summary: QI Detention - FY23-24 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Okaloosa Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
4448 Straight Line Road
Crestview, Florida 32539
Review Date(s): December 5-8, 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:
Patrick M McKinstry, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Janise Best, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Lea Herring, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Ken Myers, Office of Education, North Region Education Coordinator (Standard 2)
Cedric Prince, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Interviews
and Standard 5)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Okaloosa Regional Juvenile Detention Center MQI Program Code: 828
Provider Name: Department of Juvenile Justice Contract Number: NA
Location: Okaloosa County / Circuit 1 Number of Beds: 35
Review Date(s): December 5-8, 2023 Lead Reviewer Code: 144
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
2.10 Educational Access*
3.08 Psychiatric Services *
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 61 (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 61 (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 61 (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 * Limited
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in
a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 61 (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 61 (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 Satisfactory
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 Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
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 61 (Revised July 2023)
Program Overview
The Okaloosa Regional Juvenile Detention Center is a state-owned detention facility, operated
by the Department, located in Crestview, Florida. The center serves youth in Okaloosa and
Walton counties in circuit one. The center is co-located with a Juvenile Assessment Center
(JAC), which is operated by circuit one juvenile probation officers (JPO). Male and female youth
who are detained pending adjudication, disposition, or placement in a residential commitment
program are housed in the thirty-five bed center. Youth are provided services which include
youth orientation, behavior management, safety and emergency procedures, transportation,
mental health, and healthcare services. The center’s educational services are provided by the
Okaloosa school board. The center’s management team includes the superintendent, two
assistant superintendents, one administrative assistant, seven juvenile justice detention officer
supervisors (JJDOS), thirty-three JJDOs, one OPS JJDO, one food service director, and three
food support workers. Mental health and healthcare services are provided through the
contracted provider, VitalCore Health Strategies, LLC. Mental health services are provided by
one designated mental health clinician authority (DMHCA), and one licensed mental health
professional. 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), two advanced practice registered nurse (APRN), and
four registered nurses (RN). The medical clinic maintains nursing coverage seven days a week,
from 7:15 a.m. to 7:15 p.m., Monday through Friday, and from 7:00 a.m. to 5:00 p.m., on
weekends. Food services are provided by Department staff and include menus, meal planning,
meal schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has three living modules which are divided by male and female.
There are seventy-two security cameras at the center, of which seventy-two were operational.
The center has several areas, largely living modules, which need to be painted. Painting would
help cover a few rooms with graffiti, however, the center is unable to purchase paint. The male
living area has an issue with the air conditioning unit; a work order has been submitted. At the
time of the annual compliance review, the center had five vacancies, which were all JJDOs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 61 (Revised July 2023)
Strengths and Innovative Approaches
• The center has opened the “Yoga Experience with Staff”, which allows youth to perform
and learn yoga and meditation with staff.
• This year the center had the first ever high school equivalency diploma (GED)
graduation for a youth. This youth studied and provided a peer-to-peer teacher’s
assistant forum while in class. The center also has new programs geared towards
youth’s post incarceration plans, such as job opportunities, apprenticeship programs,
GED programs, and more provided by the Department of Education.
• The youth got to decorate their faces with scary designs and the staff got to dress up in
a kid friendly costume. The center set up stations around the facility and escorted the
youth around the different departments and let them go trick or treating, which also
included a spooky themed party for the youth.
• The center had a door decorating contest which was judged by all staff. The department
which won had a Santa surprise gift of their choosing. The center included a “Twelve
Days of Christmas” revised jingle contest. The center decorated cookies and had a staff
vs youth Family Feud game followed by traditional and untraditional holiday food.
• The center provides the high level youth the opportunity to have a special visitation with
family and the family gets to bring a fast-food order in to eat with the youth. For youth
who live out-of-county/state, they oblige this by having staff donate a meal and time to
“Break Bread” with the youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 61 (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 thirteen newly hired staff and no volunteers since the last annual compliance
review. One newly hired staff is contracted. Each of the hired staff had a background screening
completed by the Department’s Background Screening Unit (BSU) prior to their hire date. One
newly hired staff had a break in service which required a new background screening to be
completed. A criminal history report was reviewed for all newly hired staff. One newly hired staff
required an exemption which was obtained prior to working with youth. Each staff was rated as
eligible for hire with one waiver requirement. Twelve of thirteen staff had a pre-employment tool
administered and had a passing score documented. The remaining staff was not a direct care
staff. The center submitted their Annual Affidavit of Compliance with Level 2 Screening
Standards on December 21, 2022. The Okaloosa County School Board submitted their Annual
Affidavit of Compliance for Level 2 Screening Standards on January 25, 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.
The center had four staff who were eligible for a five-year background rescreening during the
annual compliance review period. Each of the five-year rescreenings were completed and
eligible at least ten days prior to the anniversary date of the staff’s initial hire date. The center
did not have any contracted staff or volunteers eligible for a five-year background rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 61 (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 a code of conduct each staff is required to sign upon hire. A review of three
personnel records found each signed a code of conduct as required. Three reviewed staff were
applicable for violations of the code of conduct and disciplinary action during the annual
compliance review period. Three staff received documented memos of retraining as reprimand.
Three reviewed staff received commendations during the annual compliance review period,
including “Employee of the Month.’’
Seven youth were interviewed. Two youth reported they have never been stopped from
reporting abuse to the Florida Abuse Hotline, and two youth reported yes, they have been
stopped from reporting abuse to the Florida Abuse Hotline. This was addressed with the center,
which provided each youth the opportunity to call the Florida Abuse Hotline; one of whom opted
to call with the center, and the remaining youth declined to call. Three youth reported they have
never requested to report to the Florida Abuse Hotline. Four youth reported staff are respectful
when talking with youth. Three youth reported staff are not respectful when talking to youth.
Three youth reported they never hear staff use curse words when speaking with youth. Three
youth reported they occasionally hear staff use curse words when speaking to youth. One youth
reported they often hear staff use curse words when speaking to youth. Five youth reported they
have never heard staff threaten them or other youth. One youth reported they heard a staff
threaten a youth once. One youth reported they occasionally hear staff threated youth. Six youth
reported they feel safe in the facility. One youth reported they do not feel safe in the facility. All
seven youth reported they have never exchanged emails, telephone numbers, or social media
contact information with staff.
Seven staff were interviewed. Each of the staff were able to explain the process for allowing
either staff or youth to call the Florida Abuse Hotline and/or the Department’s Central
Communications Center (CCC), to report suspected abuse. Four of seven staff reported they
have observed staff use profanity once while speaking to youth. Three of seven staff went on to
say they have never observed a coworker using profanity when speaking to youth. All seven
staff reported never observe a coworker using any threats, intimidation, or humiliation while
interacting with youth. Six of seven staff reported in the past year, working conditions have been
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 61 (Revised July 2023)
good or fair. One staff reported the working conditions have been very good. The
superintendent reported staff are provided corrective actions when in violation of the staff code
of conduct. During the annual compliance review week, the information regarding profanity used
by staff was shared with the superintendent and two assistant superintendents who will be
addressing it with staff.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has had twenty-four incidents reported to the Department’s Central Communications
Center (CCC) since the last annual compliance review. Four of the five reviewed CCC reports
reflected the incidents were reported within the required two-hour time frame. One reviewed
incident was reported one minute late. The CCC incidents documented the occurrence date,
time, and type of incident. One of the five reviewed CCC incidents was observed to not be
documented in the center’s logbook. It was determined the CCC report had not been
communicated to administration. There were no observed internal incidents/grievances which
should have been reported to the CCC. The acting superintendent reported CCC reportable
incidents are called into the CCC within two hours of the incident or two hours of gaining
knowledge of the incident. Reports are made by the supervisors or higher. All staff and youth
can contact the Florida Abuse Hotline at any time to make a report.
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 had 126 Protective Active Response Right Interactions model (PAR/RI) incidents
since the last annual compliance review, nine of which were reviewed. A PAR/RI Report was
completed for each use of countermoves, counter techniques, takedowns, or mechanical
restraints. All nine reviewed incidents were completed by the end of the staff’s workday. One
report did not include a statement from one staff involved; however, the statement was
completed while on-site for the annual compliance review. None of the PARs/RIs resulted in a
serious injury of youth or staff. All nine PAR/RI Reports were reviewed by either a supervisor or
acting supervisor. All nine post-PAR/RI Interviews were conducted within thirty minutes after the
incident, and none indicated the need for a post-PAR/RI medical review. None of the reviewed
PAR/RI Reports indicated or required the need for mechanical restraint usage. Seven of the
nine PAR/RI Reports were reviewed within the seventy-two-hour time frame by the
superintendent/designee. One superintendent/designee review was completed one day late. A
second report was reviewed by the superintendent/designee upon returning to the center from a
conference. The late review was documented in the Facility Management System (FMS). The
center’s PAR/RI rate during the previous quarter was 18.72, which is above the statewide
Detention PAR/RI rate of 16.29.
Seven staff were interviewed. All seven staff reported they try to talk to youth prior to using
physical restraints or mechanical restraints.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 61 (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 requirements. Two of seven staff
received pre-service training within 180 days of hire. Five of seven staff are still within the 180
days of training. All seven staff are certified to use cardiopulmonary resuscitation (CPR), first-
aid, and the automated external defibrillator (AED). Based on the Statewide Detention Center’s
Annual Training Plan, each staff received all the required trainings for their respective positions.
Two of the seven staff reviewed have completed all essential skills, Phase One, and Phase Two
training as required. Five staff reviewed have not completed Phase One or Phase Two training.
Two of seven staff have all trainings documented in the Department’s Learning Management
System (SkillPro). Five staff had not been to the academy at the time of the annual compliance
review.
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 requirements. Four of the seven staff
reviewed were juvenile justice detention officers (JJDOs), and the remaining three staff were
JJDO supervisors. A review of training records revealed all seven staff completed the twenty-
four hours of annual in-service training which included all required topics. Three of the seven
staff were applicable for eight hours of supervisory training. All three staff completed a minimum
of eight hours of supervisory related training. All in-service trainings completed were
documented within the Department’s Learning Management System (SkillPro) for each of the
seven staff reviewed. The center has an annual in-service training calendar, which is updated
as changes occur. Additionally, the list of in-service trainings approved by the Department’s
regional director was completed on November 29, 2022.
The superintendent reported in addition to the twenty-four hours of in-service requirements,
supervisory staff shall complete eight hours of training each calendar year. The mandatory
training topics which must be completed each year by staff include Protective Action Response
Right Interactions model PAR/RI update, cardiopulmonary resuscitation (CPR), automated
external defibrillator (AED), first-aid, suicide prevention, and professionalism and ethics courses.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 61 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a facility operating procedure which ensures each youth has the right to grieve
and is treated fairly, respectfully, without discrimination, and their rights are protected. The
center had seven grievances completed since the last annual compliance review. No on-site
observations were made of the juvenile justice detention officers (JJDOs) attempting to resolve
any disputes or issues which could lead to a grievance. A tour of the center revealed the center
has grievance forms available for youth to complete if necessary. A review of the Department’s
Facility Management System (FMS) revealed grievances were entered electronically on behalf
of the youth. Seven grievances were reviewed, and each reviewed grievance was appropriately
responded to within the specified time frames, including either an informal, formal, and/or
appeal phase.
Seven youth were interviewed, and each youth was able to articulate their understanding of the
center’s grievance process. Five youth reported they had never filed a grievance. One youth
rated the grievance process as very poor. One youth rated the grievance process as very good.
Seven staff were interviewed. Each of the staff were able to explain the center’s grievance
process. The superintendent was able to explain the center’s grievance process, which included
three phases.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 61 (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 were reviewed for alerts entered by the center. A total of nine alerts were entered
for the seven youth selected. All nine alerts had evidence the alert was entered and/or closed
on the date required. The reviewed alerts were observed to be identified by alert type and
appropriately documented with open and/or close dates. In addition, as needed, all alerts were
entered into either the center’s logbook and/or shift report. Staff responsible for removing and
updating alerts were identified within the Department’s Juvenile Justice Information System
(JJIS) on the same day as the alert date. Alerts are entered into the center’s alert system if a
youth is admitted with any medical conditions and/or issues which warrant placement of a youth
with a Medical Grade two to five. In addition, alerts might be utilized to identify youth with any
special needs or risks such as suicide risk, mental health, substance abuse, physical health,
and/or safety and security risk factors. The center reviews the JJIS alert roster daily with all staff
during shift briefings. Each of the staff are in receipt of the alert roster and maintain a copy of
youth alerts throughout their respective shift. An observation of a shift briefing was not
completed during the annual compliance review week due to the center being on twelve-hour
shifts. Observations of alerts entered within JJIS, and on-site documentation revealed
appropriate staff were notified of youth alerts, which included medical, mental health, and food
service.
Seven staff were interviewed. Each of the staff articulated they review information pertaining to
youth alerts from shift debriefings at the center. The alert information is specific to each youth.
Staff are notified of issues within the center either through logbook, staff briefing, alerts, JJIS, or
meetings. Staff believe the communication at the center is good or very good. The
superintendent reported medical alerts are reviewed by medical staff to ensure alerts are
entered and tracked correctly. Detention reviews are held every Tuesday morning and a juvenile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 61 (Revised July 2023)
probation officer (JPO) is part of the review. The JPO verifies alerts during the review and if
changes are made then there is an update. Alerts are also reviewed during every shift change
and changes are made if necessary.
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.
According to the center’s staff, data is captured through the Department’s Tableau system and
the superintendent is working with information systems to gather more information. Information
is shared with staff and administration during monthly meetings, daily shift debriefings, and
weekly superintendent meetings throughout the state. Additionally, the program shares
information with providers and stakeholders during weekly detention review meetings.
Documents reviewed were Protective Action Response Right Interactions model (PAR/RI)
Reports, confinements, and daily shift reports.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 61 (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 (FOPs) for admissions. An admission could not be
observed during the annual compliance review as there was no admission conducted while the
annual compliance review team was on-site. Seven youth case management records were
reviewed for youth admissions. All seven records had the Department’s Juvenile Justice
Information System (JJIS) Admission Wizard printed and placed in the record. Each of the
seven Admission Wizards documented youth were full-body and electronically searched by a
juvenile justice detention officer of the same gender. All seven records contained a completed
arrest affidavit/custody order, a Detention Risk Assessment Instrument (DRAI), and a Suicide
Risk Screening Instrument (SRSI). All seven youth records documented youth were allowed to
make a telephone call, and in three of the seven youth records, the parent/guardian could not
be reached. All seven youth were offered a snack or meal. Screenings were completed to
identify medical, mental health, and substance abuse needs during intake.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 61 (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 maintains facility operating procedures (FOPs) regarding the orientation process
which shall occur within twenty-four hours of the youth being admitted into detention. An
admission could not be observed during the annual compliance review week, but the orientation
documentation included all elements as outlined in the center’s policy. Seven youth case
management records were reviewed for orientation. All seven records included documentation
the center provided each youth an orientation within twenty-four hours of admission. All youth
signed an orientation acknowledgement to document the contents were discussed with the
youth. A copy of the orientation acknowledgement forms were in each youth record. Seven of
the seven interviewed youth reported staff provided them with information about the center’s
rules and regulations, daily schedule, education services, visitation, abuse reporting, and the
behavior management system. Two youth reported they did not receive an orientation upon
admission to the center; however, their case management record showed an orientation
checklist and detention brochure with their signature.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 19 of 61 (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 (FOPs) to ensure all youth admitted to the center
are classified to provide the highest level of safety and security. Seven youth case management
records were reviewed, and each contained documentation information concerning the youth’s
history and status, as well as all other required information, were reviewed. The Department’s
Juvenile Justice Information System (JJIS) Admission Wizards were completed and located in
all seven youth records to be reviewed for room assignment based on potential safety and
security concerns, which included information on the youth’s sex, height, weight, age, and level
of aggressiveness. Considerations on the classification form included mental illness, intellectual
disabilities, physical disabilities, history of violent behavior, gang affiliation, criminal behavior,
history of sexual offenses, Vulnerability to Victimization and Sexually Aggressive Behavior
(VSAB) information, identified or suspected medical issues, identified suicide risk or suspected
issues, escape, and security risks. All seven youth records indicated the youth were assigned to
rooms based on classification procedures, and if the youth had a history of committing sexual
offenses or was a victim of a sexual offense, they were placed in a single room. None of the
reviewed youth had a reclassification at the time of the annual compliance review. The
superintendent was interviewed and reported to maintain safety and security, all classification
factors are utilized when assigning youth to a room. The superintendent also reported being
notified of any related gang information during the weekly detention reviews and through the
JJIS alert system.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 20 of 61 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has a screening process for youth newly admitted into the center to determine if the
youth is a gang member or gang affiliate. The center had no youth applicable for gang
involvement since the last annual compliance review; therefore, no additional records could be
provided. The assistant superintendent is the center’s current gang representative. When the
center identifies youth with suspected gang affiliation or involvement, the assistant
superintendent notifies the assistant chief probation officer (ACPO) and chief probation officer
(CPO), as there is no current circuit gang representative to communicate suspected gang
activity. Center staff then provide information, by email, to the ACPO and CPO about any
indications of gang activity. The email will include pictures, copies of written statements,
drawings, graffiti, and a description of any gang signs the youth displayed, when applicable. The
staff then enter the "other suspected gang affiliation" alert into the Department’s Juvenile Justice
Information System (JJIS), along with detailed information within the alert note. All JJIS alerts
are provided to staff during shift briefings.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center maintains facility operating procedures (FOPs) to ensure a youth's personal property
is maintained securely. Seven youth case management records were reviewed, and each
record documented the youth’s property was inventoried by the admitting juvenile justice
detention officer (JJDO) and entered into the Department’s Juvenile Justice Information System
(JJIS). A Property Receipt form was printed and signed by the youth and JJDO in all seven
records reviewed. All seven youth records contained a letter of acknowledgment regarding
unclaimed property signed by each youth. Currency and other personal items of value are
placed in a clear tamper-proof bag and placed in a drop safe, under camera surveillance. None
of the seven youth records included items of value placed in the safe; however, a log is
maintained to document items placed in the drop safe and includes the date, time, youth’s
name, name of the JJDO who secured the property, and the JJDO’s initials. None of the youth
refused to sign the Property Receipt form. The personal property was placed in an assigned
bag, as documented on the Property Receipt form, and was placed in all seven active youth
records reviewed. Seven youth were interviewed and acknowledged staff checked the youth’s
personal property and staff then had youth sign a Property Receipt form acknowledging their
property was correct. The superintendent was interviewed and advised the superintendent and
admission staff are responsible for ensuring the youth’s personal property and valuables are
maintained. Youth personal property is stored in the property room located in Intake. Valuable
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 21 of 61 (Revised July 2023)
property is placed in a clear tamper proof bag and placed in a drop safe. Both locations are
under video surveillance, and only supervisors and administration have access. Any property
not picked up within thirty days will be considered abandoned. After thirty days, a Notice of
Impending Disposal of Property form shall be mailed to the last known address. If the youth is
on supervision, it is also acceptable to have the juvenile probation officer (JPO) sign for and
deliver property to the youth.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center maintains facility operating procedures (FOPs) to ensure all releases are verified by
the court’s authorization. Three closed youth case management records were reviewed for
release. All three closed youth case management records included documentation the on-duty
supervisor reviewed all paperwork related to release prior to the youth being released from the
center. All three closed youth case management records included documentation the juvenile
justice detention officer (JJDO) supervisor reviewed the release paperwork received from the
court, and the youth’s identification was verified prior to release. All three closed youth case
management records included a photocopy of the identification card (ID) of the parent/guardian
or responsible adult picking up the youth. None of the youth had an endangered person alert. All
three youth and parents/guardians were reminded of future court dates. All three closed case
management records included documentation the required parties signed all applicable release
forms. All admission and release dates correlated with the Department’s Juvenile Justice
Information System (JJIS). An observation of a youth being released was conducted, and with
no exceptions were noted.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 22 of 61 (Revised July 2023)
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center maintains facility operation procedures (FOPs) to ensure youth personal property is
maintained securely and is returned to the youth in a timely manner upon their release. Three
closed youth case management records were reviewed for the release of youth property. Two of
the three records included documentation the parent/guardian signed the receipt of property
form. All three records included a photocopy of the identification card (ID) of the parent/guardian
or responsible adult picking up the youth and the ID being verified. All three reviewed youth
were on medications at the time of release from the center. For property held over thirty-days, a
notice of impending disposal is to be completed and delivered by certified mail to the
parent/guardian to pick up the property within ninety-days of the letter date. The center
maintains FOPs for the disposal of property left in the safe which states, if the youth or
parent/guardian cannot be located, the superintendent or designee will ensure all money and
property are counted and inventoried. One money order shall be sent to the regional fiscal
manager. The regional fiscal manager will then forward the money order to the headquarters’
designee. A record must exist for any property disposed of or cash forwarded to headquarters.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures (FOPs), ensuring detention reviews are
conducted weekly for proper management of youth and the appropriate sharing of information.
Detention reviews are held weekly at 11:00 a.m. on Tuesdays. An observation was made of
detention reviews occurring during the annual compliance review week. The detention review
included representatives from administration, probation, commitment, mental health, education,
and medical. The meeting addressed youth court hearings, youth placements, youth behaviors,
well-being, and each youth’s status. All youth on detention status were reviewed, which included
any follow-up information needed from previous reviews, pending court dates, commitment
status, location of youth on home detention, and other relevant information. The reviews were
attended either in person or by video conferencing platform by circuit probation staff,
commitment managers, education, medical, mental health, and administrative staff within the
center. The superintendent interview confirmed the weekly reviews are attended by the
superintendent or designee, medical, mental health, education, probation, and commitment
manager. Discussed information included the Authorization for Evaluation and Treatment (AET)
forms, release dates, court dates, behavioral issues, status updates of committed youth, and
youth appointments.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 23 of 61 (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 maintains facility operating procedures (FOPs) to ensure youth participate in
constructive activities which will benefit the youth and the program. The daily activity schedule is
posted in each living area and outlines the days and times for each youth activity. The schedule
includes times for wake up, personal hygiene, mealtimes, visitation, education, recreation and
physical activities, indoor activities, shift change, bedtimes, groups, and open program time. A
review of logbooks and observations during the annual compliance review week indicated the
center follows the daily activity schedule. Seven youth and seven staff were interviewed, and all
staff indicated the center’s daily activity schedule is followed. Four of the seven youth indicated
the daily schedule is followed, and three indicated the schedule was not followed on occasion
due to low staffing.
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 a policy and procedures to provide educational access for the youth. All youth at
the center are provided access to education. According to reviewed documentation, school
starts at 8:00 a.m. and ends at 2:00 p.m.. A review of the education schedule and school district
calendar revealed the youth are provided education distributed over twelve months, with a
minimum of twenty-five hours of instruction each week. Teachers are also given ten days for
professional development, planning, and grading throughout the school year. Youth enrolled in
educational programs have an opportunity to earn course credit for completion of the education
and training experience. A review of the master control logbook and video indicated there were
missed days and interference with educational instruction. Three days of logbook entries each
month since the previous annual compliance review for educational access was conducted. The
logbook entries compared to the activity schedule documented minimal interference with
educational instruction and included documentation educational classes were being conducted
with youth attending and departing class on time, apart from nine entries missing regarding
school and five instances of youth beginning school late. A complete video review of three full
days of education was conducted to include start times, breaks/lunch, return times, and end
times. Each of the days observed had noted issues with the center meeting posted education
times. Seven interviewed youth agreed they attend school, Monday through Friday, while at the
center. Seven interviewed staff each agreed there is minimal interference of educational
instruction.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 24 of 61 (Revised July 2023)
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 collaborates with the school district to ensure the implementation of career
education. An interview with the education staff revealed the center provides the requirements
for Type 1 programming to include life skill group activities and instruction. The center provides
classes in career research and decision-making skills, during which youth take Florida Ready to
Work. Seven youth were interviewed, and each responded either well or very well in terms of
how the education prepares them for a high school equivalency diploma (GED), high school,
vocational school, employment, and/or college.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 25 of 61 (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 licensed mental health counselor (LMHC) who serves as the designated
mental health clinician authority (DMHCA). The DMHCA was hired in October 2023, after the
previous DMHCA left in August 2023. Both LMHCs have a clear and active license in the State
of Florida, which expire on March 31, 2025. The back-up DMHCA also has a clear and active
license in the State of Florida which expires March 31, 2025. The back-up DMHCA is a LMHC
with the provider who travels around the state to provide temporary services to the centers
when needed. A contract between the Department and the mental health and substance abuse
provider outlines the role of the DMHCA and the requirement for the DMHCA to be on-site forty
hours a week. The DMHCA’s work schedule is forty hours a week, Monday through Friday, and
the other LMHC at the center works forty hours, a week Friday through Tuesday. A review of the
contract and interview with the DMHCA confirmed their role in the implementation of all
treatment services at the center.
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 contract between the Department and the mental health and substance abuse provider
requires two licensed mental health providers to perform services at the center. The center has
two full-time licensed mental health counselors (LMHCs) who provide services at the center,
with one LMHC serving as the designated mental health clinician authority (DMHCA). There
was a LMHC with the provider who traveled and was working at the center temporarily. The
designated mental health clinician authority (DMHCA) ensures all clinical staff perform services
they are qualified to provide. All three LMHCs have clear and active licenses in the State of
Florida, which all expire on March 31, 2025.
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.
A review of the center’s contracted staff roster confirmed the center did not have any non-
licensed clinical staff providing services for any of the annual compliance review period. A
review of the contract between the Department and the mental health and substance abuse
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 26 of 61 (Revised July 2023)
provider indicated non-licensed clinical staff are not required for the center. The center does not
have a Chapter 397 license as both clinical staff performing services are licensed clinicians;
therefore, a Chapter 397 license is not required to provide substance abuse services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
Seven youth mental health records were reviewed for mental health and substance abuse
screenings, and each included the required screening documents which were completed in the
Department’s Juvenile Justice Information System (JJIS) and reviewed by the center staff. The
Suicide Risk Screening Instrument (SRSI) was completed in full by the mental health provider
upon the youth’s admission. Six of the seven youth had positive responses on the SRSI, were
placed on precautionary observation, and a referral was made to the mental health provider for
an Assessment of Suicide Risk (ASR). All six youth had a suicide risk alert appropriately
entered in JJIS. All seven youth records revealed a Massachusetts Youth Screening Instrument,
Second Version (MAYSI-2) was completed in JJIS by a trained staff. Six of the seven MAYSI-2s
indicated the youth had elevated scores, which required a comprehensive assessment. Two of
the six records with elevated MAYSI-2 scores did not include a referral for the comprehensive
assessment. Four of the six applicable youth were referred for a comprehensive assessment
using the MAYSI-2. Documentation confirmed the superintendent was notified of each of the six
youth’s need for an ASR as required.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
A review of seven youth mental health records found five were applicable for a mental
health/substance abuse comprehensive assessment, which was completed within the required
thirty-one days of admission for each youth. Two youth had not been at the center for thirty
days. All completed assessments were facilitated by center staff as a new assessment and
documented on a form which includes all required elements of the Department form. Once
completed, the form is uploaded to the Department’s Office of Health Services (OHS) Electronic
Medical Record (EMR). Treatment recommendations corresponded with the youth’s mental
health and substance abuse diagnosis. None of the youth received a comprehensive
assessment from a community provider.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 27 of 61 (Revised July 2023)
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.
A review of seven youth mental health records found six were applicable for mental health
and/or substance abuse treatment. One youth had not been at the center for thirty days and did
not arrive with a psychotropic prescription; therefore, no treatment had started. An initial
treatment plan was completed in three youth records, contained all the required elements, and
each was signed by the youth’s treatment team. Five applicable youth received an
Individualized Treatment Plan by their thirty-first day in the center, which was also within seven
days of the onset of treatment. One youth received an Initial Treatment Plan; however, was not
at the center thirty days to receive an Individualized Treatment Plan. Each Individualized
Treatment Plan included all required elements. Four youth were applicable for the inclusion of
psychiatric services and psychotropic medications with the dosage on the treatment plans
matching each youth’s prescribed medications. A review of progress notes for the six applicable
youth confirmed the youth received services as stipulated on the treatment plans. Each of the
six plans were signed by all required parties. Three of the six youth were applicable for
treatment plan reviews, and all three received reviews every thirty days as required, which were
documented on the Department’s form and signed by all required parties. None of the youth
were an alleged victim of a Prison Rape Elimination Act (PREA) event. A mini treatment team
meeting was observed, and it was confirmed all required parties were in attendance and
discussed each youth’s treatment plan and progress. Three closed youth records were
reviewed, and each included a completed mental health/substance abuse discharge summary
documented on the Department’s form. All three youth’s discharge summaries were sent to the
youth’s juvenile probation officer (JPO), youth, and parent/guardian.
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.
A review of seven youth mental health records found six were applicable for mental health
and/or substance abuse treatment. Each youth was assigned to a mini treatment team which
consisted of all required parties. Observations of the treatment team confirmed the
superintendent of the center conducts mini treatment team meetings following detention review
meetings, which include mental health clinical staff, medical, and administration. Education was
engaged in another meeting and could not attend the treatment team meeting observed. Each
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 28 of 61 (Revised July 2023)
of the six youth’s treatment plans documented the youth were to receive at least weekly
individual therapy with a licensed clinician. A review of treatment notes, documented on the
required Department form, showed all six youth received services as stipulated in their
treatment plans. A valid Authority for Evaluation and Treatment (AET) was found for each youth
authorizing treatment. All six youth were applicable for substance abuse services, the youth
received services as outlined in their plans, and their record included the required consents for
treatment and release of information. A tour of the center indicated the clinical staff have
adequate access to space, including soft rooms, to provide confidential treatment services to
youth. The center has been conducting mental health or substance abuse groups, and video
observations were made for two groups, which confirmed there were no issues with the duration
of groups being held. An informal interview with the designated mental health clinician authority
(DMHCA) and observation of groups confirmed mental health groups are fewer than ten youth
and substance abuse groups are fewer than fifteen. The DMHCA was formally interviewed and
was able to adequately explain the process for creating youth treatment plans. Seven youth
were interviewed, three youth rated the services at the center as good, one youth stated very
good, one youth reported fair, one youth said very poor, and one youth reported they were not
receiving services.
3.08 Psychiatric Services [Contract Provider] (Critical) Limited Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has a doctor of osteopathic medicine, with a specialty in child psychiatry, who serves
as the psychiatrist. The psychiatrist has a clear and active license in the State of Florida which
expires March 31, 2024. The center does not utilize an advanced practice registered nurse
(APRN) for psychiatric services and has a back-up psychiatrist with a clear and active license in
the State of Florida, which expires on January 31, 2025. The center has not utilized a back-up
psychiatrist throughout the annual compliance review period. A review of the contract between
the Department and the mental health and substance abuse provider found the center’s
psychiatrist is authorized to provide tele-psychiatry services.
Seven youth mental health records were reviewed for psychiatric services. Four of the seven
records were applicable for receiving psychiatric services. Three of the four youth entered the
program on psychotropic medications, one youth was later referred and subsequently placed on
medication. Three of the four youth were in receipt of a psychiatric evaluation which was
completed within fourteen days of referral. The remaining one youth did not receive a referral for
a psychiatric evaluation. This same youth entered the center having been previously diagnosed
and prescribed psychotropic medication. The center did not submit a referral to the psychiatrist
until after the medication was dropped off by the youth’s Department of Children and Families
(DCF) case worker, approximately thirty-three days after having been admitted to the center.
This one youth did not receive a complete psychiatric evaluation; page three of the clinical
psychotropic progress note (CPPN) was missing. The one youth did receive later in treatment, a
psychiatric follow-up evaluation which the second page of the CPPN was completed. The three
remaining youth who were in receipt of a psychiatric evaluation did have all elements of the
CPPN completed as required and identified as the initial psychiatric interview. All three
applicable youth receiving psychotropic medications also received medication management
every thirty days as required. Two of the youth who entered the center on psychotropic
medications were continued on the medications they had arrived at the center with. One youth
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 29 of 61 (Revised July 2023)
who had entered the center with no current psychotropic medications was not prescribed
medications during the initial psychiatric evaluation. One of the three youth who had entered the
center on prescribed psychotropic medication, was not administered any medication until
verification with medical staff. The medical staff followed up with the youth’s DCF case worker,
whereas, the psychotropic medication was not brought to the center for approximately thirty-
three days. Each of the reviewed youth had a properly executed Authority for Evaluation and
Treatment (AET) or court order authorizing psychotropic medications. Each of the youth
received tele-psychiatry services, which were provided as required.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written Suicide Prevention Plan, which is reviewed annually and signed by the
designated mental health clinician authority (DMHCA) and superintendent. The plan included all
required elements. The center’s Suicide Prevention Plan includes procedures for an established
review process of any serious suicide attempt or self-inflicted injury and all other required
elements.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Seven youth records were reviewed for suicide prevention services, with six youth identified as
at risk for suicide upon admission. Each of the six youth entered the center on precautionary
observation (PO) and were removed the next morning after receiving the Assessment of Suicide
Risk (ASR). A suicide risk alert was entered into the Department’s Juvenile Justice Information
System (JJIS), and a referral was made to the clinical staff in each of the six records. Each
youth was maintained on constant supervision, and their supervision was documented on the
required Department form, which was completed in full. An ASR was completed in full by a
licensed clinician within twenty-four hours for each instance. The superintendent or designee
was notified of each youth’s risk, and a conference was held with the licensed clinician and the
superintendent or designee prior to any change in PO, which was documented on the ASR.
None of the six reviewed youth were applicable for continued PO supervision and no Follow-Up
ASR was required. None of the six applicable youth were stepped down to close supervision
prior to being placed on standard supervision. Four of the six youth’s PO placements were
documented in the logbook, however, all six youth’s standard supervision placements were
documented in the logbook. Any instructions relating to the youth’s supervision were
documented as required. Alerts for each youth were appropriately closed by mental health staff
following the completion of the ASR. No youth were applicable for placement on secure
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 30 of 61 (Revised July 2023)
observation during the annual compliance review period. The center has two suicide response
kits, which contained all required tools and were maintained in master control and medical.
The superintendent was interviewed and reported secure observation is utilized at the center
and explained how youth are placed and the protocol the center uses when a youth is placed in
secure observation. Seven staff were interviewed, and each reported in the event a youth
expresses suicidal thoughts, staff are responsible for notifying mental health staff. Six staff
stated they would place the youth on constant sight and sound supervision. Four staff reported
they would notify the supervisor and search the youth’s room for sharps. Three staff said they
would document supervision, and two staff said they would place the youth behind a locked
door. Each of the seven staff reported there is a suicide response kit located in master control,
four staff reported there is a kit in medical, and one staff reported a suicide kit is in
administration. Two of seven interviewed youth reported being on PO while at the center. One
youth stated they were watched the entire time while on PO. Another youth said they were not
watched the entire time and explained the staff walked away to do ten-minute checks and the
youth could have hurt themselves if they wanted to hurt themselves. This was discussed and
acknowledged by the center’s administration.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Seven youth mental health records were reviewed, with six youth applicable for precautionary
observation (PO) supervision while at the center. Each youth’s supervision was documented as
required on the Department’s form for the duration of their time on PO. Each form was
completed in full. None of the reviewed supervision forms included warning signs while the
youth were on PO. Each reviewed log was signed by the shift supervisors for every shift the
youth was supervised, and each log was signed by the clinical staff. A review of video for three
dates of youth on PO found youth are maintained on PO as required.
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 written Suicide Prevention Plan which outlines requirements for suicide
prevention training. The center has two suicide response kits which were observed to contain all
required tools and were maintained in master control and medical. A review of seven pre-
service and seven in-service staff found each staff completed the required suicide prevention
training. A review of drills for the annual compliance review period confirmed the center held
drills at least quarterly on each shift, at least one of which demonstrated the practice of
cardiopulmonary resuscitation (CPR) and use of the automated external defibrillator (AED).
Twenty-eight staff were applicable for completion of a drill within the first six months of the
annual compliance review period and twenty-eight completed a drill as required. Thirty-seven
staff were applicable for completion of drills within the second six months and thirty-seven
completed drills as required. Each staff who participated in a drill participated in at least one
annually which included the use of CPR/AED. All drills are reviewed at the next staff meeting to
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 31 of 61 (Revised July 2023)
allow staff who did not participate a chance to review the drill. Seven staff were interviewed and
all reported suicide response kits are located in master control, and four staff said in medical.
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 crisis intervention and emergency care plan. The plan was found to
include 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 crisis intervention and emergency care plan. The plan was found to
include all required elements. The plan was last updated and approved by the designated
mental health clinician authority (DMHCA) and superintendent on October 23, 2023. The plan is
accessible to all staff and maintained in the facility operating procedure (FOP) binders located in
master control, the DMHCA’s office, and administration.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has a combined Crisis Intervention and Emergency Care Plan, which includes
procedures for responding to youth in crisis. A review of seven youth records found none of the
youth were applicable for a Crisis Assessment. Two additional records were provided for youth
receiving a Crisis Assessment during the annual compliance review period. The assessments
were conducted immediately upon identification of the youth’s crisis by a licensed clinician and
were documented on the Department form, which included all the required elements.
Notification of follow-up treatment was not required to be sent to the parent/guardian. Neither of
the two youth were placed on precautionary observation or referred for an Assessment of
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 32 of 61 (Revised July 2023)
Suicide Risk (ASR). The youth were not applicable for an assessment based on a Prison Rape
Elimination Act (PREA) incident. A review of reports to the Department’s Central
Communications Center (CCC) found the center did not have any PREA incidents during the
annual compliance review period requiring a Crisis Assessment.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 33 of 61 (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 has a board-certified physician who holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida. The licensed
physician serves as the designated health authority (DHA). The license for the DHA expires on
August 9, 2025, and was issued on August 9, 2023. The center has an advanced practice
registered nurse (APRN) with a Collaborative Practice Protocol (CPP) with the physician who is
serving as the DHA. The center’s contractual agreement with the DHA includes being on-site at
a minimum of once a week, not to exceed nine days between visits. Sign-in and sign-out logs
were reviewed for the annual compliance review period. These revealed the DHA and APRN
were on-site as required. The specific duties of the DHA include being clinically responsible for
the center’s medical care, being on-site once per week, being available by telephone for
consultations, policy and procedure development and administration, and general medical
oversight. Tele-medicine is used for staff when the medical personnel are not on-site. The
medical staff maintain a tele-medicine log to document the youth seen during each session. The
DHA was interviewed and reported being on-site once a week, as along with the APRN. The
DHA also stated when on-site each week, the clinic manager and nursing staff assist in
reviewing individual care plans and discussing documentation for review. The DHA was on-site
during the annual compliance review week and these practices were observed.
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 utilizes facility operating procedures (FOPs) for all health-related treatment protocols
used at the center. The designated health authority (DHA) and superintendent signed and dated
all respective treatment FOPs on March 1, 2023. The nursing staff reviewed, signed, and dated
a cover page on which medical FOPs, treatment protocols, and other procedures were listed. All
nursing staff reviewed, signed, and dated the cover page for the FOPs in March 2023. New
policies or changes in policies made during the annual compliance review period were
reviewed, signed, and dated by each nurse on the individual policy changes. The psychiatrist is
not on-site and provides tele-health services as approved. The FOPs include all health-related
procedures and treatment protocols utilized at the center. The center did not have new nurses
hired during the annual compliance review period; however, all newly hired staff received a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
given by a registered nurse (RN) or designated licensed healthcare professional. The DHA
approved treatment protocols or standing procedures.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 34 of 61 (Revised July 2023)
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for Authority for Evaluation
and Treatment (AET) requirements. All seven records included the original AET form filed in the
youth’s IHCR. Five AET forms were signed by the youth’s parent/guardian as required. Two
youth were involved with the Department of Children and Families (DCF). There were temporary
AETs along with court orders for medications in the youth IHCRs. The two youth involved with
DCF did have parents/guardians whose rights were terminated, and both youth had a limited
AET at the time of admission. Each of the DCF youth had valid court orders which authorized all
treatment procedures.None of the applicable youth had parents/guardians who refused to sign
an AET. No court orders were pending. An AET was obtained prior to providing medical
services for six youth. Six of the seven AET forms were signed by a Department representative.
One AET was transferred with a youth from another detention center, and it was not signed by a
Department representative. The six applicable AETs were valid. None of the reviewed youth
were eighteen years of age or older.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for parental
notification/consent requirements. Two of the seven youth were applicable, and their IHCRs
included documentation of parental notification for over-the-counter (OTC) medications beyond
those covered by the Authorization for Evaluation and Treatment (AET). Both youth IHCRs
included documentation of consent provided by the parent/guardian. The two youth IHCRs
included written notifications were sent utilizing the Department’s Parental Notification of Health-
Related Care form. Four of the seven youth were taking psychotropic medications. The staff
witnessed all telephone call attempts and conversations for psychotropic medications for one of
the youth. Two youth were involved with the Department of Children and Families and their
medications were authorized by a court order. The center staff attempted contact with the case
managers for the youth. Two of the seven youth required vaccinations, which required
parental/guardian notification.
Three of the seven youth IHCRs included documentation a new medication was ordered, and
the attempted contact to the parent/guardian was documented in the progress notes. Written
parental/guardian notifications were sent for two of the youth. The third youth was involved in
the Department of Children and Families (DCF). The IHCR included documentation of
attempted contact with the DCF case manager to provide notice. One of the three youth was
applicable for parental/guardian verbal consent for psychotropic medications being prescribed,
discontinued, or drug dosage was significantly changed. In addition, one applicable youth had
documentation of written parental/guardian notification/consent for a change in psychotropic
medication which was obtained and signed by the parent/guardian and included in the progress
notes. Two of the seven reviewed youth were involved with DCF, and both youth had
parental/guardian rights terminated. Both youth IHCRs included documentation of each having a
court order authorizing all treatment and procedures. The center obtained the court orders prior
to administering psychotropic medications. Seven IHCRs included documentation of vaccines
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 35 of 61 (Revised July 2023)
being verified within thirty days of admission. None of the reviewed youth required consent for
obtaining vaccinations.
The nurse was interviewed and reported the juvenile probation officer (JPO) is responsible for
ensuring the AET is signed and dated by the parent/guardian and then sent to the location
where the youth is in custody. The nurse also stated if the parent/guardian is unavailable during
the detention screening, the assigned JPO shall schedule an intake conference as soon as
possible to complete the AET. If a youth is eighteen years of age or older, the youth will provide
consent for healthcare services. The nurse reported the medical staff attempt to send
parental/guardian notifications immediately after a qualifying event occurs. The nurse also listed
the procedures for when a youth’s illness or injury requires emergency medical services or is life
threatening. The nurse went on to list out the procedures for parent/guardian notification when a
youth needs consent for new psychotropic medication, discontinuances, or psychotropic
medication adjustments. All vaccinations are administered by the local Health Department.
Immunization records are obtained through Florida Shots during youth admissions. The records
are reviewed within twenty-four hours. If a youth is exempt from immunizations, then the proper
form must be completed and put in the Electronic Medical Record (EMR).
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for healthcare admission
screening requirements. All seven IHCRs included documentation the medical and mental
health admission screening form was completed on the date of admission. The screenings were
completed by the intake juvenile justice detention officer (JJDO). All seven screenings were
reviewed by licensed medical staff within twenty-four hours. All seven youth IHCRs and
Electrionic Medical Records (EMRs) included documentation the designated health authority
(DHA) was notified. None of the reviewed youth changed physical custody since admission to
the center. Two youth were applicable for documentation of a qualitative urine pregnancy
screening test. The chronological progress notes for both youth included the documentation of
written consent.
The nurse was interviewed regarding healthcare admission screenings and re-screenings. The
nurse provided a list of all situations when a parent/guardian is informed of changes in
conditions and when consents must be obtained for new medications and treatments are
prescribed. The nurse also reported a parent/guardian notification without special consent must
be completed by attempting verbal contact to notify them of care. The youth are expected to see
the nurse within twenty-four hours of admission to the center. The nursing staff are notified of a
newly admitted youth through an admission packet provided to the medical staff. The admission
screening is completed by the assessment center screeners. The medical staff sign and date
the bottom of each page of the admission form. The nurse stated if a youth’s custody changes
after admission a healthcare admission rescreening is to be completed each time the physical
custody of the youth changes.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 36 of 61 (Revised July 2023)
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.
A review of the center’s facility operating procedures (FOPs) for youth orientation to healthcare
and health education included access to medical care, sick call and how to use and access this,
what constitutes an “emergency” and when to notify staff, medication process to include side
effect monitoring, the right to refuse care and how it is documented, what to do in case of a
sexual assault or attempted sexual assault, the non-disciplinary role of the healthcare providers,
and a list of healthcare contacts to ensure accuracy.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for youth orientation to
healthcare services and health education. All seven IHCRs included documentation the youth
received a general healthcare orientation. All seven IHCRs included documentation the health
education topics were documented on the Department form.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for notification requirements
to the designated health authority (DHA). Four youth had evidence in the IHCRs of known or
suspected chronic conditions and of a referral provided to the DHA. None of the IHCRs
indicated the youth was identified as in need of emergency care upon admission. The
notification to the DHA was documented in four youth’s chronological progress notes/IHCRs.
Documentation in all four youth IHCRs revealed the DHA was notified within twelve hours of
admission. Four of the reviewed IHCRs indicated the youth was on psychotropic medications
and the psychiatrist was notified.
The nurse reported the appropriate procedures for youth who enter the facility with chronic or
serious conditions. The DHA is notified within twenty-four hours. The medical staff are
responsible for this notification during working hours. Non-healthcare staff are responsible after
hours. The DHA notification is documented on the admission progress note in the IHCR and
Electronic Medical Record (EMR). If non-healthcare staff completed the notification, the
Department’s Health Care by Non-Healthcare Staff form shall be used and placed in the IHCR
and scanned into the EMR.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for the completion of the
Health-Related History form (HRH). Six of the seven IHCRs included documentation the HRH
was completed within seven calendar days of admission. One HRH expired on November 17,
2023, and a new one was completed on December 1, 2023. The HRH forms were completed or
updated prior to the Comprehensive Physical Assessment (CPA) evaluation, as evidenced by
the signature and date in six of the seven records. A review of seven HRH forms showed
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 61 (Revised July 2023)
evidence of them being completed by a licensed nurse or practitioner and the designated health
authority (DHA). All seven reviewed HRH forms confirmed the signatures and dates were for the
most current admission.
The nurse was interviewed and reported the HRH form was completed or reviewed by nursing
staff through youth interviews within seven calendar days of admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for the completion of the
Comprehensive Physical Assessment (CPA) and Tuberculosis (TB) screening requirements.
Seven IHCRs included documentation the youth CPAs were completed on the Department’s
CPA form. All seven records indicated there was already a CPA at the time of the youth’s
admission. The reviewed CPAs were completed by the designated health authority (DHA), an
advanced practice registered nurse (APRN), and a registered nurse (RN). All seven records
included Medical Grades on the CPAs. None of the reviewed CPAs were missing required
elements. Seven IHCRs included documentation a current CPA with no changes in the youth’s
medical condition was utilized. All seven CPAs were reviewed and signed off on by the DHA or
ARPN. None of the IHCRs indicated a focused evaluation was completed. In all seven records,
the sections of the CPA were marked with an “O” or “X”. Seven IHCRs included documentation
the youth refused part of the CPA exam. The applicable youth signed a refusal form which
reflected the refused portion of the CPA exam, and all matched the date of the exam. All seven
IHCRs included documentation the Department’s Problem List was updated. All seven IHCRs
included documentation each youth had a verified tuberculosis skin test (TST) within the last
year. All seven results of the TST were documented on the CPA and Infectious and
Communicable Disease (ICD) form. No further evaluation was needed for any of the youth. The
facility operating procedures (FOPs) included procedures on how to appropriately document
when any part of the CPA exam is not conducted and/or refused by the youth. The FOPs also
included procedures for TB screening and a rescreening processes.
The nurse reported the DHA completes a new CPA if one had not been completed, is not
current, or there are changes to the condition for the health of the youth. The nurse also stated
each youth must have a TB screening filed in the Electronic Medical Record (EMR) and IHCR
within the past year. If there are no records of a TST being completed within the prior twelve
months, a new TB test will be administered. The nurse reported gynecology exams are not
routinely completed at the center.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infections (STIs) and human immunodeficiency virus (HIV) screening requirements. Five out of
seven IHCRs indicated the youth were sexually active and were clinically screened and
evaluated for STIs. None of the youth were applicable for further evaluation. In five youth IHCRs
there was documentation testing was ordered. All five IHCRs included documentation the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 38 of 61 (Revised July 2023)
testing and screening results, clinical evaluations, and diagnosis were documented on the
Infectious and Communicable Diseases (ICD) form, excluding any HIV results, and were filed in
the lab section of the IHCR. Two of the seven youth were applicable for a gynecological exam,
both youth who were applicable refused the exam. Four of the seven youth IHCRs included
documentation the youth were offered counseling and testing for human immunodeficiency virus
(HIV). Three youth were not applicable. All four youth consented to receive HIV testing as
evidenced by consent forms in the IHCR. An informal interview was held with the clinic manager
about HIV results. The nurse reported the results were scanned and uploaded into the
Electronic Medical Record, and a progress note with the testing results was completed. The
progress notes are put in the IHCR, and the results are shredded. There was proof a
practitioner reviewed the information by the DHA reviewing the progress notes. Four applicable
IHCRs included documentation pre-test and/or post-test counseling was provided. All
confidentiality was protected by not including the youth’s HIV status on the program’s internal
alert system.
Seven youth were interviewed, and all 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.
The center’s sick calls are conducted Monday through Friday from 11:00 a.m. to 11:45 a.m. and
5:00 p.m. to 7:00 p.m. A review of the center’s daily activity schedule included documentation all
youth can be seen by a nurse at any time if sick. Sick call hours are posted in administration
and all youth living modules at the center. Seven youth Individual Healthcare Records (IHCRs)
were reviewed for the sick call process. Two youth were applicable for sick call documentation.
An additional IHCR was reviewed for a sampling of three. All three IHCRs included
documentation the sick calls were documented on the Sick Call Referral Log. None of the
reviewed IHCRs included documentation the youth presented with similar sick call complaints
three or more times within a two-week period. None of the reviewed youth had referrals made to
the designated health authority (DHA) or the advanced practice registered nurse (APRN). None
of the IHCRs were applicable for the youth needing an immediate referral to a licensed
healthcare professional when the youth made complaints of severe pain. All three youth and the
nurses completed a Sick Call Request form. A licensed practical nurse did not conduct any of
the sick calls. The Sick Call Request forms were filed in all three IHCRs in reverse chronological
order. No youth were applicable for restricted housing. The Sick Call forms and progress notes
were documented as required in all three IHCRs. No elements were missing. All youth sick calls
were documented on the Sick Call Index. All sick calls dates documented on the Sick Call Index
corresponded to the completed Sick Call forms located in the IHCRs.
The center has approved treatment protocols for the registered nurse (RN) staff. If a nurse is not
on-site when a sick call is submitted, the center has procedures whereby the shift supervisor
can review all sick call requests within four hours after the request is submitted. There were no
examples of youth in confinement requesting sick calls; therefore, a review of the center’s policy
was completed. For confinements under twenty-four hours, the nurses do not have to check in
on the youth unless there is a sick call request. For youth in confinement over twenty-four hours
the nurses check on the youth every two hours. If the youth is placed in confinement for any
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 39 of 61 (Revised July 2023)
amount of time and has a medical condition, the nursing staff must check on the youth every
two hours. The sick call procedures apply while youth are in confinement. A sick call
observation was completed during the annual compliance review period. The youth was
escorted to medical for the requested sick call. The nurse identified themself and stated why the
youth was there. The youth was seen in an area where no other youth were present. The youth
was interviewed in accordance with the sick call request. A staff was standing next to the youth
and the nurse.
The nurse was interviewed and confirmed in situations where medical care was needed but
could not wait until the next available scheduled medical provider sick call time, staff may submit
through electronic means a request for the youth to be seen by the medical provider. Youth also
have access to place a paper request for medical evaluations when needed.
Seven youth were interviewed, four youth reported being seen within one day, one youth
reported immediately, one youth reported within two days, and one youth had never requested a
sick call.
Seven staff were interviewed regarding sick call requests and reported the nurse reviews and
conducts sick calls.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for episodic, first-aid, and/or
emergency care. All seven IHCRs included documentation the youth required on-site first-aid or
episodic care. All seven IHCRs included documentation the on-site first-aid or episodic care was
completed by a licensed healthcare staff and documented in a problem-oriented manner
utilizing subjective, objective, assessment, and plan (SOAP) elements. Any on-site first-aid or
episodic care provided by non-healthcare staff would be documented on the Department’s
Report on On-Site Health Care by Non-Health Care Staff form. This documentation includes the
nature of the complaint, the findings of the person rendering the care, and what treatment was
rendered which was documented as required. None of the youth required off-site care. The
IHCRs included documentation education/instruction was provided to the youth, the plans for
follow-up/future care, and all were placed on the alert list. Two of the seven IHCRs included
documentation the parental/guardian notification was made. The other five youth did not have
situations which required parental/guardian notification. All entries in the Episodic Care Log
were completed. Three of the seven youth received a follow-up evaluation from a licensed
healthcare staff.
The center has thirteen first-aid kits. The first-aid kits are in master control, one in each of the
living modules, kitchen, intake desks one and two, administration, and five in backpacks for
transports. The first-aid kits were fully stocked with designated health authority (DHA) approved
contents. The center’s process for ensuring contents are maintained and stored in accordance
with guidelines to prevent expiration include checking kits monthly which is documented by
medical staff signing off on a tracking document on the first-aid kits. A log is maintained on each
first-aid kit where the DHA initials once the first-aid kit has been inspected. The items in each
first-aid kit are listed on a sticker attached to the front. The expiration dates are written next to
each item. A review of three first-aid kits confirmed they were monitored as required.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 40 of 61 (Revised July 2023)
The center maintains two automated external defibrillators (AEDs). The AEDs are in the medical
clinic and conference room. The procedures for the AED are maintained with each AED. The
on-site nursing staff check to ensure the AED batteries and pads are operable. The medical
staff maintain a binder kept in the medical clinic with the monthly checks and tests of each AED.
A review of the documentation revealed the monitoring was conducted as required. The nursing
staff completed a self-test of AED and expiration dates in front of the Monitoring and Quality
Improvement regional monitor with no issues. The expiration dates of the AED batteries are
December 6, 2026, and the last date the batteries were changed were January 11, 2023. The
expiration dates of the AED pads are April 28, 2025, and the last date the pads were changed
were January 11, 2023.
The center conducts emergency drills each month for each shift. Suicide mock drills are utilized
to demonstrate cardiopulmonary resuscitation (CPR) and AED use. The center maintains
documentation for all emergency drills. The center conducts medical emergency drills each
month on each shift. A list of emergency numbers was posted in the locked closet door in
medical which is accessible by non-licensed and licensed staff. All emergency numbers were
not accessible to youth. All authorized direct care staff were appropriately trained on the
administration of the epinephrine auto-injector. The non-medical staff were trained by the clinic
manager. Seven non-healthcare staff were trained and met training requirements regarding
episodic, first-aid, and emergency care.
The center’s policy on the use, access, and inventory of Narcan indicates the center must keep
an inventory of Narcan on-site. The center’s Narcan is stored in the medicine cart and in the
medicine closet, called the pharmacy, which is always locked. The medical staff have access to
the Narcan. The center’s medical staff who have access to Narcan have been trained on when
and how to use it. The center inventories the Narcan on a stock inventory sheet.
The nurse was interviewed about first-aid kits. The nurse reported the center has thirteen first-
aid kits. The nurse listed where the first-aid kits are located.
Seven staff were interviewed and reported they are able to call 9-1-1 if they feel it is necessary.
Seven youth were interviewed, three youth reported the healthcare is good at the center, two
youth reported it being poor, one youth reported it being very good, and one youth had not
needed medical services.
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 and
referrals. One youth IHCR was applicable. The center did not have any other applicable youth
for off-site care during the annual compliance review period. The Summary of Off-Site Care
Consultation Report form was utilized and was filed in the IHCR for one youth. The off-site care
for the youth was not emergency care. The parental/guardian notification efforts were
documented. The discharge documents, along with other applicable documents, were filed in
the IHCR. There was documentation the designated health authority (DHA) was notified of the
off-site care and the documentation included the date, time, and manner of notification. The
DHA reviewed and signed all off-site care findings, instructions, and information. One youth
required follow-up testing, referrals, and appointments. All referrals were entered on the Sick
Call Log. The center maintained tracking for the youth referrals. A review of documentation
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 61 (Revised July 2023)
revealed the referrals were tracked and the one youth received appropriate and timely follow-up
care as needed.
The nurse was interviewed for off-site care and referrals. The nurse reported any youth sent off-
site for care is tracked on the episodic log. The DHA is contacted upon the youth’s return to the
center and discharge instructions are discussed. The off-site records are placed in the DHA’s
folder to review and sign when on-site each week. The nursing staff track follow-up
appointments through a monthly calendar located in the medical clinic.
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 and
periodic evaluations. Three youth were identified on the medical health screening form with a
current chronic condition. One youth was identified as taking prescribed medication on an
ongoing basis. All three youth identified with a chronic condition were placed on the chronic
conditions list. All three youth were undergoing treatment for physical health conditions. Each
youth was assigned the appropriate Medical Grade. The remaining youth was classified as a
Medical Grade 5. None of the youth were identified as pregnant; therefore, they were not
applicable for pregnancy evaluations. All three youth were placed on the chronic conditions list.
Two of the three youth received periodic evaluations at least every ninety days. One youth had
not been at the center for ninety days and had not received a periodic evaluation at the time of
the annual compliance review. None of the applicable youth were taking anti-Tuberculosis
medication. A review of youth IHCRs confirmed each included documentation a periodic
evaluation was conducted prior to renewing a prescription medication which had expired. One
evaluation was conducted off-site and was documented on the Summary of Off-Site Care form
and these were filed in the youth’s IHCR chronological progress notes. Documentation revealed
the designated health authority (DHA) followed-up with the one youth after they received off-site
care and signed off on all documents. A review of the Department’s Problem List revealed it had
been updated as required for all three applicable youth. Periodic evaluations were tracked, and
this documentation was reviewed.
The DHA was interviewed and reported periodic evaluations for chronic conditions are done
based upon the youth’s condition. If the case is medically complex the youth will be seen at a
minimum of every thirty days. Youth who are not complex cases will be seen within ninety days.
The DHA also reported nursing staff maintain a list of chronic conditions and how often the
youth need to be seen. The nurses then schedule the youth accordingly. The nurse was
interviewed and reported the clinic manager performs a weekly review of medical charts along
with having an additional list with the medical doctor and nurse practitioner to assist in tracking.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication
management. Four youth IHCRs included documentation the youth were taking medication at
the time of admission and the medication was verified for two of the youth prior to being
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 42 of 61 (Revised July 2023)
admitted into the center. The remaining two youth reported they were on medication and were
involved with the Department of Children and Families (DCF). DCF workers were contacted.
One DCF worker brought the youth’s medication the following day of admission. The other DCF
worker did not provide the medication for verification for thirty-three days. The medical staff
provided chronological notes which documented all the attempts to contact the DCF worker and
get the youth’s medication. Three prescription verifications were included in the chronological
progress notes, IHCR, and Electronic Medical Record (EMR). For the youth whose medications
were brought in twenty-four hours after admission, there was a progress note completed on this
date. The designated health authority (DHA) and psychiatrist were contacted to obtain the order
to resume the specified medications prescribed prior to admission for four youth. The one youth
without the medication present at the center did not get a referral to the psychiatrist until the
medications were provided and verified. The clinic manager reported this was due to one of the
medications being a controlled substance. Three of the youth had medications with a current
and valid order and the medications were administered pursuant to the current prescriptions.
The DHA placed orders for any current medications which were continued for two of the youth
and orders for new medications for two of the youth on the Practitioner Order form for a total of
four youth. A review of chronological progress notes in the IHCRs revealed prescription
verifications were documented as required. There were no youth in restricted housing. Over-the-
counter (OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form
were administered for two youth according to the approved protocols. All medications and
treatment for five youth were documented on the Department’s Medication Administration
Record (MAR) and EMR. The MARs clearly indicated medication start and stop dates. Two of
the youth were placed on medications after being admitted to the center. None of the trained
non-healthcare staff assisted with the delivery of medications when licensed staff were not on-
site. Reviewed documentation revealed there were no undocumented explanations for lapses or
errors in medication management. The nursing staff conducted weekly side effect monitoring,
and this was documented on the MARs. No youth refused medication. A review of MARs
revealed the youth name, Department identification number (DJJID), date of birth, youth
allergies, precautions, Medical Grades, medical alerts, and current picture of the youth were
included. The nursing staff documented weekly side effect monitoring MARs. A review of the
MARs revealed the staff and youth initialed each medication administration entry. None of the
reviewed youth required parenteral medication. Three of the seven youth were applicable for
prescribed psychotropic medication upon admission. In all three of the youth’s IHCRs, it was
documented the DHA was notified upon admission. Of the three youth, the psychiatrist
conducted an Initial Diagnostic Psychiatric Interview with two of the youth. One youth did not
receive the current prescribed medications until thirty-three days after admission to the center.
The psychiatrist would not complete a diagnostic psychiatric interview until the youth’s current
medications were verified. One youth received medication monitoring every thirty days. The
other youth had not been in the center for thirty days at the time of the annual compliance
review. The third youth had not been back on the prescribed psychotropic medications for thirty
days at the time of the annual compliance review.
There were no standing orders, emergency treatment orders, or pro re nata (PRN) orders for
psychotropic medications. Staff who were required to conduct or supervise any other center
activities did not administer medications. Medication being administered was observed. The
youth was escorted to medical area by the assigned juvenile justice detention officer (JJDO).
The youth approached the nurse administering the medication individually. The medical provider
identified themself and stated why the youth was there. This same staff prepared and
administered the medications. The nurse providing the medication verified each youth’s allergy
and alert status. The nurse and youth initialed the MAR. The nurse observed the youth to make
sure medication was swallowed. The OTC medication administrations were documented.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 43 of 61 (Revised July 2023)
The nurse reported when a youth comes to the center the youth’s parent/guardian will be
interviewed about the youth’s current mediations. This is conducted as part of the Medical and
Mental Health Screening form in the Department’s Juvenile Justice Information System (JJIS).
Medication verification will also occur during the completion of the review of the Medical and
Mental Health Screening form. The initial medical screening is completed within twenty-four
hours of youth admission. The Health-Related History (HRH) form and Comprehensive Physical
Assessment (CPA) are completed by medical staff. The nurse summarized the steps for
administering medication to youth. The nurse reported if the medication cannot be verified as
authentic, then the dispensing pharmacy is called, or the outside provider who prescribed the
medications is contacted. The nurse stated the electronic MAR and the Department MAR are
used to document medication administration. The nurse reported the non-healthcare staff can
provide medications if they are trained. The clinic manager trains non-healthcare staff annually
to administer medications. The approved list of non-healthcare staff is kept in a binder with the
MARs. Medications are administered daily between 8:00 a.m. and 5:00 p.m., but the schedule
may vary based on prescription instructions. Medications are procured from the center’s
pharmacy vendor. The rest are received from the local pharmacy.
Seven staff were interviewed and six reported they do not provide medications to youth. One
staff reported they can provide medications to youth. Seven youth were interviewed; four youth
reported the nurse provides medications. Two youth reported not taking medications. Two youth
also stated the supervisor provides medications if the nurse is gone. One youth reported not
being on medication but is not allowed to use an inhaler when needed. The clinic manager was
informally interviewed and reported the DHA or licensed healthcare professional is responsible
for verifying the proper destruction and disposal of medications. All quarantined mediations are
destroyed, and all disposals are documented. The medical staff utilize RX Destroy. Controlled
medications are destroyed by the pharmacist during their monthly visit. All destroyed
medications are maintained on a log, which was reviewed.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The medical equipment considered sharps and medication inventory and storage process were
observed. The medical equipment classified as sharps were secured and inventoried utilizing a
routine perpetual inventory descending count as each sharp was utilized and disposed of. All
medications were identified and secured in the locked area designated for storage of
medications. The medication cart was clean and organized with stock items separate from
youth-specific medications. All medications were stored in a separate, secured area,
inaccessible to youth. Narcotics and other controlled medications were stored behind two locks.
Oral medications were stored with injectable or topical medications. The medications which
required refrigeration were stored in a secured refrigerator, which is used for medication only.
The perpetual and weekly inventories of all sharps and stock over-the-counter (OTC)
medications were observed. There was a shift-to-shift inventory count of all controlled
medications documented on the youth’s individualized Controlled Medication Inventory Record.
The non-healthcare staff, which includes supervisors and transport staff, were trained in the
delivery and oversight of medication self-administration who may perform these duties. The
training provided was delivered by a registered nurse or higher.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 44 of 61 (Revised July 2023)
An observation was completed for three controlled medications, three over-the-counter
medications, and three sharps. All counts matched the inventory numbers. The center’s
reporting criteria and procedures regarding inventory discrepancies include the medical staff
investigating to determine where the inventory has a discrepancy. The pharmacy confirmation
logs are reviewed. If the inventory is not accounted for, it is reported to the superintendent and
the Department’s Central Communications Center (CCC). The nurse reported the center has
never had this issue. The process for the disposal and destruction of expired and/or
discontinued medications is the medical staff use RX Destroyer provided by the pharmacy. The
pharmacist is on-site once a month and medications are destroyed when the pharmacist is
present. Once destroyed, it is documented in the Destroyed Medication Log. The area
designated to store youth medication was observed.
The nurse was interviewed regarding medication sharps inventory and storage. The nurse
reported an accurate summary for how medication is destroyed. The practice for securing
controlled substances is the medications must be double locked with a daily perpetual inventory
and running balances maintained. The pharmacist is on-site once a month. The pharmacist
inspects and destroys medications when on-site. The center maintains a copy of the pharmacy
consultant license on-site.
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. All seven youth were trained in infection control. All seven-
youth received infection control training within seven days of admission. The training included
hand-washing techniques, universal/standard precautions, prevention and transmission of
communicable diseases, vaccinations, and the Center for Disease Control and Prevention
(CDC) guidelines for infection control.
The exposure control plan is written in accordance with Occupational Safety and Health
Administration (OSHA) guidelines and includes risk assessment information, which includes a
list of all job classifications in which staff have the potential for occupational exposure. It also
includes the tasks or procedures which would cause staff in the job classifications to have
occupational exposure. The methods of compliance for infection control and exposure included
infection control practices, engineering, and work practice controls, which included availability of
hand washing facilities, procedures for proper disposal of needles and other sharps, procedures
for handling of contaminated laundry, and a system of medical record keeping for staff with
occupational exposure. The infection control procedures also included prevention, containment,
treatment, and reporting requirements related to infectious diseases, according to OSHA and
CDC guidelines. The infection control procedures included common, infectious diseases of
childhood, self-limiting, episodic contagious illnesses, viral or bacterial infectious diseases,
tuberculosis, hepatitis A, B, C, and human immunodeficiency virus (HIV), infectious diseases
caused by blood-borne pathogens, other outbreaks or epidemics caused by any other infectious
agent, whether spread directly or indirectly, outbreaks of pediculosis, and/or scabies, Methicillin-
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 45 of 61 (Revised July 2023)
Resistant Staphylococcus Aureus (MRSA) and other antibiotic-resistant micro-organisms, food-
borne illnesses such as those caused by E. Coli, bio-terrorist agents, and chemical exposures in
the workplace.
An informal interview was completed with the clinic manager. The center’s process for needle
stick post-exposure evaluation includes abiding by the Federal Needle Stick Act. The
community standards are followed for syringe and sharp safety.
The Hepatitis B immunization is made available for staff (on-site or by referral). The staff have
access to protective equipment. There were no instances in which infectious diseases and
sexually transmitted infections (STIs) were reported to the local health department. There were
no instances in which incidents reported to the local health department were reported to the
Department’s Central Communications Center (CCC). There were not three or more cases of
reportable infectious diseases which needed to be reported to the local health department
and/or CDC. There were no instances involving the quarantining or hospitalization of at least ten
percent of the total population of youth or staff. The superintendent maintains a separate record
containing all documents for youth and staff who have experienced a facility/occupational
exposure. All records are maintained as confidential for a ten-year period, as required. The pre-
service and in-service training for all staff completed on the center’s specific Exposure Control
Plan.
The nurse was interviewed and reported the Exposure Control Plan is available in the binder
located in medical, which was observed. The clinic manager conducts infection control training
for the staff. Youth receive infection control training upon admission to the facility and it is
conducted by the nurse. The nursing staff at the center are responsible for providing training on
the Exposure Control Plan, which includes the prevention of transmission of blood-borne
pathogens within ninety-days of hire and annually thereafter. The training records are kept in the
staff personnel record. The nursing staff also have a binder located in the medical clinic for staff
training, which was reviewed. The county health department services are routinely used for
immunizations. The process for medication storage and inventory includes the medications are
to be behind two locks, one on the medication cart and one on the medication closet door. The
medical clinic is also locked. Medications are refilled as needed and gone through each Monday
to ensure youth have at least a seven-day supply.
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 selected records were applicable. One additional record was provided to
review for prenatal care and education. Prenatal care began immediately upon determination
the youth was pregnant and continued until discharge or transfer and through postpartum. The
designated health authority (DHA) or advanced practice registered nurse (APRN) provided
routine, focused medical evaluations of the youth’s pregnancy every thirty-days, or sooner, if
ordered. One youth was placed on the internal alert system for vital nutrition and health
awareness of staff. An alert was entered into the center’s internal alert system regarding the
youth’s sleeping arrangements. The DHA/APRN conducted focused medical evaluations at
least every thirty days. The youth did not complain of issues related to pregnancy. There was
daily monitoring for danger signs of pregnancy complications for this youth. There was a plan for
post-birth psychological and physical care.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 46 of 61 (Revised July 2023)
The education provided related to the pregnant youth included alcohol and drug use, smoking,
nutrition, sexually transmitted infections (STIs), contraception, prenatal care, the birthing
process, postpartum care, basic baby care, child/infant development, and parenting skills. The
youth received nutritious food in quantities appropriate for pregnant youth. The licensed
healthcare professional staff provided routine monitoring of pregnant youth nutritional and
weight status during the pregnancy. All education for the youth was documented in the IHCR.
In-service training includes observation and monitoring of emergency care needs/symptoms of
possible miscarriage. The center has nursing protocols and treatment plans for pregnant youth.
Staff training records were reviewed for related education topics.
The nurse was interviewed and reported the services and procedures for when a pregnant
youth is admitted to the center. The topics include the DHA recommended prenatal, postnatal,
and neonatal medical care, routine healthcare services, nutrition, mental health services,
aftercare planning, and community referrals. Each female is screened for pregnancy at the time
of admission. The screening includes any history of pre-existing medical conditions, medication
therapy, and alcohol and substance use/abuse. The screening is documented in the
chronological progress notes in the Electronic Medical Record (EMR) by the nursing staff. Youth
may refuse the pregnancy test but are required by policy to comply before administering
medications. Pregnant youth in the center are monitored for weight and vital signs weekly and
follow-up with the DHA every thirty days. Fetal heart tones are also monitored if the youth is in
the second trimester or greater. Pregnant youth are provided a special diet. The clinic manager
provides non-licensed healthcare staff with education on girls’ healthcare, and this training
includes all required topics.
Seven youth were interviewed; six youth reported this service was not needed and one youth
reported they did not receive this service. None of the interviewed youth were pregnant at the
time of the annual compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 47 of 61 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
The center has facility operating procedures to ensure youth are actively supervised by staff.
During the annual compliance review week, youth supervision was observed each day. Center
staff were adhering to the daily activity schedule. Staff maintained continuous sight supervision
of all youth in their assigned area. Staff were observed supervising youth by controlling line
movements, positioning themselves appropriately, and giving clear directions to youth. The
center staff were interacting appropriately and positively with the youth. All movements were
authorized by master control prior to the youth being moved. A review of the center’s logbooks
during the annual compliance review period confirmed all movements were logged and counts
were conducted consistently. Each day of the annual compliance review week, the center had
adequate staff to meet the required staff-to-youth ratio. Observations of shift change were
unable to be conducted due to the center being on twelve-hour shifts; however, observations of
mental health staff entering the facility were made. All staff were electronically searched prior to
entry. Seven staff were interviewed, and each stated there were enough staff to provide
adequate supervision. An informal interview with the assistant superintendent confirmed the
center’s method of tracking the daily census is utilizing tableau and an alpha youth list daily.
Observations also indicated the center documents youth counts consistently within the master
control and living unit logbooks.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 48 of 61 (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) detailing the behavior management system
(BMS) to ensure the safety and security of youth and staff. The center provides a BMS, which
includes a system of rewards, privileges, and consequences. During a walkthrough of the
center, BMS posters were observed throughout the building in all common areas where youth
may be able to review. Incentive calendars were also posted alerting the youth of rewards and
privileges which can be earned. The BMS includes the use of a three-tiered level system where
youth are given the opportunity to earn points by meeting required expectations. A review of
completed point cards and logbook entries throughout the annual compliance review period
supported the center utilized the BMS in compliance with the components outlined in the
center’s FOPs. A review of all level cards revealed staff were consistent in completing the level
cards on a regular basis. Seven staff were interviewed, and each confirmed the BMS includes a
point and level system, the BMS is posted throughout the center, and is included in the
orientation process. In addition, each staff confirmed the youth receive several incentives and
believe the center’s BMS is effective. All seven staff stated each youth who earns their level
receives canteen, treasure chest, level three room, video games, popcorn and movies, level
three condiments, ice cream, television time, ten-minute telephone calls, and special level three
meals. All five staff stated they speak with youth to discuss the consequences being imposed.
Seven staff stated youth are given an opportunity to explain their behavior. None of the staff
reported they have seen a staff encourage a youth to beat up another youth. Five staff indicated
as a part of consequences for negative behavior items earned on level three can be revoked as
well as video game privileges. An interview with seven youth found one youth rated the BMS as
being very good, two stated it was good, two stated it was fair, one stated it was poor, and one
stated it was very poor. All seven youth were able to explain the difference between each level
and how to move from level to level. Seven youth also stated they receive rewards such as level
three food, canteen, treasure chest, video games, pizza, ice cream, opportunities to play more
sports, movies, and listening to music. Six interviewed youth stated all staff use rewards the
same, one youth indicated some staff are not consistent and level one youth will get rewarded
over level three youth sometimes. Seven interviewed youth stated they are not allowed to
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 61 (Revised July 2023)
punish other youth. Five of seven interviewed youth stated they have been sent to their room for
punishment reasons with the door shut and locked; however, a review indicated these youth
were in their room for supervisor approved confinement reasons and those youth also indicated
the punishment was fair. Seven youth indicated items such as a level, points, bedding, and
clothing can be taken away. Five youth stated their mats are taken away; further observation
indicated this is only when a youth is in confinement. Once they are released from confinement
their bedding is returned. All seven-youth denied having witnessed any type of restraints used
on out-of-control youth. An interview with the superintendent confirmed the center’s BMS
protocols.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures requiring ten-minute checks to be conducted
when youth are in their rooms. The center has seventy-three surveillance cameras, all of which
were operational during the week of the annual compliance review. The surveillance cameras
have a thirty-day recording capacity. An electronic wand system is used in the center to
document and collect data from the ten-minute visual checks. Staff tap an electronic wand on
the check point sensors on the outside of each youth’s assigned sleeping room door, and the
data is downloaded as wand reports. A review of three samples of video and nine wand reports,
including samples from each shift and each living module, revealed staff conducted ten-minute
checks as required. Staff were observed looking into the windows of each sleeping room before
tapping the wand to the check point sensor. A review of wand reports for one day, for thirty
minutes of checks each day, for each month, on each shift for the annual compliance review
period found checks were conducted as required with one exception on October 14, 2023, when
one check was four minutes late. A review of documentation and an informal interview with staff
demonstrated there is a weekly review of management oversight and checks are being
conducted in the required frequency ensuring checks are met with fidelity. Five staff were
interviewed and confirmed when youth are not suicidal and are in their room, checks are
conducted every ten minutes. The superintendent interview confirmed the electronic wand
should be used to document room checks when youth are placed in a room as part of the daily
schedule, including shift change, bedtime, showers, or during a facility lockdown. When a youth
is placed in a room, whether for sleeping or other reasons, officers shall conduct visual
observations to ensure safety and security and notate those checks on the Visual Observation
Report (VOR) or by utilizing an electronic wand system. Visual observation intervals should be
varied but shall not exceed ten minutes between checks. Visual observations include
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 61 (Revised July 2023)
observations of the youth's condition including outward appearance, behavior, and position in
the room. When conducting a room check, staff shall pause at the door and look into the room
to ensure there are no issues with the youth.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains facility operating procedures to address census, counts, and tracking,
which require staff to always know the exact number and location of all youth under their
supervision. Census counts are documented upon any change of population. Living module
counts are recorded in their assigned module logbooks. Master control logbooks for one day
each month of the annual compliance reviewed period confirmed the census counts of youth are
written at the beginning and at the end of each shift. Observations of counts were completed,
and in each instance each youth was patted down, staff conducted a physical head count and
then called the number over the radio. Seven staff were interviewed, all of whom indicated youth
counts are conducted at every movement to include the beginning of shift, end of shift, before
and after meals, and before and after school. Staff also indicated emergency counts are
conducted anytime a youth is missing, visibility becomes hindered, and after any major
disturbance.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 61 (Revised July 2023)
5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has facility operating procedures to ensure the census, counts, and tracking of all
youth are always maintained. The center has separate logbooks for master control, each living
module, visitors, and vehicles. A review of maintained logbooks since the last annual
compliance review found they were bound with numbered pages. All entries include the times of
the events in a.m./p.m. and not military time with the name of the staff and the youth involved as
well as a brief description of the event and 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. Any errors reviewed were struck through with a single line with
“void” written after the error followed by the staff initials. Supervisors reviewed the master
control logbook each time they accepted responsibility for the center as well as reviewed the
living unit logbooks daily. The juvenile justice detention officers (JJDOs) reviewed the logbook
entries from the previous shift when accepting responsibility from the previous shift. Each
logbook review indicated the name and position of the reviewer and the date and time the
review was completed were documented. Master control logbooks included information
regarding emergency situations, incidents, all drills, documentation of medical and mental health
alerts, population counts at the beginning and end of each shift as well as throughout shifts as
count changes occurred, youth counts following emergency situations, youth group movement,
any law enforcement presence in the facility, admissions and releases, names of youth placed
in confinement, and precautionary observation as well as the times these statuses began and
ended. A review of three days of logbook entries each month since the previous annual
compliance review for educational access was conducted. The logbook entries, compared to the
activity schedule, documented minimal interference with educational instruction and included
documentation educational classes were being conducted with youth attending and departing
class on time, except for nine entries missing regarding school and five instances of youth
beginning school late.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 61 (Revised July 2023)
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 center has facility operating procedures regarding logbook requirements. The master
control and living module logbooks for the months since the last annual compliance review were
examined. The juvenile justice detention officer supervisor (JJDOS) reviews the logbooks for
each shift, including the master control logbook, when accepting the shift to document they are
aware of current and relevant situations in the center. The JJDOs assigned to each living
module review the module logbook upon accepting the shift. The superintendent was
interviewed and stated they review all logbooks at a minimum of weekly and review the entries
for the last seventy-two hours. The reviewed documentation is highlighted in yellow marker. The
superintendent further confirmed a supervisor must review the master control logbook, going
back seventy-two hours, and document their presence in the living area logbooks every shift.
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.)
The center has facility operating procedures describing the center’s process for key control,
issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys,
and reporting and replacement of damaged keys. Missing or lost keys must be documented,
and the juvenile justice detention officer supervisor (JJDOS) must be notified immediately; a
Department’s Central Communications Center (CCC) report is generated if any key is not found
or located. An incident report is completed if any key is damaged, and the key is replaced by the
maintenance staff. An observation during the week of the annual compliance review and an
informal interview with the center’s master control staff revealed the facility keys are stored on a
tamper-resistant key ring which prohibits the removal of keys and is color coded specific to the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 61 (Revised July 2023)
position to which the keys are assigned. These keys are kept in a box in master control secured
by a padlock. When staff enter the center, their personal keys are to be secured in lockers on
the non-secure side of the center prior to being issued a key set by the master control operator.
Visitors and contracted staff turn in personal keys to master control. In addition, observations
during the week of the annual compliance review and an informal interview with the master
control staff and superintendent validated youth have no access to facility keys. The center
maintained a master key inventory which accounts for all key rings by ring number, the number
of keys on each ring, the capability of each key, and to whom the keys are assigned and issued
to. Emergency keys which provide egress through exterior doors are stored in the administration
area which staff can access. A review of the Key Control Logs and informal interviews with
administration and master control staff confirmed the issuance of keys and key rings were
documented on the Key Control Logs on each shift with the date and time of issue, name of
person receiving the key ring, and the time each was returned. Issued key sets are also
documented on the daily shift reports in SharePoint. Observations of key collection and
distribution were unable to be completed due to the center running on twelve-hour shifts;
however, staff were observed always carrying the facility keys on their person during the week
of the annual compliance review and youth did not have access to facility keys. A review of the
master key control inventory confirmed the inventory report matched the actual key rings in use.
There were no reported incidents of lost keys during the annual compliance review period. The
keys carried by three staff were examined and were confirmed to have the correct number of
keys on the ring as well as the correct assigned key ring number documented for the shift.
Seven staff were interviewed and were able to articulate the center’s key control process. Seven
staff indicated restricted keys include keys to medical, six staff stated mental health record keys,
six staff indicated case management records, six staff indicated the kitchen, one indicated
anything within master control, and one stated teacher keys. The superintendent stated
permanent keys are provided to certain staff and staff receives key control training prior to
receiving facility keys. They are to be responsible for the security of their assigned keys and be
able to always account for their assigned keys during their work schedule. The superintendent
confirmed youth are not to have access to any facility keys.
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 maintains facility operating procedures for transportation, operation, and
maintenance of each vehicle used to transport youth. The center’s maintenance mechanic is
responsible for the weekly and monthly vehicle inspections. The maintenance mechanic or staff
using vans for transport complete the vehicle checks daily to ensure all vehicles are equipped
and readily available to drive. The center has a total of six vehicles used to transport youth.
Each vehicle had an annual safety inspection conducted by a certified automobile mechanic. All
six vehicles have the appropriate number of seatbelts, a seatbelt cutter, a window punch, up-to-
date fire extinguishers, and a first-aid kit with approved items by the designated health authority
(DHA). A binder is maintained for each vehicle which contains the vehicle mileage log, vehicle
inspection log, vehicle oil change log, automobile accident reporting form, driving directions and
maps, AmeriSys information, gas card, vehicle registration, and vehicle policies. Weekly visual
vehicle inspection checks are conducted on all vehicles as required and documented on the
preventive maintenance check sheets. Prior to each transport, a pre-trip vehicle inspection is
conducted by two staff and documented in the vehicle logbook and vehicle inspection log. Two
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 61 (Revised July 2023)
youth transported to court, conducted by two juvenile justice detention officers (JJDOs), during
the annual compliance review week were observed following all required transportation
procedures prior to transport. Staff are given a mobile telephone to take with them on the
transport. The assigned mobile telephones are kept in master control. All vehicle logbooks
indicated each vehicle was searched for contraband prior to use and again upon return. The
number of youth transported and the destination with date and time were documented for each
trip. Observations of six vehicles verified each was locked when not in use. Seven youth were
interviewed, five stated they felt safe during transports. One youth stated a staff falls asleep at
the wheel, and another youth indicated the staff driving at excessive speeds. This information
was relayed to the administration, who will act accordingly. All seven youth denied ever
witnessing contraband being paced inside 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 maintains facility operating procedures detailing the requirements for tool inventory
and management. A perpetual tool inventory list is maintained by the center and inventoried
monthly by the maintenance mechanic. All tools are stored in a locked area when not in use.
Tools are maintained in a locked toolbox and are identified with an engraved number on each
tool which coincides to the tool inventory sheet. Observations indicated there were no missing
or damaged tools. Ten percent of the total number of tools within the facility was sampled to
confirm the inventory was correct and no discrepancies were found. The maintenance mechanic
reported he is the only person with access to utilize tools. An interview with the maintenance
mechanic indicated there were no instances of missing or broken tools since the last annual
compliance review. An itemized inventory of kitchen equipment and tools is also maintained. All
items, including all knives, are inventoried daily upon kitchen staff reporting for duty. The kitchen
knives and other hazardous kitchen sharps are stored in a locked cabinet. An informal interview
with the maintenance mechanic indicated all service vendors are identified prior to entering the
secure area of the center and are always accompanied. Youth are removed from the area being
serviced and are not allowed to re-enter the area until it has been searched and cleared by
center staff. The vendor checks for all their tools to ensure they leave with the tools they entered
with into the center. An interview with seven staff indicated they could articulate what to do in
the event a tool is damaged or goes missing. During an interview with the superintendent, it was
confirmed only maintenance staff and administration have access to the maintenance Class A
tools. All inspections and inventories are uploaded into SharePoint and the superintendent or
designee reviews them.
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 maintains facility operating procedures prohibiting youth from having access to any
tools, including kitchen and/or medical equipment. Youth are allowed to use cleaning items such
as mops, brooms, and scrub brushes when completing general cleaning. Youth are under staff
supervision when these items are in use. An observation of youth utilizing cleaning tools was
unable to be conducted during the annual compliance review period. Seven interviewed youth
indicated they only use mops, brooms, scrub brushes, and paint brushes. Seven interviewed
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 61 (Revised July 2023)
youth stated they do use cleaning agents, but they are not allowed to handle the cleaning
agents. The staff handle the cleaning agents, such as spraying a table, and then the youth can
wipe it down. Seven interviewed staff stated youth are permitted to use scrub brushes, mops,
brooms, and squeegees for the windows. Five staff indicated youth utilize chemicals to clean;
however, further elaboration indicated the youth did not have physical contact with the
chemicals. Staff spray the cleaning agents, and the youth wipe the surfaces down.
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 operates under a safety plan addressing the proper use, storage, and disposal of
chemicals, including flammable, toxic, caustic, and poisonous items. Additionally, the center
maintains facility operating procedures to ensure the proper inventory of flammable, toxic,
caustic, and poisonous items. All items are inventoried and securely stored. All observed items
had a Safety Data Sheet (SDS) on record for each chemical. Five chemical items were
reviewed on-site during the week of the annual compliance review, for which the center
maintained a corresponding SDS and complete and accurate inventories. Flammable, toxic,
caustic, and poisonous items were observed to be stored securely in areas inaccessible to
youth.
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 maintains a written policy and procedures to ensure limited access to flammable,
toxic, caustic, and poisonous items. These Items can only be used by authorized staff. Youth
are not permitted to use or handle hazardous chemicals. No toxic materials were observed at
the center in any place accessible to youth during the week of the annual compliance review. An
interview with seven youth indicated they do not have access to flammable, toxic, caustic,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 61 (Revised July 2023)
and/or poisonous items. An interview with seven staff indicated youth are not allowed to clean
with substances which are flammable, caustic, toxic, or poisonous.
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 (FOPs) addressing the proper use, storage, and
disposal of flammable, toxic, caustic, and poisonous items. The maintenance mechanic reported
the center has not had any chemical spills or the need for disposal of any flammable, toxic,
caustic, and/or poisonous items during the annual compliance review period. The center’s
maintenance mechanic also reported the center does not utilize grease for cooking, and all
kitchen liquid waste is disposed of in the kitchen drain. An informal interview with the
maintenance mechanic indicated the center has procedures for if a chemical spill does occur
and in the event flammable, toxic, caustic, and poisonous items and materials are needed to be
disposed of.
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures (FOPs) ensuring confinements under twenty-four
hours are used as an immediate, short-term response to incidents which affect the physical
safety of youth or others. The center utilizes the youth’s assigned sleeping room for
confinement. The center had 166 instances of confinement under twenty-four hours during the
annual compliance review period. Seventeen of the 166 confinements were reviewed. All
reports indicated rooms were free from obstruction. A review of seventeen confinement reports
found each youth was afforded the same services as youth in general population. Confinement
reports for each confinement confirmed all rooms were searched prior to youth being placed in
confinement, all non-fixed items were removed from the room, and each documented approval
by a juvenile justice detention officer supervisor (JJDOS). All youth had access to mental health
and education services as needed. Each youth showered and was given clean clothes except in
instances when the youth were making threats and were too combative to bring out of their
rooms. All youth were notified they could grieve the situation of being placed in confinement. All
confinement reports were completed before the end of the shift. Documentation showed five-
minute checks were conducted for the first hour for each of the seventeen confinements. Each
reviewed report indicated a JJDOS conducted an initial confinement review with the youth within
two hours from the incident. A JJDOS evaluated each youth every three hours and documented
the need for confinement. Each report indicated the youth were released from confinement
within twenty-four hours. Each of the twenty confinement reports indicated the superintendent or
designee reviewed the confinement report within forty-eight hours. There were no pregnant
youth confined during the annual compliance review period. Seven staff were interviewed and
demonstrated they were familiar with the confinement process to include completing the report
prior to the end of their shift, conducting ten-minute checks, and searching the room prior to
placing the youth inside. All staff indicated the youth are provided with educational materials
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 61 (Revised July 2023)
while in confinement. The superintendent interview confirmed confinements are reviewed by the
administration daily, and all confinements are discussed at the bi-weekly regional meeting.
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.16 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 maintains facility operating procedures to manage various emergencies and disaster
events. One of the two required drills during the annual compliance review period was
conducted, as required. The center still has the entirety of December to complete the second
required drill. Documentation confirmed the center conducted a hurricane drill prior to the start
of hurricane season on June 1, 2023, and in the instance, there was a written scenario, drill
form, feedback, and e-mails used to document the drill. The completed drill did have a roster
documenting staff participation and was held over multiple days. The drill was also uploaded
into SharePoint. Seven staff were interviewed and stated they have participated in various drills
to include weather, major disturbances, bomb threat, hostage situation, chemical spills, flooding,
terrorism, escape, and fire drills. The superintendent reported the Continuity Of Operations Plan
(COOP) describes the process for the relocation and continued operations of a facility during an
emergency or disaster and the center’s Emergency Plan describes how to respond to
emergency situations including fire and fire prevention/evacuation, severe weather, major
disturbances, pandemics, bomb threats, taking of hostages, chemical spills, flooding, or
terrorism threats or acts.
5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures to address escape drills and escape
prevention. The policy requires the center to conduct escape drills at least quarterly. Each of the
twelve required drills during the previous twelve-month period were conducted, as required. The
documentation of the drills included scenarios as well as the dates and times of the drills. The
drill documentation form included the signatures of the supervisory staff and the staff
coordinating the drill. Recommendations and critiques of the drills were included in each report.
A review of logbooks revealed each escape drill was documented in the logbook, as required.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 61 (Revised July 2023)
All documentation was also uploaded into SharePoint and signed off by the superintendent or
designee. A review of five in-service staff training records in the Department’s Learning
Management System (SkillPro) validated each staff completed escape prevention training
annually. Seven staff were interviewed and stated they have participated in various drills to
include weather, major disturbances, bomb threats, hostage situations, chemical spills, flooding,
terrorism, escape, and fire drills.
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a disaster plan, fire prevention plan, and evacuation plan addressing fire
prevention and safety in the center. The center has evacuation egress plans posted throughout
the center. Each egress plan defined the primary and secondary exit route and the locations of
emergency equipment such as fire extinguishers and first-aid kits. Reviewed documentation
also revealed the center’s fire extinguishers are inspected annually, most recently on October 2,
2023. Documentation verified the center conducted fire drills each month, on each shift, and at
different times throughout the annual compliance review period. Drills are also reviewed
duringshift briefings and documented within the master control logbook. All documentation is
uploaded into SharePoint and signed off by the superintendent or designee. Seven youth were
interviewed and four stated they have been instructed on what to do in case of a fire. Three
youth stated they have not been instructed on what to do in case of a fire. Seven staff were
interviewed, and six staff had participated in monthly fire drills. One staff stated they have not
participated in a monthly fire drill.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 59 of 61 (Revised July 2023)
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 a facility operating procedure (FOP) in place for searches and to ensure
contraband is prevented from entering the secure area of the center. The policy includes
procedures for electronic, frisk, strip, room, and staff/visitor searches. An admission was in
process during the walk through of the center. At the point of the process the admission was in
an electronic search observation was unable to be conducted; however, two juvenile justice
detention officers (JJDOs) of the same gender were in the process of a strip search of an
individual youth. Youth departing on a transport to court were observed. Staff inspected the
secure vehicle, and a frisk and electronic search of the youth was completed prior to the youth
returning to their mods by a JJDO of the same gender while wearing gloves. Searches of staff
and visitors prior to entering the secure area were unable to be observed; however, an informal
interview with the superintendent confirmed the center visitors sign into the visitor logbook, are
electronically searched, as well as move through a metal detector. A review of room searches
for one day each month since the last annual compliance review found documentation of room
searches in the living unit and master control logbooks. There was one instance of contraband
being found at the center during the annual compliance review period; however, it was originally
called into the Department’s Central Communication Center (CCC) under report number 2023-
04060 as a missing cellular telephone incident. Further investigation determined a youth was
allegedly in possession of the cellular telephone and prior to any contraband searches or law
enforcement involvement, the youth surrendered the telephone; therefore, no search was
conducted, and law enforcement was not contacted. This updated information was relayed to
the CCC. An interview with the superintendent confirmed searches shall take place no more
frequently than necessary to control contraband or to ensure safety. The results of any search
shall be documented in the logbook and electronically. Staff shall prepare youth prior to the
initial frisk search or any strip search by explaining the purpose and procedure of the search
while assuring youth of their safety. All searches shall follow the Right Interactions curriculum
and this policy. Throughout the search, staff shall continue to treat youth with dignity and
respect, to reduce the youth’s potential feelings of embarrassment. All contraband must be
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 60 of 61 (Revised July 2023)
documented in the master control logbook, an incident report identifying findings and the
disposition of the contraband must be completed, law enforcement must be contacted if any
found item would be considered illegal as defined in Florida Statutes, or if there is evidence of
any type of unlawful activity, items which may be used as evidence shall be secured by the
discovering JJDO and hand-delivered to the supervisor. The shift Supervisor must document
the chain of custody for the items and give the information to the responding law enforcement
officer, the CCC, and the regional director or designee must be notified.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 61 of 61 (Revised July 2023)

report_type: QI Detention

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 3.08