summary: QI Detention - FY23-24 - 8 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Marion Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3040 NW 10th Street
Ocala, Florida 34475
Review Date(s): July 25-28, 2023
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:
Tara Gilligan, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeff Campbell, Office of Education, Education Specialist (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 1,
Staff Interviews)
LeAnn Gruentzel, Office of Accountability and Program Support, Deputy Supervisor (Standard
4)
Delmonica Harris, Duval Regional Juvenile Detention Center, Assistant Superintendent
(Standard 5)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 2,
Youth Interviews)
Peacena Samuels, Office of Accountability and Program Support, Regional Monitor (Standard
4)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Marion Regional Juvenile Detention Center MQI Program Code: 094
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Marion County / Circuit 5 Number of Beds: 60
Review Date(s): July 25-28, 2023 Lead Reviewer Code: 188
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
The following limited and/or failed indicators require immediate corrective action.
Limited Ratings Failed Ratings
2.1 Educational Access* 5.15 Confinement Over Twenty-Four Hours
3.1 Suicide Prevention Services * 5.17 Escape Drills
3.11 Suicide Precaution Observation Logs * 5.18 Fire Drills
5.05 Logbook Maintenance
5.14 Confinement Under Twenty-Four Hours
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 59 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 59 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 59 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Limited
3.11 Suicide Precaution Observation Logs * Limited
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 59 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 59 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Limited
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Limited
5.15 Confinement Over Twenty-Four Hours Failed
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Failed
5.18 Fire Drills Failed
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 59 (Revised July 2023)
Program Overview
The Marion Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Ocala, Florida. The center serves youth in Marion, Citrus, Hernando,
Lake, and Sumter counties in Circuit 5. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
sixty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Marion County School Board.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant, eight juvenile justice detention officer (JJDO) supervisors, and
thirty-one JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by one
designated mental health clinician authority (DMHCA), four licensed staff, one non-licensed
staff, one psychiatrist, and one psychiatric advanced practice registered nurse (APRN). 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 APRN, four registered nurses (RNs) including the supervisory RN, and two licensed
practical nurses (LPNs). The medical clinic maintains nursing coverage Monday through Friday,
from 7:00 a.m. to 7:30 p.m. and on weekends from 7:00 a.m. to 5:30 p.m. Food services are
provided by Department staff and include menus, meal planning, meal schedules, special diets,
nutritional analysis, daily allowance, food preparation, health certifications, food product
standards, sanitation, and cleaning. Staff are responsible for the custody and control of youth in
their care, providing youth supervision twenty-four hours a day, seven days a week. The center
has four living modules which are divided by male and female. There are ninety-two security
cameras at the center, of which eighty-eight were operational. The center was mostly clean, free
of insect infestation, and graffiti. The center was experiencing issues with properly working sinks
in the restrooms on one of the modulars which was not in use at the time of the annual
compliance review. Maintenance work orders have been submitted and are pending completion.
At the time of the annual compliance review the facility had sixteen JJDO vacancies.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 59 (Revised July 2023)
Strengths and Innovative Approaches
A local artist comes to the center on a bi-monthly basis and conducts a painting class with the
youth. Each youth receives a canvas, and the artist provides step by step instructions on
painting the selected picture. The youth are able to keep their paintings to bring with them when
released.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 59 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center had fifteen direct care staff, six volunteers, and four contracted staff, for a total of
twenty-five applicable records, who required background screenings since the last annual
compliance review. A background screening was completed on each staff, volunteer, and
contracted provider prior to contact with youth or confidential youth records. Two of the six
volunteers interacted with the youth intermittently less than ten hours a month; however, each
was background screened prior to youth contact. The criminal history report was reviewed for all
twenty-five records reviewed. None of the twenty-five records were applicable for requiring an
exemption. Five staff were applicable to a break in service as indicated in the Department’s
Staff Verification System (SVS) and all five staff received a new background screening. A pre-
employment assessment tool was administered to all fifteen direct care staff. Each of the fifteen
staff had a pre-employment assessment passing score documented in the staff’s personnel
record. The center added the four contracted staff to the Clearinghouse employee roster. The
Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the
Department on January 12, 2023, meeting the annual requirement. The teachers who are paid
by the school board, or have funding provided by the school board or Department of Education,
received an Annual Affidavit of Compliance with Level 2 Screening Standards which was
completed on January 11, 2023.
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.
Six staff were applicable for requiring a background rescreening. The five-year
rescreening/renewal for the six Department staff were completed every five years, calculated
from the agency hire date, and were not completed more than twelve months and no later than
ten days prior to the staff’s five-year anniversary date in all six records. None of the contracted
staff were applicable for requiring a five-year rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 59 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures which prohibit any form of abuse, profanity, threats
of any kind, and harassment. Seven staff records were reviewed for a staff Code of Conduct. All
seven records had a signed Code of Conduct in the record. One of the seven reviewed records
was applicable for disciplinary actions for violation of the Code of Conduct. Two additional
records were requested and reviewed. The management’s response in one record was
suspension and the remaining two received counseling. All responses were documented in the
staff record. None of the seven staff had documented commendations. Seven youth were
interviewed; one stated they never had to report abuse and five advised never being denied an
abuse call. One youth advised being denied an abuse call. The youth was offered a call and
declined. Five youth reported staff are respectful when speaking to youth and two advised staff
are not respectful. Four youth reported staff never use profanity, two advised occasionally, and
one stated often. Seven youth were interviewed if staff ever threaten youth and five youth stated
never, one stated once, and one stated occasionally. Six youth reported feeling safe at the
center and one advised not feeling safe. All seven youth stated they have never exchanged
emails, telephone numbers, or social media information with staff. The center was advised of
the youth concerns and advised the Code of Conduct would be addressed during shift
debriefing. Seven staff were interviewed and each was able to explain the process for allowing
youth to make a call to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC), if the youth is eighteen years of age or older, regarding suspected abuse at the
center. Four staff stated they have never observed another staff using profanity when speaking
to youth, one stated once, and two stated occasionally. The superintendent advised the Code of
Conduct would be addressed during shift debriefing. All seven staff advised never hearing
coworkers using threats, intimidation, or humiliation when speaking with youth. Six staff stated
the working conditions at the center are fair and one stated very good. The interviewed
superintendent stated the Code of Conduct prohibits any form of abuse, threats, harassment,
profanity, intimidation, or personal relationships with youth. Staff shall receive disciplinary
actions if a violation occurs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 59 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
There were fifty-five incidents reported to the Department’s Central Communications Center
(CCC) within the annual compliance review period. Six incidents were reviewed and all were
reported to the CCC within two hours of the center becoming aware of the incident. A review of
the logbooks revealed five of the six incidents were documented. A review of seven youth
records and logbooks did not indicate additional incidents which needed to be reported to the
CCC. The superintendent explained the center’s incident reporting process (CCC/Florida Abuse
Hotline). Staff are to complete an incident report in the Department’s Juvenile Justice
Information System (JJIS). If there are any allegations of abuse, the youth are given an
opportunity to call the Florida Abuse Hotline. Administration or a supervisor are required to
report the incident to the CCC within two hours of becoming aware of the incident.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center has facility operating procedures which outline the center’s use of physical
intervention techniques in accordance with the Florida Administrative Code. The center had
sixty-four Protective Action Response (PAR) incidents during the annual compliance review
period. Nine reports were reviewed and each was completed by the end of the staff’s workday
and included statements from all staff involved. None of the reviewed reports resulted in serious
injury or included any allegations of abuse from the youth. All nine reports were reviewed by a
supervisor or a PAR instructor and included a post-PAR interview, which was conducted by the
administrator. None of the nine required a PAR medical review or utilized mechanical restraints.
The superintendent reviewed all nine reports within seventy-two hours. No additional PAR
incidents were discovered or not documented during the annual compliance review week. The
center’s PAR rate during the annual compliance review period was 2.76, which is below the
statewide Detention PAR rate of 17.73. Seven staff were interviewed and advised youth are
counseled prior to the utilization of physical restraint. The superintendent was interviewed and
advised the mechanical and physical restraints are secured in sub-control. A designee shall
conduct an interview with the youth thirty minutes after the incident. If any findings in the post-
PAR interview require medical, a PAR medical review shall be conducted. A review of the PAR
Report shall be conducted by a certified PAR instructor/supervisor staff. An administrator shall
review the PAR incident within seventy-two hours of the incident, excluding weekends and
holidays.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 59 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
Seven staff training records were reviewed for pre-service training. Each staff was certified
within 180 days of hire. Each of the seven staff completed Phase One training at the center and
Phase Two training at the academy. None of the reviewed staff were applicable as a rehire. All
staff completed the required trainings prior to contact with youth. All trainings were documented
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.
Seven staff training records were reviewed for in-service training. Training hours ranged from
twenty-nine to 109 hours. All seven staff completed cardiopulmonary resuscitation (CPR), first-
aid, automated external defibrillator (AED), mental health and substance abuse, emergency
care plan, infection control training, exposure control plan, escape prevention, fire
prevention/disaster procedures, and eight hours of Protective Action Response (PAR). All seven
staff completed sexual harassment within the last two years, as required. Six of seven staff
completed Prison Rape Elimination Act (PREA). Five of seven staff completed active shooter,
human trafficking intervention, information security awareness, professionalism and ethics, and
trauma responsive practices. Three staff completed all six required hours of suicide prevention.
The remaining three staff completed four hours of instructor-led suicide awareness and
prevention; however, the three staff were missing the two additional hours of SkillPro training.
Three supervisory staff were reviewed. One supervisor completed one-half hour of the required
eight hours of additional yearly training. The two remaining supervisors did not complete any
additional supervisory training. One of the seven reviewed staff was missing eight and one staff
was missing seven of the required yearly in-service trainings. Upon discovery of the missed
trainings in 2022, the superintendent completed disciplinary action in March 2023 for both staff.
A licensed nurse provided in-service education on girls’ healthcare annually to all non-
healthcare staff involved in the supervision or treatment of female youth which included
monitoring, observation, and emergency care of pregnant youth. The list of in-service trainings
was approved by the Department’s regional director which included course names, descriptions,
objectives, and training hours for any instructor-led training based on the above topics on April
7, 2022. The center maintains an annual in-service training calendar, which is updated as
changes occur. The superintendent indicated they received training in certified public manager
(CPM), leadership development, hiring, de-escalating emotions, equal employment opportunity,
and labor law management. Training is required for all staff including Protective Action
Response Right Interactions model, first-aid, and cardiopulmonary resuscitation.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 59 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures for the grievance process. The grievance forms
were observed during a tour of the center in areas which were easily accessible to youth. The
superintendent was interviewed and advised of the grievance process. In the informal phase,
the juvenile justice detention officer tries to resolve the complaint with youth using
communication skills. In the formal phase, the youth is provided a grievance form upon request
and submits a written grievance. A supervisor shall respond prior to the end of their shift, if
possible, or within twenty-four hours. The completed grievance is given to the supervisor within
two hours, the supervisor shall document any findings on the grievance form and advises the
youth if any actions are to be taken. The superintendent or designee reviews the completed
grievance form within seventy-two hours, excluding weekends and holidays, and shall make
corrective actions, if necessary. The superintendent's decision is final, and the youth must sign
the hard copy of the grievance. All grievances are uploaded in the Department’s Juvenile
Justice Information System (JJIS). Seven youth were interviewed and each was able to explain
the process and advised grievance forms are available. Seven staff were interviewed and each
was able to provide the steps related to the grievance process. The center had one grievance
for the annual compliance review period. The one reviewed grievance was resolved in the
formal phase and the youth was provided a response within the required time frame.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 59 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
Seven youth records were reviewed for alerts in the Department’s Juvenile Justice Information
System (JJIS). A total of twelve alerts were reviewed for the seven youth. All alerts were
appropriately entered into JJIS on the date each was identified. All twelve applicable alerts
included the name and title of the staff entering, removing, or updating the alert. All alerts were
documented in the logbooks. All the dates were entered on the same date the alert was
identified and matched the internal alert system. The JJIS alerts are reviewed daily by the
supervisors and administration. Information is shared through meetings, an alert roster,
logbooks, and shift debriefings. The shift supervisor was observed issuing the alert rosters to
staff and reviewing the youth who have alerts. Alerts are entered into JJIS and the information is
shared with administration and supervisors. The information is updated on the master control
alert board, internal alert system, and food service alert board. An interview with the
superintendent confirmed the process, which upon completion of admission, the juvenile justice
detention officer shall ensure all critical and special alerts are entered in JJIS. The supervisor
reviews the admission to identify youth with medical alerts and medical staff shall review alerts
to ensure each alert is correctly managed. Seven staff were interviewed, and all advised the
information is shared through logbooks, shift debriefing, meetings, and internal alerts.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 59 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has facility operating procedures and practices for utilizing data in decision-making
practices, including the review and analysis of data. The administration utilizes the Detention
Statewide Dashboard daily to manage trends in the center. The administration discusses
confinements, vacancies, incidents, and physical restraints during monthly meetings to improve
the day-to-day operations. Data collected is shared among administrators and with staff during
monthly meetings to proactively make policy, practice, and programming changes designed to
foster system and center improvement.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 59 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures in place to ensure proper screening, evaluation,
and documentation of each youth; ensuring all youth are admitted into the center in accordance
with Florida Administrative Code. A review of seven Admission Wizard forms from the
Department’s Juvenile Justice Information System (JJIS) found documentation of a Detention
Risk Assessment Instrument (DRAI), Suicide Risk Screening Instrument (SRSI), and an arrest
affidavit or order to retain the youth in custody for each youth. Reviewed documentation
confirmed all seven youth had a full body visual search and/or electronic search by a staff of the
same sex. Each youth’s case management record documented all youth received a telephone
call and were evaluated for medical, mental health, and substance abuse needs upon
admission. Four of the seven reviewed youth were applicable and offered a meal, due to
admission being completed two or more hours prior to the next scheduled meal. An observation
of a youth admission process was completed during the annual compliance review week, which
followed all required procedures, including offering the youth something to eat and a telephone
call to their parent/guardian, both of which were refused.
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Office of Accountability and Program Support Page 18 of 59 (Revised July 2023)
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures to ensure each youth admitted into the center is
informed of the center rules and regulations, grievance procedures, visitation, telephone calls,
available medical, mental health, and substance abuse services and how to access them, how
to access the Florida Abuse Hotline or the Department’s Central Communications Center for
youth eighteen years of age or older, expectations for behavior, related consequences for failing
to meet behavior expectations, youth rights, and Prison Rape Elimination Act (PREA) related
information within twenty-four hours of admission. Seven youth case management records were
reviewed and each included an orientation packet which was completed within twenty-four
hours of admission. Each orientation packet included the aforementioned required information.
Each of the seven reviewed case management records had an orientation acknowledgement
form signed by the youth. Seven youth were interviewed regarding the orientation process and
four of the seven indicated they had been provided information regarding the center’s rules and
regulations, daily schedule, education services, visitation, abuse reporting, and behavior
management system. Three youth stated they did not recall if the information was explained;
however, further investigation revealed documentation confirming all interviewed youth signed
an acknowledgement form when their orientation was completed and the information was
relayed during admission. An admission and orientation were observed during the week of the
annual compliance review. This observation confirmed orientation is conducted, as required.
The required orientation videotape detailing PREA guidelines was included in the orientation
process.
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Office of Accountability and Program Support Page 19 of 59 (Revised July 2023)
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures ensuring all youth admitted into the center are
classified to ensure the highest level of safety and security. The center’s procedures listed all
the required considerations, including human trafficking information. All youth are given a room
assignment based on their classification and may be reclassified if there are any changes in
the status or behavior; however, no reclassifications were noted in the seven reviewed records.
The center reviews several factors prior to placing the youth into a room inclusive of height,
weight, age, gender, level of aggression, mental illness, intellectual disabilities, physical
disabilities, history of violent behavior, gang affiliation, criminal history, history of sexual
offenses, vulnerability to victimization, medical, identified suicide risk or suspected risk, and
security and escape risk. Youth classification documents included all required considerations
and each youth was assigned to a room based on their classification. All room assignments are
documented in the Department’s Juvenile Justice Information System (JJIS). Seven youth case
management records were reviewed for classification. Each reviewed record contained a copy
of the JJIS Admission Wizard documentation, which included the classification results and the
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB). Seven reviewed youth
records contained a classification form which identified the module or room classification where
the youth was placed. Five of the seven reviewed records notated whether the youth has a
history of committing sexual offenses or is vulnerable to victimization and the youth was
assigned a single room, as required. The superintendent remains informed of how to identify
and address local youth gangs by communicating with the gang liaison for the center. An
interview with the superintendent confirmed youth are assigned a room based on their
classification and shall be reclassified if behavior/status changes. Upon identification, the intake
staff shall inform the superintendent of a youth’s gang status, which initiates the notification
process.
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Office of Accountability and Program Support Page 20 of 59 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures in place to ensure all information regarding
suspected youth gang affiliation is shared with the circuit gang representative. The center has
designated one juvenile justice detention officer supervisor (JJDOS) to serve as the gang
representative for the center. This JJDOS communicates with the center’s superintendent who
then corresponds with the chief probation officer (CPO) regarding all suspected gang activity.
The center is required to enter the suspected gang affiliation alert into the Department’s
Juvenile Justice Information System (JJIS) if there is a youth suspected to have gang affiliation.
Staff are notified of all updates and alerts during shift briefings and on the daily alert sheet. An
informal interview with the superintendent confirmed the center’s practice. Seven youth case
management records were reviewed, of which one record was applicable for gang affiliation.
Two additional youth records were requested for review and were provided. All three records
confirmed alerts have been entered into JJIS, as each was identified prior to their admission to
the center. The informal interview with the center’s gang liaison revealed there has been no
suspected gang activity or newly identified gang affiliated youth at the center during the annual
compliance review period to warrant communication with the circuit gang representative.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures in place ensuring the proper safe handling and
security of personal property including valuables, which are collected and secured at the time of
a youth’s admission. In the presence of each youth, staff inventory all personal property in the
youth’s possession and record 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. An itemized Property Receipt form, containing the youth’s signature and the
staff receiving the property’s signature, was maintained in all seven reviewed youth records. A
letter of acknowledgement regarding unclaimed property was signed by youth and included in
each of the seven youth records. Personal items, such as clothing and shoes, are placed in a
mesh bag with the itemized inventory and secured in the center’s youth property room. Valuable
items are inventoried and placed in a clear tamper-proof property bag, identified with the date,
the youth’s name, and Department identification number (DJJID). The valuables are then
secured in the locked property cabinet located in the administrative office, which is under video
surveillance. The center maintains a secured valuables logbook to document the time, youth’s
name, name of the juvenile justice detention officer (JJDO) securing the property, and the
JJDOs initials. Seven youth case management records were reviewed and each contained
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Office of Accountability and Program Support Page 21 of 59 (Revised July 2023)
documentation of a Letter of Acknowledgement of Unclaimed Property signed by the youth and
staff. Each record contained a Property Receipt form documenting the assigned locker for
personal items. An observation of all seven personal property bags was conducted and each
contained an inventory form. One admission was observed during the annual compliance review
week and property was inventoried and stored, as required. Three applicable reviewed records
contained a Property Receipt form for valuable items. The secured valuables logbook contained
all required elements for the applicable reviewed records. All three applicable youth with
valuable items had their items stored in a clear tamper-proof bag with its contents visible and
were securely stored in the administration office. A photocopy of the clear tamper-proof bag with
its contents visible is maintained in the youth’s record. None of the seven reviewed records
indicated a youth refused to sign the Property Receipt form. A review of the Department’s
Central Communications Center (CCC) reports since the last annual compliance review found
one incident regarding the reported loss of youth property. Seven interviewed youth reported
staff checked their inventoried property and each youth signed the inventory was correct. The
superintendent interview confirmed the center’s property storage practice and verified only
JJDO supervisors and administrators have access to the youth property room. The
superintendent explained when property is unclaimed after thirty days, the Disposal of Property
Notification is sent to the last known address for the youth. If no contact is made, a money order
is obtained and sent to the regional fiscal manager who shall forward the money order to
headquarters. Other property is disposed of and a record is kept of the disposal of each.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center has facility operating procedures in place to ensure all releases from the center
occur promptly and accurately. Three closed youth case management records were reviewed.
The on-duty juvenile justice detention officer supervisor (JJDOS) verified each youth’s release
by reviewing all related release paperwork, the court order, and youth identification. The JJDOS
completes the verification by signing the secure detention release form. Each of the closed
youth records had the appropriate documentation including a copy of photo identification of the
person taking custody, youth and parent/guardian notifications of any future court dates, and
signatures of all parties on all required release forms. None of the released youth had an alert
reflecting an endangered person. The release date in the Department’s Juvenile Justice
Information System (JJIS) corresponded with the youth’s release date in each reviewed record.
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Office of Accountability and Program Support Page 22 of 59 (Revised July 2023)
There were no scheduled youth releases during the annual compliance review week; therefore,
an observation of a youth released was not conducted.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures in place to ensure all youth personal property is
released to the youth or the youth’s parent/guardian. The parent/guardian, youth, and staff must
sign a receipt acknowledging all property was returned upon the youth’s release. A review of
three closed youth case management records revealed each youth record contained the
required information with all required signatures of receipt of youth’s personal property. Each
record contained identification documentation verifying the youth was released to an appropriate
person. One of the three closed youth case management records was applicable for the release
of medications which contained the Department’s Medication Receipt form signed by the youth
and person to whom the youth was being released. All three youth records contained
documentation of the youth and person the youth was being released to were reminded of any
health or welfare issues, including medical, mental health, and/or substance abuse needs, and
any pending appointments. The center keeps an inventory of unclaimed property held more
than thirty days. The center did not have any unclaimed property during the annual compliance
review week. An interview with the superintendent confirmed when there is unclaimed inventory,
a notice of impending disposal of property is sent to the last known address in effort for the
property to be claimed. Unclaimed property is inventoried, and a record kept of any disposed
property or unclaimed money, which is given to the regional fiscal manager by money order. An
observation of a youth release was not conducted, as no youth were released during the annual
compliance review week.
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 ensuring detention reviews are conducted
weekly for youth who are securely detained, placed on home detention, or placed on electronic
monitoring to ensure proper management of youth and the sharing of information. Detention
reviews are conducted on a weekly basis to address the status of each youth. The center has a
designated staff, the detention review specialist, appointed to coordinate the weekly detention
reviews. The detention review specialist reported updates are provided regarding the youth’s
next court date, behavior while in detention, residential placement status, and release status.
Documentation reflected the reviews are conducted with the center’s staff including medical,
education, mental health, commitment, and representatives from probation. Each of the staff
attending in-person signed the sign-in sheet. Attendees from outside the center participated
virtually utilizing video conferencing. An interview with the superintendent confirmed detention
reviews are conducted each Thursday, discuss each youth’s status updates, and attended by all
required participants. There were no scheduled youth releases during the annual compliance
review week; therefore, an observation of a youth released was not conducted.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 23 of 59 (Revised July 2023)
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures addressing the daily activity schedule. The
center’s daily activity schedule includes daily expectations in accordance with the behavior
management system (BMS), wake up, personal hygiene, education, mealtimes, visitation,
indoor and outdoor recreation, shift changes, bedtimes, groups, and open center time. The
center provides and maintains weekday, weekend, and holiday schedules. Observations during
the annual compliance review week revealed daily schedules are posted throughout the center
along with a monthly activity calendar. Visitations are held twice a week for youth. During the
morning and early afternoon hours, Monday through Friday, youth are participating in education.
Reviewed documentation reflected activities included behavior management incentives and a
variety of recreational activities. A review of the center’s logbook and the annual compliance
review team observations confirmed the center adheres to the daily activity schedule, with some
variation due to staffing shortages. Seven youth were interviewed, and six of the seven
indicated the center has a daily schedule which is followed. One youth reported there is a
schedule; however, the scheduled is not followed. Seven staff were interviewed and all reported
the daily schedule is followed, with one staff responding the schedule is followed the majority of
the time, unless there is a staffing issue.
2.10 Educational Access (Critical) Limited Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. The center provides
education services through the Marion County School Board and a 250-day calendar, which is
distributed over twelve months, including ten days used for teacher training and planning. A
review of the daily school schedule revealed the center provides eight class periods daily; four
class periods of forty-two minutes and four periods of thirty-seven minutes, fulfilling more than
the weekly requirement of twenty-five hours of instructional time. An interview with the juvenile
justice education manager (JJEM) from the district indicated the school built in extra time for
classes in the morning to assist when the youth arrive to school late. The JJEM also indicated
all youth receive credit for course completion, as appropriate. The JJEM verified the youth are
attending school according to the daily schedule; however, there have been long periods over
the past few months which have required the teachers to conduct classes on the male modules
with half the youth in class while the other half are locked down in their rooms for each period.
This causes each youth to receive only a half day of education on days this occurs. The female
module has regularly attended school in the classroom. A review of six random dates in the
logbook was conducted. With the exception of one day, all reviewed documentation indicated
school started eleven to twenty-seven minutes late. In many instances, the documentation in the
logbook was missing educational movement, mainly for the female’s module. The male’s
education was taking place on the modules due to staff shortages. A review of the unit logbook
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Office of Accountability and Program Support Page 24 of 59 (Revised July 2023)
did show education taking place, as scheduled. A review of three days of video indicated school
started on time with the exception of one day, which started twenty-five minutes late. All three
reviewed dates showed classes ending early for lunch, with two of the three days of classes
resuming late after lunch. Only one reviewed day showed classes resuming on time and one
day in which school ended on time. The remaining two days showed school ending twenty-five
and forty-seven minutes early, and youth were moved to the intake area without a teacher
present for the entire class period. There was no logbook documentation to explain the reason
for this movement.
Seven youth were interviewed, and all reported they attend school Monday through Friday. All
seven interviewed youth felt the school was preparing them very well or well regarding
preparation towards high school equivalency diploma (GED) , high school, vocation,
employment, and/or college. Seven staff were interviewed, and all felt there is minimal
interference in educational services. During an interview, the superintendent reported the facility
tries to make sure there is as minimal interference as possible due to safety and security.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to provide career education. The juvenile justice
education manager (JJEM) from the district indicated every youth in the center has education
programming which includes communication, interpersonal, and decision-making skills. The
JJEM also reported the district requires every youth to be given a My Career Shines account to
assist with career education and assessment. The center offers Type 1 career education
development which includes career learning strategies such as interviewing skills and
techniques, career interest, as well as completing employment applications. Seven youth were
interviewed, and all reported taking core classes such as math, science, history, and reading, as
well as life skills and career choices.
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Office of Accountability and Program Support Page 25 of 59 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor (LMHC) with a clear and active license in the State of Florida with an
expiration date of March 31, 2025. A contract between the Department and the mental health
and substance abuse provider outlines the role of the DMHCA, including the provision for the
DMHCA to be on-site forty hours a week. A review of sign-in sheets confirmed the DMHCA is
on-site at least forty hours a week. The contract also requires for the DMHCA to ensure the
appropriate coordination and implementation of mental health and substance abuse services at
the center. The back-up DMHCA is also a LMHC with a clear and active license in the State of
Florida with an expiration date of March 31, 2025. An interview with the DMHCA confirmed their
role at the center to include ensuring all youth are seen for mental health follow-up within
twenty-four hours of admission. Any youth with psychotropic medications are seen within
fourteen days of admission if they are admitted with a prescription or beginning a new
prescription. The DMHCA further confirmed their role in ensuring all youth enrolled in mental
health services are seen weekly in either a group or individual format. The DMHCA coordinates
caseload management and ensures all treatment plans, substance abuse and mental health
updates, treatment plan reviews, and psychiatric appointments are completed within the
requirements of Florida Administrative Code.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has four licensed mental health and substance abuse staff providing services to the
youth in the center in addition to the designated mental health clinician authority (DMHCA).
Each of the four licensed staff are licensed mental health counselors (LMHCs) with clear and
active licenses in the State of Florida with expiration dates of March 31, 2025. The DMHCA
ensures each licensed therapist is qualified to provide services based on their education,
training, and experience. A review of the mental health and substance abuse provider’s contract
with the Department revealed the center has the required staff in placed as outlined in the
contract.
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Office of Accountability and Program Support Page 26 of 59 (Revised July 2023)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has one non-licensed mental health and substance abuse clinical staff providing
services to youth in the center. The non-licensed staff possesses a bachelor’s-level degree in
psychology and previously completed the required pre-service training for bachelor’s-level
therapists. The provider’s contract with the Department outlines the provider should only utilize
master’s-level non-licensed clinicians unless approved by the Department’s Office of Health
Services (OHS). A review of OHS staffing verification indicated the non-licensed therapist was
approved to provide services at the center. The center does not have a Chapter 397 license for
the provision of substance abuse services; therefore, all substance abuse services are provided
by the licensed clinical staff. The non-licensed staff had documentation of training in the
facilitation of Assessments of Suicide Risk (ASRs) in addition to supervised practice to provide
ASRs to youth. A review of the center’s direct supervision log found the non-licensed staff
completed direct supervision with the designated mental health clinician authority (DMHCA) on
the weeks the non-licensed therapist worked due to the position being an as needed position.
All supervision was documented on the required Department form which included all required
elements. A review of the non-licensed staff’s degree, experience, and training verified the
DMHCA ensures the non-licensed staff under their supervision is providing services they are
qualified to perform. A review of the mental health and substance abuse provider’s contract with
the Department revealed the center has the required staff in place as outlined in the contract.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures (FOPs) which require all youth to receive a mental
health and substance abuse screening upon admission through completion of a Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2) and Suicide Risk Screening Instrument
(SRSI). Seven youth mental health and substance records were reviewed for an admission
screening and each included documentation a MAYSI-2 and SRSI were completed at intake in
the Department’s Juvenile Justice Information System (JJIS), by trained staff, and reviewed by
detention staff. The MAYSI-2 and SRSI for each youth included all required elements. The
MAYSI-2 for all seven youth indicated the youth required a referral for a comprehensive
assessment. Two of the seven MAYSI-2s were overridden due to SRSI responses. A referral for
a comprehensive assessment with the reason for the referral was found in each youth’s record.
None of the youth were indicated as a suicide risk on the MAYSI-2 and all of the youth were
indicated as a suicide risk on the SRSI. Each of the youth were referred to an Assessment for
Suicide Risk (ASR) and placed on precautionary observation. Each of the referrals documented
the superintendent or designee was notified, as required.
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Office of Accountability and Program Support Page 27 of 59 (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 mental health and substance abuse records were reviewed for completion of a
mental health and substance abuse comprehensive assessment. Five of the seven youth were
at the center long enough to have a new or updated assessment completed. One of the five
youth refused. Two of the remaining four applicable youth had community provider
comprehensive assessments completed within thirty days of being detained and the center
received and utilized those evaluations. The remaining two youth had updated assessments
completed by the detention provider within the youth’s first thirty days in detention. In the four
applicable records, treatment recommendations were made corresponding with all diagnosed
mental health and/or substance abuse disorders. In the two applicable records, the center was
able to obtain the comprehensive evaluation completed by the community provider which
contained all required elements including the signature of the licensed mental health
professional.
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 mental health and substance abuse records were reviewed and three were
applicable for requiring an initial treatment plan while in the center. One youth did not agree to
services until the completion of the individual treatment plan prior to the youth’s thirtieth day in
detention. The remaining three youth either refused treatment or were not at the center long
enough to complete an Initial Treatment Plan. The three applicable youth records included an
Initial Treatment Plan completed on the required Department form with all required elements,
within seven days of the onset of treatment. Each Initial Treatment Plan included the signature
of the youth and mini-treatment team indicating each was involved in the development of the
plan. Two of the three youth who completed an Initial Treatment Plan and the youth who agreed
to services prior to the thirtieth day at the center were applicable for completion of an
Individualized Treatment Plan. One youth who completed an Initial Treatment Plan was
released prior to completion of any further treatment. The three applicable youth’s Individualized
Treatment Plans were documented on the required Department form with all required elements
within thirty days of admission and completed by the designated mental health clinician authority
(DMHCA). The plan was signed by all required parties with the exception of the parent/guardian;
however, there was documentation center staff attempted to contact the parent/guardian to
develop the plan. The three youth were applicable for treatment plan reviews and all youth had
the required number of reviews completed while in the center, at least every thirty days. Any
modifications documented on the review form were clearly documented as such and were
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Office of Accountability and Program Support Page 28 of 59 (Revised July 2023)
signed and dated by all required parties with the exception of the parent/guardian; however,
documentation showed the center attempted to include the parent/guardian to review the plan.
Two of the three youth were receiving psychiatric services and the treatment plan included
treatment and services provided by the psychiatrist. A review of progress notes indicated each
youth received all services as stipulated on their treatment plan. Three closed youth mental
health and substance abuse records were reviewed and each included a completed mental
health and substance abuse treatment discharge plan. Each plan was completed on the
required Department form with all required elements. There was documentation each of the
three plans were sent to the youth’s juvenile probation officer (JPO); however, there was no
documentation the youth or parent/guardian was provided a copy of the plan for the plan
indicated the youth was discharged prior to the completion of the plan. The DMHCA reported
the plans are provided to the youth and parent/guardian by their JPO as the youth are
discharged prior to completion of the plan. A mini-treatment team was able to be observed. The
DMHCA reviewed the treatment plan with the treatment team members prior to obtaining the
required signature and date.
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 mental health and substance abuse records were reviewed and four were
applicable for requiring mental health and/or substance abuse treatment while at the center.
Each of the four youth were assigned to a mini-treatment team on the day of the development of
the Initial Treatment Plan. Each mini-treatment team was comprised of all required parties with
the exception of the parent/guardian; however, there was documentation the center attempted
to contact each youth’s parent/guardian. A review of progress notes for each youth confirmed
services were provided as stipulated on the plan and included at least weekly individual or
family therapy. All progress notes were documented on the required Department form. The
center did not provide groups during the annual compliance review period due to staffing, as
well as the youth not wishing to participate. Each of the four applicable youth required mental
health treatment and three were applicable for substance abuse treatment. Each youth record
included a properly executed Authority for Evaluation and Treatment (AET). The three
applicable records also included a consent for substance abuse treatment and records release,
and each was documented on the required Department form. Group therapy was unable to be
verified as the center did not provide groups during the annual compliance review period;
however, the center identified a space they would be using for groups, once initiated, which is
large enough for the groups. Seven youth were interviewed and two stated the mental health
and substance abuse services were very good, three stated good, one indicated the services
were fair, and one stated they were not receiving services. The youth reported the counselors
check on the youth a lot and feel they can talk to the counselors about what is going on with
them, the youth meet with the counselors once a week, and the counselors talk with the youth
and try to help. The designated mental health clinician authority (DMHCA) reported in an
interview, all youth are seen for a mental health follow-up on or before their thirtieth day in the
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center’s custody. Youth with hits on the Massachusetts Youth Screening Instrument, Second
Version (MAYSI-2) and/or youth requesting services are seen for completion of the substance
abuse and mental health assessment and the Individualized Treatment Plan. Youth are able to
request services at any time and are enrolled into mental health services following completion of
the initial psychiatric evaluation. Detention staff are able to complete mental health referrals for
youth if youth demonstrate behavioral issues warranting a mental health follow-up.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center utilizes a psychiatrist through a contract with the mental health and substance abuse
service provider who is a licensed physician and has completed a training program in
psychiatry. The psychiatrist’s license is clear and active in the State of Florida and expires on
January 31, 2024. The center has two back-up psychiatrists whose licenses expire on March
31, 2024 and January 31, 2024. The center does not utilize a psychiatric advanced practice
registered nurse (APRN). Seven youth mental health and substance abuse records were
reviewed and three were applicable for receiving psychiatric services while in the center. The
three applicable youth entered the center on psychotropic medications and were referred at
admission. Each of the three applicable youth received an Initial Diagnostic Psychiatric
Interview within fourteen days of referral which included all required elements and was
documented on the Department’s form. All three youth received an in-depth psychiatric
evaluation which included all required elements. Each youth was applicable for psychotropic
medications and each youth’s medications were documented with all required information on
the Department’s form. Two of the three youth were applicable for monitoring of Tardive
Dyskinesia and nursing staff documented monitoring on a monthly basis as indicated on the
Department’s form. All applicable youth records included an Authority for Evaluation and
Treatment (AET) and indicated the youth were admitted to the center with the medications. One
of the reviewed youth was in the care of the Department of Children and Families (DCF) and
none were over the age of eighteen. The center’s contract with the provider was reviewed for
tele-psychiatry; however, there was no indication tele-psychiatry was provided during the annual
compliance review period. According to the designated mental health clinician authority
(DMHCA); mental health services provided at the center include individual or group sessions,
completion of an Initial Treatment Plan, Individualized Treatment Plan, treatment plan review,
substance abuse and mental health updates, and discharge summaries. All youth requesting
services through a mental health referral are required to be seen within twenty-four hours and
any youth enrolled into mental health services are seen for a minimum of one weekly counseling
session, in either group or individual format. Youth are also seen for completion of suicide risk
assessments and crisis assessments, as required.
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3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written plan detailing suicide prevention procedures which includes all required
elements. The center has an established review process for every serious suicide attempt or
self-inflicted injury and a mortality review for a completed suicide. The multidisciplinary review
includes all required elements.
3.10 Suicide Prevention Services [Detention Staff/Contract
Limited Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has a Suicide Prevention Plan which includes an established review process for
incidents of serious suicide attempts or self-inflicted injuries. Seven youth mental health and
substance abuse records were reviewed for suicide prevention services and all seven youth
were identified upon admission as a suicide risk and placed on precautionary observation (PO).
Each of the seven youth records documented the youth was placed on PO by the detention
screeners prior to the youth entering the center, a referral was generated for an Assessment of
Suicide Risk (ASR), and a suicide risk alert was entered into the Department’s Juvenile Justice
Information System (JJIS) as soon as the Suicide Risk Screening Instrument (SRSI) was
completed by center staff. Each youth was placed on PO and supervised as required which was
documented on the Department form with all required elements completed. The referral
documented the licensed mental health counselor (LMHC) and superintendent/designee were
notified of the youth’s suicide risk immediately. An ASR was completed for each of the seven
youth within twenty-four hours of referral and documented on the required Department form.
Each ASR was completed by a LMHC who also provided supportive services while the youth
was on PO. A conference with the LMHC and superintendent/designee was documented on the
ASR prior to changing the youth’s supervision level. Each of the seven applicable youth were
stepped down to standard supervision, did not require a follow-up ASR or transition to close
supervision, which was in accordance with the center’s Suicide Prevention Plan. All
assessments included recommendations for supervision and follow-up. Each of the seven youth
had a suicide risk alert entered and discontinued in JJIS, as required. The center’s logbooks
and the ASRs had supporting evidence administration provided instructions related to the
suicide risk assessment findings and precaution findings with the exception of two instances
where the youth being placed on and/or taken off PO was not documented in the logbook. None
of the youth were released from the center prior to receiving an ASR. None of the seven
reviewed youth were applicable for placement on secure observation during the annual
compliance review period. Seven youth were interviewed and each denied ever been placed on
suicide watch while at the center. Each of the seven staff interviews indicated when a youth is a
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suicide risk they are to notify the mental health authority, search the youth and their room for
sharp objects, document supervision, and place the youth on constant sight and sound
supervision. Four of the seven staff indicated they are to place the youth in a locked room.
According to the superintendent, secure observation is only utilized when a youth exhibits
harmful acts towards others or themselves. At the time of the annual compliance review, the
center had an open deficiency assigned on July 19, 2023; therefore, this indicator was rated as
limited compliance.
3.11 Suicide Precaution Observation Logs [Detention
Limited 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 mental health and substance abuse records were reviewed for suicide prevention
services and all seven were identified upon admission as a suicide risk and placed on
precautionary observation (PO). Each of the seven records documented PO logs were
completed in their entirety for the duration of the youth’s time on PO. Each youth was
supervised, as required, with observations documented at least every thirty minutes in real time.
Each reviewed log was signed by the supervisor on each shift as well as a licensed mental
health professional and documented safe housing locations. None of the youth were applicable
for warning signs while on PO. A review of three instances of youth on PO was conducted by
video and found each youth was supervised on PO, as required. At the time of the annual
compliance review, the center had an open major deficiency assigned on July 19, 2023;
therefore, this indicator was rated as limited compliance.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has a suicide prevention plan which outlines required staff training and mock drills.
Seven pre-service and seven in-service staff training records were reviewed for suicide
prevention training. Each pre-service and in-service training record reflected the staff completed
training in suicide prevention, as required. The center has nine suicide response kits containing
all required tools maintained throughout the facility in master control, the sub-controls, and each
transport vehicle. Seven staff interviews confirmed the locations of the suicide response kits as
well as stating a kit is also available in the medical office. The center conducted suicide drills on
each shift at least quarterly for the annual compliance review period. Twenty-seven staff were
applicable and reviewed for participation in drills during the first six-month time period and thirty-
two staff were applicable and reviewed for participation in drills during the second six-month
time period reviewed. Each of the staff completed the required drills semi-annually, with at least
one drill including the use of cardiopulmonary resuscitation (CPR). All staff completed the
required number of drills; however, they are also afforded the opportunity to review each drill
scenario and procedures in an effort to understand the process and receive the necessary
training to respond to an incident of a suicide attempt or serious self-inflicted injury while in the
center.
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3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a combined Emergency Services Plan which includes all required elements.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has a combined Emergency Services Plan which includes all required elements and
was last updated on March 22, 2022. The plan was approved and signed by the superintendent
on April 7, 2022. The plan is located in the superintendent’s office and available to all staff.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center did not utilize Crisis Assessment procedures during the annual compliance review
period. The center has a combined Emergency Services Plan which includes all required
elements.
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Office of Accountability and Program Support Page 33 of 59 (Revised July 2023)
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has an Emergency Services Plan which outlines the requirements for placing youth
under a Baker or Marchman Act. The center had one youth Baker Acted during the annual
compliance review period. The youth was placed on suicide precautions upon readmission from
the Baker Act. A mental health referral was completed for a Mental Status Examination and the
examination was completed by a licensed mental health counselor (LMHC). The youth was
maintained on a minimum of constant supervision until transition to a lower level of supervision
and was not lowered until an appropriate assessment was conducted along with a conference
between the LMHC and the superintendent or designee. The youth had open suicide and
mental health alerts in the Department’s Juvenile Justice Information System (JJIS). Both alerts
were closed appropriately based on the recommendation of the Assessment of Suicide Risk
(ASR).
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Office of Accountability and Program Support Page 34 of 59 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains facility operating procedures (FOPs) ensuring a contract agreement with a
State of Florida licensed physician is maintained in order for the physician to serve as the
designated health authority (DHA). The procedures establish assigned roles and duties within
the center for both the detention center staff and the DHA. The DHA ensures a review of all
medical and mental health policies and protocols are reviewed and signed annually and ensures
all appropriate medical staff receive training on all medical policies. The center maintains a
contract with Vital Core Health Strategies, LLC (VCHS), who maintains an agreement with a
medical doctor (MD). The MD holds an unrestricted license which expires on January 31, 2025
and meets all requirements for independent and unsupervised practice in the State of Florida.
The MD has specialty training in pediatrics and is a member of the American Board of Internal
Medicine. The MD serves as the center’s DHA and is clinically responsible for the medical care
of all youth. The contract with VCHS indicates the DHA is required to be on-site each week
conducting periodic evaluations, Comprehensive Physical Assessments (CPAs), sick call
referrals, and administrative duties. The number of hours on-site depends on the size and
population of the detention center in accordance with Florida Administrative Code, with a
minimum of one visit each week, with a week defined as the seven day period beginning on
Sunday and ending on Saturday, and no more than nine days pass between on-site visits. The
DHA is on-call seven days a week, twenty-four hours a day. The provider’s contract requires the
center to utilize an advance practice registered nurse (APRN). The APRN is acknowledged by
the State Board of Nursing to practice as autonomous. Reviewed attendance logs indicated
both the DHA and APRN were on-site weekly, as required. During the annual compliance
review period, the DHA was on leave three different weeks and a back-up DHA was utilized.
The back-up DHA was a licensed physician who performed all clinical and administrative duties
with a license expiring on January 31, 2024. The interview with the current DHA supported
completion of the required position duties and indicated they are on-site once a week as well as
available by cellular telephone twenty-four hours a day, seven days a week for consultation. The
DHA meets with the medical staff weekly to discuss any youth medical needs or reports. An
interview with the APRN confirmed they are on-site once a week and their role is to complete
Comprehensive Physical Assessments (CPAs), follow-up on sick calls and referrals, and
coordination of continuity of care.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center maintains facility operating procedures (FOPs) for all utilized health-related
procedures and protocols. The designated health authority (DHA) initially reviewed, signed, and
dated all medical FOPs on May 19, 2022, as well as reviewed and signed all new or updated
policies submitted thereafter, when applicable. An annual review of medical FOPs and protocols
was completed on August 3, 2023. Reviewed documentation validated the registered nurse
(RN), the advance practice registered nurse (APRN), and other medical staff documented their
review of the center’s Vital Core Health Strategies, LLC (VCHS) healthcare FOPs and protocols
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on a cover page. An interview with the RN clinical manager indicated the center has an
established comprehensive clinical orientation for all newly employed healthcare staff which
includes the Department’s healthcare policies and procedures. Training records supported all
nursing staff completed and maintained current certifications in cardiopulmonary resuscitation
(CPR) and automated external defibrillator (AED).
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
A review of seven youth Individual Healthcare Records (IHCRs) found all were applicable for
requiring a signed Authority for Evaluation and Treatment (AET) or a Limited Consent for
Evaluation and Treatment (LCET). Six reviewed IHCRs contained an AET signed by all required
parties. One IHCR contained a LCET due to involvement with the Department of Children and
Families. A court order authorizing all treatment procedures and a court order authorizing the
administration of psychotropic medication was filed in the Electronic Medical Records (EMRs).
Each signed AET or LCET was valid, clearly marked as a copy on the form, and was obtained
prior to providing medical services.
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.
A review of seven youth Individual Healthcare Records (IHCRs) found two parent/guardian
notifications for prescribed over-the-counter medications not covered by the Authority for
Evaluation and Treatment (AET) was required. Both IHCRs included documentation of the
notification and consent of parent/guardian utilizing the required Department’s forms. Three
youth were taking psychotropic medication when admitted into the center. Each IHCR indicated
a staff witnessed all telephone call attempts or conversations for psychotropic medications.
Three applicable IHCRs indicated a new medication was prescribed. Each applicable IHCR
contained documentation of verbal and written notification to the parent/guardian. One IHCR
was applicable for new prescribed psychotropic medications and parental consent was
documented on the Clinical Psychotropic Progress Note (CPPN). Six of seven applicable
reviewed IHCRs contained the required vaccinations/immunizations records. One IHCR was not
applicable for the youth was at the center under five days. None of the youth were applicable for
needing vaccinations while at the center. The clinical manager reported immunizations records
are obtained through the Florida Health website within seven days of the youth’s admission. No
Religious Exemption from Immunization forms were submitted since the last annual compliance
review. Reviewed chronological notes and the Parental Notification of Health-Related Care form
documented each applicable parent/guardian was notified, as required. Written parental notices
were sent regardless of telephone notifications. An interview with the clinical manager confirmed
the center’s practice of parental notification and obtaining parental consent and AETs.
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Office of Accountability and Program Support Page 36 of 59 (Revised July 2023)
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains facility operating procedures (FOPs) ensuring an appropriate healthcare
admissions screening is completed for each youth entering the center. At the time of admission,
each youth is screened using the Medical and Mental Health Screening (MMHS) form found in
the Department’s Juvenile Justice Information System (JJIS) Admission Wizard. The purpose of
the screening tool is to ensure the youth does not have any emergency medical conditions
requiring immediate medical attention. In the event a youth is admitted and an injury is
discovered with certain signs and/or symptoms, there is immediate communication with the
designated health authority (DHA) and a request is made for an urgent assessment of the youth
if licensed healthcare staff are available on-site. Immediate transfer of youth to the nearest
emergency facility occurs if the licensed healthcare staff is not on-site or after the evaluation if
the condition so warrants. A review of seven youth Individual Healthcare Records (IHCRs)
found each contained a MMHS form completed on the date of admission by a juvenile justice
detention officer (JJDO). Each MMHS indicated the screening was reviewed by a registered
nurse (RN) within twenty-four hours. Each screening form was completed in the JJIS Admission
Wizard. Six applicable IHCRs documented the DHA was notified. An interview with nursing staff
confirmed the center’s practice. None of the reviewed records were applicable for a change in
physical custody since the youth’s admission date. The center reported having no youth
applicable for a change in physical custody during the annual compliance review period who
required a Healthcare Admission Rescreening. The clinical manager reported one youth was
applicable for a qualitative urine pregnancy screening test during the annual compliance review
period, and chronological progress notes included documentation of verbal consent.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains facility operating procedures (FOPs) ensuring all youth are oriented and
knowledgeable regarding access to medical and dental care. A review of seven youth Individual
Healthcare Records (IHCRs) supported each contained the Department’s completed Health
Education Record form documenting the youth’s orientation to the center’s healthcare services.
Each youth received a general healthcare orientation on the day of admission to the center.
Reviewed documentation supported each youth’s orientation included access to medical care,
sick call, what constitutes an emergency and when to notify staff, medication process and side
effect monitoring, the right to refuse care and how it is documented, what to do in the case of a
sexual assault or attempted sexual assault, and was oriented to the non-disciplinary role of the
healthcare providers. A review of healthcare contacts list was completed to ensure accuracy,
with no issues noted.
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4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center maintains facility operating procedures (FOPs) requiring the designated health
authority (DHA) to be notified when a youth is admitted and is in need of emergency care, or
routine notification in accordance with Department requirements. A review of seven youth
Individual Healthcare Records (IHCRs) supported the DHA was notified within twenty-four hours
of admission for each youth, regardless of medical condition. Notification was documented on
the nursing admission chronological notes in each IHCR. None of the seven youth were
identified as in need of emergency care upon admission. Three of the seven youth were
identified as possessing a chronic condition at admission. The DHA was notified within twelve
hours of admission for the three applicable youth. Three youth were taking prescribed
psychotropic medication upon admission and the nursing admission chronological notes
indicated the psychiatrist was notified. An interview with the nursing staff indicated the DHA is
notified by nursing staff within twenty-four hours or less of any youth admitted, regardless of
condition, either through a telephone call or e-mail, and documented in the chronological notes.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
A review of seven youth Individual Healthcare Records (IHCRs) found six contained the
Department’s Health-Related History (HRH) form completed electronically by a licensed nurse
within seven days or less of the youth’s admission to the center. One IHCR was not applicable
for the youth was only at the center for five days and was a transfer from another center. Each
of the six applicable HRHs were reviewed by the designated health authority (DHA) or
advanced practice registered nurse (APRN) and completed prior to the Comprehensive Physical
Assessment (CPA). A review of the nursing interview confirmed the HRH is completed by a
nurse within twenty-four hours and made available for the DHA to review prior to the completion
of the CPA.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains facility operating procedures (FOPs) requiring a Comprehensive Physical
Assessment (CPA) form to be completed for all applicable youth admitted determining the
health and well-being of the youth and maintaining appropriate documentation of when any part
of the exam is not conducted and/or refused by the youth. The center’s procedures for
tuberculosis (TB) control and screening addresses requirements for the routine screening of all
youth for latent and active TB, as well as environmental controls in the case of a youth with
active TB. An interview with nursing staff indicated all youth are screened for TB by placing a
Tuberculosis Skin Test (TST) in the left forearm once annually. The test is read by nursing staff
within forty-eight to seventy-two hours after placement. A review of seven youth Individual
Healthcare Records (IHCRs) revealed each had a physical assessment completed on the
Department’s CPA form. Four youth had a current CPA on file and three had a new CPA
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completed within seven days of admission by a medical doctor. All seven CPAs documented the
youth’s Medical Grade. Three of the four applicable youth with current CPA’s having no medical
condition changes were reviewed and signed by the designated health authority (DHA) on the
Department’s Additional Reviews to Comprehensive Physical Assessment form. One youth was
not applicable for the youth was at the center for five days and was transferred prior to meeting
with the DHA. Each CPA verified each youth had a negative TST completed within the last year.
All seven youth indicated a refusal to a portion of the examination with a documented signed
refusal form matching the date of the exam. Reviewed practice reflected when the CPA was
completed, the Department’s Problem List was updated. An interview with nursing staff verified
a CPA is completed within the required time frame.
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. Five youth were applicable
for STI screening and two youth were not applicable, as the youth reported they were abstinent.
After reviewing the screening tool, medical staff deemed further evaluation was required for two
of the five applicable youth and three youth did not require any further evaluation; therefore, a
referral was documented on the STI form and testing was ordered and performed for both
youth. Testing screening results, clinical evaluations, and diagnosis were documented on the
Infectious Communicable Diseases (ICD) form and filed in the lab section of the IHCR for each
applicable youth. Further review of the two applicable youth’s IHCRs indicated neither of the
youth were applicable for a gynecological exam or rescreen. Both youth had documented
consent forms for implemented HIV testing. HIV test results were filed in a sealed envelope
marked as “CONFIDENTIAL”, which was reviewed by required medical staff. Both youth’s
pre/post-test counseling was documented. Neither of the youth’s HIV status was placed on the
facility’s internal alert system. Seven youth were interviewed and each reported they could ask
for a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for the sick call process.
Three of the seven youth were applicable for sick calls, as the remaining four youth did not
request sick call during their time in the center. A review of the Sick Call Referral Log indicated
all three applicable youth’s sick call requests were documented on the log. None of the
applicable youth were present with similar complaints three or more times within two weeks.
One of the three applicable youth complained of unfamiliar severe pain which was immediately
treated as an emergency and an immediate referral was made to a licensed healthcare
professional. The determination of the nature and/or severity of the youth’s medical condition
did not require the advanced practice registered nurse (APRN) to immediately notify the
designated health authority (DHA). The three applicable youth completed a Sick Call Request
form and the nurse completed the medical portion. The Sick Call Request forms were filed in
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each of the three applicable youth’s IHCR. The licensed practical nurse (LPN) completed sick
call for two youth. One youth’s sick call was reviewed daily by required medical personnel and
one youth’s sick call was not reviewed daily, as the youth was released and the sick call was
automatically closed. The one remaining youth’s sick call was not completed by the LPN. None
of the three youth were in restricted housing. The sick call complaints were documented on the
sick call index and the detention center’s sick call referral log for each youth. Further review of
the three youth’s IHCRs indicated the dates on the sick call index and sick call forms
corresponded. There are approved treatment protocols for both the registered nurse (RN) and
LPN level staff. The nursing staff is responsible for conducting sick call. Sick call hours are
posted in each youth module and the center’s medical clinic. Sick call is conducted twice daily in
the medical clinic. When there is not a licensed nurse on-site, there are procedures in place for
the shift supervisor to review all sick call requests no longer than four hours after a request is
submitted. A sick call was unable to be observed during the annual compliance review week, as
no youth requested a sick call while on-site.
A formal interview with the nursing staff revealed youth can submit a sick call and they are seen
within twenty-four hours. Sick call is routinely conducted by the nursing staff in the clinic Monday
through Friday and on Sundays from 10:00 a.m. to 11:00 a.m. and on Saturdays from 3:00 p.m.
to 4:00 p.m. Nursing staff reported when a sick call is conducted by the LPN, the sick call is
reviewed by the registered nurse (RN) to ensure protocols have been followed. According to the
nursing staff, after three similar complaints the youth is referred to a provider. Nursing staff
further reported there are DHA approved protocols and the DHA does not conduct sick calls
when the DHA is on-site. The nursing staff indicated daily documentation is utilized to access
youth in restricted housing/confinement. Seven youth were interviewed and three youth reported
they have never requested a sick call. Three youth reported they were seen within one day of
the request. One youth reported they were seen more than three days after the request. The
four applicable youth reported the nurse conducts sick call. Seven staff were interviewed and
each reported the nurse reviews and conducts sick call.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for episodic care. Three
youth records were applicable. All three youth received episodic care provided by a licensed
healthcare provider and all information was documented in problem oriented or standard
narrative charting. Two youth were applicable for receiving episodic first-aid care by a non-
healthcare staff and the required information was documented on the Department’s Report of
On-Site Health Care by Non-Health Care Staff form. The nature of the complaint and findings
were documented for all three youth. Treatment was also rendered for all three youth. One of
the three youth was applicable for referral for off-site care and the referral was made. Education
and follow-up plans were documented for all three youth. One of the three applicable youth was
applicable for an alert. A review of the alert list in the Department’s Juvenile Justice Information
System (JJIS) revealed the youth was placed on the alert list. Parental notification was made
and documented for all three youth. An episodic log entry was also completed for all three youth
and each youth received a follow-up evaluation from a licensed healthcare staff.
The center has twenty-six first-aid kits located in areas throughout the facility to include master
control, sub control rooms, classrooms, intake room, regional trailer, training trailer, east trailer,
kitchen, briefing room, sergeant’s office, maintenance shop, and all vehicles. The center utilizes
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Office of Accountability and Program Support Page 40 of 59 (Revised July 2023)
seven first-aid kits for transportation, one for each vehicle. The first-aid kits were fully stocked
with the designated health authority (DHA) approved contents. An informal interview with the
maintenance staff revealed all first-aid kits are checked monthly. During the monthly check, if an
item is outdated and/or needs to be replaced, the kit is taken to medical staff for replacement of
items and a new red seal is applied. There was documentation reflecting the first-aid kits were
monitored monthly and replenished, as needed.
The center has two automated external defibrillators (AEDs) located in the building. One is in
the administrative conference room and one is in post nine sub control room. The AED
procedures are stored with each AED. Medical staff is responsible for checking the AED. The
medical staff conducted a self-test of the AED and provided documentation to indicate the AEDs
are monitored monthly. A review of the AED log revealed the AED batteries were last changed
on October 26, 2022 and will expire on September 6, 2026. The AED pads were last changed
on October 26, 2022 and will expire on November 28, 2024.
Emergency medical drills were reviewed since the last annual compliance review.
Cardiopulmonary resuscitation (CPR)/AED was demonstrated at least quarterly. All staff were
afforded the opportunity to participate in at least one emergency drill annually. A list of
emergency telephone numbers is maintained by master control and in the medical clinic. The
numbers are inaccessible to youth. The center’s administrative staff are trained to administer
the epinephrine auto-injector and administered when indicated. Seven staff’s training records
were reviewed and each met the training requirements for episodic, first-aid, and emergency
care. The center has facility operating procedures to address NARCAN. The center must
maintain at least one prescribed stock of NARCAN for emergency purposes of accidental
overdose for youth in the Department’s care. The center stores NARCAN in the medical clinic
locked in the medication cart. Medical staff and the center’s trained administrative staff have
access to the NARCAN. The NARCAN is inventoried in the NARCAN log located in the
medication cart.
A formal interview with the nursing staff revealed first-aid kits are located throughout the facility
in areas to include master control, sub control A, sub control B, sub control C, staff breakroom,
intake, kitchen, training trailer, maintenance, and seven vehicles. Nursing staff reported episodic
care is documented on the episodic note and if episodic care is conducted by Department staff,
the staff can utilize telehealth services or follow the Department’s officer protocols. The nursing
staff reported the center has two automated external defibrillators (AEDs) which are located in
the conference room and the sergeants’ office in the post 9 sub control room. The nursing staff
reported quarterly drills are conducted with the Department’s staff and medical staff review the
emergency medical drills for any corrections or protocols. Nursing staff further reported the
poison control telephone number is posted in the clinic. Seven staff were interviewed and each
reported they are able to call 9-1-1 if they feel it is necessary. Seven youth were interviewed
and three youth indicated medical care at the center was fair. Two youth indicated medical care
at the center was good and the two remaining youth indicated medical care at the center was
very good.
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Office of Accountability and Program Support Page 41 of 59 (Revised July 2023)
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 off-site care. One youth
was applicable; therefore, the center provided two additional youth records for review. All three
applicable youth had documentation the Summary of Off-Site Care form was completed for off-
site care. Off-site emergency care was documented on the Episodic Care Log for each
applicable youth. Parental notification was documented for each applicable youth. Discharge
documents were uploaded in each applicable youth’s IHCR. The designated health authority
(DHA) was notified of an emergency event for one of the three youth. The two remaining youth
were not applicable for DHA notification. The DHA reviewed and signed the off-site care
documentation for all three applicable youth. One of the three applicable youth required follow-
up care and all referrals were entered on the center’s Sick Call Log. Documentation in the
youth’s IHCR included discharge dates and follow up dates for the youth’s upcoming scheduled
appointments indicating all referrals were tracked.
A formal interview with the nursing staff determined youth are tracked for off-site emergency
care by documentation on the off-site log. The nursing staff indicated youth who are gone
overnight have two daily documentations on the youth’s progress which is included in an
incidental note. The nursing staff indicated hospital orders are reviewed with the provider and
orders are written. The nursing staff indicated they ensure the DHA reviews and initial all off-site
care findings, instructions, and information upon request of records. The nursing staff further
indicated they track follow-up testing, referrals, and appointments on a calendar and incidental
notes.
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 or
periodic evaluations. Four youth were applicable and each was identified with a chronic
condition on the Medical/Mental Health Screening form. Each youth had an identified chronic
health condition and each was taking prescribed medication. None of the youth had a
communicable disease nor were identified as pregnant. Each youth was undergoing treatment
for a physical health condition. Each youth was classified with the required Medical Grade. All
four youth were placed on the chronic conditions list. One youth received periodic evaluations
and the periodic evaluations were documented in the progress notes. The remaining three youth
were not applicable for periodic evaluations, as they were in the center less than ninety days.
None of the youth were taking anti-tuberculosis medication. Periodic evaluations were
conducted prior to renewing prescription medication for one applicable youth. The youth was
also applicable for off-site evaluations. Although the center’s staff provided the Summary of Off-
Site Care Form to the off-site medical personnel, the off-site medical personnel did not complete
the form. The designated health authority (DHA) followed up with the youth and signed all
required documents. There were no indications of lapse in care. The Department’s Problem List
was updated for all three youth. All periodic evaluations were tracked on a detention linked
excel spreadsheet.
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Office of Accountability and Program Support Page 42 of 59 (Revised July 2023)
When asked how the center monitors youth with chronic conditions, the nursing staff indicated
the Comprehensive Physical Assessment (CPA) contains notes and orders which must be
followed. The DHA indicated periodic evaluations are conducted no later than ninety days, as
the clinic manager keeps track of the youth’s length of stay at the center. When asked how the
DHA ensures all youth with chronic conditions receive the periodic evaluation, the DHA
indicated alpha rosters are kept with corresponding days at the center.
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. Four youth were taking
medication at the time of admission. Each applicable youth’s medication was verified prior to
being admitted into the center and the prescription verification was included in the chronological
progress note in the IHCR. The designated health authority (DHA) and, when applicable, the
psychiatrist was contacted to obtain the order to resume the specified medications prescribed
prior to admission for each youth. Each youth’s medication had a current, valid order and were
administered pursuant to a current prescription. The DHA ordered new medications for six of the
initial seven reviewed youth; therefore, six youth were applicable for placement of DHA’s order
on the Practitioner’s Order form. Documentation of the prescription verification was in the
chronological progress notes in the IHCR for all six youth. None of the applicable youth had
been in confinement. Two of the six youth were applicable for receiving over-the-counter (OTC)
medications. OTC medications not listed on the Authorization for Evaluation and Treatment
(AET) form were administered according to approved protocols for both applicable youth.
Further review of the six applicable youth’s IHCRs revealed the standard Department’s
Medication Administration Record (MAR) was utilized to document all medication and treatment
and included medication start and stop dates for all six youth. Although trained non-healthcare
staff assist in the delivery of medications when licensed staff are not on-site, none of the six
youth were applicable for delivery of medication by a trained non-healthcare staff. There were
no undocumented explanations for lapses or errors in medication for any of the applicable
youth. The nursing staff documented weekly side effects monitoring on each applicable youth’s
MAR. None of the six youth were applicable for refusal of medication. All six youth’s MARs
contained the youth’s name, Department identification number, date of birth, youth allergies,
precautions, Medical Grade, medical alerts, and a current picture of the youth. All six youth
initialed each provided medication entry. Two of the six applicable youth were prescribed
parenteral medication. One youth’s parenteral medication was administered by a licensed
healthcare staff, as the other youth was prescribed the medication as needed and had not used
the medication since being in the center. Three of the six youth were applicable for psychotropic
medications. The DHA or psychiatrist were notified upon admission for all three youth. Two of
the three applicable youth had an Initial Diagnostic Psychiatric Interview within fourteen days of
admission, as the remaining youth was released before the fourteenth day.
There were no standing, emergency treatment, or pro re nata (PRN) orders for psychotropic
mediations. An observation of medication administration process revealed the medical staff
administers and prepares the medication as required. The youth was escorted individually to the
medical clinic by the center’s staff. The youth identified themselves and stated why they are at
the medical clinic. The medical staff also verified the youth’s allergy and alert status. The
nursing staff ensured the youth swallowed the medication. There was no observation of non-
healthcare staff medication administration during the annual compliance review week.
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Office of Accountability and Program Support Page 43 of 59 (Revised July 2023)
A formal interview with the nursing staff revealed verification of the youth’s medication regimen
process requires nursing staff to verify medications with current bottle or pharmacy order for
accuracy of milligrams and dosing. Non-healthcare staff collect medication and supply a
medication receipt to the individual who brought the medication. Non-healthcare staff then give
medications to medical staff to verify. The center utilizes the Department’s electronic Medication
Administration Records and a printed version is used as back up. The nursing staff reported
sergeants or higher-level ranking administration staff are trained by the medical staff to
administer medication. The non-healthcare staff who are trained to administered medication are
documented on a roster. According to the nursing staff, medication pass is conducted Sunday
through Saturday at 8:00 a.m., 12:00 p.m., 5:00 p.m., and 8:00 p.m. The facility does not have a
modified Class II permit and routine gynecological exams are not completed for female youth at
the center. Nursing staff reported medications are provided by a pharmacy service. In the event
of an emergency, a local pharmacy is used as back up. The psychiatrist is on-site two hours
each week for medication management. The nursing staff further reported all controlled
substances are secured in a lock box in the locked medication cart. Seven youth were formally
interviewed and three youth reported the nurse administers their medication. The four remaining
youth reported they do not take medication. Seven staff were formally interviewed and six staff
reported they do not give youth any medication. One staff reported they administer the youth’s
medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
An observation of the medical clinic and designated medication storage area revealed medical
equipment classified as sharps were secured and inventoried utilizing a routine perpetual
inventory, descending count as each sharp was utilized and disposed for the annual compliance
review period. All medications were identified and secured in the locked area designated for
storage of medications. The medication cart was clean and organized with stocked items
separate from youth-specific medications, and all controlled medications had a perpetual
inventory and were stored separately from other medications. All medications were stored in a
separate, secured area, inaccessible to youth. Oral and injectable medications were also stored
separately. Narcotics and other controlled medications were stored behind two locks. The
center did not have any medication which required refrigeration, and nursing staff indicated
medications which require refrigeration are stored in a secured refrigerator which is used for
medication only. Three controlled medications, three over-the-counter (OTC) medications, and
three sharps were reviewed, and the inventory corresponded with the perpetual inventory for
each. The nursing staff reported in the event there are inventory discrepancies, they retrace
their steps and review the binders until the issue is resolved. According to the nursing staff,
when the discrepancy involves a controlled substance, law enforcement is contacted if the
discrepancy is not resolved. The nursing staff further reported when conducting the disposal
and destruction of expired and/or discontinued medications, two nurses are required to conduct
medication destruction. One nurse act as a witness and one nurse destroys the medication by
dropping it in the RX Destroyer container, and both nurses sign the destruction log. A review of
the medical training log revealed supervisory level, non-healthcare staff are trained in the
delivery and oversight of medication self-administration. Training was delivered by the
registered nurse.
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Office of Accountability and Program Support Page 44 of 59 (Revised July 2023)
A formal interview was conducted with the nursing staff. The nursing staff indicated non-
controlled medication can be destroyed by two nurses and documented; however, controlled
medication must be destroyed with the pharmacist and documented. The nursing staff indicated
all controlled substances are stored in a locked box in the locked medication cart. The nursing
staff indicated the consultant pharmacist comes to the center monthly to conduct inventory. The
nursing staff confirmed the center maintains a copy of a pharmacy consultant license on-site to
include the required licensure. The nursing staff further indicated weekly counts are conducted
for medications and inventory.
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. Six youth IHCRs had documentation the youth received
infection control training within seven days of admission on all required topics. The remaining
youth was released from the center prior to the seven day time frame. The center has infection
control procedures in place in accordance with the Occupational Safety and Health
Administration (OSHA). The procedures include risk assessments, listing all required elements
and methods of compliance which includes all required elements. The infection control
procedures also include all the required elements. A review of the facility operating procedures
indicated the center’s process for needle stick post-exposure evaluation is to notify the
supervisor. The supervisor is responsible for notifying the regional director and follow-up with
testing and prophylaxis treatment is conducted. The Hepatitis B immunization is available for all
staff. All staff have access to biohazardous kits for protective equipment. Instances of infectious
diseases and sexually transmitted diseases were reported to the local health department, as
required. There were also instances in which incidents reported to the local health department
were also reported to the Department’s Central Communications Center (CCC). The center did
not have three or more cases of infectious diseases which were required to be reported to the
local health department and/or Centers for Disease Control and Prevention. Seven staff pre-
service and seven staff in-service training records were reviewed. Each staff had training on the
center’s specific Exposure Control Plan. The nursing staff was formally interviewed and reported
a copy of the Exposure Control Plan is available and located in the clinic. The nursing staff
reported the medical staff is responsible for conducting infection control training and training of
the center’s Exposure Control Plan for all staff. The nursing staff further reported infection
control training is provided to all youth at admission.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for prenatal care and
education. None of the records were applicable. The center had one applicable youth during the
annual compliance review period. The youth was in the center for twenty-three days; therefore,
a focused medical evaluation was not completed. There was no documentation of any youth
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Office of Accountability and Program Support Page 45 of 59 (Revised July 2023)
complaints pertaining to pregnancy. Prenatal care was provided at recommended intervals and
the youth was placed on the internal alert system for vital nutrition, health awareness for staff,
and youth’s sleeping arrangements. The youth had daily monitoring of the danger signs of
pregnancy complications. Prenatal and pregnancy education was provided to the youth, which
included topics of alcohol and drug use, smoking, nutrition, sexually transmitted diseases,
contraception, prenatal care, birthing process, postpartum care, basic baby care, infant
development, and parenting skills. A documented plan for post-birth psychological, physical
care, and provided education was included in the youth’s IHCR. Additionally, a review of seven
staff training plans indicated a licensed nurse provided annual in-service prenatal healthcare
education to all seven non-healthcare staff.
A formal interview with the nursing staff revealed all female youth are screened for pregnancy
upon admission. The nursing staff indicated all pregnant youth are provided prenatal care,
special diets, and vitamins. All pregnant youth are placed on the providers list and the policy for
pregnant youth would be adhered to. The nursing staff further indicated medical staff provide
non-licensed healthcare staff education on female youth healthcare. The medical staff also
provide and review educational material with the youth. Examples of the topics discussed
according to policy included diet, healthy lifestyle, and development of the baby. Seven female
youth were interviewed and reported prenatal services were not needed, as the youth were not
pregnant.
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Office of Accountability and Program Support Page 46 of 59 (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 address active supervision of youth. Staff were
observed during daily activities such as school/education, recreation, meals, breaks, and line
movements to ensure staff were actively supervising youth. Interactions with the youth were
positive. Youth were in sight of at least one juvenile justice detention officer at all times, with the
exception of when placed in sleeping rooms or in a secure placement. All youth were accounted
for and accompanied by staff at all times. Master control authorized all movement of youth prior
to the youth being moved. The interaction between youth and staff demonstrated active
supervision. The logbooks documented resident counts were consistently conducted. Seven
staff were interviewed and three staff stated there are enough staff to provide for the safety and
security of the youth and staff and five stated no, explaining the center is so short staffed and
there is not enough staff to cover the youth supervision properly.
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Office of Accountability and Program Support Page 47 of 59 (Revised July 2023)
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations.
Each center shall implement and maintain a behavior management system to meet the needs
of the youth and the center. The system shall include rewards for positive behavior and
consequences for inappropriate behavior.
The behavioral norms and expectations for youth shall be posted in all living areas and shall
clearly specify appropriate and inappropriate behaviors.
The system restricts certain types of penalties on youth who demonstrate negative behaviors.
Group punishment shall not be used. However, corrective action taken with a group of youth
is appropriate when the behavior of a group jeopardizes safety or security, and this should
not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
The use of drugs to control the behavior of youth is prohibited. This does not preclude the
proper administration of medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) in place to address the behavior
management system (BMS) and unauthorized use of punishment. Postings of the BMS were
found in all living areas and clearly specified appropriate and inappropriate behaviors, rules,
norms, and expectations. The system includes rewards for positive behavior and consequences
for inappropriate behavior. Daily activities were observed to determine implementation of the
BMS. A review of the center’s FOPs on the BMS ensured compliance with the components
outlined in the center’s procedures. A review of documentation confirmed positive rewards are
given to youth to match the BMS incentive calendar. A review of documentation confirmed
rewards and consequences are given in accordance with the BMS and no instances of
inappropriate use of restrictions or group punishment were used.
Seven staff were interviewed regarding the BMS and all were able to explain the point and level
system, postings throughout the center, types of rewards provided to the youth, and inclusion in
the youth handbook and orientation process. All seven staff denied items other than points and
levels are taken away from youth as a consequence, indicated staff speak with youth about the
consequences being implemented, youth are given an opportunity to explain their behavior, and
staff speak with youth about alternative behaviors. All seven staff stated supervisors provide
feedback to staff regarding the implementation of the BMS by reviewing the logbook and point
sheets and the information is shared verbally and through email. All seven staff stated they
receive feedback on the implementation of the BMS daily. Three staff also stated they receive
feedback weekly. All seven staff denied ever seeing a coworker take meals, snacks, clothing,
education, or medical care from a youth because they were acting out or observing any staff
encouraging youth to beat up another youth. All seven staff stated they felt the BMS system is
effective.
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Office of Accountability and Program Support Page 48 of 59 (Revised July 2023)
Seven youth were interviewed and one youth rated the BMS as “very good,” four rated it as
“good,” and two rated it as “fair.” All seven youth were able to explain the difference between
each level and how youth move from level to level. When interviewed regarding rewards the
youth receive as part of the BMS, all seven youth stated canteen, ice cream, telephone calls,
special visitation, and student of the week were offered as rewards. All seven youth confirmed
staff used the rewards in the same manner. All seven youth denied youth are allowed to punish
other youth. When asked if they had ever been sent to their room for punishment, four youth
stated “yes” and three youth stated “no.” All seven youth were asked if the consequences they
received were fair; four stated “yes” and three denied ever receiving consequences. The four
youth who received consequences stated points and levels were taken away as part of their
consequence and their door was shut and locked. When asked if handcuffs or leg irons were
used on out of control youth to prevent them from hurting themselves or others; two youth
stated “yes” and five stated they have never witnessed restraint being used. The superintendent
stated the BMS is used to track youth behavior and was able to explain the system.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has ninety-two cameras of which eighty-eight were operational during the annual
compliance review week. The cameras store thirty days of video. A sample of security tapes
and corresponding logs were reviewed to verify ten-minute checks were completed, as required.
Reviewed documentation confirmed weekly reviews of management oversight were completed.
Observations of ten-minute checks through video observations and logs during the annual
compliance review period reflected checks were conducted in the required frequency. Seven
staff were interviewed and stated room checks are conducted every ten minutes when a non-
suicidal youth is placed in their room for sleeping or non-punishment reasons. The
superintendent was able to describe the center’s ten-minute check process by explaining the
electric wand system is used to conduct checks. The data is downloaded daily and a supervisor
or administrator review the results. The supervision matrix consists of standard supervision,
close supervision, precautionary observation, secure observation, and one-to-one supervision.
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Office of Accountability and Program Support Page 49 of 59 (Revised July 2023)
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).
Twelve months of census counts were reviewed. Counts were conducted at the beginning of
each shift, following any emergency such as power outages and evacuations for emergency
drills, prior to and following routine movement, any time a population change occurred,
randomly at least once on each shift, and during head counts and youth movements. An
observation of a count was conducted with no discrepancies noted. Seven staff were
interviewed and all staff stated counts are conducted at the beginning and end of each shift,
before and after meals, and before and after school. All seven staff stated if the count is not
correct all movement is stopped and a recount is conducted until the count is correct. All seven
staff stated an emergency count is conducted when a youth is believed to be missing, visibility is
hindered such as an electrical outage, and after a major disturbance.
5.05 Logbook Maintenance Limited Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has separate logbooks in master control, each living area, for visitors, and for each
vehicle. Logbooks are bound with numbered pages documented at the top of the page. All
entries included the times of the events in a.m./p.m. and not military time, with the name of the
staff and youth involved, a brief description of the events, and the initials of the staff making the
entries. All entries impacting the safety and security of the center, including medical/special
needs and mental health alerts, were highlighted. All errors were struck through with a single
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line and “void” written after the error followed by the staff’s initials. The JJDO supervisor(s) did
not review the master control logbook when accepting responsibility for the center or review the
living area logbooks daily, as required. The JJDOs reviewed the logbook entries from the
previous shift when accepting responsibility for the living area, as required. Each logbook review
designated the name and position of the reviewer and the date and time the review was
completed. The master control logbooks included emergency situations, incidents (including use
of Protective Action Response, Florida Abuse Hotline, and the Department’s Central
Communications Center contacts), all drills, documentation of receipt of medical/mental health
alerts, population counts at the beginning and end of each shift, population counts throughout
shifts as count changes, youth group movement, admissions and releases, presence of law
enforcement, names of youth placed in confinement with the time confinement began and the
time confinement ended, and names of youth placed on precautionary/secure observation along
with the time initiated and time ended. The logbooks did not include youth counts following
emergency situations, as required. A review of all type of logbooks for three days each month
during the annual compliance review period was completed. The activity schedule and logbook
documented minimal interference of educational instruction; however, youth were not in class as
required. A review of the logbook indicated education classes were not conducted, as
scheduled. The logbook reflected when youth arrived and departed school but were not
consistently on time according to the schedule.
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The superintendent or designee reviewed all logbooks on a weekly basis and provided
recommendations as to the completeness and accuracy of the information recorded. The
juvenile justice detention officer (JJDO) supervisors were not reviewing facility logbooks
maintained at master control when assuming center responsibility, as required. JJDO
supervisors and/or lead officers reviewed logbooks maintained in each living area daily. JJDOs
reviewed logbooks maintained in assigned living areas when accepting responsibility for the
living area at shift change. The superintendent, assistant superintendent, or staff in charge of
the center toured the youth living areas at least once during each shift and documented their
visit in each area’s logbook, as required. The superintendent was interviewed and stated
supervisors review logbooks daily looking over the past two shifts and center administration
review logbooks weekly.
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5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys.
All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of
keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch.
The key(s) on these rings shall provide egress through facility exterior doors providing access
to evacuation areas.
A key inventory shall be maintained by the Superintendent or designee at all times.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
A review of the center’s facility operating procedures on key control determined it included the
control and use of keys, key assignment and usage, restrictions on usage, inventory, daily
tracking, and reconciliation of keys, secure storage of keys not in use, procedures addressing
missing or lost keys, and reporting and replacement of damaged keys. A review of the key
inventory ensured the key rings on the inventory matched the actual key rings in use. An
observation of the key storage area showed the center has a supervisor key box for staff keys,
which are issued during shift briefing. Master control maintains a key box for transportation
vehicle keys. Medical, mental health, and education keys are issued as needed during the shift.
Master keys are kept in in the office of the assistant superintendent. Staff have assigned lockers
within the front restroom areas to store personal keys. Visitors and contracted providers turn
their personal keys into master control staff in order to receive a facility key. Restricted keys
include keys to the property room, medical records, administration keys, supervisor keys, food
services key, and maintenance keys. Facility keys are maintained on a tamper-resistant ring.
Emergency keys are located in the master control area, accessed by the staff assigned to
master control area, the supervisors, administration staff, and maintenance staff. Emergency
key rings were included as part of the facility key inventory. The master key inventory included
the ring number, number of keys on each ring, capability of each key, and to whom the key ring
was issued. All key rings were numbered and indicated the number of keys on the ring. The
facility keys are placed on the key ring hubs system and the hubs were color-coded, as
required. The issuance of keys and key ring numbers were documented on each shift report and
included the date and time of issue, name of staff issuing the key ring, name of staff who
received the key ring, and time the key ring was returned. Based on observations, all staff who
were issued keys carried issued keys on their person at all times, did not allow youth to handle
facility keys, and did not remove the keys from the facility or the facility grounds without
authorization from the superintendent. In the event staff mistakenly left the facility with keys and
the key ring, staff are to contact the shift supervisor immediately and return the key ring to the
facility within two hours of notification. The key box is not easily accessible while locked. There
were no incidents reported to the Department’s Central Communications Center (CCC) or
Program Monitoring and Management (PMM) deficiencies related to key control concerns. A
sample of key rings was observed and compared to the inventory and key log with no
discrepancies. Three staff were interviewed and were able to provide the number of keys and
each keys function with no issues. An informal interview with maintenance staff determined the
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process for restricting usage of keys such as medical, youth and staff records, and youth
property locker keys and described the center’s procedures for key control.
Seven staff were interviewed and stated the restricted keys included keys to access medical
records, youth property area, mental health records, case management records, and the
kitchen. All seven staff were able to describe the center’s key control process by explaining
personal keys are securely stored, visitors’ personal keys are given to master control upon
entry, chits or tokens are provided to visitors, and the daily tracking of keys in the key log. Staff
also explained center keys are assigned to staff, staff inventory keys, youth do not have access
to keys, staff must notify master control of missing keys, the facility must be searched for
missing keys, youth are searched for missing keys, and a key is replaced when damaged. The
interviewed superintendent indicated a key inventory is maintained when keys are permanently
issued to staff.
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has six vehicles used to transport youth. A review of documentation showed all six
vehicles undergo an annual vehicle inspection. A certified mechanic conducted an inspection on
all vehicles used to transport youth to ensure the tires, lights, and brakes were safe. Water
coolant, lights, oil, emergency equipment, brakes, horn, interior/exterior, and cleanliness
inspections were conducted monthly by staff for all six vehicles. Maintenance for tires including
spares, battery tests, windshield and wipers, windows, mirrors, and damage to include all
scratches and/or dents was conducted monthly by staff. Inspections were documented on the
mandatory inspection form and a copy of the forms were maintained by the maintenance staff
for all six vehicles. All vehicles used to transport youth are equipped with the appropriate
number of seatbelts, a seatbelt cutter, a window punch, a current fire extinguisher, and a first-
aid kit with items approved by the designated health authority. The logbook for each transport
documented the acknowledgment the vehicle was checked, the destination, number of youth
and staff names, and times the transport began and ended. A transport was observed and all
required activities were completed prior to the transport. Five of the center vehicles were
checked at random, the sixth vehicle was being utilized for a transport during the check. All five
vehicles were found to be locked while not in use. Seven youth were interviewed and each
confirmed they feel staff drive safely when transporting them. All seven youth denied ever
seeing someone place contraband in the transport vehicles.
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center has facility operating procedures addressing maintenance and kitchen tool practices.
Inspections of the maintenance room, kitchen tool and knife storage, and broom closets found
each area to be secured and inaccessible to youth. Maintenance tools are placed on a shadow
board and engraved with a Department identification code in the maintenance room. The
maintenance tool inventory sheets were reviewed to show the maintenance staff conduct a
weekly inventory of each tool and maintain the inventory in SharePoint, which is forwarded to
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the superintendent/designee. A sample of six items listed on the maintenance inventory were
observed and each was logged and accounted for. Documentation reflected the kitchen staff
conduct an itemized inventory of all equipment, including knives and other implements upon
reporting for duty daily. All kitchen items were accounted for and logs were up to date at the
time of the annual compliance review. Instances of tool replacement were documented by the
superintendent/designee according to procedures. An informal interview with the maintenance
staff revealed service vendors are escorted at all times while at the center, tools are checked,
and the vendor does not have access to the youth nor do the youth have access to the vendor
in the working area. The maintenance staff reported there were no lost tools during the annual
compliance review period. Reviewed maintenance and kitchen inventories used to document
the issuance and return of tools resulted in no discrepancies found. Informal interviews with the
maintenance and kitchen staff revealed if there are any missing, lost, or damaged tools, it would
be reported immediately to the supervisor. The superintendent was interviewed and reported
the maintenance mechanic has access to the center’s tools. Seven staff were interviewed and
each was familiar with the basic reporting procedures for missing or damaged tools.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center has facility operating procedures addressing youth access to and the use of tools
and cleaning items under direct supervision. Observations of various activities during the annual
compliance review week did not reveal any youth using tools, to include kitchen and medical
equipment. Seven staff were interviewed and each indicated only mops and brooms were used
by youth. Seven youth were interviewed and each reported they use only mops and brooms.
5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center has a safety plan included in their Continuity of Operations Planning (COOP) Plan
addressing proper use, storage, and disposal of chemicals including flammable, toxic, caustic,
and poisonous items. All flammable, toxic, caustic, and poisonous items are inventoried and
secured when not in use. On-site observations were conducted during the annual compliance
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review week. A sample of chemicals on two dorms were reviewed and confirmed items were
listed and logged on the inventory, as well as corresponding Safety Data Sheets (SDS) are
readily available. No chemicals were observed to be accessible to youth.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center has facility operating procedures which state flammable, toxic, caustic, and
poisonous items and other dangerous substances may only be drawn or acquired by authorized
staff and prohibit youth from using or handling these items or responding to chemical spills.
During the annual compliance review week, all chemicals observed were secured and
inaccessible to youth. Seven interviewed staff reported youth are not allowed to clean with
substances which are toxic, flammable, or poisonous. Seven interviewed youth all reported they
do not directly handle any cleaning agents or chemicals. Two youth reported they use chemicals
to clean, the youth reported staff handle or spray the product and youth wipe the cleaning
product off.
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures requiring the inventory, storage and disposal of any
flammable, toxic, caustic, and poisonous items. A review of the Department’s Central
Communications Center (CCC) information revealed the center did not have incidents involving
a chemical spill during the annual compliance review period. The center’s Safety Plan is
included within the approved Continuity of Operations Planning (COOP) Plan and addresses the
chemical spill process and clean-up. The superintendent reported they have not had to dispose
of any chemicals other than the grease in the kitchen during the annual compliance review
period. In the event a chemical would need disposal, contact would be made to the company
hired to remove and dispose of these products. The superintendent stated the kitchen has a
grease disposal vat which is emptied monthly by a local vendor.
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5.14 Confinement Under Twenty-Four Hours Limited 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 had a total of 306 confinements since the last annual compliance review. A sample
of twenty confinement reports was reviewed. Each was recorded in the Department’s Facility
Management System (FMS). A review of confinement documentation found all twenty youth
were given access to mental health care, clean clothing, and a mattress. A review of twenty
confinements reflected two youth were not offered a meal, two youth were not offered a shower,
and fifteen youth were not offered education materials. All twenty youth were notified of their
right to grieve the confinement. Documentation reflected the supervisor approved all twenty
confinements and all youth were placed into a room by themselves. Nineteen of the twenty
records reflected the confinement room was searched and one room was not searched.
Seventeen of the twenty confinement records were documented on a completed Visual
Observation Report (VOR). Three records did not have a documented VOR or a completed full
report. None of the twenty reviewed confinement reports indicated the youth had sustained
physical injuries. In all twenty records, the youth was notified of the reason for confinement. In
nineteen of the twenty confinement records, the supervisor conducted an initial confinement
review with the youth within one hour of the incident. One review was an hour and twenty
minutes late. Seventeen of the twenty confinement reports were completed by end of shift and
three were not completed by the end of the shift. Eighteen of nineteen applicable records
reflected an additional review with a youth was completed every three hours by the supervisor
and one record reflected the review was thirty minutes late. In each of the twenty confinements,
the supervisors/staff continually counseled the youth and considered removing the youth from
confinement as soon the youth was able to safely rejoin the population with no threat to safety.
In eight of the twenty confinement reports, the superintendent or designee reviewed the
confinement report after the required forty-eight hour time frame. No pregnant youth were
reportedly put in confinement during the annual compliance review period. All windows and
cameras were free of obstructions or scratches so the youth could be visually observed. Seven
staff were interviewed and each reported youth are given educational materials during
confinement. The superintendent was interviewed and reported administration reviews all
confinements.
5.15 Confinement Over Twenty-Four Hours and Confinement
Failed Compliance
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 had one confinement over twenty-four hours since the last annual compliance
review. The center did not conduct a confinement review for this incident; therefore, none of the
required actions, other than basic supervision, were taken prior to the youth being held in
confinement over twenty-four hours.
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Office of Accountability and Program Support Page 56 of 59 (Revised July 2023)
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has an approved Continuity of Operations Planning (COOP) Plan maintained on-site
and available for staff. The center provided documentation showing the center conducted three
COOP drills during the annual compliance review period. The drill documentation included the
date, time, and a brief scenario; however, did not list names of participants. Seven staff were
interviewed and indicated they participated in drills related to topics such as severe weather,
major disturbances, hostage situations, chemical spills, and flooding or terrorist threats/acts with
five of the seven specifically stating COOP drills. The superintendent was interviewed and
stated the facility utilizes a COOP Plan in case of an emergency.
5.17 Escape Drills Failed Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has an Escape Prevention Plan incorporated into the facility operating procedures to
ensure the facility is prepared to address youth escapes, escape notifications, and prevention. A
review of drill documentation found the center conducted three of the nine required escape
drills, one for each shift each quarter during the annual compliance review period. Drills were
not documented in the center’s logbook, as required. The deficiency of missing drills was
documented by the superintendent; however, no corrective action was notated. Four of seven
interviewed staff reported they participated in an escape drill since the last annual compliance
review with three noting having not completed an escape drill. A review of seven pre-service
and seven in-service staff training records found each staff received escape prevention training
annually, as required.
5.18 Fire Drills Failed 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 Fire Prevention Plan. Reviewed documentation reflected fifteen of the thirty-
six required drills were completed. A review of drill documentation reflected many of the
documents were not completed in their entirety and/or signed by the superintendent, as
required. A review of master control logbooks revealed all fire drills were documented and
highlighted, as required. All fire extinguishers are inspected annually. All seven interviewed staff
reported fire drills are conducted monthly. Each of the seven interviewed youth stated they have
been instructed on what to do in case of a fire.
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5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures to address illegal contraband and prohibited items.
The center delineates items and materials considered contraband when found in the possession
of youth, including 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 procedures, personal non-facility issued cellular
devices, and non-facility issued keys. The center has procedures on contraband and searches.
The center has 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.
Youth are frisk searched prior to admission, when deemed appropriate by the shift supervisor,
when there is reasonable suspicion, and during facility-wide initiative to reduce the introduction
of contraband. A review of seven admissions found all youth were frisked and electronically
searched prior to admission and documented in the Department’s Juvenile Justice Information
System (JJIS); however, the searches were not being documented in the center’s logbook.
Documentation does not notate who conducted the search, whether two staff were present
during the search, the completion of the search, or whether any contraband was found.
Electronic searches are required on all persons entering the facility to include all bags, cases,
jacket pockets, and other items. All personal keys, personal cellular telephones, and other
contraband items are prohibited from entering the secured area. Facility-wide random room
searches are conducted regularly to reduce the introduction of contraband to the center.
Searches are noted in SharePoint but not documented in logbooks for the assigned youth
dorms. A youth search was observed and a staff of the same gender conducted a search of the
youth, according to procedures. A review of the center’s logbook for the month of July 2023
reflected no entries regarding staff, visitors, or contractors/vendors being searched.
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During the annual compliance review period, one instance was found which may have
compromised the safety or security of the center. The incident was of contraband found after
family visitation. The contraband was retrieved from the youth by staff. No strip search was
conducted due to the youth turning the item over; however, a room search was documented.
The incident of contraband was located in the center’s logbook. An incident report was
completed identifying the findings and disposition of the contraband. The chain of custody for
the item was documented and the Department’s Central Communications Center and regional
director were notified of the discovery and confiscation of the illegal contraband.
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Office of Accountability and Program Support Page 59 of 59 (Revised July 2023)

report_type: QI Detention

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 3.10

rule: Indicator 3.11

rule: Indicator 5.05

excerpt: Logbook Maintenance

rule: Indicator 5.14

excerpt: Confinement Under Twenty-Four Hours

rule: Indicator 5.15

rating: Failed Compliance

rule: Indicator 5.17

excerpt: Escape Drills

rule: Indicator 5.18

excerpt: Fire Drills