summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Monroe Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
5503 College Road
Key West, Florida 33040
Review Date(s): September 16-19, 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:
Ebony Evans, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Andrice Holley, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Peter Keelan, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Monroe Regional Juvenile Detention Center MQI Program Code: 1076
Provider Name: Florida Department of Juvenile Justice Contract Number: State
Location: Monroe County / Circuit 16 Number of Beds: 10
Review Date(s): September 16-19, 2025 Lead Reviewer Code: 200
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 52
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 52
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
e d ia te a tte
s e in d ic a to
n ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
n tio n if a p ro g ra m o p e ra te s
rs . F a ilu re to 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 52
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 * Non-Applicable
* 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 52
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 52
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
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* 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 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
s e in d ic a to
n ).
N
n tio n if a p ro
rs . F a ilu re to
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
S a tis fa
o n -A p p
g ra m o p
d o s o w
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
lic a b le
e ra te s
ill re s u lt
Standard 5: Safety and Security
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 52
5 .0 1
5 .0 2
5 .0 3
5 .0 4
5 .0 5
5 .0 6
5 .0 7
5 .0 8
5 .0 9
5 .1 0
5 .1 1
5 .1 2
5 .1 3
5 .1 4
5 .1 5
5 .1 6
* T h e D
b e lo w D
re s u lt in
e p a rtm
e p a rtm
a p ro g
In d ic a to r R a tin g s
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
A c tiv e S u p e rv is io n o f Y o u th *
B e h a v io r M a n a g e m e n t S y s te m /U n a u th o riz e d U s e o f P u n is h m e n t*
T e n -M in u te C h e c k s *
C e n s u s C o u n ts a n d T ra c k in g
L o g b o o k M a in te n a n c e a n d R e v ie w s
K e y C o n tro l
V e h ic le s a n d M a in te n a n c e
In v e n to ry , M a n a g e m e n t, Y o u th A c c e s s , & U s e o f T o o ls C le a n in g Ite m s *
In v e n to ry o f a n d A c c e s s to a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s
C o n fin e m e n t U n d e r T w e n ty -F o u r H o u rs
C o n fin e m e n t O v e r T w e n ty -F o u r H o u rs
C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) D rills
E s c a p e D rills
F ire D rills
S e a rc h a n d C o n tra b a n d P ro c e d u re s
e n t h a s id e 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 e d ia te a tte
e n t s ta n d a rd 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 s e in d ic a to
ra m a le rt fo rm b e in 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 n ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
n tio n if a p ro g ra m o p e ra te s
rs . F a ilu re to d o s o w ill
Program Overview
The Monroe Regional Juvenile Detention Center is a state-owned detention center, operated by
the Department, located in Key West, Florida. The center serves youth in Monroe County in
Circuit 16. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the ten-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 Monroe County School District. The center’s
management team includes the superintendent, a shift commander, one administrative
assistant, four juvenile justice detention officer supervisors, and five juvenile justice detention
officers (JJDOIIs). Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC, who subcontracts with Guidance Care Center, Inc.,
which is a local agency located in Key West, Florida. Mental health services are provided by
one designated mental health clinician authority (DMHCA) and one non-licensed staff. Clinical
services provided by the center include mental health and substance abuse evaluations, mental
health treatment planning, individual, group, and family therapy, mental health crisis intervention
services, psychiatric services, and availability for substance abuse services for youth with co-
occurring disorders. Medical services, which are contracted through VitalCore Health Strategies,
LLC, are provided by one designated health authority (DHA), two registered nurses (RN), and
one advanced practice registered nurse (APRN). The medical clinic maintains nursing coverage
in accordance with the contract. Food services are provided by the Monroe County Sheriff’s
Office, which is located on the same property. Meals are prepared by the food service workers
in the county jail and delivered to the center. 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 two youth living modules. The center was clean and well maintained. There was
no graffiti observed during the annual compliance review week. There are twenty-nine security
cameras at the center, of which twenty-four were operational during the annual compliance
review week. At the time of the annual compliance review, the center had one JJDOII vacancy..
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 52
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures requiring compliance with the Department’s
background screening requirements for staff, and volunteers, mentors, and interns who work
with youth less than ten hours a month requiring sight and sound supervision. An Annual
Affidavit of Compliance with Level 2 Screening Standards for Law Enforcement and Security
Personnel was completed and submitted to the Department’s Background Screening Unit (BSU)
on December 31, 2024. Teachers who are paid by the school board, or funding provided by the
school board or Department of Education, received an Annual Affidavit of Compliance with
Level-2 Screening Standards on January 9, 2025. A review of the initial background screening
for one newly hired staff and three contracted providers showed a background screening was
completed for each staff and all contracted providers prior to contact with youth or confidential
youth records. A criminal history report was received and none of the four newly hired staff had
an exemption obtained prior to working with youth. A pre-employment assessment tool was
administered to each of the four direct care applicants and a pre-employment assessment with
a passing score was documented in the applicant’s record. Three of the four newly hired staff
were contracted providers and were added to the Clearinghouse Employee Roster, as required.
An interview with the shift commander indicated the center did not have any volunteers, mentors
or interns at the time of the annual compliance review.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures ensuring all staff, contracted providers, and
volunteers with access to youth undergo a criminal history background check every five years.
At the time of the annual compliance review the center had one contracted staff applicable for a
five-year rescreening. The five-year rescreening/renewal was completed within the required
timeframes and the contracted provider staff had an eligible rating in the Clearinghouse.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 52
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures to address staff code of conduct. All staff are
required to adhere to the Department’s code of conduct which prohibits any type of abuse,
profanity, threats, harassment, intimidation, horseplay, or personal relationships with youth. At
the time of the annual compliance review the center had two staff applicable for disciplinary
actions related to the code of conduct. The two staff signed the code of conduct prohibiting any
form of abuse, profanity, threats, harassment, or intimidation on January 8, and January 9,
2025. Additionally, the code of conduct addressed officer professionalism, poor performance,
negligence, insubordination, conduct unbecoming of a public employee, and misconduct.
Documentation indicated management’s response addressed each staff with a retraining
requirement. An interview with the shift commander confirmed there were no staff given any
commendations since the last annual compliance review. An interview conducted with three
staff indicated each staff was aware of the process for allowing staff and youth to call the Florida
Abuse Hotline or the Department’s Central Communications Center (CCC) to report abuse.
Each staff stated they would notify a supervisor on shift or the lieutenant, two staff stated they
were allowed to call the Florida Abuse Hotline, and one staff stated staff would make the call if
needed. Each staff stated they have never heard a co-worker using profanity when speaking
with youth, never observed a co-worker using threats, intimidation, or humiliation when
interacting with youth. Two staff stated the working conditions at the center were good, and one
said they were very good. An interview was conducted with the one youth housed at the center
during the annual compliance review. The youth stated they never had to report abuse, staff are
respectful when talking with youth, they never heard staff use profanity, they never heard staff
threaten any youth, and they felt safe at the center. The youth stated there has never been an
exchange of emails, telephone numbers or social media contact with any staff. An interview with
the shift commander stated staff are aware of the employee code of conduct and the actions
taken if abuse, threats, or profanity towards the youth occur. The process was explained, and it
was reported staff will be removed from youth contact, an abuse registry report is made, an
incident report is completed, the incident is reported to the CCC, and administration will then
notify regional staff of the incident. Additionally, an investigation will be conducted, and upon
completion of the investigation staff will face disciplinary action if warranted. The center did not
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 52
have any staff nominated or selected for employee of the month or year since the last annual
compliance review.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures to ensure, when a reportable incident occurs, the
center notifies the Department’s Central Communications Center (CCC) within two hours of
becoming aware of the incident. The center had two incidents reported to the CCC since the last
annual compliance review. The first incident was identified on December 15, 2024, at 8:00 p.m.;
however, was not reported until December 17, 2024, which was thirty-seven hours and forty-two
minutes late. The incident was substantiated for failure to report, the staff involved were
disciplined, and retraining for the two staff involved was documented by the center. The second
incident was identified on August 15, 2024, at 11:38 a.m. and was reported on the same date
and time. Each incident was documented in the center’s logbook. A review of the center’s
internal incident/grievance reports found there were no additional incidents which should have
been reported to the CCC and were not. An interview with the shift commander indicated
incident reports are completed, written in the Department’s Juvenile Justice Information System
(JJIS) before the end of each shift, and a CCC report is called within two hours of the incident.
1.05 Right Interactions (RI) Non-Applicable
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.
There have been no Right Interactions (RI) incidents during the annual compliance review
period; therefore, this indicator is rated non-applicable.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures regarding detention staff training in accordance
with Florida Administrative Code. Each newly hired staff is required to complete pre-service
training within 180 days of their hire date, which includes web-based training on the
Department’s Learning Management System (SkillPro) and 120-hours of instructor-led academy
training. One staff training record was applicable for pre-service training since the last annual
compliance review. The record documented the staff successfully completed the pre-service
certification training and new hire orientation. Training consisted of active shooter preparedness,
cardiopulmonary resuscitation (CPR), first-aid, automated external defibrillator (AED), human
trafficking intervention, information security awareness, mental health/substance abuse, Prison
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 52
Rape Elimination Act (PREA), Right Interactions (RI), sexual harassment, suicide awareness
prevention, trauma responsive practices, and professionalism and ethics. The one applicable
staff completed the required web-based training and the Department’s Juvenile Justice
Detention Officer (JJDO) Academy training. Documentation provided by the center verified the
trainings were recorded in SkillPro.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures requiring staff to complete twenty-four hours of in-
service training each calendar year after completion of pre-service certification. Additionally,
supervisory staff must complete eight hours of supervisory training. The Department provides
training through the Department’s Learning Management System (SkillPro) and instructor-led
courses. Five employee training records were reviewed for compliance, to include two
supervisors, two direct care staff, and one administrative assistant. Each of the reviewed
records confirmed staff completed the mandatory training topics within the required timeframes.
All trainings were documented in SkillPro. Reviewed documentation revealed the center
maintains an annual in-service training calendar, which is updated as changes occur. The
annual in-service training calendar was approved by the highest-ranking official at the center,
the assistant secretary of the Office of Detention Services, and the director of the Department’s
Office of Talent, Leadership, and Culture (TLC). An interview with the shift commander indicated
they received the tier two supervisory training provided by TLC, and certified public manager
training. Additionally, they reported staff are required to complete in-service and annual training
as identified in Florida Administrative Code, beginning the calendar year after the staff has
completed pre-service certification training.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures establishing all youth at the center’s right to grieve
and to ensure youth are treated fairly, respectfully, without discrimination, and their rights are
protected. This process includes a formal and informal phase, with the opportunity to appeal if
needed. The informal phase consists of direct care staff attempting to resolve the issue by
verbally communicating with the youth. The formal phase requires youth to fill out a grievance
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 52
form, which is available and accessible throughout the center. Finally, a supervisor on-site is
required to review and respond to a grievance within twenty-four hours. If a youth disagrees with
the formal response, an appeal can be filed if necessary. The center had no grievances
submitted since the last annual compliance review.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures ensuring critical and special alerts are reviewed
and responded to appropriately. All alerts are required to be documented in the Department’s
Juvenile Justice Information System (JJIS) for youth safety. The supervisory and administrative
staff are responsible for reviewing all alert reports for accuracy and dissemination of updates to
all direct care staff during shift briefings. Additionally, direct care staff are responsible for
updating alerts in the master control logbooks. If changes occur staff must be notified
accordingly. A review of three youth records’ alerts was completed to verify appropriate review
was conducted, and documented updates were made as needed. Reviewed documentation
indicated alerts were discussed at daily shift briefings by the supervisors and administrators and
maintained in JJIS. A review of logbooks confirmed the center’s practice. At the time of the
annual compliance review a shift briefing was observed validating the sharing of the alert
system. The supervisor discussed any problems or concerns as well as the alerts for each youth
as needed. Each staff was given a copy of the alert list, which was maintained on their person.
An interview with the shift commander indicated an alert is entered in JJIS by medical staff and
the shift supervisor is notified of the alert. An interview with three staff confirmed information is
shared by administrators with staff through logbook entries, daily shift briefings, alert forms,
meetings, JJIS, and through alert boards. Two interviewed staff stated they feel the process for
communicating information has been good, and one staff stated very good.
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center maintains a practice regarding data trend analysis. An interview with the shift
commander indicated the detention center implements a structured system for analyzing data
trends. The Department conducts a Detention Services Report Card which ensures all centers
provide a high-quality effective service for youth and families. The Detention Services Report
Card is a comprehensive review of policy compliance conducted through desk top audits and
observations of site visits. Detention Services headquarters staff work with the detention center
to identify areas which need improvement and center strengths. This report card includes
information based off the detention center’s meetings, operations, drills, and the center’s
inspections. The information is shared with staff and administration monthly through daily shift
briefings and monthly management meetings. At the time of the annual compliance review an
observation of the detention center's meeting agendas, report cards, data collection software,
and surveys confirmed the center's practices. The detention center's form of sharing this
information is with the providers and stakeholders through Detention Review meetings.
Additionally, the center implements the collected data to improve their processes through
necessary implementation of improvements as a result of the report card process. Reviewed
documentation supported the center’s practices.
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Office of Accountability and Program Support Page 15 of 52
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures to ensure all youth are admitted to the center in
accordance with Florida Administrative Code. The center had two youth housed at the center
during the seven-day notification; however, one youth was released on the first day of the
review. Two youth case management records were reviewed. Each reviewed record included an
arrest affidavit/custody order, a Detention Risk Assessment Instrument (DRAI), and a Suicide
Risk Screening Instrument (SRSI). Each youth record confirmed documentation of a youth full-
body and/or electronic search by a juvenile justice detention officer (JJDO) of the same gender
as the youth, a telephone call, and a meal. Each youth received medical, mental health, and
substance abuse screenings upon admission. During the week of the annual compliance
review, an observation of two youth admissions showed all the required procedures were
completed. Each youth was full body and electronically searched by an officer of the same
gender. Each youth was given a snack and offered a telephone call.
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Office of Accountability and Program Support Page 16 of 52
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures 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.
The center had two youth housed at the center at the time of the seven-day notification;
however, one youth was released on the first day of the review. A review of two youth case
management records confirmed the center provided each youth an orientation within twenty-four
hours of admission to the center and each youth signed an orientation acknowledgement to
document the contents were discussed. During the week of the annual compliance review, an
observation of the youth orientation process was conducted and included all elements as
outlined in the center’s policy. Each reviewed youth record confirmed the orientation was
provided verbally and in writing. Orientation included rules and regulations, grievance
procedures, visitation, telephone calls, access to medical, mental health, and substance abuse
services, access to the Florida Abuse Hotline, 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. During an observation of the orientation process, it was confirmed the youth
watched a PREA video upon admission. One interviewed youth reported being informed about
the center’s rules and regulations, daily schedule, education services, visitation, abuse
reporting, and behavior management system.
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Office of Accountability and Program Support Page 17 of 52
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures regarding classification and orientation to ensure
each youth is protected from harm, violence, and/or victimization. The center had two youth
housed at the center at the time of the seven-day notification; however, one youth was released
on the first day of the review. A review of two youth case management records confirmed each
contained information concerning the youth’s history and status including all required
documentation. Each record 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, suicide risk identified or suspected,
escape, security, and history of human trafficking. Reviewed records confirmed 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 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 superintendent remains
informed of how to identify and address local youth gangs through emails, alerts in the
Department’s Juvenile Justice Information System (JJIS), and during Detention Review
meetings. An interview with the superintendent reported all factors are considered when making
room assignments. The superintendent reported the youth’s charges and/or mental health
issues determine where the youth is placed.
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Office of Accountability and Program Support Page 18 of 52
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures to ensure the center has a screening process for
newly admitted youth to determine if the youth is a gang member or gang affiliated. The center
had two youth housed at the center at the time of the seven-day notification; however, one
youth was released on the first day of the review. A review of two youth case management
records confirmed neither were applicable for suspected gang affiliation. The center reported
not having any additional youth applicable for being identified as a gang member or affiliated
since the last annual compliance review. The center’s superintendent serves as the gang
representative. An informal interview with the superintendent confirmed the process for sharing
information. The process is for administration to email local law enforcement and the juvenile
probation officer (JPO) when a youth is identified as a gang member, suspected as a gang
member, or engaged in suspected gang activities..
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures in place 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. During the week of the annual compliance
review, the center reported no applicable youth were admitted with personal property and no
observations of the center receiving youth’s personal property was conducted. A review of the
Department's Central Communications Center (CCC) reports since the last annual compliance
review confirmed there were no reported incidents regarding youth property. One interviewed
youth reported when they arrived at the center they did not have any personal property. An
interview with the superintendent reported youth’s personal property is secured, the youth’s
property is inventoried in the Department’s Juvenile Justice Information System (JJIS), and the
youth signs to make sure their property is accounted for. The superintendent also indicated the
youth’s property is stored in the property closet, where only supervisors have access, and the
youth signs a property form saying if they leave their property upon release, they will have thirty
days to retrieve it.
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Office of Accountability and Program Support Page 19 of 52
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures regarding all youth releases. Three closed youth
case management records were reviewed. Each closed record confirmed the on-duty supervisor
reviewed all paperwork related to release prior to each youth’s release. Each reviewed closed
record confirmed the juvenile justice detention officer (JJDO) supervisor reviewed the release
paperwork received from the court and the youth identification was verified prior to release.
Each reviewed closed case management record confirmed 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. None of the youth had an endangered
person alert. The youth, and the person to whom youth was being released to, 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 file correlated with the Department's
Juvenile Justice Information System (JJIS). During the week of the annual compliance review,
observations of a youth being released confirmed the center’s practice.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures 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 of the youth’s
personal property. The center’s policy outlines procedures regarding release of youth with
prescription medications. Three closed youth case management records were reviewed. Each
reviewed closed record confirmed the 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 reviewed closed records
was applicable for being released from the center with prescription medications and
documentation confirmed the receipt of medications was signed by the person receiving the
youth. Each reviewed closed record confirmed 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. During the week of the
annual compliance review, the center did not have any property held for more than thirty days
and there was no observation of a release of youth property. The interviewed shift commander
stated the center has a disposal process for unclaimed property.
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Office of Accountability and Program Support Page 20 of 52
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures 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. During the week of the annual compliance review, observation of
the weekly Detention Review for youth in secure detention was conducted. The superintendent
conducted the meeting, and all participants attended the meeting in person and through virtual
communication. The Detention Reviews are held every Wednesday at 8:30 a.m. and address
the status of each youth. During the Detention Review, there were a total of two youth
discussed, and both youth were waiting to be placed in their residential commitment programs.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures ensuring youth are provided the opportunity to
participate in constructive activities which will benefit the youth. During the week of the annual
compliance review, observations of youth engaged in various activities throughout the week
were conducted which included educational programming, snack times, indoor recreation times,
and open programming times. 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 programming time. The
daily activity schedule was posted in each living area. The center had two youth housed at the
center at the time of the seven-day notification; however, one youth was released on the first
day of the review. One interviewed youth reported the center has a daily schedule which is
followed. Three interviewed staff reported the center’s daily schedule 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 Monroe County
School District. Services operate on a year-round basis, providing the youth with 242 days of
education distributed over twelve months with a minimum of twenty-seven- and one-half hours
of instruction each week. The annual academic calendar identifies the exact number of school
days and includes the provision of up to sixteen days of professional development/training for
the teaching staff. An inspection of the established academic calendar was conducted and it
was noted the calendar identified 226 days of direct instruction and sixteen days of professional
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Office of Accountability and Program Support Page 21 of 52
development. The center had an activity schedule, which was aligned with the daily academic
schedule. A review of the center’s videos for three separate dates showed the youth arrived and
exited from the classes at the appropriate scheduled time and videos showed the classes were
being conducted with minimal to no disruptions. A review of the logbooks from September 2024
through August 2025 was completed. Reviewed logbooks revealed on November 12, 2024, the
teacher arrived sixty minutes late to class; however, the teacher extended the school day to
make up the missed time. An interview with the shift commander indicated the teacher attends
Detention Reviews and other mandatory meetings at the school, which may result in tardiness.
The center had two youth housed at the center at the time of the seven-day notification;
however, one youth was released on the first day of the review. One interviewed youth revealed
the center was preparing them for their high school equivalency diploma. The youth stated they
attended school Monday through Friday while at the center. Additionally, the youth confirmed
there was minimal interference during school activities. An interview was conducted with three
staff who stated there was minimal interference with school instructional hours. The interviewed
shift commander confirmed there was minimal interference to the education instruction.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has a process for the delivery of career education to youth. This course of study is
categorized as a Type 1 Life Skills curriculum and is based upon the age of the youth and their
individual intellectual and educational abilities. The courses stress “soft skills’, have activities
which include learning and improvement of effective communication skills, and the focus on the
development and enhancement of interpersonal and decision-making skills. These courses are
available to all youth at the center. At the time of the annual compliance review the center had
one youth; therefore, there was only one youth to conduct an interview with. The youth indicated
the classes they were enrolled in included Math, Science, History, Reading, and Social Studies.
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Office of Accountability and Program Support Page 22 of 52
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 Department maintains a contract with VitalCore Health Strategies, LLC, to provide mental
health and substance abuse services to all applicable youth in the center. VitalCore Health
Strategies, LLC subcontracts with Guidance Care Center to provide a licensed mental health
counselor (LMHC) to serve as the center's designated mental health clinician authority
(DMHCA). The LMHC holds a clear and active license in the State of Florida with an expiration
date of March 31, 2027. The DMHCA is scheduled to be on-site, as needed, when there are
current youth securely detained at the center. A review of the logbook since the last annual
compliance review indicated the DMHCA was on-site at least weekly when there were youth
securely detained. The center has one back-up DMHCA in the event of scheduled leave and/or
absences. The back-up DMHCA is an LMHC, licensed under Chapter 491 in the State of
Florida, with an expiration date of March 31, 2027. The back-up DMHCA was used during the
annual compliance review period. A review of the DMHCA’s job description determined the
DMHCA is responsible for overseeing all clinical and administrative operations of all contractual
requirements. The DMHCA is available seven days a week, twenty-four hours a day, by way of
telephone for consultation. An interview with the DMHCA indicated they are responsible for
overseeing all mental health and substance abuse services at the center and the detention staff
submit a mental health referral for any needed mental health services, which generates an
email to all mental health staff including the DMHCA. During an interview with the DMHCA it
was stated the clinical services provided include assessments, when needed, and conferences
between the mental health staff, DMHCA, and superintendent or designee for every step down
from suicide precautions. The mental health team meets with administration formally one time
each week during Detention Review meetings and department head meetings.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has a contract with VitalCore Health Strategies, LLC, to provide mental health and
substance abuse services to all youth in the center. VitalCore Health Strategies, LLC
subcontracts with Guidance Care Center. The designated mental health clinician authority
(DMHCA) ensures the licensed staff working under their supervision perform services they are
qualified to provide based on education, training, and experience. The center has one DMHCA
who is a licensed mental health counselor (LMHC) with a clear and active license in the State of
Florida under Chapter 491, with an expiration date of March 31, 2027. The center’s back-up
DMHCA is an LMHC who holds a clear and active license, which expires on March 31, 2027. A
review of all licensed mental health professionals and qualified professionals verified each
license was clear an active.
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Office of Accountability and Program Support Page 23 of 52
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has a contract with VitalCore Health Strategies, LLC to ensure mental health and
substance abuse services are provided by individuals with appropriate qualifications. An
informal interview with the designated mental health clinician authority (DMHCA) reported non-
licensed clinical staff working under their supervision are performing services they are qualified
to provide based on education, training, and experience. The center has one non-licensed
master’s-level mental health and substance abuse clinical staff who works under the direct
supervision of the licensed mental health counselor (LMHC). A review of documentation
reflected the non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional received a minimum of one hour a week of on-site, face-to-
face direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the center during the annual compliance
review period. A review of the supervision logs showed supervision was documented on a form
which included all information required by the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form for all weeks where the staff provided youth services. The center is operating with a
Chapter 397 license which expires on July 10, 2026. The non-licensed master’s-level clinician
held a degree in professional counseling. The non-licensed staff is on-site Monday through
Friday, as needed.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures whereby mental health and substance abuse
needs of youth are identified through a comprehensive screening process, in which referrals are
made when youth are identified with mental health and/or substance abuse needs or are
identified as a possible suicide risk. The procedures require a thorough review of each youth’s
initial screening conducted by juvenile justice detention officers (JJDOs) and existing
documentation of mental health or substance abuse problem needs or risk factors,
administration of the Suicide Risk Screening Instrument (SRSI) upon the youth’s admission,
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) administration, a
review of the Department’s Face Sheet, alerts, and referral to the center’s mental health and
substance abuse clinical staff. The center had two youth housed at the center at the time of the
seven-day notification; however, one youth was released on the first day of the review. A review
of two youth records found documentation of each having a mental health, substance abuse,
and suicide risk screening utilizing the SRSI and the MAYSI-2, which were completed during the
admission process in the Department’s Juvenile Justice Information System (JJIS). Each SRSI
was reviewed by mental health clinical staff, who documented their summary and
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Office of Accountability and Program Support Page 24 of 52
recommendations in the screening results section. Each of the reviewed youth records were
applicable for positive “YES” responses on the SRSI. The youth were placed on suicide
precautions and a mental health referral was completed, which documented the need for an
Assessment of Suicide Risk (ASR). The applicable youth’s SRSI screening included a “YES” for
open or closed suicide risk alerts in JJIS. The center’s admission practice is to place each youth
on suicide precautions until they are evaluated by mental health staff. Each of the reviewed
SRSIs and MAYSI-2s were completed by trained staff. Both reviewed MAYSI-2s indicated the
need for further assessment, and the center notified mental health staff and the superintendent
or designee, as required. Each reviewed MAYSI-2 was a valid screening. Each of the MAYSI-2s
indicated the need for a comprehensive assessment, and the screener referred the youth as
required.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures regarding mental health and substance abuse
evaluations. The center had two youth housed at the center at the time of the seven-day
notification; however, one youth was released on the first day of the review. Two youth records
were reviewed for a mental health and substance abuse comprehensive assessment, and one
youth was applicable. The one youth was identified for the need of a mental health and
substance abuse evaluation after admission and referred to the center’s provider, and the
second youth was released prior to being assessed. A new mental health and/or substance
abuse evaluation was completed by the center’s provider. The new evaluation included the date
and had been completed within fourteen days of admission. Additionally, treatment
recommendations corresponded to all diagnosed mental health or substance-related disorders.
The comprehensive mental health/substance abuse evaluation consisted of the youth’s
substance abuse and mental health needs and was uploaded in the youth’s Department
electronic medical record. There were no youth applicable for having comprehensive
assessments completed by a community provider since the last annual compliance review.
During an interview the designated mental health clinician authority (DMHCA) stated the
process for obtaining the comprehensive mental health and/or substance abuse assessment is
for the detention staff to submit a mental health referral in the system, which generates an email
to mental health staff, including the DMHCA regarding the need. The DMHCA reviews the
youth’s electronic medical record to view status and alerts as needed.
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.
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Office of Accountability and Program Support Page 25 of 52
The center has facility operating procedures ensuring mental health and substance abuse
treatment planning focuses on the development and review of an initial or individualized mental
health treatment and or substance abuse treatment plan for each youth. During the annual
compliance review, the center had two youth available for review. Each reviewed youth record
indicated the mental health orientations were held within fourteen days of admission. Both youth
required a treatment plan. The initial treatment plans were in place within seven days of the
onset of treatment, and the plans were developed on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. Each plan included the reason for referral for
treatment, the initial Diagnostic and Statistical Manual, Fifth Edition (DSM-5) diagnosis,
symptoms, initial treatment methods including counseling and frequency, initial treatment goals,
applicable psychiatric services including psychotropic medication and frequency of monitoring,
and youth signature. Each youth was assigned a mini-treatment team. Neither youth were
applicable for psychotropic medications, or individualized treatment plans. During an interview
the designated mental health clinician authority (DMHCA) indicated the center has a process for
ensuring services are provided by offering all youth mental health and substance abuse
services within fourteen days of their arrival to the center. The mental health staff follows-up
with the youth to review the comprehensive assessment when applicable. Additionally, the
youth signs and dates the comprehensive assessment and the individualized treatment plan by
day thirty.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center has facility operating procedures ensuring mental health and substance abuse
treatment planning concentrates on providing mental health treatment and/or substance abuse
treatment, which reduces or alleviates the youth’s symptoms of mental disorder or substance
abuse impairment and enables youth to function adequately in the juvenile justice setting. Each
youth identified as needing mental health treatment, including treatment with psychotropic
medication or substance abuse treatment, must be assigned to a mini-treatment team. During
the annual compliance review, the center had two youth available for review. Two youth mental
health and substance abuse records were reviewed for mental health and substance abuse
treatment services. One youth was applicable for receiving treatment services and was
assigned to a mini-treatment team. Reviewed documentation indicated the mini-treatment team
consisted of mental health clinical staff, one staff from a different service area, the youth, and
the youth’s parent/guardian participated by telephone. The youth received either individual,
group, or family counseling according to the frequency required by their plan. The one reviewed
mental health and substance abuse record contained the proper consents for mental health
and/or substance abuse treatment services and progress notes were documented in the youth’s
Department electronic medical records. During the annual compliance review week, three video
observations were completed, which confirmed groups were being conducted as scheduled.
The mental health staff had adequate access to youth and confidential space to provide
treatment services. One interviewed youth stated the mental health and substance abuse
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services they received were good. During an interview the designated mental health clinician
authority (DMHCA) stated the mental health and/or substance abuse provider meets with the
detention supervisor weekly.
3.08 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has facility operating procedures and a Suicide Prevention Plan, which was
approved and reviewed by the designated mental health clinician authority (DMHCA) and the
superintendent annually. The plan outlines the center’s procedures addressing the identification
and assessment of youth at risk of suicide, use of suicide precautions, staff training, and the
process by which any youth identified as having suicide risk factors at any time must be placed
on suicide precautions and receive an Assessment of Suicide Risk (ASR). The plan identifies
the levels of supervision, referral process, communication, notification, and documentation
requirements. The center has an established review process for every serious suicide attempt
or serious self-inflicted injury. The multidisciplinary review includes the circumstances
surrounding the event, all relevant training received by involved staff, center procedures
relevant to the incident, pertinent medical and mental health services involving the victim,
possible precipitating factors, and any recommendations 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 has facility operating procedures and a Suicide Prevention Plan outlining
requirements to safely screen, refer, assess, monitor, and protect youth with elevated risk of
suicide, using the least restrictive means possible. Any youth identified as having suicide risk
factors by screening, information obtained from the youth, or staff observations must be placed
on suicide precautions and receive an Assessment of Suicide Risk (ASR). The center had two
youth housed at the center during the seven-day notification; however, one youth was released
on the first day of the review. One youth mental health and substance abuse record was
reviewed and was applicable for having an elevated suicide risk factor during the admission
process. The youth was placed on precautionary observation (PO) during the admission
screening process. Documentation indicated a Suicide Risk Screening Instrument (SRSI) was
completed, and an alert was generated in the Department’s Juvenile Justice Information System
(JJIS) as a result of the SRSI. Reviewed documentation confirmed, prior to the ASR, the youth
was on constant supervision. The Suicide Precautions-Observation Logs for the applicable
youth were completed in their entirety, including documenting safe housing areas, and was
signed by all required parties. The superintendent or designee was notified immediately of the
applicable youth’s suicide risk. The ASR was completed by a licensed mental health
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professional. No youth were released prior to receiving an ASR or released while on suicide
precautions. The applicable youth’s ASR was completed within twenty-four hours, as required
and the assessment included recommendations for supervision and follow-up. A conference
was held between the designated mental health clinician authority (DMHCA) and the
superintendent to reduce the level of supervision for the youth to standard supervision. A review
of the master control logbook, emails, and the youth’s ASR documented supervisory staff were
provided instructions related to the suicide risk assessment findings and suicide precaution
decisions for the youth. Further review of the logbooks indicated they documented the beginning
and ending times of the youth placed on precautions. A review of the alerts in JJIS indicated the
alert was entered and removed appropriately. The interviewed DMHCA stated all mental health
staff conduct suicide risk screenings, and the Assessment of Suicide Risk and follow-ups are
used. If a youth is screened and it is determined on the youth is applicable for PO status, the
youth is placed on PO status by administration or mental health staff. Additionally, the master
control operator and facility administration are informed of the youth’s status. The mental health
staff are notified through referrals, telephone, or a center staff will discuss with mental health
staff verbally in-person. Mental health staff and the DMHCA are on call twenty-four hours daily
for any needed support and all crisis/emergencies. Three interviewed staff stated if a youth
expresses suicidal thoughts, they are responsible for notifying the mental health authority,
placing the youth on constant sight and sound supervision, for documenting the supervision, for
searching the youth and their room for sharp objects, and for notifying the supervisor. One youth
was interviewed and stated they had been placed on suicide watch while at the center, and staff
watched the youth the whole time.
3.10 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures regarding secure observation. Youth placed on
suicide precautions may remain under secure observation if less restrictive methods are not
effective. During the annual compliance review period the center had two youth available for
review. Two mental health and substance abuse records were reviewed, and none were
applicable for secure observation. The center reported they had no youth applicable for secure
observation since the last annual compliance review.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures regarding Suicide Precautions-Observation Logs
which details the process to monitor and protect youth with an elevated risk of suicide in the
least restrictive means possible. During the annual compliance review week the center had two
youth available for review. A review of two mental health and substance abuse records found
one youth was placed on precautionary observation (PO) upon admission to the center. The
Suicide Precautions-Observation Logs were maintained for the duration of the youth’s
placement on PO. Reviewed documentation reflected staff observations did not exceed the
required intervals and were documented in real-time. The applicable Suicide Precautions-
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Observation Log was reviewed and signed by the shift supervisor and mental health clinical
staff. Safe housing areas were clearly documented on each log. Observations of camera
footage during the week of the annual compliance review confirmed appropriate supervision of
youth on PO was maintained by staff.
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 has facility operating procedures outlining the process for all staff who work with
youth to be trained in suicide precautions. Staff must participate in “mock” suicide drills quarterly
on each of the three shifts. A review of one pre-service and five in-service staff training records
validated each staff completed at least six hours of annual training on suicide prevention and
implementation of suicide precautions. Reviewed documentation of “mock” suicide drills
completed since the last annual compliance review indicated the center completed drills on
Alpha, Bravo, and Charlie shifts monthly, as required. An informal interview with the juvenile
justice detention officer supervisor (JJDOS) confirmed the center has one suicide response kit,
which is co-located with a first-aid kit in master control. The suicide response kit included a
rescue tool, needle nose pliers, and wire cutters. Reviewed documentation indicated the
center’s “mock” suicide and mental health prevention drills were simulated by the center. The
training included mock suicide drills held no less than quarterly on each shift, for all staff who
come in contact with youth. No youth were used in drill simulations. The center provided semi-
annual training on emergency response procedures which included “mock” training in
emergency response to suicide attempts or incidents of serious self-inflicted injury. Three
interviewed staff reported the suicide kits are located in master 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 has facility operating procedures and a Combined Emergency Services Plan,
ensuring the center responds 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 center. The plan
outlines the process for handling a notification and alert system, means of referral to include
youth self-referral, communication, supervision levels, documentation, and review, as required.
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3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures regarding an Emergency Care Plan outlining
mental health and substance abuse emergency procedures and ensuring 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.
The plan addressed immediate staff response, notifications, communication, supervision of
youth, transport for emergency mental health evaluation and treatment under Chapter 394
Florida Statute, Baker Act, transportation for emergency mental health evaluation and treatment
under Chapter 397 Florida Statute, Marchman Act, documentation, training, and review. The
policy and plan were signed by the superintendent on August 7, 2023, and the designated
mental health clinician authority (DMHCA) on August 31, 2023. The plan was updated and
signed on August 8, 2025. A copy of the plan is located within the superintendent’s office,
clinical office, and mental health office.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures to ensure youth in crisis are administered a Crisis
Assessment. During the annual compliance review period the center had two youth available for
review. Two youth mental health and substance abuse records were reviewed, and none were
applicable for a Crisis Assessment. The center reported they had no youth applicable for a
Crisis Assessment since the last annual compliance review.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
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 did not utilize Baker Act or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures to ensure clinical services are provided to all youth
in the center. The center maintains a contract with VitalCore Health Strategies, LLC, who
subcontract with a medical doctor (MD) to serve as the center’s designated health authority
(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,
2027. The center utilizes an advanced practice registered nurse (APRN) whose license is clear
and active to practice in the State of Florida, which expires July 31, 2026, and two licensed
registered nurses (RNs), whose licenses were clear and active in the State of Florida both
expiring July 31, 2026. The APRN and the DHA both signed the Collaborative Practice Protocol
agreement on May 29, 2025, and June 4, 2025. The center’s DHA is contracted to be on-site at
least once a month and is on-call twenty-four hours a day, seven days a week and the APRN is
scheduled to be on-site at least once a week. A review of the center’s healthcare staff’s sign-in
sheets since the last annual compliance review showed the DHA was on-site once a month, as
required. There was one exception for the month of February, as the DHA signed in and was
on-site; however, the DHA did not sign-out upon exiting the center. The back-up DHA has a
clear and active license in the State of Florida with an expiration date of January 31, 2026.
When the DHA is on vacation or a scheduled absence, a back-up licensed physician is
designated by VitalCore Health Strategies, LLC, to provide clinical services. An informal
interview with the center’s juvenile justice detention officer supervisor (JJDOS), indicated the
back-up DHA was not utilized during the annual compliance review period. An interview with the
DHA confirmed they are on-site at a minimum of once a month to provide clinical services and
are available by email and telephone communication twenty-four hours a day, seven days a
week. The DHA is responsible for communicating with the center’s staff regarding youth medical
needs, providing on-site clinical services, and are available twenty-four hours a day, seven days
a week for acute medical concerns, emergency medicine, and for coordination of off-site care.
The DHA has an APRN who assists with the medical services provided to the youth. The
interviewed DHA reported the specific duties of the DHA include the supervision of the medical
department, and the designated APRN provides on-site clinical services and coordination of off-
site care. All off-site care findings, instructions and information is reviewed by the DHA or by the
APRN. Additionally, the DHA indicated they meet with the medical staff on a weekly basis to
review all medical issues at the center.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center maintains a written policy and procedures for all utilized health-related procedures
and protocols. The designated health authority (DHA) reviewed/revised, signed, and dated the
policies on September 10, 2025, and the superintendent signed on September 4, 2025. The
psychiatrist reviewed and signed the relevant policies on July 14, 2025. Reviewed
documentation validated the licensed registered nurses (RNs) and the advanced practice
registered nurse (APRN) reviewed and respectively signed and dated the cover page of the
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policies on April 9, April 30, May 15, and August 7, 2025. The center’s non-healthcare staff
protocols were signed and dated by the DHA on November 28, 2024, and April 9, 2025.
Reviewed documentation showed facility operating procedures (FOPs) for all health-related
procedures and treatment protocols were utilized at the center. VitalCore Health Strategies, LLC
has an established comprehensive clinical orientation for all newly employed healthcare staff,
which includes the Department’s healthcare policies and procedures. Reviewed documentation
found all newly employed healthcare staff received a comprehensive clinical orientation to the
Department’s health care policies and procedures, given by a registered nurse (RN) and the
approval of treatment protocols or standing procedures were written and authorized by the DHA.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures to 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. A review of two youth Individual
Healthcare Records (IHCRs) reflected each record had a signed AET. Each applicable signed
AET was marked as a copy on the form if it was not the original AET. Reviewed documentation
indicated each AET form was valid and signed by a Department representative. There were no
youth applicable for being under the care and custody of the Department of Children and
Families (DCF). Each reviewed youth was under eighteen years of age. In an interview with
nursing staff, the nurse reported all efforts are made to obtain a valid AET, which includes
contacting the assigned juvenile probation officer (JPO) to assist in obtaining the
parent’s/guardian’s signature. The nursing staff confirmed the procedure for documenting
consent for youth who are eighteen years of age or older.
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 to ensure the parent/guardian is notified of
significant changes in the youth’s condition and obtain consent when new medications and
treatments are prescribed. A review of two applicable youth Individual Healthcare Records
(IHCRs) reflected each record contained documentation of parental notification for an over-the-
counter (OTC) medication beyond those covered by the Authority for Evaluation and Treatment
(AET). One youth record was applicable for having a new medication order and significant
changes to existing medications, and the reviewed record documented parental notification and
consent. When applicable, telephone attempts were documented in the progress notes.
Reviewed documentation confirmed none of the applicable youth were taking psychotropic
medications at admission. Two youth IHCRs were reviewed for vaccination status, and each
contained a vaccination record from Florida Shots, which was reviewed by medical staff within
thirty days of each youth’s admission. There were no Religious Exemption From Immunization
forms submitted since the last annual compliance review. An interview with the nursing staff
confirmed the center’s practice for obtaining parental consent, documenting attempted parental
notifications, and the procedures followed when there is a youth with an illness or injury which
requires emergency medical services. Additionally, the nursing staff explained the procedures
for obtaining the immunization records upon admission.
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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 facility operating procedures to ensure each youth receives a healthcare
admission screening utilizing the Department’s Medical and Mental Health Admission Screening
form. A review of two applicable youth Individual Healthcare Records (IHCRs) found each had a
Medical and Mental Health Admission Screening form completed on the date of admission.
Each reviewed form was completed on the date of admission by a juvenile justice detention
officer (JJDO), and each indicated the screening was reviewed by a licensed medical staff
within twenty-four hours. Reviewed documentation validated the designated health authority
(DHA) was notified of both youth admissions, as required. Each youth’s screening form was
completed in the Department’s Juvenile Justice Information System (JJIS), as required. There
were no youth applicable for change in physical custody, since the youth’s arrival, requiring a
healthcare admission rescreening. An interview with the nursing staff confirmed the center’s
practice for completing an admission screening within the required timeframe.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures to ensure all youth are oriented to the general
healthcare delivery services at the center. A review of two applicable Individual Healthcare
Records (IHCRs) showed each reviewed IHCR included documentation to support the youth
received a general healthcare orientation within twenty-four hours of admission to the center.
Each youth’s orientation included topics addressing access to medical care, sick call, instances
which constitute an emergency and when to notify staff, the medication process and 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
general infection control/hygiene. A review of each of the youth’s Department Health Education
Records confirmed all required elements were addressed during the orientation process. Youth
with chronic conditions are educated on their medical condition by the on-site licensed medical
staff and recorded in the youth’s IHCR.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center has facility operating procedures to ensure the designated health authority (DHA) is
notified when youth admitted to the center require emergency care or a youth is admitted with
chronic health conditions. The center’s practice is to notify the DHA of the admission of any
youth with a chronic medical condition, psychotropic medication, or medical concern. A review
of two applicable Individual Healthcare Records (IHCRs) showed each youth was applicable for
known or suspected chronic conditions upon admission. Reviewed documentation confirmed
the Medical and Mental Health Admission Screening form was completed on the date of the
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youth’s admission by the center’s registered nurse (RN) and the notification to the DHA or
advanced practice registered nurse (APRN), was documented in the youth’s IHCR/electronic
medical record (EMR), within the required timeframe. None of the youth were applicable for
taking psychotropic medications upon admission. The center reported there were no additional
youth with chronic conditions or who were taking psychotropic medications since the last annual
compliance review. An interview with the nursing staff indicated whenever a youth is admitted
and identified with an emergency or chronic condition the DHA is notified immediately and the
DHA is to be notified within, and not to exceed twelve hours, if there are no urgent medical
needs. The DHA is notified by the nursing staff, and it is documented in the youth’s EMR and in
the youth’s chronological progress note.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center has facility operating procedures requiring completion, or review, and updating of the
Department’s standard Health-Related History (HRH) form. The center utilizes and completes
the standard Department HRH form for all youth admitted into the center’s physical custody. A
review of two applicable youth Individual Healthcare Records (IHCRs) confirmed the HRH was
completed within seven calendar days of the youth’s admission and was updated or completed
prior to the Comprehensive Physical Assessment (CPA). Each HRH form was completed by a
licensed nurse within seven days of the youth’s admission to the center. Reviewed
documentation indicated each HRH form was reviewed by a licensed nurse or practitioner. The
HRH form was completed before or at the same time as the CPA for each youth and reflected
the most current admission, as evidenced by signature and date. A review of the nursing
interview confirmed the HRH is completed by the nursing staff within seven days of the youth’s
admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures to ensure each youth in the center has a completed
Comprehensive Physical Assessment (CPA) upon their admission into the center. The CPA
form is to be completed or updated for all youth admitted to the facility. A review of two
applicable Individual Healthcare Records (IHCRs) was completed and each contained
documentation of a completed CPA. Each youth had a current CPA on record, completed by the
advanced practice registered nurse (APRN). Each reviewed CPA was completed within seven
days of the youth’s admission and signed by the APRN. Each CPA was completed in full to
include the Medical Grade, Tanner Stage, cardiovascular, body mass index, visual acuity field,
and most recent Tuberculosis Skin Test (TST). Both youth records documented a Tier 1
Tuberculosis (TB) screening was completed on the Medical and Mental Health Admission
Screening form. All sections of the CPA were marked with “O”, except for sections which were
noted by the medical doctor (MD) or the APRN as not being clinically indicated. None of the
reviewed records documented a youth refusal on any part of the exam. The Department’s
Problem List was updated, as required. Each of the applicable youth had at least one verified
TST formerly purified protein derivative (PPD) test documented in the IHCR within the last year.
The results of the TSTs were documented on the CPA and Infectious and Communicable
Disease (ICD) forms matched. The center’s policy and procedures for TB control and screening
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require the routine screening of all youth for latent and active TB and outline environmental
controls in the case of a youth with suspected active TB. A review of the nursing interview
indicated the designated health authority (DHA) or APRN completes the CPA within seven days
of admission and updates, or a new CPA is completed if there are significant changes identified
in the youth’s physical exam. Nursing staff indicated TB screenings are provided to youth within
seventy-two hours of admission to the center. Additionally, gynecological examinations are not
routinely completed for female youth.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center has facility operating procedures to ensure all youth entering the center are clinically
screened, evaluated, and treated, if necessary, for sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV). At admission, the youth are screened and referred to the
designated health authority (DHA) or advanced practice registered nurse (APRN) to determine if
further testing is indicated. A review of two Individual Healthcare Records (IHCRs) reflected the
youth were not applicable for being screened for STIs. The center reported there were no other
youth applicable for STI testing during the annual compliance review period. It is the center’s
practice to document STI screenings, evaluations, and referrals, which are maintained in each
youth’s IHCR. There were no youth applicable for being out of the Department’s custody for
thirty days or more needing a rescreening since the last annual compliance review. Reviewed
documentation confirmed all applicable youth were offered counseling, testing, and if indicated,
treatment for HIV. The center had no applicable youth who consented to HIV testing since the
last annual compliance review. The center’s practice is to obtain counseling and testing orders
at the direction of the DHA and/or APRN. The youth’s screening results, clinical evaluations,
and diagnoses are documented on the Infectious and Communicable Disease (ICD) form, and
HIV results are maintained confidentially in the youth’s IHCR. An interview with the nursing staff
indicated all youth entering the center are screened for STIs and afforded the opportunity to
receive HIV testing and counseling services. If a youth’s STI screening indicates further
evaluation is required, the youth is referred to the DHA or APRN for further treatment/testing.
STI results are documented on the youth’s Infectious and Communicable Disease form and the
laboratory results section of the record and maintained in the youth’s IHCR. HIV testing results
are kept confidential in the youth’s IHCR. Additionally, HIV pre-counseling, testing, and post-
counseling are conducted by the certified HIV counselor. One interviewed youth reported they
are able to request HIV testing.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures to ensure all youth will be able to make sick call
requests and have their complaints treated through the sick call system. Sick call care, including
dental complaints are available to all youth. The center conducts sick calls to respond to a
youth’s medical illness or injury of a non-emergent nature by a healthcare professional. A review
of two applicable Individual Healthcare Records (IHCRs) indicated one youth was applicable for
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having submitted a sick call request. The youth’s’ sick call was documented on the Sick Call
Referral Log. There were no instances of a youth presenting with a similar sick call complaint
three or more times. The sick call was conducted by the licensed registered nurse (RN), within
twenty-four hours. When the youth had a complaint of severe pain, which staff was unfamiliar
with or the youth’s medical condition could not be determined, the medical staff immediately
notified and referred the youth to the designated health authority (DHA) or advanced practice
registered nurse (APRN). The reviewed IHCR confirmed the youth and nursing staff completed
a Sick Call Request form. The youth was not in restricted housing of any kind. The dates listed
on the Sick Call Index corresponded to the completed Sick Call Request forms in the IHCR. The
center maintains treatment protocols appropriate to the level of the provider conducting sick call,
which was approved and signed by the DHA on April 9, 2025. 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 RN. Postings
throughout the center indicated sick call takes place seven days a week on from 8:00 a.m. to
11:00 a.m. and 7:30 p.m. to 9:00 p.m. Monday through Friday, and at 9:00 a.m. and 1:00 p.m.
Saturday and Sunday. Shift supervisors are trained in the center’s sick call procedures and are
to review the sick call requests in the absence of healthcare professionals. During the week of
the annual compliance review, one sick call was observed. The youth was escorted to the
medical clinic by a direct care staff. The APRN identified themselves and stated the reason the
youth was there. The youth was seen and examined in a private area with no other youth
present to hear or see the examination. The medical staff was able to maintain privacy while the
officer was located by the door of the medical area. An interview with the nursing staff confirmed
the process for youth requesting to see a physician or nurse, indicating youth are able to
complete a sick call request at any time, and these requests are reviewed by the shift supervisor
or designated center staff within four hours to determine if any immediate medical attention is
required. All sick calls are conducted by either the nursing staff or the DHA within twenty-four
hours, the medical staff are on-site daily and are on call twenty-four hours a day, seven days a
week, and is conducted at the nurse’s station. Three interviewed staff stated the doctor, nurse
or authorized staff review and conduct sick calls. An interview with one youth indicated they are
seen immediately upon submitting a sick call request. Additionally, the youth indicated the sick
calls are conducted by the nursing staff.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures to ensure a comprehensive process of episodic
care, first-aid treatment, and emergency care. The center utilizes an Episodic Care Log to
document episodic care and first-aid treatment. The log contains information to include the date,
name of youth, the youth’s Department identification number, nature of illness or injury,
treatment rendered, staff initials, nurse initials, verification of who provided episodic care, and if
the youth was recommended for off-site care. A review of two youth Individual Healthcare
Records (IHCRs) showed the two youth were applicable for episodic or emergency care. The
center reported there were no additional records applicable for episodic or emergency care
events since the last annual compliance review. Each applicable record documented the
problem-oriented elements which were used to capture pertinent information pertaining to the
nature of the youth’s complaint including identification of the subjective, objective, assessment,
and plan (SOAP) to address the complaint for each incident. None of the reviewed instances of
episodic care required a referral to off-site care. Each reviewed instance documented the
education/instruction provided to the youth, and an entry in the Episodic Care Log was
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completed. When applicable, a plan for follow-up care was documented. The center maintains
six first-aid kits which are located on each of the two youth living units, in master control, in the
intake area, in the medical clinic, and two kits are used for the transport vehicles. The first-aid
kits for each of the two transport vehicles are stored within master control and in the medical
office. The center’s policy states first-aid kits shall be inspected and restocked monthly and are
to be sealed with breakaway tabs. Observations of three kits during the annual compliance
review week validated the kits were stocked with the designated health authority (DHA)
approved contents. Informally interviewed nursing staff indicated they conduct weekly perpetual
counts of the contents to ensure the integrity of the contents. The center maintains one
automated external defibrillator (AED). The center’s AED is located on a wall-mounted AED box
in the medical clinic. The AED procedures were in the AED box, as well as audio instructions.
The AED batteries and pads are checked by medical staff and an outside medical provider, to
confirm it is operable. A review of the center’s AED tracking sheets since the last annual
compliance review confirmed the center’s practice. During the annual compliance review
nursing staff checked the expiration dates, conducted a self-test of the AED, and there were no
issues discovered. The batteries in the AED expire on December 31, 2027, and the pads expire
on November 3, 2026. Observations confirmed emergency contacts and telephone numbers
were posted in the medical clinic and in master control to include the number for the statewide
Poison Information Control Center which were accessible for the non-licensed and licensed staff
throughout the center, as well as inaccessible to each youth at the center. A review of three pre-
service and three in-service staff training records found each was trained and held current
certifications in cardiopulmonary resuscitation (CPR), first-aid, and AED. Each of the three
training records supported each staff received the required training on the center’s Emergency
Care Plan, and the supervisory staff received training on the epinephrine auto injector. All non-
healthcare staff and nursing staff are required to maintain certifications. Only healthcare and
trained non-healthcare staff can administer the epinephrine auto injector for youth requiring
administration when indicated. Reviewed documentation supported the DHA, the advanced
practice registered nurse (APRN), and all nursing staff maintained current certifications in CPR
and AED. The center’s policy and procedures indicated emergency drills are to be conducted for
each shift on a quarterly basis, at a minimum, and AED/CPR procedures must be demonstrated
at least annually. A review of documentation and video observation revealed drills simulated
episodic care events which called for immediate first-aid, AED and/or administration of CPR
techniques and the initiation of the emergency procedures to follow when a life-threatening
emergency occurs The center maintained proper documentation of each monthly drill with an
effort to ensure, at a minimum, all staff with direct contact on a day-to-day basis had the
opportunity to participate in at least one emergency drill annually. The center reported their drills
are discussed during the staff debriefings and drills are simulated as required according to
policy. All documented drills included the type of medical event, time the drill/event occurred,
time 9-1-1 was called, if applicable, name of the juvenile justice detention officer supervisor,
healthcare provider in charge, healthcare provider response time, type of medical care
rendered, time the event concluded, clinical manager/medical staff review, and critique. The
center has a policy and procedures regarding the use of NARCAN®. The center’s nurses are
responsible for conducting staff training on NARCAN® as a standalone, instructor-led class for
the supervisors trained and approved for medication administration. The center maintains
NARCAN® in the locked medication cart which is accessed only by the licensed nurses and
authorized staff who have completed training on medication administration. The center
maintains a perpetual and weekly inventory of the NARCAN®. An informal interview with the
nursing staff indicated the center has not utilized NARCAN® since the last annual compliance
review. An interview with the nursing staff confirmed the center’s process for documenting and
tracking on-site episodic care. The nursing staff was knowledgeable of the locations of the
center’s AED and first-aid kits. Additionally, the nursing staff indicated all emergency and
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medical drills are held monthly on each shift. Three interviewed staff stated they can call 9-1-1,
as needed. One youth was interviewed and rated the medical care at the center as very good.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures for the provision of off-site emergency and non-
emergency referrals for medical care and treatment. The center provides referrals and
coordination of medical services to ensure youth have timely access to off-site care services.
Evaluations conducted off-site shall 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. A review of two youth Individual Healthcare Records (IHCRs) found
there were no applicable youth for off-site care. The center reported there were no additional
youth applicable for off-site care since the last annual compliance review. An interview with the
nursing staff indicated youth who require first-aid or emergency care are sent off-site and are
tracked and documented in the Episodic/Medical Tracking Log. The log is utilized by staff to
ensure all hospital orders are followed. The medical staff ensure the DHA or advanced practice
registered nurse is notified, and all hospital orders are followed, upon the youth’s return. Nursing
staff ensure the DHA reviews and initials the off-site care findings, and maintains the tracking
log for follow-ups, referrals, and appointments. Additionally, all documentation is recorded in the
youth’s electronic medical record (EMR).
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures to ensure youth identified with chronic conditions
receive regularly scheduled evaluations and necessary follow-up care. A review of two youth
Individual Healthcare Records (IHCRs) found one youth was applicable for the existence of
chronic conditions. One youth was taking a prescribed medication with a Medical Grade of two.
The youth was placed on the chronic list for the prescription medication; however, had not been
in secure detention long enough for a periodic evaluation to be completed every ninety days.
There were no youth applicable for taking anti-tuberculosis medication. There were no youth
identified as pregnant or morbidly obese. The center reported there were no other youth
applicable for chronic conditions during the annual compliance review period. The Department’s
Problem List for the applicable youth was updated to indicate the youth’s chronic condition upon
completion of the Comprehensive Physical Assessment (CPA). An interview with the nursing
staff indicated the center monitors youth with chronic conditions, within seven days of
admission. Additionally, a care plan assessment is completed by the designated health authority
(DHA) or advanced practice registered nurse (ARNP) with follow-ups to be conducted every
ninety days, unless the youth’s medical status changes or develops. An interview with the DHA
indicated periodic evaluations for youth with chronic conditions are addressed, tracked, and
reviewed every ninety days, to ensure ongoing monitoring and management for the youth’s
continuity of care.
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4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures which outline the process of how medication and
pharmaceutical products are procured, dispensed, administered, and stored safely, accurately,
and in accordance with state, federal, and industry standards. The center’s practice is for
nursing staff to verify all medications have a current, valid order, and are given according to a
current prescription or practitioner’s order. Nursing staff verify medications with the
parent/guardian when they deliver the medication to the center. The Department’s Medication
Receipt, Transfer, and/or Disposition form is used to document medication received in the
original packaging from a licensed pharmacy with a current, legible, patient-specific label
affixed. A review of two applicable Individual Healthcare Records (IHCRs) showed there was
one youth taking medication upon admission and there were no additional applicable youth
available for review. A review of the youth’s medication showed there was a current, valid order,
and medications were administered pursuant to the current prescription. The prescription
verification was included in the chronological progress note, in the IHCR/electronic medical
record (EMR). Reviewed documentation confirmed the nursing staff verbally notified the
designated health authority (DHA) of the admission on the youth’s day of admission. A review of
the youth’s record showed the youth was not applicable for restricted housing while taking
prescribed medications. The youth was applicable for over-the-counter (OTC) medications not
listed on the Authority for Evaluation and Treatment (AET) form. The center utilizes a local
pharmacy as a back-up for emergency purposes. All medications are delivered to the center in
blister packs. When current medications were continued, discontinued, or changed, the
reviewed record indicated the DHA or advanced practice registered nurse (APRN) placed an
order on the Practitioner Order form, as required. The center utilizes the standard Department
Medication Administration Record (MAR) for each youth receiving either prescription
medications on a routine basis and/or OTC medications, which included all required elements.
The center maintains a written policy and procedures to ensure the usage of the MAR by
licensed healthcare staff and non-licensed staff. The applicable youth record was reviewed and
contained a MAR documenting administered medication. The reviewed MAR documented side
effect monitoring by the nursing staff at each medication administration. A review of the
standardized MAR form showed the form included the youth’s name, Department identification
number (DJJID), date of birth, youth allergies, precautions, Medical Grade, medical alerts, and a
current picture of the youth. There were no applicable youth records containing a MAR requiring
a trained non-healthcare staff assisting in the delivery of medications when licensed healthcare
staff were not on-site. There were no undocumented explanations for lapses or errors in
medication administration. Reviewed documentation reflected the staff initialed each
administered medication entry and each applicable youth documented their initials on the MAR.
There were no youth requiring parenteral medication at the center since the last annual
compliance review. The center did not have any standing orders for psychotropic medications,
no pro re nata (PRN) orders for psychotropic medications, or emergency treatment orders for
psychotropic medications. There were no records applicable for the youth entering the center
while on prescribed psychotropic medication. The center’s policy and procedures indicate if a
youth enters the center while on prescribed psychotropic medication, a psychiatrist shall be
notified upon the youth’s admission, and the psychiatrist will conduct an Initial Diagnostic
Psychiatric Interview within fourteen days of admission. The center has a list of trained non-
healthcare staff who are approved to assist in the administration of medication. Observations of
a medication administration could not be conducted during the week of the annual compliance
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review. An interview with nursing staff indicated the center has a process for monitoring and
tracking youth with chronic conditions and medication upon entering the center. Additionally, the
nurse indicated the center has non-healthcare staff who are trained by medical staff and
authorized to provide OTC medication to youth. Nursing staff indicated the center provides
youth medications every day, during the day, during the evening, or as required, and all
medications are documented on the Department’s MAR. An informal interview with the center’s
juvenile justice detention officer supervisor (JJDOS) confirmed the staff were trained on
medication administration by the APRN, on January 23, 2025. The center utilizes a chemical
pharmaceutical drug disposal system to dispose of expired and/or discontinued medications
with the assistance of the consultant pharmacist. An informal interview with the nurse confirmed
the center’s practice regarding medication management and the center’s disposal process. An
interview with three staff, confirmed the staff are authorized to provide youth their medication.
An interview with one youth stated the nursing staff provide the youth with their medication.
4.16 Psychiatric Services [Contract Provider] Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures summarizing the provision of psychiatric services to
youth in need, to include psychiatric evaluation, consultation, medication management, and
medical supportive counseling. The policy requires the center to provide psychiatric services to
the youth determined to need services, as indicated by symptoms of mental disorder or
substance-related disorder, or to youth who are treated with psychotropic medication after their
admission to the center. The center maintains a contract with VitalCore Health Strategies, LLC.,
for the provision of a licensed psychiatrist to provide psychiatric services for applicable youth in
the center. A review of the psychiatrist’s license confirmed they maintained a clear and active
license with an expiration date of March 31, 2026. The center does not utilize an advanced
practice registered nurse (APRN) and does not have a back-up psychiatrist. The center utilizes
tele-psychiatry for their psychiatric services. The interviewed designated mental health clinician
authority (DMHCA) indicated they meet with the psychiatrist weekly and as needed. A review of
two youth Individual Healthcare Records (IHCRs) reflected there were no youth applicable for
entering the center on psychotropic medications or were referred for a psychiatric interview. The
center and VitalCore Health Strategies, LLC., have a policy and procedures for the mental
health evaluation, the psychotropic/medication management, monitoring and documentation on
each youth. The reviewed documentation confirmed the DMHCA, and mental health/substance
abuse staff provide the individual sessions and group sessions to all youth who have accepted
mental health services. Additionally, tele-psychiatry sessions held, include the participation of all
the mental health staff, which allows them to discuss any issues or concerns with the
psychiatrist.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center has facility operating procedures ensuring medical equipment classified as
medications/sharps are secured and inventoried by using a routine perpetual inventory. The
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dose-by-dose daily administration and documentation of medication is documented utilizing a
perpetual inventory process for the daily distribution of non-controlled prescription medications
and over-the-counter (OTC) medications. Observations of the medical clinic were conducted
during the annual compliance review week and found the clinic is secured under lock and key.
The medical equipment classified as sharps to include syringes, needles, scissors, and suture
removal kits were secured and inventoried utilizing a routine perpetual inventory descending
count as each sharp was utilized and disposed, all medications were identified and secured in
the locked area designated for storage of medications, the medication cart was clean/organized
with stock items separate from youth-specific medications, and all controlled substances had a
perpetual inventory and were stored separately from other medications. The locked medication
cart is located in the medical office which stores all oral prescription and OTC medications
prescribed for youth. Narcotics and other controlled medications are securely stored and double
locked within the medication cart. The center did not have any controlled medications on-site
during the annual compliance review week. The center only had one prescription medication
and there were no opened OTC medications. The center had no medication requiring
refrigeration during the annual compliance review week; however, the center has a refrigerator
which is used for medication only, if needed. A review of three OTC medications was conducted
and confirmed the inventories were accurate. The interviewed nurse indicated the center
conducts perpetual inventories with running balances which are maintained on all controlled
substances with a shift-to-shift inventory conducted by the nursing staff. The center maintains
an inventory of all sharps and medical equipment classified as sharps, to include syringes,
butterflies, needles, scissors, and suture removal kits. A review of three sharps was observed,
in which perpetual inventories were accurate with verified weekly inventories. A review of the
inventory logs confirmed perpetual and weekly inventories are conducted on sharps and stock
OTC medications. Items designated as sharps are stored in a designated cabinet in the medical
clinic and are inaccessible to youth. An informal interview with the licensed registered nurse
(RN) indicated the center maintains an extensive inventory of OTC medications and a perpetual
count is conducted as required. The nurse indicated the center’s inventory of medication is
stored securely, and any narcotic medications are maintained behind double locks within the
medication cart. The nurse was able to explain the procedures regarding inventory
discrepancies. The nurse validated the center’s process for the disposal of medication and
indicated the center maintains expired medication in a secure cabinet until they are disposed
utilizing a chemical pharmaceutical drug disposal system to dispose of expired or discontinued
medication. An interview with the nursing staff confirmed the process for disposal of medications
and indicated all prescribed controlled substances were securely stored, in compliance with the
safety protocols. Additionally, the nursing staff confirmed the center has an agreement with the
consulting pharmacist, who visits on a monthly basis and is responsible for reviewing
medications and to ensure the center is in compliance with all laws and regulations. The center
maintains a copy of the pharmacy consultant’s license on-site, as required.
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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 be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures requiring the implementation of infection control
procedures including prevention, containment, treatment, and reporting requirements related to
infectious diseases, according to the Occupational Safety and Health Administration (OSHA)
federal regulations and the Centers for Disease Control and Prevention (CDC) guidelines. A
review of two applicable youth Individual Healthcare Records (IHCRs) reflected each youth
received infection control training within seven days of admission. A review of the center’s
Exposure Control Plan/Infection Control Plan documentation showed the plan was written in
accordance with Occupational Safety and Health Administration (OSHA) guidelines to include
risk assessment and methods of compliance. The exposure/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. The plan addressed common childhood infectious
diseases, self-limiting, episodic contagious illnesses, viral or bacterial infectious diseases,
Tuberculosis (TB), Hepatitis A, B, and C, human immunodeficiency virus (HIV), blood-borne
pathogens, other outbreaks and epidemics, and outbreaks of pediculosis. In addition, the plan
included Methicillin Resistant Staphylococcus Aureus (MRSA) and other antibiotic-resistant
micro-organisms, food-borne illnesses, bioterrorism agents, chemical exposures in the
workplace, and protocols for needlestick post-exposure intervention and treatment. The center’s
post-exposure process for evaluating needle sticks includes reporting the stick to the immediate
supervisor, documenting the circumstances, route of exposure, and the source individual and
their status. Results of testing are to be made available to the exposed staff, in addition to
providing appropriate counseling, and a referral to the nearest medical center/hospital or
Department of Health for post-exposure evaluation through worker’s compensation. The center
ensures Hepatitis B immunizations are made available for staff and staff have access to
protective equipment as needed. When applicable, infectious diseases will be reported to the
local health department or CDC. There were no reportable incidents for which the local county
health department, CDC, or the Department’s Central Communications Center (CCC) had to be
notified of an infectious disease since the last annual compliance review. A review of three staff
training records found each staff completed Exposure Control Plan/Infection Control Plan
training. An interview with the nurse indicated the medical staff are responsible for providing
detention staff and youth with training on the Exposure/Infection Control Plan. The nursing staff
indicated the Exposure/Infection Control Plan is available to staff and a copy of the plan is
located in the medical office.
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 did not have any pregnant youth during 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 has facility operating procedures (FOPs) regarding active supervision of youth.
During the annual compliance review week, on-site observations showed youth were actively
supervised during all daily activities such as school, recreation, medication pass, the admission
process, transportation, mental health sessions, while on precautionary observation, and during
meals. Observations confirmed positive interactions between staff and youth, youth were in
sight of at least one juvenile justice detention officer and accounted for at all times. All
movement was reported to and approved by the master control operator. A random review of
the center’s logbooks for the annual compliance review period found youth counts were being
consistently conducted. The center keeps track of the daily census through counts being
conducted randomly throughout the day, census being tracked in shift meetings, module
logbooks, the master control logbook, the Department's Juvenile Justice Information System
(JJIS), and on a white board in master control. Three staff were interviewed, and all stated there
are enough staff to provide for the safety and security of both 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 has facility operating procedures (FOPs) in place providing a system of rewards and
privileges for positive behavior, and consequences for inappropriate behavior to encourage
youth to meet the center’s expectations utilizing a behavior management system (BMS).
Observations during the annual compliance review week indicated the center has postings of
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the BMS in all modules clearly specifying appropriate and inappropriate behaviors, rules, norms,
and expectations. A review of logbooks confirmed positive rewards and consequences are
given in accordance with the BMS and there were no instances of inappropriate use of
restrictions or group punishment. Three staff were interviewed and each indicated the BMS is a
point and level system, posted throughout the center, and included in the youth handbook and
orientation process. One staff said rewards include later bedtimes, canteen access, and special
food on Wednesdays and Sundays. Two staff said youth receive snacks and special food on
Wednesdays and Sundays. All three interviewed staff reported the BMS is effective. All three
stated they discuss consequences with youth and give youth the opportunity to explain their
behavior. All three said staff talk to youth about alternative acceptable behaviors. One staff said
supervisors provide feedback through daily debriefings, email notifications, and trainings. Two
staff said supervisors encourage staff to inform youth about consequences and rewards. One
staff said feedback is given daily, and two said feedback is given as needed. All three said
points and levels can be taken away as consequences. All three said they have never seen a
coworker take meals away from youth. All three said they have never observed staff
encouraging youth to harm another youth. The superintendent was interviewed and stated the
center uses the statewide BMS. One youth was interviewed and rated the center’s BMS as
good. The youth explained the levels and explained level one is the beginning level, level two is
the working level, and level three is the high level where staff expect more. Rewards in the
center include canteen snacks and extra telephone calls. The youth stated all youth are treated
equally since families live far away and cannot visit often. The youth stated all staff use rewards
consistently and treat youth like family, with good behavior leading to good rewards and bad
behavior resulting in loss of privileges. The youth reported never being sent to their room for
punishment; however, mentioned privileges like television and fun time might be taken away for
bad behavior. The youth said they have never received consequences and never witnessed
handcuffs or leg irons used on out-of-control youth to prevent harm.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures addressing ten-minute checks. The center has
twenty-nine cameras with a recording capacity of thirty days. During the week of the annual
compliance review, twenty-four cameras were operational. The center indicated a work order
had been submitted for the remaining cameras. The center does not utilize a wand system for
ten-minute checks. Staff utilize handwritten Ten-Minute Observation Logs to document ten-
minute checks. Video observations of six different dates, for at least thirty minutes each,
including a random sampling of youth living modules, indicated ten-minute checks were
conducted as required. A review of ten-minute check logs for thirty-minute increments from each
shift and each housing module from September 2024 through September 2025 was conducted.
All ten-minute checks were documented as completed as required and included documentation
of weekly management oversight. Three staff were interviewed, and all responded room checks
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are conducted every ten minutes when a non-suicidal youth is placed in their room for sleeping
or non-punishment reasons. The superintendent was interviewed and explained the ten-minute
check process. They reported when youth are locked down in their rooms, staff conduct room
checks every ten minutes or less.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures (FOPs) which requires staff to always know the
exact number and location of all youth under their supervision. During the annual compliance
review week an informal count was called by master control. When the count was conducted,
both staff assigned to supervise the youth in the cafeteria counted the youth and called in the
count to master control. Staff were aware of the total number of youth assigned to them, and the
actual number of youth present. Master control verified the location of all youth with the staff
supervising the youth. A review of logbooks for one full day from each month during the annual
compliance review period was conducted. Counts were consistently conducted at the beginning
and end of each shift, prior to and following group movement, anytime a population change
occurred, and randomly at least once on each shift. Three staff were interviewed regarding
youth counts. All three stated counts are conducted at the beginning and end of each shift,
before and after school, and before and after meals. When asked about steps taken if a count is
incorrect, one staff member said the center will go into lockdown with a code green. Two staff
said a recount is conducted and the center pauses movement. All three staff confirmed counts
occur on all three shifts and anytime youth have any movement. Emergency counts are
conducted when a youth is believed to be missing, when visibility is hindered such as during an
electrical outage, and after a major disturbance.
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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 has facility operating procedures (FOPs) governing logbooks. The center maintains
logbooks in master control, for each module, transport vehicle, for visitors and for contracted
staff. A review of logbooks for one day each month since the last annual compliance review
revealed logbooks were bound with numbered pages and displayed the date at the top of each
page. All entries had the times of the events displayed in a.m./p.m. format, included the name of
the staff and youth involved, a brief description of the event, and the initials of the staff who
made the entry. Any entry impacting the safety and security of the center was highlighted. Any
errors were struck through with a single line, had void written after the error, and included the
staff’s initials. Entries included safety and security of the center, including medical, special
needs, and mental health alerts which were highlighted. 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, name of youth
placed on precautionary/secure observation, and the time precautionary/secure observation
began, and the time precautionary/secure observation was discontinued. The juvenile justice
detention officer supervisor (JJDOS) reviews the logbooks when accepting the shift, to
document they are aware of current relevant situations in the center. Logbook reviews included
the superintendent’s or designee’s weekly review, the JJDOS reviews when assuming center
responsibility, the daily JJDOS’s review of logbooks maintained in the living area, the juvenile
justice detention officer’s (JJDO) review of the living area logbook when beginning their shift,
and the superintendent’s, assistant superintendents, or JJDOS’s review during their daily tour of
each living area. The superintendent was interviewed and stated management’s role regarding
center and living area logbooks is to review them weekly and ensure a minimum review of the
past seventy-two hours.
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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 facility operating procedures (FOPs) requiring the center to be responsible for
maintaining inventory and control of all center keys. The FOPs include key assignment and
usage, restrictions on usage, inventory and daily tracking of keys, secure storage of keys,
procedures to follow when keys are missing or lost, and the reporting and replacement of lost or
damaged keys. A review of the key storage area revealed master control has a locked key box
where keys are maintained. An inspection of the area was conducted during the annual
compliance review, and the key box was found to be secured. All keys are stored on a tamper-
resistant key ring which inhibits the removal of keys. The center maintained 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. Restricted keys are only
issued to approved staff from each department. The key box contains a list of the staff
authorized to check out a particular key ring. The staff must turn in their personal keys to
retrieve the center key ring. Emergency keys are maintained in the superintendent’s office. The
regional director and the superintendent have access to the emergency keys. The center keeps
a separate inventory for the center and emergency keys. During the annual compliance review
week, staff were observed carrying the keys on their person and youth did not have access to
center keys. A review of the master key control inventory revealed the inventory report matched
the actual key rings in use. There were no reported incidents during the annual compliance
review period of lost keys or staff taking keys home after their shift. If keys were to be taken
home by staff, the staff are required to return the keys to the center within two hours of
discovering the keys were taken home. Personal keys are stored in staff lockers, visitor lockers,
or secured in master control. The center does not utilize system color-coded key ring hubs.
Observations verified staff placed their personal keys in designated lockers prior to entering the
secure area of the center. Master control would issue center keys to staff and document the Key
Control Logs. A random check of five different sets of center keys compared to the inventory list
indicated the keys were accounted for, the key tag matched the number of keys on the key ring,
and the ring was documented on the key log. The informally interviewed master control operator
verified keys are restricted only to staff authorized to have each key type. A random check of
three staff verified the number of keys on their key ring matched the inventory and each staff
knew the function of each key. The superintendent was interviewed and reported the
superintendent and captains are assigned permanent keys and are responsible for maintaining
their security. Three staff were interviewed and identified medical records, the youth property
area, mental health record storage, and case management record storage as restricted key
areas. They explained the center’s key control process includes staff turning in their keys to
master control upon entry, securely storing personal keys, visitors giving their personal keys to
master control upon entry and notifying master control immediately if any keys go missing.
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5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures in place for transportation procedures and
operation of Department vehicles. The center has two vehicles used to transport youth. Both
vehicles had the appropriate number of seatbelts, a seatbelt cutter, a window punch, a fire
extinguisher, and a first-aid kit with approved items, which was maintained in master control
when there were no youth requiring transportation. A transport was observed during the annual
compliance review week. Transport staff were observed to inspect the vehicle for contraband,
ensure the vehicle had sufficient fuel, verified the equipment to include the seatbelts were
present and functioning, ensured they had the proper documentation and logs for the transport,
ensured they had a cellular telephone for the transport, and documented the vehicle inspection
in the logbook. Transportation staff conducted searches of youth prior to the youth being placed
in the vehicle, and ensured the youth were secured with a seatbelt prior to departing. Both
center vehicles were inspected, and confirmed all were locked when not in use. A review of
documentation since the last annual compliance review found each vehicle was inspected prior
to transports. Documentation verified the shift supervisor completed weekly and monthly vehicle
checks. A review of the vehicle maintenance invoices revealed both vehicles assigned to the
center received an annual inspection within the previous year. Each of the vehicles had
documentation of a visual inspection conducted, as well as maintenance sheets to inspect the
levels for water coolant, lights, oils, emergency equipment, horn, cleanliness of the vehicle, and
the condition of the interior/exterior. A review of the center’s logbook confirmed youth were
searched prior to the transports, and all youth were securely fastened into their seatbelt. The
logbook contained the beginning and end time of each transportation, staff and youth names,
and the destination for transport. One youth was interviewed. The youth stated staff drive safely
when transporting youth and they had never seen anyone place contraband in a transport
vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures (FOPs) which require all tools and equipment used
to be properly maintained and accounted for. There are no kitchen or maintenance tools stored
at the center. Class B tools such as brooms and mops are secured in the janitor’s closet. Youth
may use cleaning items such as mops, brooms, buckets, and other common household items
under the direct supervision of the juvenile justice detention officer (JJDO). In an informal
interview, the juvenile justice detention officer supervisor (JJDOS) stated staff accompany
service vendors at all times when entering the secure area of the center. An observation of two
youth using a broom and dustpan was conducted through video observation. Staff monitored
the youth while the youth were using Class B tools. One youth was interviewed and reported
using mops and brooms as cleaning tools. Three staff were interviewed about the center’s
practice for damaged or missing tools. One staff said a work order is placed, the Department’s
Central Communications Center (CCC) is called, and the supervisor is notified. Another staff
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said they would contact the supervisor and master control. The third staff said they have never
had any tools missing; however, explained a CCC report would be conducted, and the
supervisor would be notified. All three staff confirmed youth are allowed to use mops and
brooms. The superintendent was interviewed and confirmed there are no tools at this center.
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 biohazardous material, bodily
fluids, or human waste.
The center has facility operating procedures (FOPs), which name the superintendent as the
person responsible for the implementation of a Safety Plan addressing proper use, storage, and
disposal of chemicals, including flammable, toxic, caustic, and poisonous items. A review was
conducted of the center’s Safety Plan which requires flammable, toxic, caustic, and poisonous
items to be maintained in a shed with limited staff access and no youth access. Safety Data
Sheets (SDS) must be located where the chemicals are stored. Observations and an informal
interview with the juvenile justice detention officer supervisor (JJDOS) confirmed flammable,
toxic, and/or caustic materials are stored in the janitor’s closet under lock and key and are only
accessible to supervisory staff. The SDSs and inventories were compared to a sample of five
items on-site and were found to be accurate and complete. Three staff were interviewed and
reported youth are not allowed to clean with substances which are toxic, flammable, or
poisonous. One youth was interviewed and the youth reported youth do not clean with any type
of cleaning agent such as bleach, laundry soap, window, or toilet cleaners. The youth reported
they do not have access to flammable, toxic, caustic, or poisonous items.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) which address proper use, storage, and
disposal of flammable, toxic, caustic and poisonous items. The center’s Safety Plan addresses
what procedure to follow in the event of a chemical leak, or spill. An interview with the center’s
juvenile justice detention officer supervisor (JJDOS) reported the local waste management
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department handles all disposal of flammable, toxic, caustic, and poisonous items and there
have been no chemical spills or leaks since the last annual compliance review.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains facility operating procedures (FOPs) which govern the requirements for
behavioral confinement for less than twenty-four hours. A review of the Department’s Juvenile
Justice Information System (JJIS) revealed the center has not had any confinements under
twenty-four hours since the last annual compliance review. During a tour of the center, windows
and two youth rooms’ cameras were free of obstructions, so the youth may be visually
observed. Three staff were interviewed and indicated the step-by-step process for placing youth
in confinement includes completing a confinement report, conducting and documenting ten-
minute checks, and searching the confinement room. All three confirmed youth placed in
temporary confinement are provided with educational materials. The superintendent was
interviewed and reported the use and appropriateness of confinement is tracked through
supervisory approval of the confinement and an administrative review within forty-eight hours.
Regional detention management staff review the use of confinement, lockdown, and restraints
every twenty-four hours.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures (FOPs) in place requiring the establishment of a
Continuity of Operations Plan (COOP), and for COOP drills to be conducted at a minimum of
twice a year. Two COOP drills were conducted during the annual compliance review period.
Hurricane drills were conducted in May and August 2025. A review of documentation
determined both drills contained the type of drill, date and time, participants, brief scenario,
findings, and recommendations, as required. The superintendent was interviewed, and
confirmed the center’s comprehensive safety/emergency program is the COOP. The
interviewed juvenile justice detention officer supervisor (JJDOS) stated the center has a COOP
which includes emergency plans for safety and emergencies which may arise.
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5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures (FOPs) which require the center to develop and
implement an Escape Prevention Plan. In addition, the center is required to conduct escape
drills at least quarterly on each shift. The escape drills since the time of the last annual
compliance review were reviewed. The center conducted monthly escape drills on each shift,
which exceeded the requirement. A review of five staff training records was conducted and
revealed all staff were trained in escape prevention annually. A review of logbooks confirmed
the documentation of each drill. Three staff were interviewed and all confirmed participation in
drills since the last annual compliance review, including fire, escape, chemical spills, major
disturbances, and weather drills.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has facility operating procedures (FOPs) requiring the implementation of a disaster
preparedness fire prevention plan. In addition, the center is required to conduct monthly fire
drills on each shift. The center has a Fire Prevention and Evacuation Plan which addresses fire
prevention and safety of the center. The plan was reviewed and approved by the local fire
official who conducted an annual inspection of all fire extinguishers. A review of fire drill
documentation since the time of the last annual compliance review revealed fire drills were
conducted monthly on each shift. The fire drills were documented in the master control
logbooks. Staff sign-in sheets were used to document staff participation in the drills. Three staff
were interviewed and all three confirmed fire drills take place at least monthly. One youth was
interviewed and reported they have been instructed on what to do in case of a fire.
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
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recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) designed to stop illegal contraband and
prohibited items from entering the center. Upon entering the detention center, youth undergo a
search conducted by center staff. During the annual compliance review, a pat-down search was
witnessed, with staff utilizing gloves and reporting the procedure to master control. Searches
were observed both during a youth transport and at the time of a new admission. Each youth
was searched individually. Electronic screenings for all individuals entering the center were
verified through both observation and video recordings. During the annual compliance review
week, members of the review team were subjected to electronic searches. These were
conducted anytime a staff, visitor, or volunteer entered the secure part of the center. All bags,
cases, jacket pockets, and other items were searched. All personal keys were collected by
master control before entering the secure area. Personal cellular telephones and other
contraband items were prohibited. Room searches were completed upon releasing a youth and
prior to placing a new youth in a room. Room searches were conducted on each awake shift. A
review of room search documentation was conducted for one day each month during the annual
compliance review period and confirmed both awake shifts completed and documented room
searches. Since the time of the last annual compliance review, there have been no instances
which may have compromised the safety or security of the center. All visitors entering the center
are required to review and complete a contraband attestation. The superintendent was
interviewed and reported if a youth or staff member is found with contraband, the item is given
to the supervisor for chain of custody, law enforcement is notified if the item is illegal, and
reports and notifications are completed. All staff and visitors are wand searched before entering
the center. Additionally, signs are posted regarding the consequences of bringing contraband
into the center.
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report_type: QI Detention