summary: QI Detention - FY24-25 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Escambia Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
1800 Saint Mary Avenue
Pensacola, Florida 32501
Review Date(s): October 1-4, 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:
Kayshala Patterson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Supervisor (Standard
1)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Ken Myers, Office of Education, Education Coordinator Circuit 1 (Standard 2)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Molly Stewart, North Detention Regional Office, DJJ Operations Analyst (Standard 5)
Bradley Taylor, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Escambia Regional Juvenile Detention Center MQI Program Code: 2
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Escambia County / Circuit 1 Number of Beds: 50
Review Date(s): October 1-4, 2024 Lead Reviewer Code: 227
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
1.05 Right Interactions (RI) 5.07 Vehicles and Maintenance
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 54 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 54 (Revised July 2023)
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * S a tis fa c to ry
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a tis fa c to ry
S ta ff C o d e o f C o n d u c t S a tis fa c to ry
In c id e n t R e p o rtin g C C C * S a tis fa c to ry
R ig h t In te ra c tio n s (R I) L im ite d
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a tis fa c to ry
In -S e rv ic e T ra in in g S a tis fa c to ry
G rie v a n c e s S a tis fa c to ry
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n * S a tis fa c to ry
D a ta T re n d A n a ly s is S a tis fa c to ry
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D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to d o
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Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 54 (Revised July 2023)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n S a tis fa c
O rie n ta tio n S a tis fa c
C la s s ific a tio n S a tis fa c
N o tific a tio n o f J P O C irc u it G a n g R e p S a tis fa c
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty S a tis fa c
R e le a s e S a tis fa c
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s S a tis fa c
R e v ie w o f Y o u th in S e c u re D e te n tio n a n d H o m e D e te n tio n S a tis fa c
D a ily A c tiv ity S c h e d u le S a tis fa c
E d u c a tio n a l A c c e s s * S a tis fa c
C a re e r E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 54 (Revised July 2023)
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
3 .1 7
* T h e D e p
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In d ic a t o r R a t in g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
L ic e n s e d M H /S A C lin ic a l S ta ff *
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
M H /S A A d m is s io n S c re e n in g
M H /S A A s s e s s m e n t/E v a lu a tio n
M H /S A T re a tm e n t
T re a tm e n t a n d D is c h a rg e P la n n in g
P s y c h ia tric S e rv ic e s *
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia
m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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lic a b le
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ill re s u lt
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 54 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Failed
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 54 (Revised July 2023)
Program Overview
The Escambia Regional Juvenile Detention Center is a state-owned detention facility, operated
by the Department, located in Pensacola, Florida. The center serves youth in Escambia and
Santa Rosa counties in Circuit 1 and is co-located with the Escambia Juvenile Assessment
Center. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the fifty-bed center. Youth are
provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Escambia County School Board. The center’s
management team includes the superintendent, two assistant superintendents, one
administrative assistant, seven juvenile justice detention officer (JJDO) supervisors, and forty-
four JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by one
designated mental health clinician authority (DMHCA), one psychiatrist, two licensed mental
health counselors (LMHCs), two licensed clinical social workers, and one non-licensed mental
health and substance abuse clinical staff. Clinical services provided by the center include
mental health and substance abuse evaluations, mental health treatment planning, individual,
group, and family therapy, mental health crisis intervention services, on-site psychiatric
services, and availability for substance abuse services for youth with co-occurring disorders.
Medical services are provided by one designated health authority (DHA), one advanced practice
registered nurse (APRN), seven registered nurses (RNs), and one records clerk. The medical
clinic maintains nursing coverage seven days a week from 8:00 a.m. to 5:00 p.m., Monday
through Friday and 8:00 a.m. to 4:30 p.m. Saturday and Sunday. Food services are provided by
Department staff and include menus, meal planning, meal schedules, special diets, nutritional
analysis, daily allowance, food preparation, health certifications, food product standards,
sanitation, and cleaning. Staff are responsible for the custody and control of youth in their care,
providing youth supervision twenty-four hours a day, seven days a week. The center has three
living modules which are divided by male and female. There are sixty-four security cameras at
the center, of which sixty-three were operational. At the time of the annual compliance review,
the center had three JJDO vacancies.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 54 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures (FOPs) outlining the process of background
screening for all new staff, volunteers, and contracted staff. 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 requirement. The center employs local
school board teachers and their Annual Affidavit of Compliance with Level 2 Screening
Standards was completed on January 24, 2024, meeting the annual requirement. Since the last
annual compliance review, the center had eleven newly hired staff, four volunteers, and six
contracted staff. Each staff was found to have an eligible background screening in the BSU,
which was completed prior to their hire date. A review of each staff’s personnel record found the
center reviewed each staff’s criminal history report in all applicable staff records. Additionally, a
pre-employment assessment, with a passing score or exemption documentation, was in all
applicable staff records. Also, six contracted staff were added to the Clearinghouse employee
roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures (FOPs) outlining the process of five-year
background rescreenings for staff. Five staff were applicable and reviewed for five-year
rescreenings. All staff had the five-year rescreening completed every five years, calculated from
the agency hire date. The center did not have any contracted provider staff who required a
rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 54 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures (FOPs) outlining the guidelines of staff code of
conduct. The FOPs state any form of abuse, profanity, threats, harassment, intimidation,
“horseplay,” or personal relationships with youth are prohibited for staff. If the code of conduct is
violated, there is a process in place for management to follow to address each violation. Six
staff records were reviewed for the staff code of conduct. All six of the staff had signed codes of
conduct in their personnel records. Three of the staff were applicable for receiving disciplinary
actions for violations of the code of conduct during the annual compliance review period.
Management took immediate action to investigate or address all allegations or violations of the
code of conduct. Three staff received an oral reprimand. The remaining three staff were
applicable for receiving an award. One staff received an award on December 6, 2023, one staff
received an award on April 18, 2024, and one staff received an award on June 11, 2024. Seven
youth were interviewed. Four youth indicated they have never been stopped from reporting
abuse to the Florida Abuse Hotline since they have been at the center. Three youth indicated
they had never had to report abuse to the Florida Abuse Hotline since they have been at the
center. Six youth indicated staff are respectful when talking to them and other youth at the
center. One youth indicated staff are not respectful when talking to them and other youth at the
center. Four youth stated they have never heard staff use profanity toward youth and two youth
stated they have heard staff use profanity once. The remaining two youth stated they have
heard staff use profanity often when talking to them and other youth at the center. Six youth
stated they have never heard staff threaten a youth. The remaining youth stated they have
heard staff threaten a youth once. All seven youth reported feeling safe at the center. All seven
youth reported never exchanging emails, telephone numbers, or social media contact
information with staff. Seven staff were interviewed and indicated youth are allowed to make the
call to the Florida Abuse Hotline or the Department’s Central Communications Center (CCC) to
report suspected abuse. Regarding having observed a co-worker using profanity when speaking
to a youth, four staff indicated this has never occurred. The remaining three staff indicated they
have occasionally observed a co-worker using profanity when speaking to a youth. Seven
interviewed staff also indicated they have never observed a co-worker using threats,
intimidation, or humiliation, when interacting with youth. Three staff stated, in the past year, the
working conditions at the center have been good. Three interviewed staff stated, the working
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 54 (Revised July 2023)
conditions have been fair, and one staff indicated the working conditions were poor. Interview
results were shared with the superintendent who reported this may be due to staff working
twelve hour shifts and a high number of vacancies with a high youth population. Further, the
superintendent was interviewed and appropriately summarized the staff code of conduct.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures (FOPs) outlining the process of contacting the
Department’s Central Communications Center (CCC). Since the last annual compliance review,
the center had sixty-three CCC incidents. Six reports were reviewed, and each incident was
reported to the CCC within the required time frame. A review of logbooks revealed four of the six
were documented appropriately. During the annual compliance review period, there were no
additional incidents/grievances which should have been reported to the CCC. The
superintendent was interviewed and appropriately summarized the incident reporting process.
1.05 Right Interactions (RI) Limited 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 has facility operating procedures (FOPs) outlining the staff’s use of physical
intervention techniques. During the annual compliance review period, the center had 173 Right
Interactions (RI) incidents. Nine youth records were reviewed for RI compliance by the facility.
Three of the nine RI Reports were completed on the same day as the RI incident. In six RI
Reports, not all of the explanation of incident narratives were complete by the end of the staff’s
workday. Six narratives were completed the day after the incident, one narrative was completed
two days late, one narrative was completed three days late, one narrative was completed thirty-
nine days late, and one narrative was completed forty days late. One RI Report was missing a
lead staff narrative. None of the incidents resulted in serious injury to the youth. None of the
youth alleged abuse. All nine of the RI Reports were reviewed by a supervisor or instructor and
a post-RI interview was conducted with the youth by the administrator, or designee, as soon as
possible, but no longer than thirty minutes after the incident. None of the nine youth were
applicable for a RI medical review. Eight of the nine RI Reports were reviewed by the
superintendent or designee within the required time frame. One report was reviewed thirty-five
days late. The center’s RI rate during the previous quarter was 8.44, which is below the
statewide Detention PAR rate of 15.17. Seven staff were interviewed and indicated staff try to
talk to youth prior to using physical or mechanical restraints. The interviewed superintendent
appropriately summarized the process for monitoring RI incidents and the use of force.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 54 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures (FOPs) outlining the training requirements for all
new staff. Seven staff were reviewed for pre-service training. Three staff were new staff who
completed all pre-service training and certification requirements within the required 180 days of
hire, which included the completion of academy training. Each staff also completed orientation
within thirty days of hire. Four staff were direct care staff returning within one year. Each staff
completed all required re-trainings with the exception of one staff missing mental health and
substance abuse and two staff missing four hours of instructor led suicide awareness and
prevention training. In the remaining five staff records, all trainings were entered in 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.
The center has facility operating procedures (FOPs) outlining the annual training requirements
for staff. The center has an annual in-service training calendar, which was approved by the
assistant secretary of the Department’s Office of Detention Services on November 17, 2023, the
director of the Department’s Office of Talent, Leadership and Culture (TLC) on December 15,
2023, and the facility superintendent on December 20, 2023. The superintendent indicated
during an interview, they have received the management trainings including conflict
management, emotional intelligence, fundamentals of coaching, interviewing dos and don’ts,
real colors for leaders, and supervising for success. Seven staff were reviewed for in-service
training. Three staff completed all required in-service training. The remaining four staff
completed all trainings with the exception of three of the four staff who did not complete
emergency care plan; two staff did not complete infection control training and exposure control
plan; one staff did not complete professionalism, interpersonal communication, and ethics
including standards of conduct, and one staff did not complete an annual review of mental
health plans. Three supervisors were reviewed and completed at least eight hours of annual
training in addition to the twenty-four hours required for all staff. Also, a licensed nurse provided
in-service education on girls’ healthcare annually to all non-healthcare staff involved in the
supervision for treatment of girls. The training also included monitoring, observation, and
emergency care of the pregnant youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 54 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a facility operating procedure (FOP) which ensures each youth has the right to
grieve, is treated fairly, respectfully, without discrimination, and their rights are protected. A
review of the Department’s Facility Management System (FMS) revealed the center did not
have any grievances during the annual compliance review period. There were grievance forms
available for the youth in each youth living module. During an interview with the superintendent,
the grievance process, to include all three phases, was appropriately summarized. Seven youth
were interviewed and were able to accurately describe the grievance process at the center. Six
youth reported they have never filed a grievance. One youth indicated they had filed a grievance
and rated the process as fair; however, documentation in FMS did not support the youth filed a
grievance during the annual compliance review period. Seven staff were interviewed and were
able to accurately summarize the grievance process.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately. Upon completion of the Admission Wizard, the officer shall ensure all critical
and special alerts are listed in JJIS. The JJIS alert report shall be reviewed daily by
supervisors and administrators to ensure it correctly reflects the status of youth. If the
electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately. Medical and mental health staff shall
review alerts to ensure each alert is correctly tracked and managed. The responses and
updates by medical, mental health, and other staff should be documented in JJIS alerts as
they pertain to the specific alert. JJDOSs shall inform staff of alerts during shift briefing. When
a JJDOS receives changes to the alert list, he/she shall notify the staff affected by changes
and add the information to the shift briefing for the oncoming shift upon receipt of the
information.
The center has facility operating procedures (FOPs) outlining the process of entering and
sharing alerts. Seven youth records were reviewed, six were applicable for a total of twenty-five
alerts. Twenty alerts required documentation in the logbook, however, five of the twenty were
not documented in the logbook/shift report. All alerts were entered into the Department’s
Juvenile Justice Information System (JJIS) and the internal alert system within the required time
frame. The JJIS alert reports were reviewed daily by supervisors and administrators. Each staff
is notified of alerts during daily shift briefings. The center’s process for updating alerts in JJIS is
the medical and mental health staff are responsible for updating all alerts in their respective
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Office of Accountability and Program Support Page 14 of 54 (Revised July 2023)
areas. The supervisors are responsible for updating all other alerts in JJIS. The annual
compliance review team members reviewing case management, medical, mental health, and
safety and security found no other alerts which should have been entered into the alerts system.
The superintendent was interviewed and was able to appropriately summarize the process for
entering alerts for the center. Seven staff were interviewed and reported they are informed of
alerts through shift briefings, alerts forms, JJIS, email, and verbally. Two of the seven staff
reported communication at the center is very good, three staff reported communication is good,
one staff reported communication at the center is fair, and one staff reported communication is
poor.
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.
An informal interview was facilitated with the superintendent at the center regarding the center’s
data trend analysis. The center uses information gathered from various reports and information
is discussed during the superintendent’s monthly meetings. Management reviews the reports
and any trends noticed are discussed in management meetings. Monthly meetings are held with
administrative and center staff during which an agenda with specific topics is discussed. Staff
members are afforded the opportunity to discuss any issues and ask questions. Meeting
agendas for the annual compliance review period were reviewed in SharePoint. The
documentation supports this practice.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 54 (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.
The center has facility operating procedures (FOPs) for admissions. Seven youth case
management records were reviewed for youth admission requirements. All seven records
contained a completed arrest affidavit/custody order, a Detention Risk Assessment Instrument
(DRAI), and a Suicide Risk Screening Instrument (SRSI). All seven records had the
Department’s Juvenile Justice Information System (JJIS) Admission Wizard printed and placed
in the record. Three of the seven records reviewed did not include documentation a review of
the court order was completed on the Admission Wizard; however, the detention order was
observed in each record reviewed. Each of the seven Admission Wizards documented youth
were full-body and electronically searched; however, it is unable to be determined based on the
Admission Wizard as to which staff performed the search. According to the center’s
administrative team, all youth searches are done by staff of the same gender. Samples of
logbook entries were observed to show searches being done by staff of the same gender. There
is no space available on the Department of Juvenile Justice Admission Wizard form to indicate
who performed the intake search. All seven youth records documented youth were allowed to
make a telephone call. All seven youth were offered a snack or meal. Screenings were
completed to identify medical, mental health, and substance abuse needs during intake. An
admission was not observed during the annual compliance review week. According to the
superintendent and captains, no admissions occurred while the annual compliance review team
was on-site for the annual compliance review week.
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Office of Accountability and Program Support Page 16 of 54 (Revised July 2023)
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center maintains facility operating procedures (FOPs) regarding the orientation process
which shall occur within twenty-four hours of the youth being admitted into detention. Seven
youth case management records were reviewed for orientation. Documentation indicated
orientation was completed within twenty-four hours of admission for each youth. There were
individual documents signed by each youth, which included the date of admission. The
orientation process included rules and regulations, grievance procedures, visitation, telephone
calls, access to medical, mental health, and substance abuse services, access to the Florida
Abuse Hotline and the Department’s Central Communications Center, behavior expectations
and related consequences, possible new law violations for destruction of property, youth rights,
and Prison Rape Elimination Act (PREA) related information. An admission could not be
observed during the annual compliance review week for no youth were admitted while the
annual compliance review team was on-site, however, orientation documentation included all
elements as outlined in the center’s policy. Seven youth records included the signed PREA
video acknowledgment form. The center’s captain provided the Department approved PREA
video disc indicating what is used during youth orientation. According to youth interviews, six of
the seven youth reported staff provided them with information about the center’s rules and
regulations, daily schedule, education services, visitation, abuse reporting, and the behavior
management system.
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Office of Accountability and Program Support Page 17 of 54 (Revised July 2023)
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) to ensure all youth admitted to the center
are classified to provide the highest level of safety and security. Seven youth case management
records were reviewed, and all included a review of information concerning the youth’s history
and status. The Department’s Juvenile Justice Information System (JJIS) Admission Wizard
forms were completed in each record, which included a review of each youth’s sex, gender,
height, weight, age, and level of aggressiveness. The identified special needs taken into
consideration included mental illness, intellectual disabilities, physical disabilities, history of
violent behavior, gang affiliation, criminal behavior, any history of sexual offenses including
sexual battery charges which were reduced to a lesser offense, Vulnerability to Victimization
and Sexually Aggressive Behavior (VSAB), and identified or suspected medical, suicide,
escape, and security risks. Youth were assigned to rooms based on classification procedures
and youth are reclassified if changes in behavior or status are observed. Youth with a history of
committing sexual offenses or who have been the victim of a sexual offense are placed in a
room alone. The center’s administration reported one juvenile detention supervisor (JDOS) has
been identified as the new gang liaison for the facility. The center administration stated there
has been no incidents for the annual compliance review period requiring notification to the
Circuit 1 gang representative. During the superintendent interview, it was reported youth with a
history of committing a sexual offense, a history of being a victim of a sexual offense and/or
abuse, or youth determined to be physically or sexually aggressive are not to be placed in a
room with other youth.
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Office of Accountability and Program Support Page 18 of 54 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has a screening process for youth newly admitted into the center to determine if the
youth is a gang member or gang affiliate. The center has a new interim gang representative,
who is a juvenile detention supervisor (JDOS). During the annual compliance review week, the
sergeant was not present for an informal interview. Seven youth records were reviewed, of
which all were non-applicable due to not having gang activity or alerts. The center’s
administration stated there have been no incidents for the annual compliance review period
requiring notification to the Circuit 1 gang representative, who also serves as a juvenile
probation officer (JPO).
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center maintains facility operating procedures (FOPs) to ensure a youth's personal property
is maintained securely. Seven youth case management records were reviewed, each record
documented the youth’s property was inventoried by the admitting juvenile justice detention
officer (JJDO) and entered into the Department’s Juvenile Justice Information System (JJIS). A
Property Receipt form was printed and signed by the youth in all seven reviewed records. All
seven youth records contained a letter of acknowledgment regarding unclaimed property,
signed by each youth. Currency and other personal items of value are placed in a clear tamper-
proof bag and placed in a drop safe, which is under camera surveillance. The tamper-proof
bags are labeled with the youth’s name, the Department’s identification number, and a listing of
the items in the bag. A log is maintained to document items placed in the drop safe and includes
the date, time, youth’s name, name of the officer who secured the property, and the officer’s
initials. Six total youth property bags were reviewed. Three valuable property bags were
reviewed from the drop safe. One bag in the safe was not documented in the logbook. Three
additional personal property bags were reviewed. One of the three bags did not have a personal
property form stored with the assigned bag. None of the youth refused to sign the Property
Receipt form. The personal property was placed in an assigned bag, as documented on the
Property Receipt form in in all six reviewed youth records. Seven youth were interviewed. Five
youth stated when they arrived at the center, staff checked their personal property and had
them sign a form stating the personal property was correct. Two stated they could not
remember. The superintendent was interviewed and advised the admission staff is responsible
to ensure all youth’s personal and valuable property is inventoried on the JJIS Property Report
and signed by both the youth and admission staff. Valuable property shall be placed in a clear
tamper-proof bag and placed in a drop safe. This safe is under video surveillance at all times. At
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Office of Accountability and Program Support Page 19 of 54 (Revised July 2023)
no time shall anything with property value be done out of view of camera. Any property which is
not picked up within thirty days will be considered abandoned. After thirty days, a Notice of
Impending Disposal of Property shall be mailed to the youth’s last known address. If the youth is
on supervision, it is also acceptable to have the juvenile probation officer (JPO) sign for and
deliver property to youth. A review of the Department’s Central Communications Center (CCC)
reports for the annual compliance review period indicated there were no incidents regarding
youth property reported. An admission was unable to be observed during the annual compliance
review week to confirm the center’s practice for admission of youth property as no admissions
occurred while the annual compliance review team was on-site.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center maintains facility operating procedures (FOPs) to ensure all releases are verified by
the court’s authorization. Three closed youth records were reviewed for release. Each record
contained documentation of a detention order advising the youth to be released. The on-duty
supervisor reviewed all paperwork prior to the youth being released. All three youth were
identified prior to being released and the identification of the parent/guardian or responsible
adult was verified prior to the release with an identification card (ID) which was photocopied and
placed in each record. None of the youth were identified as an endangered person. All three
youth and parents/guardians were provided with future court dates and times upon release. All
three closed records’ admission and release dates correlated with the dates documented in the
Department’s Juvenile Justice Information System. An observation of a youth being released
from the detention center could not completed due to a release not being conducted while the
annual compliance review team was on-site.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center maintains facility operating procedures (FOPs) to ensure each youth's personal
property is maintained securely and returned to the youth in a timely manner upon their release.
Upon the release of the youth, the juvenile justice detention officer (JJDO), the youth, and the
parent/guardian shall review and sign the Property Receipt form and account for all the youth’s
personal property. Three closed youth records were reviewed for youth released with personal
property, medication, and aftercare instructions. In one record the parent’s/guardian’s signature
was missing. All three records indicated the youth were released without requiring medication.
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Office of Accountability and Program Support Page 20 of 54 (Revised July 2023)
Three applicable youth records included documentation a reminder was provided to the youth
and the person to whom the youth was released of any health or welfare issues, including
medical, mental health, and/or substance abuse needs, and any pending appointments. The
centers’ administration noted there was no property held more than thirty days during the annual
compliance review period. The center maintains FOPs for the disposal of property left in the
safe which states, if the youth or parent/guardian cannot be located, the superintendent or
designee will ensure all money and property are counted and inventoried. A money order shall
be sent to the regional fiscal manager. The regional fiscal manager will then forward the money
order to the headquarters’ designee. A record must exist for any property disposed of or cash
forwarded to headquarters. An observation of a youth being released from the detention center
could not completed due to a release not being conducted while the annual compliance review
team was on-site.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures (FOPs) ensuring detention reviews are
conducted weekly for proper management of youth and the appropriate sharing of information.
Detention reviews are held weekly at 9:00 a.m. on Wednesdays and attended either in person
or video by circuit probation staff, commitment managers, education, medical, mental health,
and administrative staff within the center. An observation was made of detention reviews
occurring during the annual compliance review week. The detention review included
representatives from all required areas. Each attendee was provided a copy of the current youth
confinement list. Topics of discussion were each youth’s next court date and time, school
standing, and mental health and medication compliance. Committed youth were updated as to
the youth’s placement on the commitment wait list for their program and if any commitment
staffing’s were required. A review of documentation within the SharePoint system was observed
for previous detention review meetings during the annual compliance review period.
Observations found the meetings were documented weekly as required. One meeting did not
indicate the juvenile probation officer (JPO) on the list of participants. The superintendent’s
interview confirmed the detention reviews are conducted weekly and involve each area of the
facility who share information for each youth.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center maintains facility operating procedures (FOPs) to ensure youth participate in
constructive activities which benefit the youth and the program. The daily activity schedule is
posted in each living area and outlines the days and times for each youth activity. The schedule
includes times for wake-up, personal hygiene, mealtimes, visitation, education, recreation and
physical activities, indoor activities, shift change, bedtimes, groups, and open program time.
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Office of Accountability and Program Support Page 21 of 54 (Revised July 2023)
Youth were observed in the school classrooms or on the modules and secured in their rooms
during educational hours. The center reported the youth go on a bathroom break in between
classes. The center’s administration also noted most youth participation in school takes place
on the modules due to overpopulation and the classrooms not being of adequate size for youth
the facility has care and custody for. Medication pass and line movements were also observed,
which were in compliance with the center’s policy. Seven staff were interviewed, of which all
reported the center’s daily schedule is followed. Seven interviewed youth reported the center
does have a daily activity schedule. Each of the seven youth stated the daily activity schedule
was followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The facility’s education program is directly managed and supervised by the Escambia 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 place aside up to ten days of
the 250 days for teacher planning/professional development. Upon review of the annual
academic calendar and daily class schedule, it was found the program’s annual calendar
supports 240 days of instruction with ten additional days of teacher planning/professional
development. Upon the inspection of the daily academic schedule, it was revealed the schedule
offers 315 minutes of instruction daily amounting to more than the required twenty-five hours of
weekly teaching. In verifying the classes started on time and are conducted with minimal
interruptions, a review of the center’s movement videos was completed for three days. The
videos showed the classes were being conducted with minimal interference. The interviews with
the superintendent, seven youth, and seven staff indicated classes are conducted with minimal
interference. A review of the program’s logbooks for the dates for one day each month of the
annual compliance review period documented the youth arrived in class on time; however, due
to staff shortage or too many youth in the classroom, classes were held on the dorms. On two
days, classes started late because the teachers were tardy.
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 Escambia County School Board, the facility provides the youth
under its care with an appropriate career education curriculum based upon their age and
assessed intellectual and educational abilities. The career education course is offered 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 in middle school have career and planning activities in
Social Studies class. Youth are administered the Xello career assessment.
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Office of Accountability and Program Support Page 22 of 54 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has an identified single licensed mental health professional who serves as the
designated mental health clinician authority (DMHCA) and is on-site forty hours weekly to
ensure appropriate coordination and implementation of mental health and substance abuse
services are taking place. The DMHCA is a licensed clinical social worker with a clear and
active license with an expiration date of March 31, 2025. The back-up DMHCA has a clear and
active license, which expires on March 31, 2025. The DMHCA was on-site as required by
contract to ensure coordination and implementation of mental health services were taking place.
Copies of the DMHCA’s position description were reviewed. Contract requirements were
reviewed. A minimum of forty hours weekly was confirmed. An interview with the DMHCA was
conducted. The DMHCA reported their role as coordinating with the facility psychiatrist and
medical staff to ensure youth on psychotropic medications are receiving initial psychiatric
evaluations within fourteen days and a follow-up within thirty days, and supervising all mental
health staff and reviewing documentation to ensure timely, accurate, and thorough record-
keeping is completed. The DHMCA also conducts intake assessments, completes training with
new mental health staff and detention as necessary, ongoing reviews with mental health staff to
ensure understanding of expectations, mental health and substance abuse comprehensive
assessments, provides ongoing treatment, crisis intervention, suicide risk assessments, and
participates in multidisciplinary team meetings. The DMHCA completes monthly schedules to
ensure contract hours and coverage are met, provides weekly updates of the statistical
reporting instrument, and communication with clinical staff daily and ongoing.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center employs three licensed mental health and substance abuse clinical staff including
the designated mental health clinician authority (DMHCA). The clinical supervisor ensures the
licensed clinical staff working under their supervision are performing services they are qualified
to provide based on their education, training, and experience. The licensed mental health
professionals are all licensed under the appropriate Florida Statutes chapter. Copies of licenses
were available on-site. All licensed mental health professionals and licensed qualified
professional’s licenses were reviewed with no noted issues.
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Office of Accountability and Program Support Page 23 of 54 (Revised July 2023)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has one non-licensed mental health and substance abuse clinical staff providing
services. The non-licensed professional holds a master’s-level degree from an accredited
university or college in the field of counseling, social work, psychology, or related human
services field. The non-licensed mental health clinical staff completed twenty hours of training
and supervised experience in assessing suicide risk, mental health crisis intervention, and
emergency mental health services.
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.
Seven youth records were reviewed for mental health and substance abuse admission
screenings. All records were eligible for mental health and substance abuse admission
screenings. Each record contained screening documents completed by probation. Each record
indicated screening documents were reviewed by detention staff. In each record, the Suicide
Risk Screening Instrument (SRSI) was completed at intake. Each record indicated the SRSI and
the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) were initiated within
the Department’s Juvenile Justice Information System (JJIS). Due to Department-wide system
outages, there were issues with inputting this information into JJIS. Those documents which
were unable to be initiated in JJIS were completed manually. In each record, documentation
reflected nursing and/or mental health staff completed the required sections of the SRSI, and
the completed entries included accurate referral selections in the screening results section. Six
of seven records indicated the youth had a positive response on the SRSI and each youth was
placed on suicide precautions and a mental health referral was completed which documented
the youth’s need for an Assessment of Suicide Risk (ASR). Six of seven records contained a
SRSI which included a yes response when the youth had an open or closed alert in JJIS. A
review of the Department’s Learning Management System (SkillPro) confirmed the MAYSI-2
and SRSI screenings in all reviewed records were completed by a trained staff. In six of seven
records, the results of the SRSI and the MAYSI-2 indicated a need for further assessment. One
of seven records included all negative responses on the MAYSI-2 and was marked as invalid.
The youth was referred for a comprehensive assessment. Documentation confirmed the proper
referral for each eligible youth requiring further assessment was made and the superintendent
was notified of each. The MAYSI-2 results in six of seven records indicated an elevated suicide
risk subscale which prompted the youth to be placed on suicide precautions and referred for an
ASR. The screener for each youth made a referral to the mental health clinical staff for
comprehensive Substance Abuse and Mental Health (SAMH) assessment.
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Office of Accountability and Program Support Page 24 of 54 (Revised July 2023)
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.
Seven youth records were reviewed for mental health and substance abuse evaluations. Each
of the seven youth were identified after admission and referred to the center provider for
comprehensive and or mental health evaluations. Four of seven comprehensive mental health
or substance abuse evaluations were classified as new. The remaining youth comprehensive
mental health or substance abuse evaluations had not yet been completed at the time of the
annual compliance review as the youth had not yet been at the center for thirty days. All eligible
comprehensive mental health and/or substance abuse evaluations were completed by the
center’s on-site provider by the youth’s thirty-first day of admission. For all eligible evaluations,
treatment recommendations corresponded to all diagnosed mental health or substance abuse
disorders. All comprehensive mental health/substance abuse evaluations consisted of the
Substance Abuse and Mental Health (SAMH) form documented within the Department’s Office
of Health Services Electronic Medical Record.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
Seven youth records were reviewed for treatment and discharge planning. The reviewed
documentation confirmed all mental health orientations were held within fourteen days of each
youth’s admission to the center. Each record indicated the youth required a treatment plan. Five
were eligible for initial treatment plans. The remaining two youth refused participation in
treatment. All eligible youth initial treatment plans were in place within seven days of onset of
treatment. For all eligible records, the initial treatment plans were developed on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form and contained all
required information such as reason for referral for treatment, initial Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis/symptoms, initial treatment
methods including counseling and frequency, initial treatment goals, and psychiatric services
including psychotropic medications and frequency of monitoring. Three of the seven reviewed
youth were admitted to the center with psychotropic medications. There was evidence in each
record indicating the initial treatment plan contained medications the youth was admitted with to
compare with the initial treatment plan. Each eligible record indicated the initial treatment plan
was signed by the mental health and substance abuse professional as well as each youth. Each
eligible youth was assigned to a mini-treatment team and the mini-treatment team members
were involved in the development if the initial treatment plan. Four of seven youth were eligible
for an individualized treatment plan. Each eligible youth’s individualized treatment plan was
developed by the youth’s thirty-first day of admission. The remaining youth were not applicable
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for a treatment plan or had not been in the center long enough. Each eligible individualized
treatment plan contained a DSM-5 diagnosis, symptoms which are treatment focused, treatment
goals including mental health services if the youth had a mental illness and substance abuse
services if the youth had a substance related diagnosis, and strengths and needs. Two of the
four individualized treatment plans indicated the youth were eligible for psychiatric services and
each plan included psychotropic medications and frequency of monitoring. In each eligible plan,
psychotropic medications listed in the initial treatment plan matched the psychotropic
medications the youth was prescribed at the time the treatment plan was developed and each
plan contained pharmacological interventions. In all eligible records, progress notes validated
the youth were receiving treatment services as stipulated on the treatment plans.
Documentation confirmed each individualized treatment plan contained signatures of the youth,
mental health and substance abuse professional, and treatment team members. Four records
indicated the youth were eligible for treatment plan reviews. Each individual treatment plan
review was completed and documented on the Individualized Mental Health and Substance
Abuse Treatment Plan Review form. Each treatment plan review was held every thirty days by
the treatment team. Two of four treatment plans required modifications and, in each record,
modifications were documented on the review form and clearly identified as such. Each
individualized treatment plan review was signed by the clinical staff, youth, licensed mental
health professional, and treatment team members. Each treatment plan included treatment
services provided by a licensed psychiatrist or a certified psychiatric advanced practiced
registered nurse (APRN). There were no youth who were alleged victims of a Prison Rape
Elimination Act (PREA) event. None of the reviewed records were eligible for treatment and
discharge planning. A request for three additional closed records was made and records were
provided. Each record indicated the discharge plan was documented on the Department’s
Mental Health Substance Abuse Treatment Discharge Summary form and was completed upon
the youth’s discharge. Evidence supported a copy of the mental health discharge summary was
provided to the youth, the parent/guardian as allowed, and the juvenile probation officer (JPO).
In each record, documentation practices adhered to Department policy. In each record, all
additional uploaded information was completed within fourteen days, provided the completion
date of service, and contained the signature of the licensed mental health professional. A mini
treatment team review was not able to be observed during the annual compliance review week.
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.
Seven youth records were reviewed for mental health and substance abuse treatment. Six
records were applicable for mental health and substance abuse treatment. Documentation
confirmed each youth was assigned to a min-treatment team, and the treatment team consisted
of mental health staff, staff from a different service area, the youth, and the parent/guardian.
Each youth required mental health treatment and documentation confirmed each youth received
individual, group, or family counseling according to the frequency of the plan. Each plan
included individual, group, or family therapy prescribed at least weekly. Four of seven youth
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required substance abuse treatment and documentation within each record was consistent
confirming each youth received individual, group, or family counseling according to the
frequency of the plan. Each record contained the proper Authority for Evaluation and Treatment
(AET). For the youth requiring substance abuse treatment, the proper consent for substance
abuse treatment was obtained through the signed mental health and substance abuse form and
the proper consent for substance abuse treatment records release was obtained through a
signed form. Each record contained treatment notes documented on the Department’s
Counseling Therapy Progress Note form. A video review of four groups was conducted with a
verified facilitator. The group durations were twenty minutes, seventeen minutes, twenty-six
minutes, and eighteen minutes respectively. Mental health staff had adequate access to youth
and confidential space to provide treatment. A record review confirmed group therapy was
limited to ten or fewer youth with mental health diagnoses for mental health groups and
substance abuse groups were limited to fifteen or fewer for youth with a substance abuse
diagnosis. Seven youth were interviewed. Four of seven youth reported mental health and
substance abuse services were very good. Two youth reported mental health and substance
abuse services were good. The remaining youth reported not having received mental health and
substance abuse services. The designated mental health clinician authority (DMHCA) was
interviewed and reported youth's comprehensive substance abuse and mental health
evaluations are completed by their thirty-first day and assist in identifying youth needs and
determining recommendations for treatment. Youth sign a consent for substance abuse
treatment and release of substance abuse treatment records prior to beginning the
comprehensive evaluation. Utilizing a record review, mental health staff review available records
to complete comprehensive assessments if needed. Mental health staff will review initial
treatment plans for any youth who were engaged in or receiving psychiatric services to ensure
the diagnostic information from facility psychiatrist and current psychotropic medications are
carried over to the youth's individualized treatment plan.
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.
Seven youth records were reviewed for psychiatric services. Three were eligible for psychiatric
services and each was admitted to the center on psychotropic medications. Documentation in
each record indicated the youth received an initial psychiatric interview within fourteen days of
admission to the center. Each initial psychiatric interview included the reason for referral, history,
Mental Status Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnosis, treatment recommendations specific to mental health or substance abuse
diagnoses, prescribed medication, medication name, explanation for psychotropic medication,
and frequency of medication monitoring. Documentation in each record revealed an in-depth
psychiatric evaluation was conducted on all referred youth within thirty days of referral or
admission. The in-depth psychiatric evaluation included the stated reason and factors leading to
the referral, history, history of psychiatric illness, psychotropic medication management, mental
health treatment and/or substance abuse treatment, assessment of symptoms, mental status
examination, identification of individual, family, and/or environmental factors which may
potentially account for, influence, or ameliorate the youth’s difficulties, diagnostic formulation,
treatment recommendations and interventions, prescribed medication and frequency of
medication monitoring, the explanation of the need for psychotropic medication related to the
youth’s diagnosis, target symptoms, potential side effects, risks, and benefits of taking the
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medications. The in-depth psychiatric evaluation in each record contained the youth’s most
recent applicable therapeutic serums drug levels as well as the signature of the practitioner
conducting the evaluation. The Clinical Psychiatric Progress Note (CPPN) in each record was
completed and each was clearly identified. Each record contained the required information
when psychotropic medications are prescribed, dispensed, or administered such as identifying
data, diagnosis, target symptoms of each medication, evaluation and description of effects of
prescribed medication on target symptoms, prescribed medication including the name, dosage
and quantity of the medication, normal dosage range, ordered dosage, frequency and route of
administration and reason for changes in medication or dosage, side effects, youth’s adherence
to the medication, height, weight, blood pressure, most recent serum drug levels or laboratory
findings, telephone contact with the youth’s parent/guardian to discuss medication, the signature
of the psychiatrist or psychiatric advanced practice registered nurse (APRN), date of signature,
and monthly documentation of Tardive Dyskinesia by the psychiatrist, APRN, and nursing staff.
Each record contained an Authority for Evaluation and Treatment confirming the
parental/guardian notification whenever a new psychotropic medication was prescribed,
discontinued, or drug dosage was significantly changed was documented on page three of the
CPPN. None of the reviewed records indicated the youth was in foster care or eighteen years of
age. The center’s contract was reviewed for tele-psychiatry inclusion. The center did utilize tele-
psychiatry and the standard of psychiatric care delivered through tele-psychiatry was the same
as if rendered in person. Tele-psychiatry was only utilized by youth who agreed to participate,
and proper consent was obtained. Psychiatric services at the center are provided by a physician
licensed pursuant to Chapter 458. The center also has an APRN under Chapter 464, Florida
Statute, who works under the clinical supervision of a 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. All licenses of the psychiatrist, psychiatric APRN, and
the back-up psychiatrist were reviewed and were all up to date. The psychiatrist has a license
expiration date of January 31, 2025, the APRN has a license expiration date of April 30, 2026,
and the back-up psychiatrist has a license expiration date of January 31, 2026. An interview with
the designated mental health clinician authority (DMHCA) was conducted. The DMHCA meets
with the psychiatrist weekly when they are at the center. Prior to meeting with the youth, the
psychiatrist is provided with the needed information to carry out evaluations. A follow-up with
mental health staff occurs after to report any findings necessary for treatment, discuss any
issues with youth, request administration of diagnostic assessments for youth if necessary, and
to report any changes made in medication.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a written plan detailing suicide prevention procedures. The center’s
suicide prevention plan was reviewed and signed by the designated mental health clinician
authority (DMHCA) and the superintendent. The plan includes identification and assessment of
youth at risk of suicide, staff training, suicide precautions, levels of supervision, referral,
communication, documentation, immediate staff response, and review process as referenced.
The center has an established review process for serious suicide attempts or serious self-
inflicted injuries. The process includes the multidisciplinary review of 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
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factors, and recommendations for changes in policy, training, physical plant, medical or mental
health services, and/or operational procedures.
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).
Seven youth records were reviewed for suicide prevention services. Six were eligible for suicide
prevention services. Five of the eligible youth were determined to be at risk and were exhibiting
suicidal risk behaviors during the admission process. Each youth was placed on precautionary
observation (PO). The remaining youth self-reported suicidal risk behaviors subsequent to
admission and was placed on PO. In each record, a suicide risk assessment referral was
initiated as well as an alert entered in the Department’s Juvenile Justice Information System
(JJIS). Each Assessment of Suicide Risk (ASR) was completed on the Department’s required
form and information was documented in real time. Each youth was placed on constant
supervision prior to completion of the ASR. Suicide Precautionary Observation Logs in each
record were completed in their entirety with documented signatures and safe housing areas. In
each case, a qualified mental health professional was involved. There was no evidence in either
record which indicated an eligible youth was released from PO prior to receiving an ASR. There
was evidence in each eligible record indicating staff documented a consultation with the
designated mental health clinician authority (DMHCA) or licensed mental health professional on
the mental health and substance abuse referral summary, the superintendent was notified
immediately of suicide risk, the referral to the mental health professional contained a time and
date, and the time and date the youth was placed on PO was documented. Each ASR was
completed within twenty-four hours of referral. Follow-Up ASRs were not required as no youth
was determined to be in crisis. Each eligible record contained documentation to confirm a
conference was held by the center’s superintendent and a mental health professional to reduce
level of supervision, the date and time discontinuation of PO, and discontinuation of close
supervision were documented in accordance with the center’s suicide prevention plan. Each
youth was stepped down to standard supervision. All suicide risk assessments were completed
by a licensed mental health professional. All ASRs provided results of the assessment including
recommendations for supervision, there was evidence in the center’s logbook and the ASR
indicating staff was provided specific instruction related to ASR findings and precautionary
decisions. A review of JJIS determined all alerts were entered and removed following the
youth’s removal from PO. A review of logbooks determined the beginning and ending times for
youth placed on PO were documented. An interview with the DMHCA was conducted. The
DMHCA reported written concurrence of supervision level recommendations, which are
communicated by email and include all mental health clinicians and center administration.
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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.
Seven youth records were reviewed for secure observation, and none were applicable. A
request for additional records was made to meet the minimal requirements. Two eligible records
were provided by the center. No additional records were applicable for secure observation
during the annual compliance review period. Documentation in each applicable record
confirmed the youth’s placement in secure observation was authorized by the center’s
superintendent, the secure room was designated in writing, and the Health Status Checklist was
completed prior to placement in secure observation. Suicide Precaution Observation Logs were
completed in their entirety and a Follow-Up Assessment of Suicide Risk (ASR) was completed
within eight hours of placement with parental/guardian and juvenile probation officer (JPO)
notification indicated. Neither record indicated the youth remained on secure observation
beyond twenty-four hours. Mental health staff provided supportive counseling services during
secure observation, observation logs documented supervision, and the youth’s level was only
reduced after a conference with the superintendent and licensed mental health professional.
Discontinuation of secure observation and step-down to close supervision was documented in
the center’s logbook and youth’s mental health record by mental health clinical staff.
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.
Seven youth records were reviewed for Suicide Precaution Observation Logs. Seven records
were eligible for logs. In each eligible record, the logs were maintained for the duration the youth
was on suicide precaution, and the appropriate level of supervision and observation of the
youth’s behavior were documented in real time and not exceeding thirty minutes. Warning signs
were documented when observed with notification to the superintendent and mental health
clinical staff. Logs were reviewed and signed by each shift supervisor and mental health clinical
staff. All logs documented safe housing requirements. The video review revealed documentation
and supervision were appropriate.
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.
Fourteen staff training records were reviewed for suicide prevention training. Seven staff were
reviewed for pre-service, and seven were reviewed for in-service training. Documentation
supports staff training included suicide drills, which are held no less than quarterly on each shift.
The center maintains three suicide response kits. Each was observed during the annual
compliance review week. One suicide response kit is in medical, one in the hall near the girl’s
module, and one in the hall near the staff training room. The kits are co-located with the first-aid
kits. The center’s suicide training does include mock drills for staff who have contact with youth
including kitchen and maintenance staff. All mock drills were in response to a suicide attempt or
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incident of serious self-injury. There were no youth used in drill simulation related to mental
health or substance abuse care. The program did provide semi-annual training on emergency
response procedures which include mock training in emergency response to a suicide attempt
or incident of serious self-inflicted injury. Staff who were not present during quarterly drills had
an opportunity to review each drill scenario and procedures to understand the process and
receive the necessary training to respond to an incident of a suicide attempt or incident of
serious self-inflicted injury. Seven staff were interviewed, and each reported suicide response
kits are in master control, medical, sub control, shift supervisors’ office, and the hallway.
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 maintains a mental health crisis intervention plan which allows a response to youth
in crisis in the least restrictive means possible while protecting the safety of the youth and
others. The mental health crisis intervention plan contained all required elements such as 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.
The center maintains an emergency care plan which was approved on March 18, 2024, and
was last updated on March 15, 2022. The emergency services plan contained all the required
elements such as immediate staff response, notifications, communication, supervision,
authorization to transport for emergency mental health or substance abuse services, transport
for emergency mental health evaluation and treatment, transport for emergency substance
abuse assessment and treatment, documentation, training, and review. There is a plan located
in the staff conference room and one in the staff training office.
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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.
Seven youth records were reviewed for Crisis Assessments. None of the reviewed records were
eligible. A request was made for additional records to meet the minimum requirement. The
center provided one applicable record and reported it as the only eligible record for Crisis
Assessments during the annual compliance review period. The Crisis Assessment in the eligible
record contained the date the youth was determined to be in crisis, the reason for the
assessment, the date of the crisis assessment, Mental Status Examination and interview,
determination of danger to self or others, initial clinical impressions, supervision
recommendations, treatment recommendations, recommendations for follow-up, and notification
to the parent/guardian of follow-up treatment. A review of the Department’s Juvenile Justice
Information System (JJIS) revealed a mental health alert had been entered. The youth was
identified by staff as having acute emotional or behavioral problems or acute psychological
distress. The Crisis Assessment was conducted by a licensed mental health professional, and
the assessment was conducted immediately or within two hours for emergencies or within
twenty-four hours based on the needs of the youth. There was no evidence in the record which
indicated the youth was an alleged victim in a Prison Rape Elimination Act (PREA) event.
3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth records were reviewed for Baker and Marchman Acts. None of the reviewed
records were eligible for a Baker or Marchman Act. A request was made for additional records.
The center provided one record which qualified for Baker Act and reported it as the only eligible
record for the annual compliance review period. A suicide risk alert was entered into the
Department’s Juvenile Justice Information System (JJIS) while the youth awaited transport, the
youth was placed on one-to-one supervision, supervision was documented on a precautionary
observation (PO) log until authorized release, the youth was placed on suicide precautions upon
re-admission from the Baker Act, and a mental health referral was made for a Mental Status
Examination (MSE). The MSE was completed by a licensed mental health professional, and the
youth was maintained on a minimum of constant supervision until properly transitioned to a
lower level of supervision. The youth’s supervision level was maintained until an appropriate
assessment was conducted and mental health staff conferred with the superintendent. The
discontinuation of the suicide risk alert entered in JJIS was based upon an Assessment of
Suicide Risk. The discontinuation of the JJJIS mental health alert and constant supervision was
based on the Crisis Assessment.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center’s designated health authority (DHA) is a board-certified physician who is a licensed
medical doctor (MD) who specializes in family medicine. The DHA’s license is unrestricted and
meets all requirements for practice in the State of Florida, which expires on January 31, 2026.
The center utilizes an advanced practice registered nurse (APRN) who has a Collaborative
Practice Protocol in place, which is signed by the DHA and APRN. During the annual
compliance review week, it was found the DHA has been on-site at least once a week with no
time lapse of more than nine days between visits, which is in contractual compliance. The
center did not utilize a physician assistant (PA) or have a need to utilize a backup DHA. No tele-
medicine was used during the annual compliance review period. The DHA was interviewed and
stated their role was performing Comprehensive Physical Assessments, conducting periodic
evaluations, sick call, and policy and procedure development. The DHA stated they
communicate with the program staff regarding youth medical needs by telephone or when they
are on-site. If off-site, they are on call twenty-four hours a day, seven days a week, and staff call
them with any needs or concerns. Any off-site care findings, instructions, or information are
reviewed by the DHA by paper records on a weekly basis.
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 utilizes facility operating procedures (FOPs) for all health-related procedures and
protocols. During the annual compliance review week, it was found the designated health
authority (DHA) signed the FOPs on September 11, 2024, the superintendent signed on
September 11, 2024, and the psychiatrist signed on April 10, 2024, for all respective treatment
FOPs. No new policies or changes had been made during the annual compliance review period.
FOPs and nursing protocols were reviewed annually as required and signed on September 12,
2024. Newly employed healthcare personnel received a comprehensive clinical orientation to
the Department’s healthcare policies and procedures, which was conducted by a registered
nurse (RN). Nursing staff reviewed, signed, and dated a cover page between the dates of July
8, 2024, and September 23, 2024, of all medical FOPs, treatment protocols, and other
procedures.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for Authority for Evaluation
and Treatment (AET) requirements. Six of seven IHCRs included an AET obtained prior to
providing medical services with one record missing the date of the AET. Each of the seven
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applicable youth’s AETs were either originals or stamped as a “COPY” and filed in the youth’s
IHCR. Six of the seven IHCRs were signed by the youth’s parent/guardian and the remaining
record belonged to a youth who was eighteen years of age. Each applicable AET was signed by
a Department representative. Six of the seven AETs were valid and were obtained prior to the
provision of medical services. The one remaining AET was not valid, as it was missing the date
as to when it was signed.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for parental/guardian
notification/consent requirements. Four out of seven youth were found to have
parental/guardian notification for over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET). All four youth IHCRs included documentation
of consent provided by the parent/guardian. All four youth IHCRs included written notification
sent utilizing the Department’s Parental Notification of Health-Related Care form. Three of the
seven youth were taking psychotropic medications on admission. Two of the seven youth on
medications and one on psychotropic medications had medications which were prescribed,
discontinued, or had a significant change in the dosage. Written notification was sent for all
three of these youth and telephonic contacts were recorded in the progress notes. None of the
youth IHCRs reviewed were involved or committed to the Department of Children and Families.
All seven youth’s vaccines were verified within thirty days of the youth’s admission with no
vaccines needed. Only one youth was applicable for and had a “Religious Exemption from
Immunization” documented within the IHCR.
The nurse was interviewed and reported the juvenile probation officer (JPO) is responsible for
ensuring each AET is fully executed by the parent/guardian of the youth and forwarded to the
holding facility. Where parental/guardian rights have been terminated, the Department of
Children and Families has limited authority to consent to treatment and youth eighteen years of
age or older can provide consent. The nurse detailed the procedures for the parental/guardian
notifications for emergency treatment, medication changes, immunizations, and other services.
The vaccination information for each youth is obtained through the Florida Shot Record and
reviewed within twenty-four hours of admission. Religious exemptions will be documented on
the designated form and filed in the Electronic Medical Record (EMR).
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for healthcare admission
screening requirements. Seven youth received a medical and mental health admission
screening completed on the Department’s Facility Entry Physical Health Screening form on the
date of admission by the juvenile justice detention officer (JJDO) with the screening reviewed
with the youth by a licensed nurse within twenty-four hours. Notification was made to the
designated health authority (DHA) for all seven youth and documented in the youth’s IHCR.
None of the reviewed youth changed physical custody since admission to the center. None of
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the applicable youth received a qualitative urine pregnancy screening test as each youth
declined testing. Refusals were found in each youth’s IHCR.
The nurse was interviewed and stated the youth are seen by medical staff within twenty-four
hours of admission to the center. At a minimum, vital signs are taken, and the youth is
questioned concerning medical needs, chronic conditions, medications, and medical complaints.
The admission packet is reviewed, and each page must be signed and dated.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for youth orientation to
healthcare services and health education. All seven youth received a general healthcare
orientation within twenty-four hours of admission and was documented on the Health Education
form. The center’s facility operating procedures (FOPs) included access to medical care, sick
call access, what constitutes an “emergency” and when to notify staff, medication process to
include side effect monitoring, the right to refuse care and how it is documented, what to do in
the case of a sexual assault or attempted sexual assault, the non-disciplinary role of the health
care provider, and the review of the list of healthcare contacts to ensure accuracy.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for notification requirements
to the designated health authority (DHA). Three of the seven youth were admitted with known or
suspected chronic conditions, in which a referral was made to the DHA within twelve hours. No
youth were identified as in-need of emergency care upon admission. The notifications to the
DHA for all three youth were documented in the youth’s ICHR in the chronological progress
notes. Three of the seven youth were taking psychotropic medications upon admission. The
psychiatrist was also notified within twelve hours of admission for each youth and the
notification was documented in the chronological progress notes section in each youth’s IHCR.
The nursing staff interview stated the DHA, as well as the psychiatrist, are notified within
twenty-four hours of admission if the youth is admitted on any psychotropic medications. All
notifications are documented on the intake progress note of the IHCR by the licensed medical
staff. If the notification is made by non-healthcare staff after hours, the Report of Healthcare by
Non-Healthcare Staff form is completed and placed in the youth’s IHCR.
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Office of Accountability and Program Support Page 35 of 54 (Revised July 2023)
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.
Seven youth Individual Healthcare Records (IHCR) were reviewed for Health-Related History
(HRH). Six of the seven youth’s HRH forms were updated or completed within seven calendar
days of admission. The one remaining youth had a HRH conducted from a previous admission
date to the center, with no indications of an update having been completed timely. The six
applicable HRH forms were completed prior to the Comprehensive Physical Assessment (CPA)
or focused evaluation by evidence of a signature and date by a licensed nurse. The DHA or
APRN reviewed each HRH, by documenting the review on the HRH with a date and signature.
Nursing interviews were conducted, and the nurse stated the HRH is completed or reviewed by
the nursing staff with the youth no later than seven days from admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for the Comprehensive
Physical Assessment (CPA) and tuberculosis (TB) screening requirements. Each of the seven
youth’s CPAs were completed on the Department form. Five out of the seven youth had a
current CPA on file at the time of admission. Two out of seven youth did not have a CPA on file
at the time of admission, however, a CPA was completed for one youth after eighty-one
calendar days of admission and one youth’s CPA was completed, however, undated. The youth
with the CPA dated eighty-one days past admission was seen upon admission as noted in the
medical record, however, the CPA form was lost. The seven youth CPAs were conducted by the
advanced practice registered nurse (APRN). The correct Medical Grade was listed on all CPAs.
Five of the seven youth’s CPAs were current with no changes in the youth’s medical condition.
Six of the seven CPAs were reviewed by the designated health authority (DHA) or APRN and
signed off on within seven days of admission. Six of seven sections of the CPA were marked
with either an “O” or an “X” with any “X” documenting in further detail in the comment section to
elaborate on the abnormality. Six of the seven youth refused a portion of the exam, and a
refusal was documented in the chronological progress notes which was signed by the youth, a
nurse, and the DHA or APRN. Five out of seven applicable youth’s problem lists were updated
to reflect any current issues and dates resolved if any issues were resolved. All seven CPAs
had a Tuberculosis Skin Test (TST) documented in the IHCR which was administered within the
last year. The results of six youth were found documented on the Infectious and Communicable
Disease (ICD) forms which matched their results documented on the CPA. One youth did not
have their results documented on the CPA, however, the results were located on the ICD form.
None of the seven youth required further evaluation, treatment, or transportation for
hospitalization as a result of the TST.
The nurse reported the DHA is responsible for conducting a new CPA at a minimum of every
two years, however, at the center they are completed yearly. All youth are required to undergo a
TST and have a documented TST in their Electronic Medical Record (EMR).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 36 of 54 (Revised July 2023)
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. Three out of
seven youth stated they were sexually active and were screened for STIs. Further evaluation
was required for two youth and the referral was documented on the STI form. Two of the three
requested to be tested and testing was ordered and conducted within seven days of admission
and the results were documented on the Infectious Communicable Diseases (ICD) form and
filed in the lab section of the IHCR. None of the seven youth received a gynecological exam or
were ever out of the Department’s physical custody. All seven youth were offered counseling
and testing for HIV. None of the youth were tested for HIV and refusals were documented for
those youth. All interviewed youth stated they were able to request an HIV test if they have the
desire.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sick call process
requirements. Three out of seven youth received sick call services. All three youth’s sick calls
were documented on the Sick Call Referral Log. None of the three youth presented with a
similar sick call complaint three or more times within a two-week period; therefore, no referral
was needed to the designated health authority (DHA). All three youth completed a sick call on
the Sick Call Request form. Only nursing staff completed the Sick Call Request form. None of
the youth’s sick calls were conducted by a licensed practical nurse (LPN). All three youth’s sick
calls were filed in the youth’s IHCR in reverse chronological order. None of the reviewed youth
were in restricted housing during sick call hours. All three applicable youth’s sick call forms were
documented in accordance with Florida administrative rule. One of the three youth’s sick calls
were documented on the Sick Call Index inside the IHCR with the dates listed on the sick call
forms matching the dates of the sick call index. The other two records were each missing
documentation on the sick call index for a singular sick call form. A nurse was interviewed and
noted sick calls hours are seven days a week from 9:00 a.m. until 10:00 a.m. and 2:00 p.m. until
3:00 p.m. These hours are posted in medical clinic area. There are approved treatment
protocols for registered nursing staff to utilize. Only licensed nurses complete sick calls. When
there is not a licensed nurse on-site, the center has procedures whereby the shift supervisor
reviews all the sick call requests as soon as possible and within four hours after the request is
submitted and notifies the DHA. The center has a policy for room restrictions/confinement in
which youth in restricted housing shall be afforded access to healthcare at equal or greater
intervals of youth which are in regular housing. No observations of a sick call were completed as
monitoring staff requested verbally and through daily debrief to observe without response during
the annual compliance review week. One out of seven interviewed youth stated they were seen
upon submitting a sick call request immediately, five stated they were seen within one day, and
one stated they were seen within two days. Each of the seven youth stated the nurses conduct
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Office of Accountability and Program Support Page 37 of 54 (Revised July 2023)
sick call. Seven staff were interviewed, and all staff stated the nurse reviews and conducts sick
calls.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for episodic/first-
aid/emergency care requirements. Three out of seven youth required on-site first-aid or episodic
care. All three youth received episodic or first-aid care by a licensed healthcare staff which was
documented in subjective, objective, assessment, and plan (SOAP) format. None of the youth
received episodic or first-aid care by a non-healthcare staff. All three youth complaints were
documented with findings of the person rendering care to include received treatment. All three
youth’s episodic/first-aid care instances were documented on the Episodic/First-Aid Care Log.
None of the three youth required a referral or plan for follow-up care.
The center has a total of nineteen first-aid kits located throughout program areas, and
accessible to staff in the event of an emergency. A first-aid kit is available for each of the six
transport vehicles. Additionally, two are located in master control and one in each of the youth
modules, front lobby, time clock, medical office, school hallway, gym, principal’s office, kitchen,
and in tandem with the automated external defibrillator (AED) located in the medical hallway.
The first-aid kits include an approved list of items present documented on each kit. Three kits
were opened and examined. All three had contents within their date of expiration. First-aid kits
are inventoried monthly by the medical staff. Documentation of all of the inventory was
conducted and documented on the monthly first-aid kit and AED logs. The center has a total of
two AED units with one located in the medical hallway, and the other in medical. Both are
inspected monthly by medical staff and a log is kept documenting any findings or discrepancies
fixed with dates of pads changed and batteries changed. The batteries and pads of the device
were observed within their date of expiration. A licensed medical staff was observed performing
an inspection of the AED during the annual compliance review week. The device was operating
as required.
Emergency drills have been conducted every month, on each shift, unannounced in which a
simulated episodic care event took place. Two drills were conducted in which cardiopulmonary
resuscitation (CPR) was rendered and the use of the AED was conducted to show proper
techniques were being used. The center maintains documentation of all emergency drills
conducted. A list of emergency numbers were found accessible to licensed and unlicensed staff
which included the number to Poison Information Center. The numbers were not accessible to
any youth. All authorized direct care staff were appropriately trained by a registered nurse on
the administration of an epinephrine auto-injector. Seven staff records were reviewed which
showed training requirements were met regarding episodic care, first-aid, and emergency care.
The policy on the use, access and inventory of Narcan states the center must stock and
inventory of NARCAN for emergency treatment of a known or suspected opioid overdose. The
center stores NARCAN in their medication cart which is accessible to the registered nurse and
non-healthcare supervisory staff. Each staff with access to Narcan has been trained on when
and how to use it and it is inventoried by a licensed nurse weekly. Training sign in logs were
reviewed to ensure compliance.
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Office of Accountability and Program Support Page 38 of 54 (Revised July 2023)
Four of the seven interviewed youth stated they would rate the medical care at this center very
good, with one youth rating it good, and two youth rating it as fair. Each of the seven interviewed
staff stated they are able to call 9-1-1 if needed.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion requirements
concerning off-site care/referrals. Three out of seven youth required off-site care for which the
Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR. All off-
site care was also documented on the Episodic Care Log. Parental/guardian notifications were
made for each youth and documented in the IHCR. Discharge documents were filed in each
youth’s IHCR and the designated health authority (DHA) reviewed the discharge instructions,
findings, and care rendered within seven days from the incidents by evidence of signature and
date. All three youth received non-emergent off-site care. None of the three youth receiving off-
site care required follow up testing, referrals, or appointments. The nurse stated any off-site
care appointment or treatment is tracked in the episodic log. The DHA is contacted upon the
youth’s return to the center regarding outcomes and instructions. The DHA will review and sign
all off-site medical documentation during next on-site weekly shift. Nursing staff track any follow-
up appointments.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for chronic
conditions/periodic evaluation requirements. Three youth were identified on the Medical/Mental
Health Screening forms for having a chronic condition. None of the seven youth had a
communicable disease. None of the seven youth were taking prescribed medication on an on-
going basis. One youth was undergoing treatment for a physical health condition. Three of the
seven youth were classified with a Medical Grade of 2 through 4. One youth was identified as
pregnant and placed on the chronic conditions list. Two of the three applicable youth had a
periodic evaluation which was documented and found in the progress notes section with proof
the review was conducted. The third youth had been at the center for several weeks and had
not received a periodic evaluation at the time of the annual compliance review. None of the
youth were identified as taking anti-tuberculosis medication. None of the youth required an
evaluation by off-site care. The Department’s Problem List was updated in accordance with
Florida Administrative Code for the three applicable youth. The designated health authority
(DHA) was interviewed and stated all youth with chronic conditions are seen for evaluations for
chronic conditions every ninety days or sooner if needed. The DHA also reported each youth
with a chronic condition is discussed at their weekly clinic meeting to ensure appropriate
tracking and appointment scheduling.
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Office of Accountability and Program Support Page 39 of 54 (Revised July 2023)
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication management
requirements. Three of the seven youth were taking medication at admission and the
medication was verified prior to being admitted into the center. Prescription verifications for all
three youth were completed utilizing the Prescription Medication Verification Checklist form. The
physician and psychiatrist were notified and an order to continue the medications was made.
For the youth who entered on psychotropic medications, the psychiatrist was notified within
twelve hours of admission and an order was obtained to continue the current prescribed
medication, documented on a Practitioner Order form. The three prescription verifications were
noted in the progress notes, IHCR, and Electronic Medical Record (EMR). None of the seven
reviewed youth were in restricted housing during medication administration hours. Four of the
seven youth were given over-the-counter (OTC) medications which were not listed on the
Authority for Evaluation and Treatment (AET) form. Each of the four youth utilized a standard
Department Medication Administration Record (MAR) in the EMR. All four of the youth’s MARs
clearly indicated medication start and stop dates. None of the four youth received a medication
by a trained non-healthcare staff after hours when a licensed staff was not on-site. No lapses or
errors in medication administration were noted. Side effect monitoring and documentation was
noted on all four youth MARS. One of the seven youth refused a medication which was
documented by a “R” on the MAR with the youth’s initials found under the “R” indicating refusal.
All three refusal forms were found in the youth’s IHCR indicating the date of the refusal,
medication refused, reason for refusal, the youth’s signature, date, and staff signature with date.
Each of the four youth’s MARs contained all required elements to include the youth’s name,
Department identification number, date of birth, youth allergies, precautions, Medical Grade,
medical alerts, and current picture of the youth attached. All four MARs documented medical
staff assisted in medication administration and each instance was found to have the staff initials
and youth’s initials for each medication given. None of the four youth required parenteral
medication. Three of the seven youth entered on psychotropic medications and, for each youth,
the psychiatrist conducted an initial diagnostic psychiatric interview with the youth within
fourteen days of admission. Two of the three youth received medication monitoring by the
psychiatrist every thirty days, as required. The third youth had not been at the center for thirty
days as of the date of the annual compliance review. The center’s medical department reported
there are no standing orders, pro re nata orders, or emergency treatment orders for
psychotropic medications. A medication pass was observed. Medication administration was
completed by the licensed medical staff. Youth were escorted to medical by the juvenile justice
detention officer (JJDO). The youth approached the nurse station individually. The medical
provider identified themselves and prepared the medications for each youth as prescribed. The
allergy and alert status were verified on the MAR. Each youth initialed for their medication after
receiving it and the nurse indicated they have given the medication by initialing. A mouth check
was completed to ensure the youth had swallowed the medication. The nurse stated non-
healthcare staff can administer medication if they are trained. The latest training was conducted
by a licensed nurse on September 30, 2024, and the training log and names of trained staff
remain in a binder in the medical clinic area.
Four of the seven interviewed staff indicated they do not give medications and three stated they
did give medications to youth. Two out of seven interviewed youth stated the nurse administers
medications, five stated they do not take medications. The nurse indicated the disposal process
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Office of Accountability and Program Support Page 40 of 54 (Revised July 2023)
for any medications included the proper logging and disposal through a return to the pharmacy
or the utilization of the RX Destroyer. This system is monitored and verified by the DHA and
clinic manager.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The medical office, including where sharps and medications were maintained, was found to be
neat, clean, organized, and inaccessible to youth. Medical equipment classified as sharps was
found secured and inventoried utilizing a routine perpetual inventory descending count as each
sharp was utilized or disposed of in the medical clinic. Three sharps were reviewed and counts
of the items matched the ending inventory numbers. All medications were identified and secured
in the locked area designated for storage of medications inside the medical office. The
medication cart was found to be clean and organized with stock items separate from youth-
specific medications. All medications were stored in a separate, secured area, inaccessible to
youth. Narcotics and other controlled medications were stored behind two locks. No oral
medications were stored with topical medications. Medications requiring refrigeration were
found inside a secured refrigerator labeled “Medication Only”. For youth on controlled
medications, a perpetual shift-to-shift inventory count was conducted and documented on the
youth’s individualized Controlled Medication Inventory Record. Non-healthcare staff were
trained in the delivery and oversight of medication self-administration when nursing staff are not
on-site. This training was delivered by a registered nurse. Three controlled medications samples
were reviewed with no discrepancies and counts matched ending counts. Three OTC
medication samples were reviewed with no discrepancies and counts matched ending counts.
Perpetual weekly inventories of all sharps and OTC medications were observed. Observations
of inventories conducted confirmed the center’s medical staff conduct inventories of medications
and sharps as required. The procedure for reporting inventory discrepancies states any
medication inventory discrepancy shall require notification to the superintendent and the
Department’s Central Communications Center (CCC). Medical staff are responsible for all
disposal of medications, along with the pharmacy consultant. Each disposal will be inventoried
prior to destruction, with the pharmacy consultant present. Destruction of medication is
completed utilizing the RX Drug Buster. The nurse was interviewed and stated all outdated
medications are removed and securely stored in a quarantine area. Disposal utilizing the RX
Drug Buster is completed at least monthly in the presence of the pharmacy consultant. All
disposals are documented in the Destroyed Medication Log.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 54 (Revised July 2023)
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for infection control,
exposure control, and education requirements. Six of the seven reviewed youth received
infection control training on admission to include hand-washing techniques, universal/standard
precautions, prevention/transmission of communicable disease, vaccinations, and the Center for
Disease Control and Prevention (CDC) guidelines for infection control. The Exposure Control
Plan was written in accordance with Occupational Safety and Health Administration (OSHA)
guidelines and included a risk assessment listing job classifications in which staff have the
potential for occupational exposure, including tasks and procedures which would cause staff in
specific job classifications to have an occupational exposure. A method of compliance outlining
infection control practices and engineering and work practice controls was also found in the
plan. Infection control procedures in place included prevention, containment, treatment, and
reporting requirements related to infectious diseases, according to OSHA and the CDC
guidelines. Infection control procedures included all required elements such as common
infectious diseases of childhood, the common cold, viral or bacterial infections, tuberculosis,
Hepatitis A, B, or C, human immunodeficiency virus (HIV), other outbreaks or epidemics caused
by any other infectious agent, pediculosis and or scabies, food-borne illnesses, chemical
exposure, bio-terrorist agents, and Methicillin-Resistant Staphylococcus Aureus (MRSA). The
facility operating procedure containing the inflection control plan includes processes for needle
stick post-exposure evaluation. Hepatitis B immunizations are made available for staff. All staff
have access to protective equipment. The registered nurse stated there have been no instances
in which infectious diseases and sexually transmitted infections needed to be reported to the
local health department as required or the Department’s Central Communications Center
(CCC). There were not three or more cases of reportable infectious diseases which needed to
be reported to the local health department and/or CDC. There were also no hospitalizations or
quarantine of at least ten percent of the total population for youth or staff. The superintendent
was interviewed and stated a separate file is maintained containing all documents for youth and
staff who have experienced facility/occupational exposure for a ten-year period as required.
Seven staff training records were reviewed. Five of the seven staff received pre-service or in-
service training on the center’s specific Exposure Control Plan by the clinic manager as noted in
the nursing interview results and as found in the staff’s training records.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
One reviewed youth was identified as pregnant at the center at the time of the annual
compliance review. Two additional youth records were provided to review prenatal care and
education. All three youth received prenatal care immediately upon determination the youth was
pregnant at admission. Two of the three youth received routine, focused medical evaluations
every thirty days or sooner, if ordered. The third youth had not been at the center for thirty days
at the time of the annual compliance review. Prenatal care was provided at recommended
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Office of Accountability and Program Support Page 42 of 54 (Revised July 2023)
intervals for the two applicable youth. All three were placed on an internal alert system for vital
nutrition and health awareness for staff along with an alert in the Department’s Juvenile Justice
Information System (JJIS). An alert was entered into the center’s internal alert system for
sleeping arrangements for two youth and a doctor’s order was written for the third youth. None
of the youth had complaints or issues during their stay nor were daily monitoring for danger
signs of pregnancy complications warranted. The one applicable youth had a documented plan
for post-birth psychological and physical care. Education for all three youth, which was
conducted by a licensed staff, was found in the youth’s Individual Healthcare Record (IHCR)
under the education tab to include alcohol and drug use, smoking, nutrition, sexually transmitted
infections, contraception, prenatal care, birthing process, postpartum care, basic baby care,
child/infant development, and parenting skills. The youth received nutritious food and
appropriate servings as ordered by the designated health authority (DHA). Two of the three
youth received routine monitoring for nutrition and weight status, the remaining youth did not
require/have an active order for this monitoring. In-service training was found to include
observation and monitoring of emergency care needs/symptoms for possible miscarriage and
has nursing protocols and treatment in place for pregnant youth. Staff training records were
reviewed to ensure compliance.
The nurse indicated each female is offered screening for pregnancy at admission. Prenatal
services begin immediately upon determination and the DHA will monitor the pregnant youth at
the minimum of once every thirty days. Nutritional and sleep accommodations are ordered and
weight and nutrition are monitored by healthcare staff. Off-site obstetrician appointments will be
managed by the center’s healthcare staff and all documentation is reviewed by the DHA. A
licensed healthcare staff will be responsible for providing in-service training to all nonhealthcare
staff regarding pregnant youth and cover all required topic areas.
Seven youth were interviewed. None of the interviewed youth stated they had received prenatal,
obstetrical, or gynecological services at the center. All seven interviewed youth stated they did
not need these services.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 43 of 54 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures to ensure youth are actively supervised by staff.
During the annual compliance review week, staff were observed maintaining appropriate
positioning with continuous sight supervision of all youth in their assigned area during
education, meals, transportation, and line movements. All movements are authorized by master
control prior to the youth being moved. A review of the center’s logbooks during the annual
compliance review period confirmed all movements were logged and counts were conducted
consistently. Facility staff adhered to the daily activity schedule. The center staff were
interacting appropriately with the youth. Seven staff were interviewed, and four stated there
were enough staff to provide adequate supervision, and three stated even though the facility
only has three vacancies, there were not enough staff at the moment due to the center being
overpopulated.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) detailing the behavior management system
(BMS) to ensure the safety and security of youth and staff. During a walkthrough of the center,
BMS posters were observed throughout the building where youth may be able to review. These
posters clearly specified rules, norms, and expectations. The center provides a BMS which
includes incentives for positive behavior and consequences for inappropriate behavior. The
BMS includes the use of a three-tiered level system where youth are given the opportunity to
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Office of Accountability and Program Support Page 44 of 54 (Revised July 2023)
earn points by meeting required expectations. Seven staff were interviewed, and each was able
to explain the BMS, including a point and level system. In addition, each staff confirmed the
youth receive several incentives and believes the center’s BMS is effective. All seven staff
stated each youth who earns their level receives incentives for positive behavior including
canteen, later bedtimes, meal with administration, and special events. All seven staff stated they
speak with youth to discuss the consequences being imposed and youth are given an
opportunity to explain their behavior and discuss alternative acceptable behaviors. None of the
staff reported they have seen a staff encourage a youth to beat up another youth or had a
youth’s basic rights taken away. Six interviewed staff stated they received implementation of the
BMS feedback daily, and one staff stated weekly. This feedback is provided to staff in briefings,
emails, trainings, and one on ones. An interview with seven youth found three youth rated the
BMS as being very good, three stated it was fair, and one stated it was very poor. Seven youth
also stated they receive rewards such as canteen, treasure chest, extra activities, telephone
calls, and a meal with administration. Six of seven youth stated all staff use rewards the same,
staff are fair, and give all youth the same rewards, and one youth disagreed. Seven interviewed
youth stated they are not allowed to punish other youth. Five youth stated they have never been
sent to their room for punishment reasons, two youth stated they had been sent to their room for
punishment before, and the door was shut and locked. All interviewed youth stated they did not
witness handcuffs or leg irons used on out-of-control youth. The superintendent was interviewed
and stated the center uses a uniform BMS with predictable awards, privileges, and
consequences for behavior. It is a three-level system which tracks youth behavior. Regardless
of the level, all youth receive their basic rights.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures requiring ten-minute checks to be conducted
when youth are in their rooms. The center has sixty-four surveillance cameras, with sixty-three
being operational during the week of the annual compliance review. The inoperable surveillance
camera is located in the recreation yard and a replacement has been requested. The
surveillance cameras have a thirty-day recording capacity. An electronic wand system is used in
the center to document and collect data of the ten-minute visual checks. Staff tap an electronic
wand on the checkpoint sensors on the outside of each youth’s assigned sleeping room door
and the data is downloaded as wand reports. A review of video in comparison with wand checks
was completed for nine time periods on each youth module, which revealed staff conducted ten-
minute checks as required with the exception of two late checks, one by one minute and one by
two during showers. Staff were observed looking into the windows of each sleeping room before
tapping the wand to the checkpoint sensor. Facility administration provides management
oversight by conducting weekly reviews of ten-minute checks to ensure fidelity. This oversight is
documented in SharePoint. Seven staff were interviewed, and all indicated room checks are
conducted every eight to ten minutes when a non-suicidal youth is placed in their room. The
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 45 of 54 (Revised July 2023)
superintendent interview confirmed all youth on standard supervision are checked every ten
minutes to ensure the youth are safe and not trying to harm themselves.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains facility operating procedures to address census, counts, and tracking
which require staff to know the exact number and location of all youth under their supervision at
all times. A review of logbooks for one day each month during the annual compliance period
indicated counts were conducted at the beginning of each shift, prior to and following routine
group movement, anytime a population change occurred, randomly at least once on each shift,
for regular head counts, and during youth movements. Observations conducted during the
annual compliance review week confirmed master control conducted all required headcounts
and documented them in the logbook. Seven staff were interviewed, all of whom stated
emergency counts were conducted if a youth is believed to be missing, when visibility is
hindered such as during an electrical outage, after drills, and following major disturbances.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 46 of 54 (Revised July 2023)
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has a facility operating procedure outlining the use of logbooks to maintain a
chronological record of events, incidents, and activities. The center has separate logbooks for
master control and each living module, visitors, and vehicles. A review of twelve logbooks found
seven were bound with numbered pages, and five logbooks had loose or detached covers,
however, all pages were accounted for. All entries in the logbooks were legible and written in ink
with no erasures or whiteout areas. A few errors only had a single strike-through without the
staff initials and the word “void”. A review of logbooks for three full days each month during the
annual compliance review period found counts were conducted and documented at the
beginning and end of each shift, prior to and following any movement of youth, at least once
randomly during the shift, any time the population changed, and following routine group
movement. Observations during the annual compliance review week showed there was no
youth movement until master control confirmed the count. Entries included the date and time of
the event, name of the staff and youth involved, a brief description of the event, and the initials
of the person making the entry. Documentation included highlighted entries for special needs,
mental health alerts, the opening and closing populations, and emergency situations including
drills. Admissions and releases, line movements, and names of youth placed in confinement
were documented, including the time confinement began and ended. When education was
provided in the facility classrooms, documentation was accurate to the daily schedule; however,
if youth had classes in the living areas, staff were not consistent with documenting when the
education staff entered and departed making it difficult to track. Seven staff and seven youth
were interviewed, and all stated the center’s daily activity schedule was followed with minimal
interference. The juvenile justice detention officer supervisor (JJDOS) reviewed the logbooks
each shift, including the master control logbook, when accepting the shift, to document they are
aware of current relevant situations in the center. The juvenile justice detention officers (JJDOs)
assigned to each living module reviewed the module logbook upon accepting the shift. The
superintendent or one of the assistant superintendents reviewed logbooks weekly approximately
eighty-five percent of the time.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 47 of 54 (Revised July 2023)
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures describing the center’s key control process,
issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys,
and reporting and replacement of damaged keys. When detention staff enter the center, their
personal keys are to be secured in lockers on the non-secure side of the center and issued a
facility key set during shift briefing. These keys are then documented by the supervisor in the
shift report located in SharePoint. Visitors, kitchen staff, and contracted staff have personal keys
secured in master control. Kitchen staff and contracted staff then receive a facility key set from
master control and master control documents this in a key log. An observation during the week
of the annual compliance review and an informal interview with the center’s master control staff
revealed the facility keys are stored on a tamper-resistant key ring which prohibits the removal
of keys and is color coded specific to the position to which the keys are assigned. These keys
are secured in master control and in the supervisor’s office. Keys are consistently checked and
maintained by supervisors and above. Staff were observed always carrying the facility keys on
their person during the week of the annual compliance review and youth did not have access to
facility keys. In addition, an informal interview with the master control staff and shift supervisor
validated youth has no access to facility keys. The center maintained a master key inventory
located in the superintendent’s office which accounts for all key rings by ring number, the
number of keys on each ring, and the capability of each key. Emergency keys which provide
egress through exterior doors are also stored in the superintendent’s office. A review of the
master key control inventory confirmed the inventory report matched the actual key rings in use.
Five keys were randomly selected and compared to the inventory and key log. Two of the five
key sets were missing a key; a water key, and a cuff key. An interview with the maintenance
mechanic stated the keys broke, and the sets were resecured on new key hubs and the chits
and inventory had not been changed. The keys carried by three staff were examined and one
set had an extra key on it not indicated by the chit, this key hub was also intact. The
maintenance mechanic stated one set belonged to admin and an extra key was needed, the key
was added and resecured on a new key hub, however, the chit and inventory had not been
changed. These three staff were also questioned and able to indicate the function of each key.
No reports to the Department’s Central Communications Center (CCC) have been documented
for missing keys during the scope of the annual compliance review. Seven staff were
interviewed and stated the restricted keys are for medical or mental health records and case
management records. Each staff reported they knew the key control process and were able to
explain the process for missing and/or broken keys. The superintendent stated they are
responsible for authorizing permanent key assignments, and this is reflected by a signature on
the key inventory. Permanent keys are assigned to the maintenance mechanic, administrative
assistant, facility training coordinator, captains, and the superintendent.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 48 of 54 (Revised July 2023)
5.07 Vehicles and Maintenance Failed Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains a facility operating procedure for transportation, operation, and
maintenance of each vehicle, which is used to transport youth. The center has a total of eight
vehicles. One van does not transport youth and is considered the maintenance van and one van
was at the shop at the time of the annual compliance review. All seven applicable vehicles were
checked to ensure they were locked and all were locked. Each vehicle which transports youth
had an annual safety inspection conducted by a certified automobile mechanic. Documentation
to confirm monthly visual checks to include water coolant, lights, brakes, horn, interior/exterior,
tires, battery, windshield and windshield wipers, windows, mirrors, damage, and cleanliness
records were not provided for the annual compliance review period. Five out of twelve
SharePoint monthly vehicle inspections were entered. All vehicles have the appropriate number
of seatbelts, a seatbelt cutter, and a window punch. Four of the six vehicles had a fire
extinguisher; however, all four fire extinguishers were expired. A first-aid kit with approved items
by the designated health authority (DHA) is checked out for transport from master control. A
binder is maintained for each vehicle which contains the vehicle mileage log, gas card, and
vehicle registration. Seventeen vehicle logbooks were reviewed. Six out of seventeen logbooks
reviewed did not have the number or names of youth and staff involved in the transport. None of
the seventeen logbooks acknowledged the vehicle was inspected for contraband before or after
transport. Observations of one youth transported to court conducted by two facility staff during
the annual compliance review week. An administrator with a Department-issued cellular
telephone was on the transport so a facility mobile telephone was not necessary, however, a
mobile telephone is available for transport from master control. Seven youth were interviewed,
and all indicated they feel staff drive safely during transports and none of the youth ever
observed anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains a facility operating procedure detailing the requirements for tool inventory
and management. All tools are stored in a locked area when not in use. Observations confirmed
maintenance tools and kitchen sharps are secured when they are not in use. A perpetual tool
inventory list is maintained by the center and inventoried by the maintenance mechanic.
Documentation and an informal interview with the maintenance mechanic also indicated there
were no missing or damaged tools. A review of five tools in the maintenance office was
completed. Observations confirmed each tool was secured, was marked for easy identification,
the inventory accurately reflected the number of tools, and the inventory was signed by the
superintendent/designee. An itemized inventory of kitchen equipment is also maintained. All
kitchen sharps are inventoried twice daily and all kitchen inventories are uploaded in SharePoint
on a weekly basis. No service vendors were observed during the week of the annual
compliance review. An informal interview with the maintenance mechanic indicated all service
vendors are identified prior to entering the secure area of the center and are accompanied at all
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 54 (Revised July 2023)
times. Youth are removed from the area being serviced and are not allowed to re-enter the area
until it has been searched and cleared by center staff. The vendor checks for all their tools to
ensure they leave with the tools they entered into the center with. Seven staff were able to
explain the process when there are missing or damaged tools by reporting, removing a
damaged item, and securing it until repaired. During an interview with the superintendent, it was
confirmed only maintenance staff and administration have access to facility tools. The center
also maintains a policy and procedures prohibiting youth from having access to any tools,
including kitchen and/or medical equipment. Youth are allowed to use cleaning items such as
mops and brooms when completing general cleaning. Youth are under staff supervision when
these items are in use. Seven interviewed youth indicated they only use mops and brooms.
Seven interviewed youth all stated they do use cleaning agents, however, they are not allowed
to handle the cleaning agents.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center maintains a facility operating procedure to ensure the proper inventory and limited
access to flammable, toxic, caustic, and poisonous items. Five chemical items were reviewed
on-site during the week of the annual compliance review for which the center maintained a
corresponding SDS, and complete and accurate inventories. Flammable, toxic, caustic, and
poisonous items were observed to be stored securely in areas inaccessible to youth. Seven
staff and seven youth were interviewed, and all stated youth are not allowed to clean with
flammable, toxic, caustic, and poisonous items. These Items can only be used by authorized
staff. No toxic materials were observed at the center in any place accessible to youth during the
week of annual compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 54 (Revised July 2023)
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) addressing the proper use, storage, and
disposal of flammable, toxic, caustic, and poisonous items. The maintenance mechanic reported
in the event a chemical is to be disposed of it is done in accordance with the FOPs. The center’s
maintenance mechanic also reported the center does not utilize grease for cooking and all
kitchen liquid waste is disposed of in the kitchen drain. A log confirmed medical sharps and
waste are disposed of through a contracted medical waste disposal company. No disposal of
chemicals could be observed during the annual compliance review week. The superintendent
and the maintenance staff reported the center has not experienced any chemical spills or leaks
during the annual compliance review period.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures (FOPs) ensuring confinement under twenty-four
hours are used as an immediate, short-term response to incidents which affect the physical
safety of youth or others. The center utilizes youth sleeping rooms for confinement. The center
had 821 instances of confinement under twenty-four hours during the annual compliance review
period. Fifteen confinement reports were reviewed. Confinement reports for each confinement
confirmed all rooms were searched prior to youth being placed in confinement, all non-fixed
items were removed from the room, and each documented approval by a juvenile justice
detention officer supervisor (JJDOS). Observations of the confinement rooms indicated some
windows were scratched, however, this did not interfere with visual checks. All youth had
access to mental health and education, as needed, and each youth showered and was given
clean clothes if in confinement during this time except in two incidents where a shower was not
documented on the Visual Observation Report (VOR). All youth were notified they could grieve
the situation of being placed in confinement. All fifteen confinement reports were completed
before the end of the shift. Documentation showed fourteen of the fifteen confinements had five-
minute checks conducted for the first hour for each confinement. One confinement had checks
every ten minutes for the first hour of confinement. Each reviewed report indicated a JJDOS
conducted an initial confinement review with the youth within one hour from the incident except
for one. A JJDOS evaluated each youth every three hours and documented the need for
confinement. Each report indicated the youth were released from confinement within twenty-four
hours. Each of the twenty confinement reports indicated the superintendent or designee
reviewed the confinement report within forty-eight hours. There were no pregnant youth
confined during the annual compliance review period. None of the reviewed youth confinement
records had any notation of physical injury, youth complaint of injury or illness, a known chronic
health condition, or experienced an injury which would have required a healthcare professional
to be immediately notified for timely assessment and treatment. Seven staff were interviewed.
All were able to explain the key components of the confinement process. The superintendent
also stated the use of confinement is only used as an immediate, short-term, crisis management
strategy for use during situations in which one or more youths’ behavior imminently and
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 54 (Revised July 2023)
substantially threatens the physical safety of others or compromises security. The
superintendent and assistant superintendents review all confinements to determine if
confinement was appropriate or not appropriate.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinement reports over twenty-four hours during the annual
compliance review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains a facility operating procedure to manage various emergencies and
disaster events. Each of the two required drills during the annual compliance review period were
conducted, as required. Documentation confirmed the center conducted hurricane drills on April
30, 2024, and July 31, 2024. Written scenarios, drill forms, copies of logbook pages, Delegation
of Authority, Cooperative Agreements, Continuity of Operations Plan checklists, and emails
were used for documentation. Seven staff were interviewed and each indicated they have
participated in weather, escape, fire, mental health, and medical drills.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains a facility operating procedure to address escape drills and escape
prevention. The policy requires the center to conduct escape drills at least quarterly. Three of
the four required drills during the annual compliance review period were conducted, as required.
The documentation of the drills included scenarios, as well as the dates and times of the drills.
The drill documentation form included the signatures of the supervisory staff and the staff
coordinating the drill. Recommendations and critiques of the drills were included in each report.
A review of logbooks revealed each escape drill was documented in the logbook, as required.
All documentation was also uploaded into SharePoint and signed off by the superintendent or
designee. A review of seven staff training records in the Department’s Learning Management
System (SkillPro) validated each staff completed escape prevention training. Five of the seven
interviewed staff indicated they had participated in an escape drill in the past twelve months.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 54 (Revised July 2023)
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a disaster plan, fire prevention plan, and evacuation plan addressing fire
prevention and safety in the center. The center has evacuation egress plans posted throughout
the center. Each egress plan defined the primary and secondary exit route and the locations of
emergency equipment such as fire extinguishers and first-aid kits. The center’s disaster plan,
fire prevention, and evacuation plan were reviewed and approved by the local fire marshal.
Documentation verified the center conducts fire drills each month, on each shift. All
documentation is uploaded into SharePoint and signed off by the superintendent or designee.
Seven youth were interviewed and four stated they have been instructed on what to do in case
of a fire. Seven staff were interviewed, and all stated fire drills take place at least monthly.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) for search and contraband procedures.
Strip searches are to be conducted during admission if there is a reasonable suspicion a youth
is harboring contraband, and when deemed appropriate by the shift supervisor. All searches are
to be documented in the logbook. Staff are to wear gloves during all searches. Electronic
searches are conducted on all staff and visitors entering the facility. All shoes, bags, cases,
jacket pockets, and other items were searched. All personal keys, personal cellular telephones,
and other contraband items were prohibited from entering the secure area. All visitors sign an
Attestation form when entering the facility. These forms are then scanned and placed on the
facility K drive in a folder. Prior to admission, all youth are searched for contraband by electric
wand and strip searches, verified electronically using the Admission Wizard. No admissions
were observed during the annual compliance week. A frisk search was also observed during the
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Office of Accountability and Program Support Page 53 of 54 (Revised July 2023)
annual compliance week prior to a transport. The staff completing the search was of the same
gender as the youth and wearing gloves. The superintendent stated room searches are
conducted upon a youth’s release, prior to new youth being placed in a room, and searched for
contraband on each awake shift. A sampling of shift reports of one day from each month during
the annual compliance review period indicated room searches were completed during each
awake shift. Searches of all staff and visitors were observed prior to entering the secure area
every day of the annual compliance review week. Center staff completed Attestation forms and
training rosters were reviewed. Each of the seven staff records included the required training
and Attestation forms. There were no instances which may have compromised the safety and
security of the center throughout the annual compliance review week. There have been no
incidents of contraband reported during the year of annual review. The superintendent stated if
contraband is found, it is gathered by staff and if the contraband is illegal, law enforcement is
contacted.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 54 (Revised July 2023)

rule: Indicator 1.05

excerpt: Right Interactions (RI)

rule: Indicator 5.07

excerpt: Vehicles and Maintenance