summary: QI Detention - FY24-25 - 1 finding

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ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Okaloosa Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated )
4448 Straight Line Road
[Crestview, Florida 32539
Review Date(s): September 17-20, 2024
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Andre Watson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Ken Myers, Office of Education, Education Coordinator Circuit 1 (Standard 2)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
4)
Kamille Payne, Office of Accountability and Program Support, Regional Supervisor (Standard 2)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Okaloosa Regional Juvenile Detention Center MQI Program Code: 828
Provider Name: Department of Juvenile Justice Contract Number: NA
Location: Okaloosa County / Circuit 1 Number of Beds: 35
Review Date(s): September 17-20, 2024 Lead Reviewer Code: 228
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 52 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 52 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 52 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 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 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education 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 7 of 52 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Limited
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 52 (Revised July 2023)
Program Overview
The Okaloosa Regional Juvenile Detention Center is a state-owned detention facility, operated
by the Department, located in Crestview, Florida. The center serves youth in Okaloosa and
Walton counties in Circuit 1. The center is co-located with a Juvenile Assessment Center (JAC),
which is operated by a contracted provider. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
thirty-five-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Okaloosa County School Board.
The center’s management team includes the superintendent, two assistant superintendents,
one staff assistant, one administrative assistant, seven juvenile justice detention officer (JJDO)
supervisors, thirty-two JJDOs, one OPS JJDO, one food service director, and three food support
workers. Mental health and healthcare services are provided through the contracted provider,
VitalCore Health Strategies, LLC. Mental health services are provided by one designated mental
health clinician authority (DMHCA), and one licensed mental health professional. The DMHCA
position has been vacant since August 9, 2024; however, interim coverage has been provided
by the regional director. Clinical services provided by the center include mental health and
substance abuse evaluations, mental health treatment planning, individual, group and family
therapy, mental health crisis intervention services, on-site psychiatric services, and availability
for substance abuse services for youth with co-occurring disorders. Medical services are
provided by one designated health authority (DHA), one advanced practice registered nurse
(APRN), and four registered nurses (RNs). The medical clinic maintains nursing coverage seven
days a week, from 7:15 a.m. to 7:15 p.m., Monday through Friday, and from 7:00 a.m. to 5:00
p.m., on weekends. Food services are provided by Department staff and include menus, meal
planning, meal schedules, special diets, nutritional analysis, daily allowance, food preparation,
health certifications, food product standards, sanitation, and cleaning. Staff are responsible for
the custody and control of youth in their care, providing youth supervision twenty-four hours a
day, seven days a week. The center has three living modules which are divided by male and
female. There are seventy-two security cameras at the center, of which all were operational.
The center has several areas, largely living modules, which need to be painted, there are also a
few rooms with graffiti; however, the center is unable to purchase paint. Work orders were
submitted by the program. Email notification received to pause painting projects until further
notified. The male living area has an issue with the air conditioning unit; a work order has been
submitted. At the time of the annual compliance review, the center had eighteen vacancies
including seventeen JJDOs and one JJDO supervisor.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 52 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center maintains facility operating procedures addressing background screenings for all
Department staff and volunteers and all contracted provider and grant recipients, volunteers,
mentors, and interns with access to youth and confidential records. An Annual Affidavit of
Compliance with Level 2 Screening Standards was submitted to the Department’s Background
Screening Unit (BSU) on January 4, 2024, meeting the annual compliance requirements. The
teacher’s Annual Affidavit of Compliance with Level 2 Screening Standards was completed on
January 11, 2024, meeting the annual compliance requirements. Seven staff were applicable
and reviewed for initial background screening. All staff had a background screening completed
prior to the hire date and a criminal history report was reviewed. Six of seven staff had a pre-
employment assessment tool administered with a documented passing score. The remaining
staff was a contracted staff who was added to the Clearinghouse employee roster as required.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center had five staff eligible for a five-year rescreening during the annual compliance review
period. Each staff’s rescreening was completed no more than twelve months and no less than
ten days prior to the anniversary date of the staff’s initial date of hire. There were no contracted
staff who were eligible for a five-year background rescreening.
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
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 52 (Revised July 2023)
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 (FOPs) to address staff code of conduct. A review
of three staff records confirmed each signed the code of conduct form. Three staff records were
applicable for disciplinary action for violations of code of conduct for the annual compliance
review period. Two of the three staff received oral reprimands as part of management’s
response to violation of code of conduct. The remaining staff received a written reprimand as
part of management’s response. Three staff personnel records were reviewed for
commendations. All three records indicated staff received commendations for employee of the
month. Five youth were interviewed. Three of five youth reported they have never been stopped
from reporting abuse to the Florida Abuse Hotline. One of five youth reported they have been
stopped from reporting abuse. The remaining youth reported never having had to report abuse.
Two of five youth reported never having heard staff use profanity when speaking with youth.
Two of five youth reported they occasionally heard staff using profanity when speaking with
youth. The remaining youth reported they often heard staff use profanity when speaking with
youth. Four of five youth reported never having heard staff threaten youth. The remaining youth
reported once hearing staff threaten youth. Three of five youth reported they feel safe in the
program. Two of five youth reported they do not feel safe in the program. One youth who
reported not feeling safe in the program reported staff members allowed another youth to jump
them in a classroom and did not stop the altercation from happening. The remaining youth who
reported not feeling safe stated they have been threatened several times by staff to be thrown
down on the ground. Four of five youth reported never having exchanged emails, telephone
numbers, or social media contact information with staff. The remaining youth did report having
exchanged emails, telephone numbers, or social medial contact information with staff. It should
be noted, during the youth interviews, one youth reported with all negative responses. All
interview findings were reported to the center’s management team. The annual compliance
review team reviewed the alleged abuse situations described during interviews and found all
situations were reported to the Department’s Central Communications Center (CCC) and the
Florida Abuse Hotline. Five staff were interviewed. Each staff reported if a youth wants to report
abuse, they notify the supervisor and allow youth to call the Florida Abuse Hotline or CCC.
Three of five staff reported working conditions at the center during the past year have been fair.
The remaining two staff reported working conditions at the center the past year have been good.
Five staff reported never observing a co-worker using threats, intimidation, or humiliation when
interacting with the youth. Three of five staff reported never observing a co-worker use profanity
when speaking to a youth. One of five staff reported occasionally hearing a co-worker use
profanity when speaking to a youth. The remaining staff reported once hearing a co-worker use
profanity when speaking to a youth and the staff member is no longer employed at the center.
The superintendent was informed of staff responses of hearing staff use improper language
toward youth. The superintendent indicated additional staff training will be provided to educate
staff on subject matter. An interview was completed with the superintendent. The
superintendent reported the code of conduct ensures staff communicate and interact with youth
in a manner which provides a role model of socially accepted behaviors, and staff behavior shall
be respectful of others and reflect desired behaviors for youth. Staff shall adhere to a code of
conduct which prohibits any form of abuse, profanity, threats, harassment, intimidation, or
personal relationships with youth. When interacting with youth, officers shall maintain
professional behavior and relationships. Officers shall not verbally abuse, demean, or otherwise
humiliate any youth, and shall not use profanity in the performance of their job. Physical abuse
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 52 (Revised July 2023)
of youth is prohibited by law and a suspicion or knowledge of such shall be reported to both the
Florida Abuse Hotline and CCC.
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.
There was a total of twenty-five incidents reported to the Department’s Central Communications
Center (CCC) during the annual compliance review period. Five CCC reports were reviewed. All
CCC reports reflected they were reported in the required time frame and documented in the
center’s logbook. There were no additional internal incidents/grievances which should have
been reported to the CCC. An interview with the superintendent was conducted. The
superintendent stated whenever a reportable incident occurs, it shall be called into the CCC
within two hours of the program or contracted staff learning or gaining knowledge of the incident
or event. All staff may contact the CCC.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center had a total of ninety-one Right Interactions (RI) Reports for the annual compliance
review period. Nine RI Reports were reviewed. A RI Report was completed for each use of a
countermove, control technique, or mechanical restraint. Each reviewed RI Report was
completed by the end of the staff’s workday and included a statement from each staff involved.
There were no RI Reports which indicated serious injury to youth or staff occurred. There were
no RI Reports indicating a youth alleged abuse of any type. Each RI Report was reviewed by a
supervisor or certified RI instructor. Each report indicated a post RI interview was conducted
with the youth by an administrator within thirty minutes after the incident. There were no reports
which indicated a need for a medical review and no mechanical restraints were used. Each RI
Report was reviewed by the superintendent within seventy-two hours after all other reviews with
an added comment. The center had no additional RI incidents not documented by a RI Report.
The center’s RI rate during the previous quarter was 27.08, which is above the state Detention
RI rate of 15.17. Five staff were interviewed. Five staff reported they try to speak with youth
prior to using physical restraints or mechanical restraints. An interview with the superintendent
was conducted. According to the superintendent, the use of physical and mechanical restraints
is tracked daily by the juvenile justice detention officer supervisor (JJDOS). The superintendent
further explained RI incident reports are reviewed by the superintendent or designee, within
seventy-two hours, excluding weekends and holidays. A review of RI incidents by closed circuit
television video is conducted by the superintendent or designee, within twenty-four hours,
excluding weekends and holidays.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 52 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
Five staff records were reviewed for pre-service training certification. Two of the five staff
received all pre-service training within 180 days of hire. The remaining three staff were within
the 180 days of training at the time of the annual compliance review. Each of the five staff were
certified to use first-aid, cardiopulmonary resuscitation (CPR), and automated external
defibrillator (AED), and received new staff orientation within thirty days of hire. Each of the two
staff applicable for completion of all pre-service trainings had all trainings documented within the
Department’s Learning Management System (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.
Five staff records were reviewed for in-service training of which two records were for
supervisors. According to training records, all five staff completed the required in-service
training to include active shooter preparedness, first-aid, cardiopulmonary resuscitation (CPR),
automated external defibrillator (AED), human trafficking, information security awareness,
mental health and substance abuse, Prison Rape Elimination Act (PREA), Right Interactions
(RI), professionalism, interpersonal communication, and ethics, sexual harassment, suicide
prevention, trauma response practices, emergency care plan, infection control, exposure control
plan, escape prevention, and fire prevention/disaster procedures. The two identified supervisor
records indicated staff completed the additional minimum of eight supervisory training hours. All
trainings were documented within the Department’s Learning Management System (SkillPro).
All records indicated nursing staff provided in-service training on girls’ healthcare annually.
Trainings included monitoring, observation, and emergency care of pregnant youth. According
to nursing staff, there were no pregnant youth at the center during the annual compliance review
period. The center maintains an annual in-service training calendar which is updated as
changes occur. The annual training calendar was approved by the highest ranking official at the
center, the assistant secretary of Detention Services, and the director of the Department’s Office
of Talent, Leadership, and Culture. An interview with the superintendent was conducted.
According to the superintendent, in addition to the twenty-four hours of in-service requirements,
supervisory staff shall complete eight hours of training each calendar year. Pre-service training
shall consist of 120 hours of certification training with the juvenile justice detention officer
(JJDO) Academy consisting of 120 hours. In-service staff shall complete twenty-four hours of
annual training.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 52 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center maintains a facility operating procedure (FOP) for addressing youth grievances,
ensuring each youth has the right to grieve, is treated fairly, respectfully, without discrimination,
and their rights are protected. Grievance forms are accessible for all youth. The center had four
grievances completed during the annual compliance review period. Each grievance was
documented within the Department’s Facility Management System (FMS). Each grievance was
responded to in the required time frame according to the center’s FOP. Three of the four
grievances were resolved at the formal phase. The remaining grievance was forwarded through
the appeals process and verified through video surveillance. Five youth were interviewed. Four
of five youth reported knowing and were able to articulate the center’s grievance process. The
remaining youth reported not knowing the grievance process. Two of five youth rated the
grievance process as good. One youth reported the grievance process as poor. The remaining
two youth reported never having to utilize the grievance process. Five staff were interviewed
and were able to articulate the center’s grievance process. The superintendent was interviewed
and was able to articulate the center’s grievance process, the three phases, and where
grievance forms are located, stored, and maintained.
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.
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Office of Accountability and Program Support Page 14 of 52 (Revised July 2023)
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center maintains facility operating procedures (FOPs) outlining the process of entering and
sharing alerts information. Five youth were reviewed for alerts entered by the center. A total of
ten alerts were reviewed. Nine of the ten alerts entered were able to be identified by staff title
and name of who entered or updated the alert. The remaining alert had no identifiable
information of who entered or updated the alert. Alert information was updated during the
annual compliance review week. Each alert contained a Department Juvenile Justice
Information System (JJIS) entry date, and each was entered within the appropriate time frame.
According to documentation, JJIS alert reports are reviewed daily by supervisors and
administrators. Information regarding youth alerts is shared with staff daily by means of shift
debriefings. Alert updates occur as needed and when appropriate within JJIS. A shift debriefing
was unable to be observed during the annual compliance review week. There were no
additional alerts found during the annual compliance review week which should have been
entered into the alert system. Five staff were interviewed. Five staff reported they are informed
of alerts through shift debriefings. Five staff reported management informs them of center
issues through shift debriefings. Three of five staff reported the center’s process for
communicating information is fair. One staff reported the center’s process for communicating
information is good. The remaining staff reported the center’s process for communicating
information is very good. An interview was conducted with the superintendent. The
superintendent reported the alert process is to ensure the safety and well-being of youth with
critical or special alerts and to ensure alerts are reviewed, responded to appropriately, and
documented.
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 practices data trend analysis by reviewing incidents, Right Interactions (RI) Reports,
and confinement reports daily, as well as reviewing vacancies. Information is shared with staff
during shift debriefings, monthly staff meetings, and bi-annual staff meetings. Reviewed meeting
minutes supported the practice of information distribution. Providers and stakeholders are
provided with information during quarterly facility advisory board meetings. The center reviews
information to identify trends and develop techniques to correct.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 52 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, 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.
Five youth were reviewed for admission requirements, in accordance with Florida Administrative
Code and the center’s facility operating procedures (FOPs). Two of the five youth records
included an Admission Wizard, completed in the Department’s Juvenile Justice Information
System (JJIS), which documented all required information was received and reviewed. The
remaining three Admission Wizards were completed as a hard copy due to Department-wide
system outages. One of the three hard copy Admission Wizards did not indicate an
affidavit/custody order was reviewed and the remaining two hard copy Admission Wizards did
not denote any of the required documentation was reviewed; however, all documents were
found in each youth’s record. Three of the five reviewed records documented a full-
body/electronic search, telephone call, meal, and a mental health and medical screening were
completed. One Admission Wizard, which was a hard copy, did not document a search,
telephone call, or meal was completed and one Admission Wizard, which was a hard copy, did
not document a mental health and medical screening were completed. An observation of an
admission was unable to be conducted during the annual compliance review week as no youth
were admitted to the center while the annual compliance review team was on-site.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
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7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
Five youth records were reviewed for orientation to the center. Each of the five youth records
included a signed acknowledgement form indicating each youth was provided an orientation to
the center within twenty-four hours of admission, which included all required topics. An
observation of an orientation was unable to be conducted during the annual compliance review
week as no youth were admitted to the center to be oriented while the annual compliance
review team was on-site. Five youth were interviewed, and four of the five youth reported they
were given an orientation to the center upon admission. The remaining youth reported they
were not provided orientation; however, the interviewer noted the youth often reported the
opposite of the remaining interviewed youth.
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.
Five youth records were reviewed for classification procedures to provide the highest level of
safety and security. The program’s facility operating procedures (FOPs) outline the required
classification factors which need to be reviewed prior to making a classification determination;
however, the center does not use a specific classification form. Each of the five youth records
contained a cover sheet of all reviewed documents upon admission and each required
classification factor was found throughout the reviewed documents, with the exception of human
trafficking history. Three of the five youth had a Human Trafficking Pre-Screen in their record,
the remaining two did not have the form included in their record. The classification process was
found to include all required topics; however, three of the five youth admissions were completed
by hard copy due to Department-wide system outages. In the three hard copy admissions the
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youth’s height, weight, gender, and room number were not documented in each record. The two
most recent admissions, which were completed in the Department’s Juvenile Justice Information
System (JJIS), included all required topics. The superintendent was interviewed and reported
youth are assigned to a room based on their classification and are reclassified if needed. The
superintendent reported they remain informed of how to identify and address local gangs
through ongoing training and communication with the circuit gang representative.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures (FOPs) in place which address notification of
required parties in the event of suspected gang involvement or activity. Five records were
reviewed and none of the youth were applicable for being known or suspected gang members.
The center reported there have been no gang involved youth during the annual compliance
review period. An informal interview with the center’s gang liaison, who is the assistant
superintendent, revealed in the event there is suspected gang involvement or activity for any
center youth, the gang liaison will communicate this to the circuit’s juvenile probation officer
(JPO) who serves as the circuit gang representative.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
Five youth records were reviewed for the admission and storage of youth personal property and
each youth record contained an Unclaimed Property Acknowledgement form which was signed
by the youth. Each of the five records contained a Property Receipt form which documented the
items the youth brough into the center and included both youth and staff signatures. None of the
youth were applicable for valuable property. An observation of the storage area found all youth
items are stored in the property storage room, which is only able to be accessed by supervisors.
Each of the five reviewed youth’s personal property was found in a youth locker in the property
storage room with a copy of the Property Receipt form located with the items. Only two youth at
the center were applicable for valuable property and both youth’s property was in a clear
tamper-proof bag and located in the drop safe. Both youth’s property was documented in the
safe logbook. The safe is in the intake room and under video surveillance. The safe is only able
to be accessed by master control. A review of reports to the Department’s Central
Communications Center (CCC) found no incidents regarding youth property during the annual
compliance review period. Five youth were interviewed and four of the youth reported their
property was inventoried and stored upon intake. The remaining youth reported they only came
in with Department-issued clothing. The superintendent was interviewed and confirmed the
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center’s practice to inventory and store all youth personal property. They also reported in the
event property is left at the center for more than thirty days a Notice of Impending Disposal is
mailed to the youth’s last known address.
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.
Three closed youth records were reviewed for release procedures. Each of the three records
included a Release Wizard completed in the Department’s Juvenile Justice Information System
(JJIS), which documented the supervisor reviewed the court paperwork and required documents
prior to releasing the youth. Each youth was released to a Department representative and the
identification was verified. The supervisor reviewed the youth’s future court dates with the youth
and Department representative they were being released to and ensured all documents were
signed as required. Each youth’s admission and release dates in their record correlated with
JJIS. None of the youth were applicable for an endangered person alert or notification to the
Department of Children and Families (DCF). An observation of a youth release was conducted,
and all required procedures were completed.
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.
Three closed youth records were reviewed, and each youth was released to a Department
representative whose identification was verified prior to release. Each of the three youth records
included the Receipt of Property form signed by the youth and the Department representative.
All three youth were applicable for release of medications and the medications were
documented on the required Department form and signed by the receiving Department
representative. The representative the youth was released to was reminded of all required
information. The center provided examples of property which was held for over thirty days. Each
item was placed in a clear bag which the property receipt and attached to a copy of the
Notification of Impending Disposal form which was sent to the youth’s last known address. The
center reported if the property is not claimed they would donate any property and send any
money to Detention Operations. An observation of a youth release was conducted and all
required procedures for the release of property, medication, and aftercare instructions were
completed.
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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.
A review of documentation in the center’s SharePoint found the center conducted weekly
Detention Reviews every Tuesday during the annual compliance review period and maintained
documentation to support all required parties were in attendance. A Detention Review was
observed during the annual compliance review week and confirmed all required parties
participated in the meeting to share information on center youth. The superintendent was
interviewed and reiterated the required parties for Detention Reviews and reported any parties
unable to attend in person can attend the meetings by video call.
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 a daily activity schedule which lists all required activities. The daily activity
schedule was found posted in each living area of the center. A review of one day each month in
the center logbooks and observations each day of the annual compliance review week
confirmed the center follows the daily activity schedule and provides youth all required activities.
Five youth were interviewed, and each reported the center has a schedule which is followed.
Five staff were interviewed, and each staff reported the center follows the daily activity
schedule.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center’s education program is directly managed and supervised by the Okaloosa County
School Board. It is required to operate on a year-round basis providing the youth with at least
250 days of instruction distributed over twelve months with a minimum of twenty-five hours of
weekly instruction. This schedule also allows the school board to use up to ten days of the 250
days for teacher planning/professional development. Upon review of the annual academic
calendar and daily class schedule, the program’s annual calendar supports 240 days of
instruction with ten additional days of teacher planning/professional development. A review of
the daily academic schedule confirmed the schedule offers 275 minutes of instruction daily
amounting to just under twenty-three hours of weekly teaching. This does not meet the required
educational hours each week. Documentation was provided confirming the superintendent and
school principal submitted the schedule to the Department’s Office of Education upon taking
over educational services July 1, 2024. Upon discovery of the shortage of hours during the
annual compliance review week, the center created a new schedule to remedy the school
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hours. Three days of video were reviewed, and the video showed classes were being conducted
with minimal interference, and youth were in class in accordance with the schedule. A review of
the program’s logbooks for one day each month of the annual compliance review period found
youth arrived in class on time for six days. On two days, only the girls were documented
attending classes. On three days there was no documentation of the boys leaving class. An
interview with the superintendent found the boys remain in the classroom for snacks and group;
therefore, the documentation was not missing. An interview was conducted with the
superintendent. According to the superintendent, classes are conducted with minimal
interference. Five interviewed staff and five youth all confirmed there is minimal interference to
educational instruction and youth attend school Monday through Friday.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
Under the supervision of the Okaloosa County School Board, the center provides youth under
its care an appropriate career education curriculum based upon their age and assessed
intellectual and educational abilities. A career education course is offered which is categorized
as a Type 1 career and vocational curriculum. This classification, which stresses soft skills,
includes activities centered on but not limited to youth learning or improving their interpersonal,
communication, and decision-making skills. All youth are enrolled in personal development and
careers, and career planning. Youth will start taking the Xello career assessment in the future.
Five interviewed youth indicated none of them were attending life skills or career choices
courses.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center had a full-time designated mental health clinician authority (DMHCA) until their
employment was terminated on August 12, 2024. In the interim, the regional supervisor for the
contracted mental health and clinical service provider, VitalCore Health Services, LLC, has
taken the role of DMHCA and is on-site approximately twenty hours a week. The previous and
acting DHMCA have clear and active licenses in the State of Florida with an expiration date of
March 31, 2025. The provider’s contract with the Department requires licensed mental health
clinical staff to be on-site forty hours a week. The remaining twenty hours a week are covered
by two additional licensed clinicians, to ensure appropriate coordination and implementation of
mental health and substance abuse services are taking place. Copies of the DMHCA’s
agreement and position description were reviewed along with the contract requirements, which
confirmed weekly hours of coverage as specified in the contract were met. The interview results
from the acting DHMCA were reviewed. The interview concluded the previous full-time DMHCA
was terminated on August 12, 2024; therefore, leaving an opening for the position. Mental
health services are provided to the youth regarding their individual needs weekly or as needed.
The center has four full-time licensed therapy staff positions, which were all filled during the
annual compliance review week.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The interim designated mental health clinician authority (DMHCA) ensures the licensed clinical
staff working under their supervision are performing services they are qualified to provide based
on education, training, and experience. The center has four licensed mental health
professionals. All licenses were reviewed and indicated the licensed mental health professionals
are licensed under the appropriate Florida Statue and in accordance with the Florida
Department of Health. Each license expires March 31, 2025, and copies of all licenses were
available within the health administration office. The center did not have any non-licensed
clinical staff working under the supervision of the DMHCA. The center does not have any non-
licensed clinicians; therefore, they do not have a Chapter 397 license.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center did not have any non-licensed clinical staff working under the supervision of the
designated mental health clinician authority (DMHCA). Non-licensed staff are not required by
the provider’s contract with the Department.
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.
Five youth records were reviewed. All five records had a Suicide Risk Screening Instrument
(SRSI) completed upon intake and reviewed by detention staff. Three of the youth records
showed the SRSI was completed in the Department’s Juvenile Justice Information System
(JJIS). Two were completed as hard-copies due to Department-wide system outages. Four of
the five youth had a Massachusetts Youth Screening Instrument, Second Version (MAYSI-2)
completed upon intake. All MAYSI-2s were completed manually and not within JJIS due to
Department-wide system outages. The remaining youth did not require a MAYSI-2 as they were
a transfer from a residential program. All five youth records indicated a nurse and/or mental
health staff completed the required sections of the SRSI. The completed entries included an
accurate referral selection in the “screening results” section. Four of the five youth had a
positive “yes” response on the SRSI. All four youth were placed on suicide precautions, and a
mental health referral was completed. Two suicide risk alerts could be verified in JJIS; however,
the remaining could not be due to Department-wide system outages. All five youth screenings
were completed by licensed mental health staff at the center. All five of the youth’s MAYSI-2s or
SRSIs indicated a need for further assessment. One of the five youth’s response was marked
“invalid”, and the youth was referred for comprehensive assessment on the MAYSI-2 referral
section. The remaining four youth records were marked not applicable in this section. All five
youth required further assessments, referrals were made, and the superintendent was notified.
Two youth’s MAYSI-2s indicated suicide risk subscales, however, the youth were not placed on
suicide precautions or referred for an Assessment of Suicide Risk or to the mental health clinical
staff for a comprehensive assessment.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
Five youth records were reviewed for mental health and substance abuse evaluations. Four of
the five youth were identified as in need of a mental health/substance abuse evaluation after
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admission; however, all five were referred to the center provider. Four of the five youth received
new evaluations and one youth received an updated evaluation. Two of the five evaluations
were completed within the first fourteen days of admission. The remaining three evaluations
were completed by the thirty-first day after admission. Four of the five evaluations included
treatment recommendations which corresponded to all diagnosed mental health or substance-
related disorders. One youth did not require any treatment recommendations. None of the
evaluations were completed by a community provider. All evaluations were completed by
licensed clinical staff.
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.
Five youth mental health records were reviewed for treatment and discharge planning. All five
youth records included documentation a mental health orientation was completed within
fourteen days of admission and all youth required a treatment plan. All five initial treatment
plans reviewed were in place within seven days of the onset of treatment. All five initial
treatment plans were developed on the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form and all five contained the required information. Each youth was assigned
to a mini-treatment team and all members were involved in the development of the plan. Four of
the five youth mental health records included documentation of the individualized treatment
plan. One youth had not been in the center for thirty-days at the time of the annual compliance
review week. All four individualized treatment plans were developed for youth receiving mental
health and/or substance abuse treatment in the center by the thirty-first day of youth admission.
All four individualized treatment plans included the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-V) diagnosis, symptoms which are treatment focused, treatment
goals which include mental health services and/or substance abuse services, and strengths and
needs. Three of the five youth were applicable for psychiatric services, which included
psychotropic medication and frequency of monitoring. All three individualized treatment plans
included the psychotropic medications which matched the initial treatment plan and
pharmacological interventions. Four applicable records included progress notes which validated
the youth was receiving treatment services as stipulated on the treatment plan. All four reviewed
individualized treatment plans included dates and signatures of the youth, mental health and
substance abuse professionals, and treatment team members. One of the five youth was
involved with the Department of Children and Families (DCF) and the assigned case manager
signed the treatment plan. The center attempted contact with the other parents/guardians,
however, they did not participate or sign the treatment plans. One youth was applicable for
thirty-day reviews of the individualized treatment plans. The one youth had treatment plan
reviews as required. All modifications were documented on the review form and were clearly
identified. All the reviews for the applicable youth were signed and dated by all required parties
and included treatment and services provided by the psychiatrist. Three closed youth mental
health records were reviewed. All three records included discharge plans documented on the
Department’s Mental Health/Substance Abuse (MH/SA) Treatment Discharge Summary which
were all completed upon the youth’s discharge. A copy of the MH/SA Treatment Discharge
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Summary was provided to the youth, parent/guardian, and juvenile probation officer (JPO) for all
three youth. The Electronic Health Record was completed upon the day of service for all three
youth. Documentation was signed by the licensed mental health professional and all uploads
were completed within fourteen days. A mini-treatment team meeting was observed. All required
staff were present during the treatment team meeting. All youth information was reviewed for
the youth.
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.
Five youth mental health records were reviewed for mental health and substance abuse
treatment. Four of the five youth required treatment. All five youth were assigned to a mini-
treatment team. A review of documentation revealed mini-treatment teams consisted of mental
health staff, one staff from a different service area, youth, and parents/guardians, if possible. All
five youth received mental health treatment. One youth did not require treatment; however,
documentation showed the youth received weekly counseling through mental health requests.
The other four youth received mental health treatment as required. All four treatment plans
included individual therapy and group therapy. Three of the five youth were applicable for
substance abuse treatment. All three treatment plans included the required substance abuse
treatment for substance abuse related diagnoses. All five youth had proper consents for
treatment. Four of the youth had the proper consent for substance abuse treatment. One youth
did not require substance abuse treatment at the time of the annual compliance review. All
reviewed treatment notes were documented on the Department’s Counseling/Therapy Progress
Notes form and included all required elements. Three groups were observed on video review
with no issues noted. Two of the three groups were documented in the logbooks. All sign-in
sheets were also reviewed with no issues noted. All mental health staff had adequate access to
youth and confidential space to provide treatment services. A review of sign-in sheets confirmed
mental health group therapy was limited to ten or fewer youth with mental health diagnoses and
substance abuse group therapy was limited to fifteen or fewer youth with substance abuse
diagnoses. Five youth were interviewed about mental health and substance abuse treatment
and mental health and substance abuse services. One youth reported services were very poor,
one reported they were fair, two youth reported the services were good, and one youth reported
not receiving mental health and substance abuse services. One youth went on to report they
would like to talk to mental health when requested instead of waiting. Another youth reported
not liking group therapy, however, attends individual sessions. The designated mental health
clinician authority reported the facility operating procedures are reviewed once, at minimum.
The initial treatment plan is developed seven days from the date the youth is evaluated by
psychiatry. Individual treatment plans are developed based on the Substance Abuse and Mental
Health (SAMH) assessment by the thirty-first day from admission. A review of the individualized
treatment plans must be conducted every thirty days while a youth is in secure detention.
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3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The psychiatric services at the center are provided by a physician licensed pursuant to Florida
Statute, who is board certified in Child and Adolescent Psychiatry. The center also has a
psychiatric advanced practice registered nurse (APRN), who works under the clinical
supervision of the psychiatrist as specified in the Collaborative Practice Protocol with the
supervising psychiatrist providing services. A current and updated copy of the official
Collaborative Practice Protocol between the supervising psychiatrist and psychiatric APRN was
stored on-site where the psychiatric APRN provides psychiatric services. All licenses of the
psychiatrist, psychiatric APRN, and the back-up psychiatrist were reviewed and were all up to
date. The contract included tele-psychiatry. The designated mental health clinician authority
(DMHCA) reported meeting with the psychiatrist to discuss youth receiving psychiatric services
once a week, at a minimum. Five youth were reviewed for psychiatric services. Three of the five
youth were applicable for psychiatric services. The three youth entered the center on
psychotropic medications or were referred for a psychiatric interview and received an initial
diagnostic interview within fourteen days of admission. All three initial psychiatric interviews
included the reason for referral, history, Mental Status Examination, Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis, treatment recommendations
specific to mental health and/or substance abuse diagnoses, prescribed medication, medication
name, explanation for the need of medications, and the frequency of medications. The in-depth
psychiatric evaluation was completed within thirty days of referral/admission. All three in-depth
psychiatric evaluation included the stated reasons and factors leading to the referral, medical
history, substance abuse history, school history, social history, emotional development, peer
relations, family relationships, interest, and traumatic experiences. The evaluation also included
each youth’s history of psychiatric illness, medication management, mental health and/or
substance abuse treatment, assessment of symptoms, Mental Status Examination, identification
of individual, family, and/or environmental factors which may potentially account for youth
difficulties, DSM-V diagnoses, treatment recommendations and interventions, prescribed
medications, explanation of the need for psychotropic medication related to each youth’s
diagnosis, target symptoms, potential side effects, risks, and benefits to taking the medication,
most recent applicable therapeutic serum drug levels, and signature of the practitioner who
conducted the psychiatric evaluation. The identifying data, diagnosis, target symptoms of each
medication, evaluation, and description of effect of prescribed medication, prescribed
psychotropic medications, side effects, youth’s adherence to medications, height, and weight
were collected for each youth. Two of the three youth’s parents/guardians were contacted. One
youth was involved with the Department of Children and Families (DCF) and the assigned case
worker was contacted. The evaluation included the signature of the psychiatrist or psychiatric
APRN and signature date. The psychiatrist and/or psychiatric APRN, and the nursing staff
documented monitoring for Tardive Dyskinesia monthly on the Clinical Psychiatric Progress
Note (CPPN). Page three of the CPPN was completed for each youth when there was any
change to the dosage of the medication or when a new medication was prescribed. Two of the
three had a current Authorization for Evaluation and Treatment (AET). One youth was in DCF
custody and had a current court order for psychotropic medications. Two youth had
parental/guardian notifications regarding their medication and the assigned DCF case manager
was contacted for the remaining youth. Whenever a new psychotropic medication was
prescribed, discontinued, or the drug dosage was significantly changed, verbal consent from the
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youth’s parent/guardian or DCF case manager was documented on the CPPN. The standard of
psychiatric care was delivered through tele-psychiatry, which was the same as in-person care
for all three youth. All three youth agreed to participate in the tele-psychiatry session and proper
consent was obtained.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written suicide prevention plan detailing suicide prevention procedures which
were reviewed and signed by the designated mental health clinician authority (DMCHA) and
superintendent annually. The plan included all required elements. The center has an
established plan for every serious suicide attempt or serious self-inflicted injury, and mortality
review for a completed suicide. The process includes circumstances surrounding the event,
center procedures relevant to the incident, all relevant training received by involved staff,
pertinent medical and mental health services involving the victim, possible precipitating factors,
and recommendations.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Five youth were reviewed for suicide prevention services. Four youth were admitted to the
center and placed on precautionary observation (PO). One youth was placed on PO after a
referral from staff based upon observed behaviors. The start date and time of the youth being
placed on PO matched the Department’s Juvenile Justice Information System (JJIS) alert date
and time. Four of the five had a suicide risk assessment referral which matched the date and
time of the JJIS alert and placement on PO. One youth was transferred in from another facility
on PO. The Assessments of Suicide risk (ASRs) were completed on the Department’s ASR
form for all five youth. All youth were on constant supervision prior to the ASR being completed.
All five youth had PO logs completed in their entirety for the full time they were on PO. A
qualified mental health professional was involved for all five youth. The staff documented a
consultation with the designated mental health clinician authority (DMCHA) or licensed mental
health professional on the summary, and the superintendent or designee was notified
immediately of the suicide risk for all five youth. The date and time the referrals were made
matched the date and time all five youth were placed on PO. Four of the five youth had an ASR
completed upon intake. One youth had a Suicide Risk Screening Instrument (SRSI) completed
upon intake. Two of the five youth received a Follow-Up ASR prior to being removed from PO.
Three youth remained with mental health staff during their intake and were removed from PO
prior to entering the general population. All five records included documentation a conference
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Office of Accountability and Program Support Page 27 of 52 (Revised July 2023)
was held by the superintendent and licensed mental health professional to reduce the level of
supervision. All five youth records included documentation the discontinuation of close
supervision was documented in accordance with the center’s suicide prevention plan. The
suicide risk assessments for all five youth were completed by a licensed mental health
professional and included results of assessment with recommendations for supervision and
follow-up, and documentation in the center’s logbooks and on the ASR indicated administration
or supervisory staff provided specific instructions related to the suicide risk assessment findings
and decisions. Four of the five youth had alerts in JJIS entered appropriately. One youth did not
have the alert closed timely. Two of the five youth did not have logbook entries with begin and
end times. One of the remaining three youth had the start time, however, no end time. The other
two had all required information. The designated mental health clinician authority (DMCHA)
indicated the meeting between the DMHCA and the superintendent or designee takes place in
the office or by telephone and is documented through email.
3.11 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.
Five youth mental health records were reviewed for secure observation documentation. One
youth was applicable. More records were requested for review; however, the center did not
have any other youth on secure observation during the annual compliance review period. The
mental health record included documentation the youth’s placement in secure observation was
authorized by the superintendent and designated mental health clinician authority (DMCHA) and
the secure room designation was completed in writing. The Health Status Checklist, Suicide
Precautions Observation Logs, and Follow-Up Assessments of Suicide Risk (ASRs). The youth
was in the custody of the Department of Children and Families (DCF); therefore, no
parents/guardians were notified. There was no documentation the assigned juvenile probation
officer (JPO) was notified of the youth’s potential suicide risk. There was documentation the
mental health staff provided supportive counseling services during the time the youth was on
secure observation. The observation logs documented supervision for the entire time the youth
was in secure observation. The level was reduced after a conference between the
superintendent and the licensed mental health professional was completed and the
discontinuation was documented in the center’s logbook.
3.12 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.
Five youth mental health records were reviewed for Suicide Precaution Observation Logs. All
five records included documentation the logs were maintained for the duration each youth was
on suicide precautions and the appropriate level of supervision and observations of each
youth’s behavior were documented in real-time and not exceeding thirty-minute intervals. One of
the five youth displayed warning signs, and these were documented on the logs. Mental health
staff and the superintendent or designee were notified of the observations. The logs were
reviewed and signed by each shift supervisor and mental health clinical staff. All logs
documented safe housing requirements.
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Office of Accountability and Program Support Page 28 of 52 (Revised July 2023)
3.13 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.
Suicide prevention training documentation was reviewed for the center. A review of the training
documentation revealed suicide dills were conducted no less than quarterly on each shift. The
center has two suicide response kits containing all required elements located in master control
and the medical office. Both suicide response kits are co-located with first-aid kits. The mock
suicide drills included all staff who come into contact with the youth, to include kitchen and
maintenance staff. All mock suicide drills were in response to a suicide attempt, and/or an
incident of serious self-injury, and were related to mental health care. The center provided semi-
annual training on emergency response procedures to include mock training in emergency
response to a suicide attempt or incident of serious self-inflicted injury. All staff who were not
present during a quarterly drill had an opportunity to review each drill scenario as evidenced by
sign-in sheets. Five staff were interviewed regarding suicide response kits in the center. Four
staff reported the kits are kept in master control and one staff reported the kit is kept in the
closet.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a combined emergency services plan which included a notification and alert
system, means of referral, including self-referral, communication, supervision, documentation,
and review.
3.15 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.
A review of the center’s emergency care plan revealed immediate staff response, notification,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services, transport for emergency mental health evaluation and treatment for
Baker Acts, transport for emergency substance abuse assessment and treatment for Marchman
Acts, documentation, training, and review were included. The plan was updated and approved
on October 23, 2023, and is located in the facility operations book. The plan is accessible to all
staff.
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Office of Accountability and Program Support Page 29 of 52 (Revised July 2023)
3.16 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.
Five youth mental health records were reviewed for Crisis Assessments. None of the five youth
were applicable. The center provided two additional records for review. The center had no other
applicable youth during the annual compliance review period. Both youth mental health records
included documentation the Crisis Assessments included the reason for assessment, Mental
Status Examination and interview, determination of danger to self/others, initial clinical
impressions, supervision recommendations, treatment recommendations, and
recommendations for follow-up or further evaluation. None of the records included
documentation the parents/guardian were notified of follow-up treatment. Both Crisis
Assessments were conducted by a licensed mental health professional and were conducted
immediately or within twenty-four hours based upon the needs of both youth. Neither youth
required an alert to be entered after administration of the Crisis Assessment and neither was
identified as having acute emotional or behavioral problems, or acute psychological distress.
One youth was an alleged victim in a Prison Rape Elimination Act (PREA) and was offered
ongoing mental health treatment services.
3.17 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 or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 30 of 52 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains facility operating procedures (FOPs) ensuring a contract agreement with a
State of Florida licensed physician is maintained for the physician to serve as the designated
health authority (DHA). The procedures establish assigned roles and duties within the center for
both the detention center staff and the DHA. The DHA ensures a review of all medical and
mental health policies and protocols are reviewed and signed annually and ensures all
appropriate medical staff receive training on all medical policies. The center maintains a contract
with VitalCore Health Strategies, LLC (VCHS), who maintains an agreement with a medical
doctor (MD). The MD holds an unrestricted license which expires on January 31, 2026, and
meets all requirements for independent and unsupervised practice in the State of Florida. The
MD has specialty training in family medicine and is a member of the American Board of Family
Medicine. The MD serves as the center’s DHA and is clinically responsible for the medical care
of all youth. The contract with VCHS indicates the DHA is required to be on-site each week
conducting periodic evaluations, Comprehensive Physical Assessments (CPAs), sick call
referrals, and administrative duties. The number of hours on-site depends on the size and
population of the detention center in accordance with Florida Administrative Code, with a
minimum of one visit each week, with a week defined as the seven-day period beginning on
Sunday and ending on Saturday, and no more than nine days passing between on-site visits.
The DHA is on-call seven days a week, twenty-four hours a day. The provider’s contract
requires the center to utilize an advanced practice registered nurse (APRN). The APRN is
acknowledged by the State Board of Nursing to practice autonomously. Reviewed attendance
logs indicated the DHA was on-site weekly during the annual compliance review period, as
required. There were no occasions during the annual compliance review period where the DHA
required a back-up. The provider’s tele-medicine policy was reviewed and only utilized for staff
to access when medical staff are not on-site. There were no occasions of tele-medicine being
utilized during the annual compliance review period. The interview with the current DHA
supported completion of the required position duties and indicated they are on-site once a week,
as well as available telephonically twenty-four hours a day, seven days a week for consultation.
The DHA meets with the medical staff weekly to discuss any youth medical needs or reports.
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 facility operating procedures (FOPs) for all utilized health-related
procedures and protocols. There were no new policies or any updates made to the FOPs during
the annual compliance review period. The designated health authority (DHA) and
superintendent initially reviewed, signed, and dated all medical FOPs on September 20, 2023,
and reviewed and signed all new or updated policies submitted thereafter. An annual review of
medical FOPs and protocols was completed by the nursing staff on August 27 and 28, 2024.
Reviewed documentation validated the registered nurse (RN), the advance practice registered
nurse (APRN), and other medical staff documented their review of the center’s VitalCore Health
Strategies, LLC (VCHS) healthcare FOPs and protocols on a cover page in August 2024. The
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Office of Accountability and Program Support Page 31 of 52 (Revised July 2023)
psychiatrist reviewed and signed the healthcare FOPs August 28, 2024. The psychiatrist is not
on-site and provides tele-health services as approved. The psychiatrist, or if delegated within
the Collaborative Practice Protocol, the psychiatric APRN reviewed and developed the FOPs, or
other protocols related to psychiatric services and psychotropic medication management. The
approval of treatment protocols or standing procedures were written and authorized by the DHA
and not delegated to any other person. The FOPs include all health-related procedures and
treatment protocols utilized at the center. The center did not have any new nurses hired during
the annual compliance review period; however, all newly hired staff receive a comprehensive
clinical orientation to the Department’s healthcare policies and procedures, given by a
registered nurse (RN) or designated licensed healthcare professional. Training records
supported all nursing staff completed and maintained current certifications in cardiopulmonary
resuscitation (CPR) and automated external defibrillator (AED).
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.
A review of five youth Individual Healthcare Records (IHCRs) found all were applicable for
requiring a signed Authority for Evaluation and Treatment (AET) or a Limited Consent for
Evaluation and Treatment (LCET). Three of the five reviewed IHCRs contained an AET signed
by all required parties. One IHCR did not contain an AET signed by all required parties; the
youth was a transfer in from another detention center. While on-site the center notified the
youth’s parent/guardian and juvenile probation officer (JPO) to obtain a current AET. The
remaining one youth’s IHCR contained an LCET due to involvement with the Department of
Children and Families. A court order authorizing all treatment procedures and a court order
authorizing the administration of psychotropic medication was filed in the Electronic Medical
Records (EMRs). Each signed AET or LCET was valid and was obtained prior to providing
medical services There were no youth reviewed over the age of eighteen.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for parental/guardian
notification/consent requirements. Four youth were applicable for parental/guardian notification;
the remaining one youth was under the care of the Department of Children and Families (DCF).
One youth was applicable and included documentation for parental/guardian
notifications/consents for over-the-counter (OTC) medications beyond those covered by the
Authority for Evaluation and Treatment (AET). Written notifications were sent using the
Department’s Parental Notification of Health Related Care form. Four youth were applicable for
taking psychotropic medication. Three of the four youth were applicable and included
documentation of parent/guardian verbal consent for psychotropic medications being
prescribed. The remaining one youth who was also in receipt of psychotropic medications was
under the care of DCF and had parent/guardian rights terminated. A court order authorized all
treatment and procedures. For any new psychotropic medication being prescribed or
discontinued, or significantly changed drug dosage, parental/guardian verbal consent for
psychotropic medication was documented on page three of the Clinical Psychotropic Progress
Note. All five of the youth records included documentation of verified vaccinations within thirty
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Office of Accountability and Program Support Page 32 of 52 (Revised July 2023)
days of admission. None of the five reviewed youth were applicable for requiring vaccinations or
obtaining Religious Exemption from Immunization. The nurse was interviewed and indicated
medical staff attempt parental/guardian notification immediately after a qualifying event occurs.
The nurse reported parental/guardian notifications are required with significant changes in the
youth’s conditions, new medications and treatments are prescribed, and outside appointments
are made, some of which require written consent.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains facility operating procedures (FOPs) ensuring an appropriate healthcare
admissions screening is completed for each youth entering the center. At the time of admission,
each youth is screened using the Medical and Mental Health Screening (MMHS) form found in
the Department’s Juvenile Justice Information System (JJIS) Admission Wizard. The purpose of
the screening tool is to ensure the youth does not have any emergency medical conditions
requiring immediate medical attention. In the event a youth is admitted and an injury is
discovered with certain signs and/or symptoms, there is immediate communication with the
designated health authority (DHA) and a request is made for an urgent assessment of the youth
if licensed healthcare staff are available on-site. Immediate transfer of youth to the nearest
emergency facility occurs if the licensed healthcare staff is not on-site, or after the evaluation
and the condition so warrants. A review of five youth Individual Healthcare Records (IHCRs)
found each contained a MMHS form completed on the date of admission by a juvenile justice
detention officer (JJDO). Each MMHS indicated the screening was reviewed by a registered
nurse (RN) within twenty-four hours. Each screening form was completed in the JJIS Admission
Wizard. Two applicable IHCRs documented the DHA was notified. An interview with nursing
staff confirmed the center’s practice. None of the reviewed records were applicable for a change
in physical custody since each youth’s admission date. The center reported having no youth
applicable for a change in physical custody during the annual compliance review period who
required a Healthcare Admission Rescreening. The clinical manager reported two youth were
applicable for a qualitative urine pregnancy screening test during the annual compliance review
period, and chronological progress notes included documentation of verbal consent.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains facility operating procedures (FOPs) ensuring all youth are oriented and
knowledgeable regarding access to medical and dental care. A review of five youth Individual
Healthcare Records (IHCRs) supported each contained the Department’s completed Health
Education Record form documenting each youth’s orientation to the center’s healthcare
services. Each youth received a general healthcare orientation on the day of admission to the
center. Reviewed documentation supported each youth’s orientation included access to medical
care, sick call, what constitutes an emergency and when to notify staff, 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 and was oriented to the non-disciplinary role of
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Office of Accountability and Program Support Page 33 of 52 (Revised July 2023)
the healthcare providers. A review of healthcare contacts list was completed to ensure accuracy,
with no issues noted.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center maintains facility operating procedures (FOPs) requiring the designated health
authority (DHA) to be notified when a youth is admitted and needs emergency care, or routine
notification in accordance with Department requirements. A review of five youth Individual
Healthcare Records (IHCRs) supported the DHA was notified within twenty-four hours of
admission for each youth, regardless of medical condition. Notification was documented on the
nursing admission chronological notes in each IHCR. None of the five youth were identified as
in need of emergency care upon admission. One youth was identified as possessing a chronic
condition at admission. The DHA was notified within twelve hours of admission for the one
applicable youth. Four youth were taking prescribed psychotropic medication upon admission
and the nursing admission chronological notes indicated the psychiatrist was notified. An
interview with the nursing staff indicated the DHA is notified by nursing staff within twenty-four
hours or less of any youth admitted, regardless of condition, either through a telephone call or e-
mail, and documented in the chronological notes.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
A review of five youth Individual Healthcare Records (IHCRs) found all five contained the
Department’s Health-Related History (HRH) form completed electronically by a licensed nurse
within seven days or less of each youth’s admission to the center. Each of the five applicable
HRHs were reviewed by the designated health authority (DHA) or advanced practice registered
nurse (APRN) and completed prior to the Comprehensive Physical Assessment (CPA). A review
of the nursing interview confirmed the HRH is completed or reviewed by a nurse through an
interview with the youth within seven calendar days of the youth’s admission to the center and
made available for the DHA to review prior to the completion of the CPA.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains facility operating procedures (FOPs) requiring a Comprehensive Physical
Assessment (CPA) form to be completed for all applicable youth admitted determining the
health and well-being of the youth and maintaining appropriate documentation of when any part
of the exam is not conducted and/or refused by the youth. The center’s procedures for
tuberculosis (TB) control and screening address requirements for the routine screening of all
youth for latent and active TB, as well as environmental controls in the case of a youth with
active TB. A review of five youth Individual Healthcare Records (IHCRs) revealed each had a
physical assessment completed on the Department’s CPA form. Three youth had a current CPA
on file and two had a new CPA completed within seven days of admission by a medical doctor.
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Office of Accountability and Program Support Page 34 of 52 (Revised July 2023)
All five CPAs documented the youth’s Medical Grade. Three of the five applicable youth with
current CPA’s having no medical condition changes were reviewed and signed by the
designated health authority (DHA) on the Department’s Additional Reviews to Comprehensive
Physical Assessment form. None of the reviewed CPA’s were missing required elements. Three
of the IHCRs indicated a focused evaluation was required and completed. In all five records, all
sections of the CPA were marked with an “O” or “X.” Five IHCRs included documentation the
youth refused part of the CPA exam. The five youth signed a refusal form which reflected the
refused portion of the CPA exam, and all matched the date of the exam. Two IHCRs required
and included documentation the Department’s Problem List was updated. All five IHCRs
included documentation each youth had a verified tuberculosis skin test (TST) within the last
year. All five results of the TST were documented on the CPA and Infectious and Communicable
Disease (ICD) form. No further evaluation was needed for any of the youth. An interview with
nursing staff indicated the DHA completes a new CPA if one had not been completed, is not
current, or there are changes to the condition for the health of the youth. The nurse also stated
each youth must have a TB screening filed in the Electronic Medical Record (EMR) and IHCR
within the past year. If there are no records of a TST being completed within the prior twelve
months, a new TB test will be administered. The nurse reported gynecology exams are not
routinely completed at the center.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening. Three youth were applicable
for STI screening, and two youth were not applicable, as the youth reported they were not
sexually active. After reviewing the screening tool, medical staff deemed further evaluation was
required for the three applicable youth; therefore, a referral was documented on the STI form
and testing was ordered and performed. Testing screening results, clinical evaluations, and
diagnoses were documented on the Infectious Communicable Disease (ICD) form and filed in
the lab section of the IHCR for each applicable youth. Further review of the five youth’s IHCRs
indicated none of the youth were applicable for a gynecological exam or rescreen. There was
evidence in all five records of youth being offered counseling, testing, and, if indicated,
treatment/referral for HIV. Three youth had documented consent forms for implemented HIV
testing. One youth refused testing. The remaining youth did not undergo testing due to not being
sexually active. HIV test results for two of the three applicable youth were filed in a sealed
envelope marked as “CONFIDENTIAL”, which was reviewed by required medical staff. HIV test
results for the remaining youth were verbally provided to the youth. The youth was also notified
they can contact the testing site if written results are desired. The MD was also notified of the
testing results. Pre/post-test counseling was documented in all three records. None of the
youth’s HIV status was placed on the facility’s internal alert system. Five youth were
interviewed, and each indicated they could ask for a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
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Office of Accountability and Program Support Page 35 of 52 (Revised July 2023)
Five youth Individual Healthcare Records (IHCRs) were reviewed for the sick call process. Four
of the five youth were applicable for sick calls, as the remaining one youth did not request sick
call during their time in the center. A review of the Sick Call Referral Log indicated all four
applicable youth’s sick call requests were documented on the log. None of the applicable youth
presented with similar complaints three or more times within two weeks. None of the four
applicable youth complained of unfamiliar severe pain which required the youth to be
immediately treated as an emergency and an immediate referral be made to a licensed
healthcare professional; therefore, immediate notification to the designated health authority
(DHA) was not applicable. The four applicable youth completed a Sick Call Request form, and
the nurse completed the medical portion. A licensed practical nurse (LPN) did not complete any
of the sick calls. The Sick Call Request forms were filed in all four IHCRs in reverse
chronological order. No youth were applicable for restricted housing. The Sick Call forms and
progress notes were documented as required in all four IHCRs. No elements were missing. The
sick calls were documented on the sick call index and the detention center’s sick call referral log
for each youth. Further review of the four youth’s IHCRs indicated the dates on the sick call
index and sick call forms corresponded. There are approved treatment protocols for both the
registered nurse (RN) and LPN level staff. Sick call is conducted each day at 7:30 a.m. to 8:00
a.m., 11:20 a.m. to 12:05 p.m., and 5:00 p.m. to 7:00 p.m. Sick call hours were observed on the
modules and in the medical clinic. The nursing staff are responsible for conducting sick call.
When there is not a licensed nurse on-site, there are procedures in place for the shift supervisor
to review all sick call requests no longer than four hours after a request is submitted. There
were no examples of youth in confinement requesting sick calls; therefore, a review of the
center’s policy was completed. The center’s written policy and procedures indicate youth in
restricted housing shall be afforded access to healthcare at equal or greater intervals of youth
who are in regular housing. A sick call was unable to be observed during the annual compliance
review week, as no youth requested a sick call while on-site. An interview with nursing staff
indicated in situations where medical care is needed but could not wait until the next available
scheduled medical provider sick call time, staff may submit through electronic means, a request
for the youth to be seen by the medical provider. Youth also have access to place a paper
request for medical evaluation. Five youth and five staff were interviewed regarding who
conducts sick call and how quickly youth are seen once a sick call request is made. Five youth
and five staff indicated the nurse conducts sick call. Five staff also indicated the nurse reviews
sick call. Four youth indicated once they make the sick call request, they can be seen within one
day. One youth indicated they can be seen within two days.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures (FOPs) addressing maintenance and storage of
first-aid kits ensuring contents do not expire or deteriorate. One of the five Individual Healthcare
Records (IHCRs) was applicable for episodic care. Two more examples were requested. In the
three applicable IHCRs each youth required an on-site episodic/first-aid care event. All three
episodic care events were conducted by a licensed nurse on-site and documented in problem-
oriented charting: subjective, objective, assessment, and plan (SOAP) format. In each record,
the nature of the complaint was documented along with the findings of the person rendering
care. None of the three youth received a referral for off-site care. Education/instruction was
documented in each record. None of the three youth were applicable for plans for follow-
up/future care. No alerts were needed for the youth. In each record the parental/guardian
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notification was made and documented. In each record, entries were included in the Episodic
and First-Aid Emergency Care Log. None of the three youth were applicable for receiving a
follow-up evaluation from a licensed healthcare staff. The center had a total of thirteen first-aid
kits, five for transport, one in master control, two in the intake area, one on each of the three
modules, one in the kitchen, and one in administration. Three first-aid kits were reviewed with
the nursing manager. All kits were fully stock with the designated health authority (DHA)
approved contents and there were no discrepancies. The center’s process for ensuring contents
are maintained and stored is for the first-aid kits to be checked monthly by the registered nurse
(RN) and documented in a log. The center has two automated external defibrillators (AEDs),
one is in the administration area of the center, and one is in the hallway outside the medical
clinic. The AED procedures were located with the devices. The on-site nursing staff check to
ensure the AED batteries and pads are operable. Reviewed documentation reflected monitoring
was conducted as required. Nursing staff checked the expiration dates and conducted a self-
test of the AED in front of annual compliance review monitor. There were no issues discovered
during the AED test. Both AED batteries expire on December 6, 2026. The batteries were last
changed on January 11, 2023. Both sets of pads expire on April 28, 2025. The pads were last
changed on January 11, 2023, for both AEDs. Emergency drills included cardiopulmonary
resuscitation (CPR) and AED demonstrations and were practiced annually. All reviewed drills
simulated an episodic care event which called for immediate first-aid, administration of CPR
techniques, and the initiation of the emergency procedures to follow when a life-threatening
emergency does occur. The center maintains all documentation for emergency drills. Staff are
provided with drill reviews during shift briefings. Announced and unannounced emergency
medical drills were conducted at least quarterly on each shift. A list of emergency numbers,
including the Poison Control Center, are posted in master control and are accessible for non-
licensed and licensed staff. The numbers are inaccessible to the youth. All healthcare and
supervisory direct care staff were properly trained on the administration of the epinephrine auto-
injector and administered the epinephrine auto-injector when indicated. Five pre-service and five
in-service staff training records were reviewed, and each met the training requirements for
episodic, first-aid, and emergency care. All documentation was maintained in a binder in the
medical center. The center has facility operating procedures to address NARCAN. The center
must maintain at least one prescribed stock of NARCAN for emergency purposes of accidental
overdose for youth in the Department’s care. The center stores NARCAN in the medical clinic
locked in the medication cart. Only medical staff have access to the NARCAN. Medical staff
have been trained on when and how to use NARCAN. The NARCAN is inventoried on the stock
inventory sheet located in the medication cart. The nursing staff was interviewed and reported
emergency drills are conducted for each shift on a quarterly basis, at a minimum. The drill is
either announced or unannounced and simulates an episodic care event which calls for first-aid
and/or CPR techniques along with the initiation of emergency procedures to follow when a life-
threatening emergency does occur. The nursing interview also reported CPR techniques must
be practiced on a regular basis and at least once a quarter per shift. Five youth were
interviewed, and two youth stated medical services at the center were very good and one stated
they were good, and one stated they were fair. One youth stated medical services at the center
were poor. Five staff were interviewed and reported they were all able to call 9-1-1 if they felt it
necessary.
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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.
Five youth Individual Healthcare Records (IHCRs) were reviewed for off-site care. None of the
five were applicable; therefore, three additional youth records were requested for review. There
was only one off-site care referral for the annual compliance review period. The applicable youth
had documentation the Summary of Off-Site Care form was completed for offsite care. Off-site
emergency care was not applicable. Parental/guardian notification was documented for the
youth. Discharge documents were uploaded in the youth’s IHCR. The designated health
authority (DHA) was notified of a non-emergency event for the youth. The DHA reviewed and
signed the off-site care documentation for the applicable youth. The youth did not require follow-
up testing, referrals, or appointments. The nurse reported youth are tracked utilizing the
episodic log and the monthly calendar. The DHA is also contacted upon the youth’s return to the
center and discharge instructions are discussed. Off-site records are placed in the DHA’s folder
for review and signature.
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.
Five Individual Healthcare Records (IHCRs) were reviewed for chronic conditions and periodic
evaluations. One record was applicable for the inclusion of chronic conditions and periodic
evaluations. Two additional records were requested and reviewed for chronic conditions and
periodic evaluations. All three of the youth were identified on the Medical/Mental Health
Screening form with a current chronic condition. None of the three youth had a communicable
disease or were taking prescribed medication on an on-going basis for any reason. None of the
three were undergoing treatment for physical health conditions. Each of the three reviewed
records were classified with a Medical Grade between two and four. The three youth were
placed on a chronic conditions list. None of the three reviewed youth have reached ninety days
at the center as of this review; therefore, they were not applicable for receiving periodic
evaluations at least every ninety days. The Department’s Problem List was updated in
accordance with Florida Administrative Code. All periodic evaluations were tracked on the
Chronic Physical Health Conditions Roster. The nursing staff was interviewed and reported
youth with chronic medical conditions are tracked via the chronic care log which medical staff
maintains. The clinic manager also performs a weekly review of medical charts. The designated
health authority (DHA) was interviewed and reported periodic evaluations for youth with chronic
conditions occur every ninety days unless otherwise indicated on the youth’s care plan. The
medical staff review the roster for youth possibly needing to be seen for periodic evaluations.
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.
Five Individual Healthcare Records (IHCRs) were reviewed for medication management. Four of
the five youth records were applicable for medication management. All four of the youth were
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taking medication at the time of admission. All medication was verified prior to the youth being
admitted into the center. The designated health authority (DHA) was contacted to obtain the
order to resume the specified medications prescribed prior to admission. All medications had a
current, valid order and were administered pursuant to a current prescription. All four of the
youth had medications which were continued, discontinued, changed or new ones were
ordered. The DHA placed an order for these medications on the Practitioner Order form. All four
records included documentation of prescription verification in the chronological progress notes
in the IHCR. Restricted housing was not applicable for any of the four youth. All four youth were
applicable for receiving over-the-counter (OTC) medications. OTC medications not listed on the
Authorization for Evaluation and Treatment (AET) form were administered according to
approved protocols for all applicable youths. The standard Department Medication
Administration Record (MAR) was used to document all medication and treatment. The MARs
clearly indicated the medication start and stop dates. In two of the four applicable records,
trained non-healthcare staff assisted in the delivery of medications when licensed staff were not
on-site and there was documentation by both youth and non-licensed staff present when staff
assisted with the delivery of medications. There were no undocumented explanations for lapses
or errors in medication administration for any of the applicable youth. The nursing staff
documented weekly side effects monitoring on each applicable youth’s MAR. Two youth refused
medication and it was clearly documented on the MAR and both youth signed the Refusal of
Treatment form indicating the refusal. Each MAR included youth’s name, Department
identification number, date of birth, allergies, precautions, medical grade, medical alerts, and
current picture of the youth in all five records. The nursing staff documented weekly side effect
monitoring on each MAR. The nursing staff and youth initialed each entry for administered
medication. None of the five records were applicable for requiring parenteral medication. Four of
the five youth were applicable for psychotropic medications. The DHA or psychiatrist was
notified upon admission for all four youth. All four of the youth were applicable for having an
Initial Diagnostic Psychiatric Interview within fourteen days of admission and each record
indicated it was completed. Each youth also received medication monitoring every thirty days as
required. There were no standing, emergency treatment, or pro re nata (PRN) orders for
psychotropic mediations. An observation of medication administration process revealed the
medical staff administers and prepares the medication as required. The youth was escorted
individually to the medical clinic by the center’s staff. The youth identified themselves and stated
why they are at the medical clinic. The medical staff also verified the youth’s allergy and alert
status. The staff and youth initialed the MAR. There was no observation of non-healthcare staff
medication administration during the annual compliance review week. The nursing staff ensured
the youth swallowed the medication. The nursing staff were interviewed and reported all
medication shall be identified and stored in separate and secure areas which are inaccessible to
youth. This includes prescribed medications, OTCs, and controlled and non-controlled
medications. All controlled substances, such as narcotics, are kept in a medication storage area
which secures them behind a double-lock system. A double lock system consists of two
separate locks where there is an external lock securing a separate storage area which has
another individual internal lock. Inventory of medications shall be conducted weekly, no more
than seven days between counts. Controlled medications are counted at every shift change
daily. All controlled substances will be double locked, with daily perpetual inventories and
running balances maintained. If a controlled substance is administered to a youth as ordered
through a prescription, the number of pills, tablets, or dosages remaining after each
administered dosage must be documented on the youth’s Individualized Controlled Medication
Inventory form. Additionally, the administration of the medication shall be documented on the
MAR in the youth’s record. Shift-to-shift witnessed inventory counting of controlled substances
shall also be maintained. Five youth were formally interviewed, and four youth reported the
nurse administers their medication. One youth also indicated staff administers their medication
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at night. One youth indicated they are not prescribed medications. Five staff were formally
interviewed and three staff indicated they do not administer medication to youth. Two staff
indicated they do administer medication to youth.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
An observation of the medical clinic and designated medication storage area revealed medical
equipment classified as sharps were secured and inventoried utilizing a routine perpetual
inventory with descending count as each sharp was utilized and disposed for the annual
compliance review period. All medications were identified and secured in the locked area
designated for storage of medications. The medication cart was clean and organized with
stocked items separate from youth-specific medications, and all controlled medications had a
perpetual inventory and were stored separately from other medications. All medications were
stored in a separate, secured area, inaccessible to youth. Narcotics and other controlled
medications were stored behind two locks. The center has a refrigerator designated for the use
of storing medications only. Perpetual and weekly inventories of all sharps and stock over-the-
counter (OTC) medications from the annual compliance review period was observed, with no
issues noted. A shift-to-shift inventory/count of all controlled medications was found to be
documented pursuant to the Board of Pharmacy regulatory requirements. A third shift to first
shift count of controlled medications was observed prior to medical staff beginning medication
pass, with no issues noted. The center maintains an approved list of supervisory level, non-
healthcare staff trained in the delivery of medication self-administration in the event nursing staff
is not on-site. The training provided to non-healthcare staff was delivered by a registered nurse
and completed annually. The center only had one controlled medication available for this review.
Additionally, three OTC medications, and three sharps were reviewed, and the inventory
corresponded with the perpetual inventory for each. The nursing staff reported in the event there
are inventory discrepancies, the confirmation log is reviewed, and the designated health
authority (DHA) and superintendent are notified within two hours of discovering any inventory
issues. In addition, the Department’s Central Communication Center (CCC) is contacted to file a
report for the discrepancy. The center’s process for disposal of expired and/or discontinued
medications indicates, two nurses are required to conduct medication destruction. One nurse
acts as a witness and one nurse destroys the medication by dropping it in the RX Destroyer
container, and both nurses sign the destruction log. The nursing staff was interviewed and
reported all medication shall be identified and stored in separate and secure areas which are
inaccessible to youth. This includes prescribed medications, OTC medications, and controlled
and non-controlled medications. All controlled substances, such as narcotics, are kept in a
medication storage area which secures them behind a double-lock system. A double lock
system consists of two separate locks where there is an external lock securing a separate
storage area which has another individual internal lock. Inventory of medications shall be
conducted weekly, no more than seven days between counts. Controlled medications are
counted at every shift change daily. All controlled substances will be double locked, with daily
perpetual inventories and running balances maintained. If a controlled substance is
administered to a youth as ordered, the number of pills, tablets, or dosages remaining after
each administration must be documented on the youth’s Individualized Controlled Medication
Inventory form. Additionally, the administration of the medication shall be documented on the
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MAR in the youth’s record. Shift-to-shift witnessed inventory counting of controlled substances
shall also be maintained.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
Five Individual Healthcare Records (IHCRs) were reviewed for infection control training.
Documentation reflected all five youth received infection control training within seven days of
their current placement. Training documentation included hand washing techniques,
universal/standard precautions, prevention of communicable diseases, vaccinations, and
Centers for Disease Control and Prevention (CDC) guidelines for infection control. The center
has a written Exposure Control Plan, which is in accordance with Occupational Safety and
Health Administration (OSHA) standards and has all required information. In addition, the center
has written infection control procedures which meet requirements outlined within OHSA and
CDC guidelines and address all required information. The center has a process in place for
needle stick post-exposure evaluation. The hepatitis B immunization is available to staff. Staff
have access to protective equipment. There were no instances during the annual compliance
review period in which there were any infectious diseases or sexually transmitted infections
requiring to be reported to the local health department, the Department’s Central
Communication Center (CCC), or the CDC. There were no applicable instances involving the
quarantining or hospitalization of at least ten percent of the total population of youth or staff. If
necessary, the superintendent would maintain a separate file containing all documents for youth
and staff who have experienced facility exposure; there were no cases during the annual
compliance review period. All IHCRs are maintained as confidential and kept for a ten-year
period. A review of five pre-service and five in-service training records revealed each staff
completed site specific training for Exposure Control Plan. The nursing staff was interviewed
and reported the center has an Exposure Control Plan. The plan is in the Safety Data Sheet
(SDS) binder in medical. The infection control training is conducted by the registered nurse who
serves as the clinical manager for the center. Training for youth is provided at each admission
and for nursing intake. In addition, the center’s provider medical staff shall conduct training
regarding the site-specific Exposure Control Plan, to include the prevention of transmission of
blood-borne pathogens within ninety days of hiring of staff and annually thereafter. A record of
the training shall be kept in the staff personnel file.
4.18 Prenatal Care/Education [Contract Provider] Non-Applicable
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has not had any pregnant youth throughout the annual compliance review period;
therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
Observations were made each day of the annual compliance review week to monitor and review
the staff’s active supervision of youth. Youth were observed being supervised at all times.
Observations found the center was in adherence to the daily activity schedule. Youth were seen
in education classes, line movements, medication pass, and transports. No youth were seen
unattended by staff. A sample of three full days of video observation for therapeutic groups was
made and found no issues. Overall observations made of active supervision found positive
interactions with the youth by staff. Master control authorized all movement and documented
youth movements in the master control logbook. Five interviewed staff all reported they believe
there are enough staff to provide for the safety and security of 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’s behavior management system (BMS) incorporates a system of levels and points in
which youth may earn points daily in order to advance their level, by which they earn additional
privileges while in the center. The center’s BMS was observed to be posted in program areas.
Daily activities were observed confirming the center’s implementation of the BMS. The youth
point books were observed in each youth living area and completed as required daily. The
center’s written policies and procedures on the BMS ensured compliance with the components
outlined. Rewards and consequences are given to youth in accordance with the incentive
calendar and in accordance with the BMS. There were no incidents observed of group
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punishment. The center’s superintendent was interviewed and stated the standardized BMS
shall enhance safety and security as it relates to youth's behavior and promotes the health and
well-being of youth by providing an environment which fosters social, emotional, intellectual, and
physical development. Five interviewed staff were able to summarize the center’s BMS. All five
confirmed the system was effective. Staff gave examples of rewards the center offers such as
canteen, treasure chest, level parties, video games, and special visitations. All five staff
confirmed staff speak with youth to discuss the consequences being imposed, and give youth
the opportunities to explain their behaviors, while also speaking with youth about alternative
acceptable behavior. Staff also reported they are provided feedback by their supervisors on
their implementation of the BMS through one-on-one discussions and debriefings. The five
interviewed staff reported this discussion is done daily or as needed. Five interviewed staff
reported level may be taken from a youth as a consequence. One staff stated a snack may be
taken. Five staff all denied ever seeing a co-worker take meals, snacks, clothing, education, or
medical care form a youth as a consequence. Three of five staff reported not observing a staff
encourage a youth to beat up another youth. Two reported they have observed this, and stated
during a class, a staff told a youth they may as well fight and get it over with. Results of the staff
interviews were conveyed with the center’s administration for follow-up and additional training
for staff. Five youth were interviewed. One rated the center’s BMS as fair, one rated it as very
good, and three rated the BMS as good. Each youth was able to summarize the BMS process
and gave examples of rewards the center provides as a result of positive behavior. Four of five
youth reported staff all use rewards the same. One youth reported they were unable to answer
the question due to never having been rewarded. One youth stated youth are allowed to punish
other youth, and four denied youth punish other youth. Five of five youth all reported having
been sent to their room for fighting. Four of five youth reported when they have received
consequences before, the consequences were fair. One youth reported they were not fair. All
five youth reported only levels and points were taken from them as a result of a consequence.
All five interviewed youth reported the center had not utilized handcuffs or leg irons on out of
control youth to prevent them from hurting themselves.
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 a total of seventy-two cameras, all operating as required, according to the center
administration. Video recordings are stored for up to thirty-days. The center is currently
operating on two twelve-hour shifts. Nine video review samples of ten-minute checks were
observed which incorporated examples from both shifts, in various time periods, and in thirty-
minute increments. Staff were observed looking into rooms and documenting ten-minute checks
on Visual Observation Report (VOR) forms affixed to each youth room door when conducting
checks. All reviewed examples found staff conducting checks at, or within, the required ten-
minute timeframe with the exception of one period. On one evening, a staff was observed
checking youth rooms and documenting the checks on the form at 6:02 a.m. and then again at
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Office of Accountability and Program Support Page 43 of 52 (Revised July 2023)
6:28 a.m. No checks were observed between these times. The VOR form for the checks was
unable to be found, according to the center administration. The center’s superintendent reported
their electronic wand monitoring system has not been operating for the last two months, and
staff had to revert to utilizing the hard-copy forms to document the checks. The forms were
discovered for eight of the nine samples reviewed on video, with the exception of the one
showing the check was missed. Previous wand reports were also unable to be observed for the
annual compliance review period, due to the center reporting the Wand Guardian System as
unable to be accessed. The center has notified the Department’s Information Technology staff
to rectify the issue. Five of five interviewed staff reported room checks are done every ten-
minutes. The center’s superintendent was interviewed and stated when a youth is placed in a
room, whether for sleeping or other reasons, officers shall conduct visual observations to ensure
safety and security and notate those checks on the VOR or by utilizing an electronic wand
system. Visual observation intervals should be varied but must not exceed ten minutes between
checks. According to center administration, weekly oversight by management is conducted to
validate the fidelity of checks.
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’s master control operator was observed calling for and documenting formal facility
headcounts of youth during the annual compliance review week. Five interviewed staff reported
headcounts are done at the beginning and end of shifts, and in the event a count is not cleared,
movement is ceased, and a re-count will occur. Five interviewed staff reported examples of
when emergency counts may occur, such as times of a major disturbance, any type of code, or
after electrical outages. A review of the center’s logbooks from previous months of the annual
compliance review period was conducted. One full day of headcounts each month were
reviewed and discovered counts being conducted each day as required with one exception. On
one reviewed day there was no clear documentation of the mid-shift count conducted.
Documentation observed did find evidence staff documented counts at the beginning and end of
the shifts, youth movement from one location to another, anytime a population change occurred,
and prior to and following routine group movement.
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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.
One full day for each month of the annual compliance review period was reviewed in the
logbooks for adherence to logbook maintenance and review requirements. The program
maintains separate logbooks for master control, youth modules, visitation, and vehicles. Several
of the logbooks were falling apart; however, still contained all pages. All logbook pages were
numbered and the date was found at the top of each page. Most errors were struck through with
a single line and voided with the exception of a few instances where one letter or number was
overwritten. Each entry was completed with all required elements and incidents affecting the
safety and security of the center were highlighted. The master control logbooks included all
required information. The master control staff and supervisor in charge of the shift reviewed the
logbook and accepted responsibility of the shift and logbook. The logbooks and activity
schedule documented minimal interference with educational instruction; however, showed some
errors with documenting the end times of some classes. There was documentation the
administrator in charge of the center toured the center at least once each shift. The
superintendent or designee reviewed the master control and module logbooks at least weekly,
as required. Logbooks also included the supervisory review when they assumed responsibility
of the center and supervisory signatures in each living module logbook daily. Direct care staff
reviewed their respective living area logbook when arriving for their shift. The superintendent
was interviewed and reported the logbooks must be reviewed by them at least weekly and they
must look over the last seventy-two hours of entries.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has a written policy and procedures regarding key control, which address key
assignment, usage, restricted keys, secure storage of keys, inventory, daily tracking,
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reconciliation, and procedures for missing and damaged keys. Staff keys are maintained
secured in the master control room in a locked box. All duplicate keys and emergency keys are
also maintained in the center’s superintendent office, with restricted access to this area. Visitor
keys and staff personal keys are not authorized in the secure areas of the center. The master
control operator reported when a staff arrives for duty, they secure their personal keys in a
locker outside of the secure area and are given assigned keys by the supervisor or master
control staff. The key assignment is documented on the key log, indicating the staff name
receiving the keys, the key and radio number, and the date and time in and out for those keys.
The distribution of keys could not be observed due to the time frames of shift change not
occurring while the annual compliance review team was on-site. Keys are affixed to a tamper-
resistant ring and are on a colored hub system coded as required. The master key inventory is
also maintained with the key storage box and includes emergency key rings. The master
inventory includes the key ring number, number of keys, capability of each key, and to whom
the key was assigned. A sampling of five sets of keys was done and compared with the ring
number, the master inventory, and total number of keys on the ring. Four of five matched as
required. One set of medical keys had a total of eighteen keys on the ring, which concluded the
ring had one extra key not indicated on the engraved key ring tab. All other keys matched as
required. Informal interviews were done with three staff and found their assigned staff keys
matched the keys disseminated to them on the key log. Each staff reported they knew the
function of each key on their ring assigned. A review of reports to the Department’s Central
Communication Center (CCC) for the annual compliance review period found no incident
involving missing or damaged keys for the center. In addition to the Key Inventory Log
maintained in master control, the key issuance is also documented on the facility shift reports,
which notates the keys assigned to each staff coming on duty. Previous shift reports for the
annual compliance review period were reviewed, which confirmed the practice. Shift reports are
maintained electronically in the center’s SharePoint system. The key storage box was observed
to be not easily accessible while locked in the master control room. All additional copies of keys
are maintained in the superintendent’s office in a locked box. Throughout the annual compliance
review week all staff were observed carrying their keys on them at all times, ensuring youth had
no access to their keys, and did not remove keys from the facility. The superintendent was
interviewed and stated permanent issued key rings are defined as those key rings assigned to
specific personnel at the discretion of the superintendent which authorizes the individual to
remove the keys from the facility or the facility grounds. Five staff were interviewed regarding
the center’s key processes. All five gave examples of restricted keys in the center such as keys
for medical, mental health and case management records, kitchen keys, and youth property
areas. All five staff were able to summarize the center’s key control process.
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 program had a total of six vehicles used to transport youth. Each was observed to be
secured when not in use. Five had documentation of a signed annual vehicle inspections
completed by a certified mechanic; the remaining vehicle was new and had not needed an
updated annual inspection. Maintenance records confirmed documentation of monthly visual
checks of each vehicle for all required elements and safety features. Each vehicle was observed
and included a current fire extinguisher, seatbelt cutter, window punch, and appropriate number
of seatbelts. Each vehicle was clean with no trash or debris observed. One vehicle had a can of
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disinfectant spray in the front seat of the vehicle. The item was removed by maintenance after
discovery. Safety cages were observed in each vehicle separating the driver section from the
passenger section behind it. Approved first-aid kits were available for each of the six vehicles in
master control and were checked out as required during transports. The van logbooks were
maintained in master control and used when conducting transports. A review of these logs
confirmed they documented the destination, number of youth and staff names for the transport,
and the time transport began and ended. A transport was observed one day of the annual
compliance review week and found the vehicle was inspected by staff prior to the transport. The
vehicle had sufficient gasoline and transportation procedures were maintained by staff. Each
youth was secured using seatbelts as required. One staff had an assigned cellular telephone
with them for the transport. The vehicle inspection was documented in the vehicle log. The
vehicle log contained all required documentation, such as the restraint keys, gas card, and
vehicle registration. The appropriate staff to youth ratio was maintained as required for the
transport. Five interviewed youth reported never witnessing anyone place contraband in a
transport vehicle. Three of five youth reported they feel staff drive the vehicles safely when
being transported. Two of five reported they have never been transported by staff.
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 a written policy and procedures which outline the tool inventory, management,
youth access to, and use of tools and cleaning items. An inspection of each area used to store
and maintain tools, including the secured kitchen knife cabinet, found each to be secured and
inaccessible to youth. Each was organized and contained a master inventory. A review of
twenty-five tools was conducted and found each to have the correct tool as indicated on the
inventory form, along with an engraved identification number on the tool itself which matched
the inventory sheet. There was one exception noted; the maintenance cart located in the
maintenance office had a pair of hog ring pliers which was present, however, it was located in
the wrong box within the secured office area. The maintenance staff was interviewed and stated
they are required to accompany any outside vendors who may be on-site to perform any
maintenance work within the secure facility. Monthly inventories of maintenance tools were
observed to be documented and included the issuance and return of tools. The dietary staff in
the kitchen document an inventory of all kitchen knives and utensils three times each day.
Inventory forms were observed confirming the practice. The maintenance staff reported there
have been no incidents of lost or damaged tools at the center for the annual compliance review
period. The maintenance staff indicated if there are missing or damaged tools, the
superintendent and assistant superintendent would be notified. An observation of youth tool
usage was unable to be made during the annual compliance review week. The superintendent
was interviewed and stated youth may use mops, brooms, buckets, and other common
household items under direct supervision. Five interviewed staff reported youth are only
authorized to use scrub brushes, mops, and brooms at the center. Five interviewed staff
reported in the event a tool is missing, they are responsible to call the supervisor, report the
incident, and conduct a search for the item.
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5.09 Inventory of and Access to all Flammable, Toxic, Caustic,
Limited Compliance
and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has a written policy and procedures which outline the inventory of and access to all
flammable, toxic, caustic, and poisonous items. The center’s safety plan is incorporated into
their Continuity of Operations Plan (COOP). Only authorized personnel are permitted to access
flammable, toxic, caustic, and poisonous items. Youth are not authorized to handle these items
directly. An inspection of the areas used to store and maintain any chemicals found each to be
secured and inaccessible to youth. Observations made during the annual compliance review
week found multiple areas which contained supplies and storage of various chemicals, cleaning
agents, and flammable and toxic items. A sampling of thirty-two items was compared with the
center’s inventory as well as the Safety Data Sheets (SDS). The center’s outside chemical
storage shed had a SDS present for each of the items observed. Three of the five items
selected for review had inconsistencies with the amount of the items stored compared with the
master inventory. One had a total of five present, however, there was thirteen on the inventory
form. One other had seventeen items present, however, there was thirteen on the inventory,
and the last of the three had sixteen jugs present, with seventeen on the inventory form. The
center’s kitchen was observed and found one of the five chemicals maintained was not noted
correctly on the inventory form, as the chemical had one gallon jug present, however, the
inventory reflected three. Each of these items had a corresponding SDS. Another outside
storage shed was discovered to have a large supply of various chemicals. A review of twelve of
these items found three were not indicated on the inventory form, and one did not have a SDS
present. Youth do not have access to the chemicals and cleaning agents. All areas which stored
the items were observed secured. All five interviewed youth reported staff spray any chemicals
and they wipe them down. All five interviewed staff all denied youth directly handle any
chemicals at the center.
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).
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The center has a written policy and procedures which document the disposal requirements of all
flammables, poisonous, toxic, and caustic items. An interview with the center administration and
a review of reports to the Department’s Central Communication Center (CCC) for the annual
compliance review period found no evidence of any chemical spills occurring. The manner to
clean any chemical spills is documented within the center’s Continuity of Operations Plan
(COOP) approved by Department personnel. The center reported they do not utilize grease or
have an area used for grease disposal. The maintenance staff reported there have been no
incidents of required disposal of any chemical for the annual compliance review period. The
medical staff have an agreement with an outside provider who comes monthly to the center to
dispose of any biohazardous waste. The waste is stored in a marked container secured in the
medical office. A disposal log was observed to be maintained by the medical staff showing
invoices of recent pickups by the company for waste disposal. The maintenance staff and center
administration confirmed materials are to be disposed of in accordance with Safety Data Sheet
(SDS) requirements.
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.
A sample of fifteen confinement reports and incidents were reviewed for completion
requirements of confinements under twenty-four hours. Each indicated the supervisor approved
all placements. One of fifteen did not indicate the room was searched prior to placing the youth.
Five of fifteen reports did not document each youth was provided education materials when in
confinement. None of the youth were applicable for being afforded a shower while in
confinement and none interfered with visitation. All fifteen reports indicated each youth was
notified of their right to grieve the placement. Each youth received meals as scheduled, clean
bedding and clothing, and access to medical and mental health care when applicable. Youth
rooms are utilized for confinement placement. Windows of youth rooms were observed free
from obstructions so youth may be visually observed in their rooms. Only one youth can be
placed in a room during a period of confinement. Initial confinement reviews were done by the
supervisor for all fifteen reviewed. Additional supervisory reviews were documented every three
hours of each youths’ placement with the exception of one incident where one supervisory
review was done two minutes late. The supervisors and staff were noted as continually
counseling each youth to consider removing them from confinement as soon as possible. The
full report was completed by each applicable staff member for thirteen of the fifteen
confinements reviewed. For the two remaining exceptions, one had two staff complete their
report three days late and in another confinement incident, the staff completed their report one
day late. Each youth was confirmed to be supervised as documented on the reports. There was
evidence the superintendent or designee reviewed fourteen of fifteen confinements within forty-
eight hours. For the one exception, the administrative review was done one day late. None of
the confinements selected for review had documentation of physical injury noted. According to
the center administration, there have been no incidents of pregnant youth being placed in
confinement for the scope of the annual compliance review. The superintendent was
interviewed and stated the superintendent or designee shall review all confinement reports
within forty-eight hours, excluding weekends and holidays, and shall determine whether each
confinement was appropriate or inappropriate. In addition, regional detention management
reviews the use of confinements, lockdowns, and restraints. Five of five interviewed staff
summarized the confinement placement process. Five of five interviewed staff reported youth
who are in confinement are provided education materials.
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5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
A review of the Department’s Juvenile Justice Information System (JJIS) and an interview with
the center administration revealed the center had no incidents involving a youth being placed in
confinement for over twenty-four hours; 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 an approved Continuity of Operations Plan (COOP) which outlines emergency
preparedness and procedures. The center maintains a drill calendar and binder which included
documentation of all emergency drills such as fire, escape, and COOP drills. The center had
documentation of having conducted two mandatory COOP drills involving a weather-related
emergency for the annual compliance review period. The drill documentation included the
scenarios and any corrective action if warranted, date and time, list of participants, and type of
drill. The center’s superintendent was interviewed and stated the COOP describes the process
for the relocation and continued operations of a facility during an emergency or disaster.
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’s Continuity of Operations Plan (COOP) incorporated the Escape Prevention Plan.
The center maintained documentation of escape drills which were conducted quarterly on each
shift. In addition, a review of five in-service staff training records found evidence all five staff
received escape prevention training annually as required. The logbook documentation for each
drill was present and highlighted. Five interviewed staff all reported they have participated in
various drills for the past year to include weather-related emergencies, major disturbances,
bomb threats, fire drills, escape drills, and chemical spills.
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5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center had documentation of fire drills taking place monthly on each shift as required. A
review of the documentation found the drill scenarios, list of participants, findings, and
recommendations were attached to each drill. In addition, a copy of the logbook documentation
was also attached and highlighted, indicating the drill was documented in the logbooks as
required. The center has a total of twenty-seven fire extinguishers. Monthly fire extinguisher
inspections are conducted by the maintenance staff and documented on the monthly fire
extinguisher inspection log. Four of five interviewed staff reported fire drills take place monthly.
The remaining staff didn’t confirm the drills took place monthly. Three interviewed youth
reported they have been informed as to what to do in the event of a fire. Two youth reported
they have not been instructed in this area.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has a written policy and procedures which address searches and contraband within
the facility. The superintendent was interviewed and stated, the introduction, removal or
possession of certain unlawful articles and the associated penalties are outlined in Florida
Statute, indicating searches shall take place no more frequently than necessary to control
contraband or to ensure safety. Room searches are conducted daily for each shift and
documented in the SharePoint system. A review of the SharePoint system allowed only the
ability to go back two months. A review of these past two months found searches were
conducted as required on each shift. The center’s administration indicated anytime a youth is
released, all items are removed from the room and the youth is responsible for cleaning the
room. In addition, each room is searched prior to placement of a youth in their room for
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confinement. The administration stated there have been no instances for the annual compliance
review period involving contraband, which may have compromised the safety and security of the
center. A room search was unable to be observed during the annual compliance review week.
The administration also noted there have been no strip searches conducted or required other
than during admission in the annual compliance review period. Observations were made of
visitor searches being conducted prior to entering secure areas where youth were present. All
personal keys and cellular telephones are not permitted into these areas. Five youth records
were reviewed and confirmed youth signed a contraband form indicating they have been made
aware of the center’s search and contraband procedures. Visitors and staff are required to
complete and sign an attestation form regarding contraband. The forms are maintained in the
entrance of the facility. A total of thirty-seven staff records were reviewed and found all thirty-
seven had a signed contraband attestation included. A review of reports to the Department’s
Central Communication Center (CCC) for the annual compliance review period found two
reported incidents involving the discovery of contraband. Neither of the incidents involved illegal
contraband being discovered; however, law enforcement was contacted on one occasion
involving a vape pen. In both incidents the contraband was documented as confiscated and
destroyed, as required. The shift supervisor properly documented the chain of custody of the
confiscated item. The regional director for detention services was contacted through telephone
by center administration about this item.
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Office of Accountability and Program Support Page 52 of 52 (Revised July 2023)

report_type: QI Detention

rule: Indicator 5.09

rating: Limited Compliance