healthcare staff at least annually on medication administration and the list is in medical and
in master control. According to the nurse, medications/prescriptions are procured and obtained
from a vendor. Medications are provided to youth each day at 8:00 a.m.,1:00 p.m., 7:00 p.m.,
and any other time as ordered. Seven staff were interviewed and asked if they administered
medication to youth. One staff reported they did administer medications and six reported the
nurse administers medications. The center has a list of non-medical staff who are authorized to
give medication to the youth.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center maintains a written policy and procedures regarding the requirements for psychiatric
services. The psychiatric services are provided by an advanced practice registered nurse
(APRN). A current and updated copy of the official Collaborative Practice Protocol between the
supervising psychiatrist and psychiatric APRN was stored on-site where the psychiatric APRN
provides psychiatric services. The APRN and the supervising psychiatrist both signed the
Collaborative Practice Protocol agreement on April 19, 2025. The APRN’s license expires July
31, 2026. The APRN had a clear and active license in the State of Florida with no disciplinary
cases or public complaints on record at the time of the annual compliance review.
Telepsychiatry is authorized and utilized at the center. Telepsychiatry is provided for two hours
a week. The designated mental health clinician authority (DMHCA) was interviewed and
indicated the psychiatrist meets with the DMHCA once a week on Mondays for two hours.
Seven youth records were reviewed and only three were applicable for psychiatric services. The
three records included a referral for, and completion of an Initial Diagnostic Psychiatric Interview
within fourteen days of admission. Each interview documented the reason for the referral,
history of medical, mental health and substance abuse, a Mental Status Examination,
Diagnostic and Statistical Manual, Fifth Edition (DSM-5) diagnosis, treatment recommendations,
medications, explanation of psychotropic medication, and frequency of medication
management. Reviewed documentation confirmed the Clinical Psychotropic Progress Note
(CPPN), page three, was completed if new psychotropic medication was prescribed or there
were any changes to the existing prescription and it was clearly identified as a “Psychiatric
Evaluation”. Each in-depth evaluation included the stated reasons and factors leading to the
referral, developmental history, all medical history including disorders, head trauma, prenatal
exposure to alcohol/drugs, substance abuse history, school history, emotional development,
peer relations, family relationships, interests/talents and traumatic experience. A history of
psychiatric illness, psychotropic medication management, mental health treatment, and/or
substance abuse treatment was included with the in-depth evaluations. The three youth records
were applicable for mental health status evaluation and identification of individual, family, and/or
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environmental factors which may account for DSM-5 diagnoses. The three youth records
documented treatment recommendations and interventions for youth in order to assist in
stabilizing the psychiatric disorder, prescribed medications with the frequency being monitored,
an explanation of the need for psychotropic medication related to the youth’s diagnosis, target
symptoms and potential side effects, risks and benefits of taking medication, most recent
therapeutic serum drug levels, and the signature of the practitioner conducting the psychiatric
evaluation. Each youth record was applicable for prescribed psychotropic medications and
evaluations included identifying data, diagnosis, target symptoms of each medication,
evaluation, and a description of the effect of prescribed medication on target symptoms. The
psychotropic medication included the name, dosage, and quantity of the medication, the side
effects, the youth’s adherence to the medication regimen, height, weight, blood pressure, and
most recent serum drug levels or laboratory findings. Telephone contact was made with the
parent/guardian to discuss the medication and the psychiatrist signed and dated the
chronological progress note for the three applicable youth. The Authority for Evaluation and
Treatment (AET) was valid for the three applicable youth. All three youth records were
applicable for the utilization of telepsychiatry. Telepsychiatry was utilized only for youth who
agreed to participate and where consent was given by the parent/guardian.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center maintains a written policy and procedures regarding the requirements for the storage
and inventory of medications and sharps ensuring all medication is inaccessible to youth at the
center. Observations of the medication cart showed it was clean and organized, with stock items
separate from youth specific medications. An observation of the medication cart found all
medications were stored in the locked cart which is kept in the locked medical clinic. All non-
controlled medications were stored in a separate, secure, locked medication cart. Narcotics and
other controlled medications were securely stored and double locked within the medication cart.
Observations found all medications were securely stored in the medical clinic inaccessible to
youth. The center had no medication requiring refrigeration during the annual compliance review
week; however, the center has a refrigerator which is used only for medication, if needed.
Perpetual inventories with running balances are maintained on all controlled substances with a
shift-to-shift inventory conducted by the nurses. The center did not have any youth with
prescribed controlled medication at the time of the annual compliance review. A review of three
over-the-counter (OTC) medications was conducted, each of which validated the respective
inventories were accurate. Syringes and sharps are counted through a perpetual inventory and
are verified weekly. A review of three sharps verified all three matched the count on the
perpetual inventory. It is the center’s practice for inventory discrepancies to be reviewed with the
clinical nurse manager to determine when and how the error occurred and to subsequently
document the correction on the related inventory. An interview with the nurse was completed in
reference to the medication/sharps inventory storage process. The nursing interview confirmed
the center has a current agreement with a consulting pharmacist. The agreement consists of
monthly visits for reviewing, labeling, and medication disposition. The center maintains a copy of
a pharmacy consultant license on-site. The center’s process for disposal of medication is for the
pharmacist to come on-site for inspection monthly, and the destruction of expired or
discontinued medications is conducted. Unexpired non-controlled drugs are returned to the
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pharmacy for credit as needed. All controlled substances shall have a perpetual inventory and
are stored behind two locks with two separate key accesses.
4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has a written policy and procedure in place ensuring there is an approved plan for
exposure control and infection control ensuring staff, youth, volunteers, and visitors are not
exposed to infectious and communicable diseases. The infection control procedure in place
includes prevention, containment, treatment, and reporting requirements related to infectious
diseases, according to Occupational Safety and Health Administration (OSHA) federal
regulations and the Centers for Disease Control (CDC) and Prevention. The designated health
authority (DHA), superintendent, and nursing staff reviewed and signed the Exposure Control
Plan/Infection Control Plan. A review of seven youth Individual Healthcare Records (IHCRs)
was conducted. The reviewed documentation indicated two youth were applicable for receiving
infection control training within seven days of admission and the remaining five youth received
the infection control training at a prior admission. The infection control training included hand-
washing techniques, universal/standard precautions, prevention/transmission of communicable
diseases, vaccinations, and the Centers for Disease Control and Prevention (CDC) guidelines
for infection control. A review of the center’s Exposure Control Plan/Infection Control Plan
showed the plan was written in accordance with Occupational Safety and Health Administration
(OSHA) guidelines to include risk assessment and methods of compliance. The plan addresses
common infectious diseases of childhood, self-limiting, episodic contagious illnesses, viral or
bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, Human Immunodeficiency
Virus (HIV), infectious diseases caused by bloodborne pathogens, other outbreaks or epidemics
caused by any other infectious agent, outbreaks of lice or scabies, Methicillin-Resistant
Staphylococcus Aureus (MRSA) and other anti-biotic resistant micro-organisms, foodborne
illnesses, bio-terrorist agents, and chemical exposures. The centers maintain procedure for staff
to adhere to universal precautions and the center provides staff with the opportunity for Hepatitis
B immunizations and access to protective equipment. There were no instances in which the
local county health department, CDC, and/or the Department’s Central Communications Center
(CCC) should have been notified of an infectious disease, since the last annual compliance
review. The Exposure Control Plan was written in accordance with OSHA standards and is
available to all staff. All records are maintained as confidential for a ten-year period as required.
The center’s process for needle stick post-exposure evaluation consists of counseling,
evaluation of reported illness, and providing information to the individual who was exposed. An
interview with the nurse indicated the Exposure Control Plan is available to staff and is in
medical. The medical staff conduct infection control training for staff. Infection control training is
provided to youth during the medical admission intake. The medical staff are responsible for
providing training for staff on the center’s Exposure Control Plan.
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4.19 Prenatal Care/Education [Contract Provider] Non-Applicable
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has not had any pregnant youth throughout the annual compliance review period;
therefore, this indicator is rated non-applicable.
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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 maintains a written policy and procedures to ensure all youth are always in sight of
at least one juvenile justice detention officer, apart from when youth are placed in sleeping
rooms. The center’s policy requires, at a minimum, ten-minute checks to be conducted.
Observation checks are documented on Visual Observation Report (VOR) forms. All
movements are authorized by master control, prior to the actual movement. During the annual
compliance review week, youth were observed during outdoor recreation, in the cafeteria,
classrooms, and multipurpose room, during line movement, during medication pass, and on
video participating in groups with no issues or concerns noted regarding youth supervision. All
youth were observed under staff supervision. Logbook entries revealed all movements were
documented in the master control logbooks. Headcounts were documented at the beginning,
randomly, at the end of shift, and after emergency situations. All youth were participating in
education services Seven staff were interviewed, and all stated the center has enough staff to
provide safety and security for the youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center maintains a written policy and procedures to provide a system of rewards, privileges,
and consequences to encourage youth to fulfill the center’s expectations. Behavior
management system (BMS) posters were observed throughout the center, including youth living
modules, classrooms, main hall, multipurpose area, dining hall, and medical. Level boards were
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in all living modules. Youth can view their progress daily. A review of the center’s logbooks and
the Department’s Facility Management System indicated the center is following the BMS and
the youth are being rewarded for positive behavior and issued consequences for inappropriate
behaviors. Positive interactions were observed between staff and youth during the annual
compliance review week. The center’s incentive calendars were posted on the living modules
and throughout the center. Pictures of level three events and parties were reviewed. Seven
youth were interviewed and two of the seven youth stated the BMS is fair. Four youth stated the
system is good. One youth stated the system is very good. All seven youth were able to explain
the difference between each level. All seven-youth stated they are rewarded for good behavior
and are never allowed to punish their peers. Five youth stated as a punishment, youth were
sent to their sleeping rooms for horseplaying, arguing, and not following center rules. All of the
youth agreed the consequences received were fair and consistent using the level system. In
addition, all the youth reported never witnessing the use of handcuffs or leg irons to control
youth. Seven staff were interviewed, and all agreed the center’s BMS is effective. All seven
reported the center’s BMS is managed by the use of the points and level system. The BMS is
posted throughout the center and is included in the youth handbook upon admission. In
addition, staff described the rewards for the BMS included, and were not limited to additional
telephone calls, canteen, level three parties, snacks, and special planned activities. All seven
staff reported youth are given an opportunity to explain their actions and alternative acceptable
behaviors. Staff indicated the supervisor provides feedback daily on the implementation of the
BMS during shift briefings, which included coaching and training. All seven staff reported they
have never seen a co-worker deny meals, medical care, or education as a consequence for the
BMS. Each staff stated they have never observed a staff encourage a youth to beat up another
youth. Durning an interview with the center’s superintendent it was confirmed the center utilizes
the three level BMS for tracking youth behavior.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains a written policy and procedures addressing ten-minute checks. The
center’s policy requires staff to utilize the electronic wand system by tapping on the check point
sensors on the outside of each youth’s room. A review of Ten-Minute Check Logs during the
annual compliance review period confirmed ten-minute checks were being conducted while
youth were in their sleeping rooms. The center has a total of 101 cameras and eighty-nine were
operational at the time of the annual compliance review. The center’s system has recording
capability for thirty days. Video observations of nine samples of ten-minute checks showed the
checks were conducted within the required frequencies and staff were observed walking by the
rooms and stopping at each youth’s room. Ten-minute checks are conducted utilizing an
electronic wand for the data collection process. The data from the wand is downloaded daily to
ensure no data is lost. The superintendent is responsible for and documented weekly
management oversight. A review of ten-minute check logs for each shift for each month since
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the last annual compliance review found checks were conducted as required. Seven staff were
interviewed and all seven reported room checks are conducted every ten minutes when non-
suicidal youth are placed in their room. During an interview with the center’s superintendent, it
was confirmed staff shall visually observe any youth who is secured in a room for sleeping
purposes or any other reason. Staff shall observe the youth every ten minutes while inside the
room.
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 maintains a written policy and procedures requiring staff to always know the exact
number and location of all youth under their supervision. A review of the master control
logbooks for the annual compliance review period, confirmed documented headcounts were
conducted at the beginning and end of each shift. Documentation indicated counts were
completed at a minimum once each hour on each shift, following any emergencies such as a
power outage, and during evacuations. Counts were conducted prior to and following group
routine movement, anytime the population changed, and for additional youth movements. Seven
interviewed staff stated youth counts are conducted at the beginning of shifts, end of shifts,
before/after school, and before and after meals. Six out of seven staff stated emergency counts
are conducted when a youth is believed to be missing, after a major disturbance, and when
visibility is hindered, such as an electrical outage.
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5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center maintains a written policy and procedures regarding logbooks. The center maintains
separate logbooks in master control and for each living module, as well as one for visitors, one
for contracted staff, and one for education staff. A review of logbooks for the annual compliance
review period 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, 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/or
secure observation began, and the time precautionary and/or secure observation was
discontinued. A review of the center’s activity schedule and logbooks documented minimal
educational instruction interference. Reviewed master control and module logbook entries for
each month confirmed the center’s practices. The officers assigned to the modules conducted
reviews of the logbook upon accepting the shift, documenting the pages reviewed. The
supervisors reviewed 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. An interview with the superintendent indicated management
reviews logbooks, at a minimum, weekly.
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5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has a written policy and procedures regarding key control. The center’s policy
addresses key control, distribution of keys, inventory and tracking, key restrictions, storage,
missing or lost keys, and reporting and replacing damaged keys. All staff are trained in key
control prior to key assignments. All keys are stored on a tamper-resistant key ring prohibiting
the removal of keys. 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 to. Emergency keys providing egress through exterior doors
are stored in master control and inside sub control. The inventory sheet is used to track all keys.
The counts are documented in a shared network drive. There were no incidents reported to the
Department’s Central Communication Center (CCC) regarding lost or missing keys during the
review period. A review of the master key control inventory revealed the inventory report
matched the actual key rings in use. Randomly selected staff were all able to explain the
process for missing or lost keys, and they could identify the keys and the capabilities of each
key on their assigned key ring. Observations confirmed personal keys were stored in staff
lockers. Visitor keys are stored inside master control on a hook. Once the visitor departs, the
keys are returned. Supervisors, administration, and maintenance staff have access to
emergency keys. Observations confirmed staff carried keys on their person and did not allow
youth access to keys. An informal interview with the master control operator confirmed the key
control practices. The center has a process in place for reporting lost or missing keys. Seven
staff were interviewed regarding the key control process. Each staff stated keys are given to
master control upon entry and personal keys are securely stored. Visitors’ personal keys are
given to master control upon entry to the center. The center’s keys are inventoried on the daily
tracking sheets and each staff is assigned program keys. All interviewed staff agreed they did
not have access to the kitchen, medical, mental health, and case management record keys.
During the interview with the center’s superintendent it was confirmed staff are not issued
permanent keys.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains a written policy and procedures to ensure vehicles utilized to transport
youth are properly maintained and serviced. The center has seven working vehicles assigned to
transport youth off-site. All vehicles were on-site during the week of the annual compliance
review. Observations confirmed each vehicle had the appropriate number of seat belts, seat belt
cutters, window punch, fire extinguisher, and first-aid kits with approved items assigned to each
vehicle. The use of tobacco products, vape devices, or personal cellular telephones are
prohibited. A review of the vehicle logs showed the center’s staff documented an
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acknowledgement the vehicle was checked for contraband and required equipment, destination,
number of staff and youth, the name of the officer riding in the back of the vehicle, the time
transport began, and the time transport ended. A youth transport was observed during the week
of the annual compliance review. Staff conducted a frisk search of the youth prior to exiting the
center, and a search of the vehicle was conducted prior to placing youth inside. The transport
staff were in possession of the vehicle logbook, binder containing the vehicle log, vehicle and
mechanical restraint keys, gas credit card, vehicle registration, and cellular telephone. Staff and
youth were observed wearing seat belts. Upon return, the youth and vehicle were searched and
the vehicle was locked. A random check of six center vehicles ensured each was locked when
not in use. Documentation supported the maintenance mechanic completed weekly and monthly
vehicle checks. This information is documented in a shared network drive. A review of the
vehicle maintenance invoices confirmed all seven transport vehicles received an annual
inspection. All seven vehicles appeared to be in good repair, and no damage was observed to
the cages inside the vehicles. Seven youth were interviewed, and all youth stated they felt safe
when being transported by detention staff and they had never seen anyone place contraband
into the transport vehicles.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains a written policy and procedures to ensure all tools and equipment related
to maintenance and the kitchen area are properly maintained, stored, and inventoried.
Maintenance tools are secured inside the maintenance shop, which is located in a secure area
of the center, with limited access. Maintenance tools are located on a shadow board which can
easily identify missing tools. Each tool is engraved with an identification number. The
maintenance mechanic conducts an inventory monthly. Both the maintenance mechanic and the
assistant superintendent review and sign the inventory, acknowledging all tools are accounted
for. The maintenance mechanic maintains documentation when tools are being used and
returned. Vendors entering are properly searched and supervised. Both the maintenance
mechanic and the food service director were able to explain the process regarding lost, missing,
or damaged tools. The center’s food service director uploads an itemized inventory of all
equipment, tools, and sharps monthly into a shared network drive. Kitchen tools include knives,
and other sharps, which are stored in a locked box located inside the kitchen area. All tools
were documented and accounted for on the inventory sheets reviewed. The center’s food
service director is responsible for tracking and verifying all sharps. There were no sharps
missing or documented as missing from the center and all tools listed on the inventory were
verified. A review of ten randomly selected maintenance and kitchen tools verified the tools
were inventoried, marked, and stored in accordance with policy. Seven staff were interviewed
and all reported youth are not allowed to use tools while in detention. Seven youth stated they
are prohibited from using tools with the exceptions of scrub brushes, mops, and brooms used to
assist with center cleaning. Each staff reported they do not allow youth to clean with toxic or
flammable substances. The superintendent interview indicated only the maintenance mechanic
and administrators have access to Class A tools.
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5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center maintains a written policy and procedures to address proper usage, storage, and
disposal of chemicals, including flammable, toxic, caustic, and poisonous items. The center’s
policy requires all flammable, toxic, caustic, flammable and poisonous items to be inventoried
and secured in a location with limited access. The chemicals are stored in a locked shed not
attached to the center. Authorized personnel, the maintenance mechanic, and center
administration have access to the chemicals. Safety Data Sheets (SDS) were verified for all
chemicals during the annual compliance review week, and none were missing. The
maintenance mechanic conducts monthly inventories of all chemicals. Five randomly selected
chemicals were inventoried during the annual compliance review week, and the actual counts
matched the documented inventory. There were no youth performing cleaning detail during the
annual compliance review week. Documentation review confirmed the center had a Safety Plan
for emergencies accessible to the staff. Seven youth were interviewed and reported, during
center cleaning activities, the staff spray the chemicals. Each youth stated they do not have
access to flammable, toxic, caustic, and poisonous items. Seven staff were interviewed. All
seven reported youth do not have access to flammable, toxic, caustic, and poisonous items.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center maintains a written policy and procedures to address the inventory and disposal of
flammable, toxic, caustic, and poisonous items. The center’s policy requires flammable, toxic,
caustic, and poisonous items to be securely maintained outside and away from the secure area.
A review of the center’s policy confirmed the procedures for disposal of flammable, toxic,
caustic, and poisonous items were documented. During the annual compliance review period
the center did not have any chemical spills, or disposal of any flammable, toxic, caustic, or
poisonous items. Monthly inventories of flammable, toxic, caustic, and poisonous items are
maintained by the maintenance mechanic, and then reviewed and signed by the center
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administration. The Safety Data Sheets (SDS) and Chemical Inventory Sheets were compared
to the items on-site and were found to be accurate and complete.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains a written policy and procedures addressing the process for youth placed in
temporary confinement under twenty-four hours. The center had 411 instances of confinement
under twenty-four hours during the annual compliance review period. A review of ten
Confinement Reports found each youth was afforded the right of three meals a day plus snacks,
counseling, clean clothing, bedding, and notice of right to grieve confinement. All ten youth were
applicable for a shower based on the time and duration of confinement. Each applicable youth
was afforded the right to shower. All ten youth were applicable for educational materials during
educational hours and materials were provided. For each of the ten reviewed confinements, the
supervisor approved all confinements, the staff placed only one youth in the confinement room
at a time, the reason for confinement was explained to youth, and the supervisor conducted an
initial confinement review with the youth within the required time frame. For each confinement,
the full report was completed within the required time frame. The supervisor conducted
additional reviews with the youth at a minimum of every three hours, and the supervisor/staff
continually counseled the youth to consider removing the youth from confinement. The center
has confinement rooms separate from youth rooms called “D cells.” A review of the cameras
and windows indicated there were no obstructions to visual observations. A room search was
documented for all reviewed confinements prior to confinement placement. All ten reviewed
confinements had all required checks completed including checks every five minutes during the
first hour for confinement. The superintendent or designee reviewed all ten Confinement
Reports within the required time frame. A review of the Confinement Reports confirmed one
youth was applicable for having a physical injury which required treatment from a healthcare
provider immediately. Documentation showed a healthcare professional was immediately
notified for timely assessment and treatment which was documented in the youth’s Individual
Healthcare Record. The program had no pregnant youth in confinement during the annual
compliance review period. All seven interviewed staff stated youth placed in temporary
confinement are provided with education materials. All seven staff stated once the decision is
made to place a youth in temporary confinement, the confinement room is searched. Then, five
to ten-minute checks are conducted and the staff complete a Confinement Report. Two out of
seven stated the youth is counseled with before placement in confinement and staff ask youth if
they want a grievance form. During an interview with the center’s superintendent it was
confirmed confinement is a short-term strategy used for managing youth behaviors.
Confinements are tracked in the Department’s Facility Management System with monthly and
quarterly reports. The superintendent indicated regional detention management reviews the use
of confinement, lockdown, and restraints at least monthly.
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5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains a written policy and procedures to address the Continuity of Operations
Plan (COOP). Reviewed drill documentation revealed the center conducted at least two COOP
drills during the annual compliance review period, as required, including at least one drill
completed prior to the hurricane season. The drill documentation included scenarios, any
resulting critique or corrective action, date and time of drills, and participants. The center has
eighty radios on hand, six cell phones, seven vans, and flashlights on all living modules. The
superintendent was interviewed and indicated the COOP is updated yearly and reviewed by
regional leadership.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains a written policy and procedures to address the Escape Prevention Plan.
The center’s policy requires the center to conduct escape drills at least quarterly.
Documentation for drills conducted since the last annual compliance review confirmed the
center completed quarterly escape drills. The documentation of the drills included scenarios,
dates, and times of the drills. The drill documentation form included the signatures of the
supervisor and the staff coordinating the drill. Recommendations and critiques of the drills were
included in each report. A review of logbooks revealed each mock escape drill was documented
in the logbooks, as required. A review of seven staff training records validated each staff
completed escape prevention training during the previous year. Seven staff were interviewed,
and two staff stated they participated in a weather drill. Six staff stated they participated in
escape and major disturbance drills. One staff stated they participated in bomb threat and
hostage situation drills. All seven staff stated they participated in fire drills.
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5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center maintains a written policy and procedures for addressing fire prevention and safety.
The center has evacuation egress plans posted throughout the center. Each egress plan
defined primary and secondary exit routes and the locations of emergency equipment, such as
fire extinguishers and first-aid kits. Reviewed documentation supported the center’s fire
extinguishers were inspected annually. A review of the fire drills and logbook documentation
since the last annual compliance review found the center conducted fire drills each month and
on each shift. Drills are reviewed during staff meetings and shift briefings. Seven youth were
interviewed and all reported they had been instructed on what to do in the case of a fire. Seven
staff were interviewed and each confirmed fire drills were conducted monthly.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
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 maintains a written policy and procedures to address searches and contraband.
During the annual compliance review week, a youth admission was observed. A youth frisk
search, electronic wand search, and a full body search was completed during the admission
process as deemed appropriate and necessary. The search consisted of two staff, who were
both of the same gender as the youth. A review of documentation indicated searches are noted
in the logbook, as well as electronically. Observations during the annual compliance review
week indicated the center staff wore gloves when conducting a room search. The center
conducts electronic/wand searches on all people entering the center, with all items entering the
secure area being examined, prohibiting personal keys, personal cellular telephones, and any
additional contraband items. A review of room search documentation since the last annual
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compliance review indicated room searches were conducted upon a youth’s release, prior to
placing a new youth in the room, and on each awake shift. A review of random shift reports for
one day for each month during each awake shift for the annual compliance review period
verified youth room searches were documented and completed as required. Upon discovery
and confiscation of contraband an incident report identifying findings, and the disposition of the
contraband was completed, which was documented in the master control logbook. Law
enforcement was contacted, when applicable, due to contraband being considered illegal. Items
used as evidence were secured by the discovering staff and hand-delivered to the supervisor.
The shift supervisor documented the chain of custody for the items and gave the information to
the responding law enforcement officer. Additionally, the Department’s Central Communications
Center (CCC) and the regional director or designee were notified. Observations during the
annual compliance review week confirmed searches of staff, visitors, and contractors/vendors
were completed prior to entering the secure area. All members of the annual compliance review
team were electronically searched and physically searched prior to entering the secure area of
the center. The annual compliance review team was required to read, acknowledge, and sign a
contraband attestation statement. A review of seven staff records indicated all staff had signed
contraband attestation forms. The superintendent interview indicated youth searches shall take
place as often as necessary to control contraband and to ensure safety. All staff, visitors, and
vendors are searched prior to entering the center. The center placed lockers in the lobby for
guests to store their personal property. During an interview, the superintendent stated the
center's procedures for when a youth or staff is found with contraband is to confiscate and
document the findings in the master control logbook. Staff will complete an incident report. Law
enforcement will be called for all items deemed illegal as defined by Florida Statutes.
Additionally, the CCC will be called, and the administration team will be informed of the incident.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 59 of 59

source: DJJ

report_type: QI Detention