state: FL

summary: QI Detention - FY24-25 - 3 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Leon Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
2303 Ronellis Drive
Tallahassee, Florida 32310
Review Date(s): December 10-13, 2024
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Patrick M McKinstry, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, North Central Region Education Coordinator, (Standard 2)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
James Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard4)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Leon Regional Juvenile Detention Center MQI Program Code: 32
Provider Name: Department of Juvenile Contract Number: NA
Location: Leon County / Circuit 2 Number of Beds: 50
Review Date(s): December 10-13, 2024 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
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 56 (Revised July 2023)
Lim ited R atings
1.05 R ight Interactions (R I)
2.05 A dm ission and S torage of Y outh P ersonal P roperty
2.08 R eview of Y outh in S ecure D etention and H om e D etention
Failed R atings
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 56 (Revised July 2023)
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * S a tis fa c to ry
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a tis fa c to ry
S ta ff C o d e o f C o n d u c t S a tis fa c to ry
In c id e n t R e p o rtin g C C C * S a tis fa c to ry
R ig h t In te ra c tio n s (R I) L im ite d
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a tis fa c to ry
In -S e rv ic e T ra in in g S a tis fa c to ry
G rie v a n c e s S a tis fa c to ry
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n * S a tis fa c to ry
D a ta T re n d A n a ly s is S a tis fa c to ry
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to d o
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 56 (Revised July 2023)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n S a tis fa c
O rie n ta tio n S a tis fa c
C la s s ific a tio n S a tis fa c
N o tific a tio n o f J P O C irc u it G a n g R e p S a tis fa c
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty L im ite
R e le a s e S a tis fa c
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s S a tis fa c
R e v ie w o f Y o u th in S e c u re D e te n tio n a n d H o m e D e te n tio n L im ite
D a ily A c tiv ity S c h e d u le S a tis fa c
E d u c a tio n a l A c c e s s * S a tis fa c
C a re e r E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 56 (Revised July 2023)
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
3 .1 7
* T h e D e p
b e lo w D e p
in a p ro g ra
aam rtm
rtm
a
eele n t h
n t s
rt fo
a s id e n
ta n d a rd
rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
L ic e n s e d M H /S A C lin ic a l S ta ff *
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
M H /S A A d m is s io n S c re e n in g
M H /S A A s s e s s m e n t/E v a lu a tio n
M H /S A T re a tm e n t
T re a tm e n t a n d D is c h a rg e P la n n in g
P s y c h ia tric S e rv ic e s *
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia
m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
te a tte n tio n if a p ro
d ic a to rs . F a ilu re to
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
S a
g ra
d o
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
tis fa
m o p
s o w
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
c to ry
e ra te s
ill re s u lt
Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 56 (Revised July 2023)
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * S a tis fa c
F a c ility O p e ra tin g P ro c e d u re s S a tis fa c
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t S a tis fa c
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa c
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm S a tis fa c
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n S a tis fa c
D H A /D e s ig n e e A d m is s io n N o tific a tio n S a tis fa c
H e a lth -R e la te d H is to ry S a tis fa c
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g S a tis fa c
S e x u a lly T ra n s m itte d In fe c tio n S c re e n in g & H IV S c re e n in g S a tis fa c
S ic k C a ll P ro c e s s S a tis fa c
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re S a tis fa c
O ff-S ite C a re /R e fe rra ls S a tis fa c
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s S a tis fa c
M e d ic a tio n M a n a g e m e n t S a tis fa c
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s S a tis fa c
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n S a tis fa c
P re n a ta l C a re /E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to ry
to d o
Standard 5: Safety and Security
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 56 (Revised July 2023)
5 .0 1
5 .0 2
5 .0 3
5 .0 4
5 .0 5
5 .0 6
5 .0 7
5 .0 8
5 .0 9
5 .1 0
5 .1 1
5 .1 2
5 .1 3
5 .1 4
5 .1 5
5 .1 6
* T h e D e p a
o p e ra te s b e
d o s o w ill re
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
A c tiv e S u p e rv is io n o f Y o u th * S a tis fa c to ry
B e h a v io r M a n a g e m e n t S y s te m /U n a u th o riz e d U s e o f P u n is h m e n t* S a tis fa c to ry
T e n -M in u te C h e c k s * S a tis fa c to ry
C e n s u s C o u n ts a n d T ra c k in g S a tis fa c to ry
L o g b o o k M a in te n a n c e a n d R e v ie w s S a tis fa c to ry
K e y C o n tro l S a tis fa c to ry
V e h ic le s a n d M a in te n a n c e S a tis fa c to ry
In v e n to ry , M a n a g e m e n t, Y o u th A c c e s s , & U s e o f T o o ls C le a n in g Ite m s * S a tis fa c to ry
In v e n to ry o f a n d A c c e s s to a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s S a tis fa c to ry
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s S a tis fa c to ry
C o n fin e m e n t U n d e r T w e n ty -F o u r H o u rs S a tis fa c to ry
C o n fin e m e n t O v e r T w e n ty -F o u r H o u rs S a tis fa c to ry
C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) D rills S a tis fa c to ry
E s c a p e D rills S a tis fa c to ry
F ire D rills S a tis fa c to ry
S e a rc h a n d C o n tra b a n d P ro c e d u re s S a tis fa c to ry
rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to
s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
Program Overview
Leon Regional Juvenile Detention Center is a state-owned detention facility, operated by the
Department, located in Tallahassee, Florida. The center serves youth in Franklin, Gadsden,
Leon, and Wakulla counties in Circuit 2. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-bed center. Youth are provided services which include youth orientation, behavior
management, safety and emergency procedures, transportation, mental health, and healthcare
services. The center’s educational services are provided by the Leon County School Board. The
center’s management team includes the superintendent, two assistant superintendents, two
administrative assistants, and eight juvenile justice detention officer (JJDO) supervisors. The
center has twenty-nine JJDOs. Mental health and healthcare services are provided through the
contracted provider, VitalCore Health Strategies, LLC. Mental health services are provided by
eight staff including one designated mental health clinician authority (DMHCA), five licensed
mental health staff, and two non-licensed mental health staff. Clinical services provided by the
center include mental health and substance abuse evaluations, mental health treatment
planning, individual, group and family therapy, mental health crisis intervention services, on-site
psychiatric services, and the availability of substance abuse services for youth with co-occurring
disorders. Medical services are provided by six staff including one designated health authority
(DHA), one advanced practice registered nurse (APRN), three registered nurses (RNs), and one
licensed practical nurse (LPN). The medical clinic maintains nursing coverage seven days a
week, eight hours a day. Food services are provided by three kitchen 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. The center was clean and no exceptions were noted during the
annual compliance week. There are sixty-three security cameras at the center, of which all were
operational. At the time of the annual compliance review, the center had thirteen vacancies,
which included twelve JJDOs and one food service worker.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 56 (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.
There were eighteen staff hired at the center since the last annual compliance review. All staff
reviewed had a background screening completed prior to their hire date. A criminal history
report was reviewed for each of the staff reviewed. Two out of the eighteen staff required an
exemption prior to working with youth. An exemption was found for the two staff in each of their
personnel records. All staff had a pre-employment assessment tool administered. In addition, a
passing score was found and documented within the staff record. The center has a policy and
procedures for volunteers, mentors, and interns who work with the youth less than ten hours a
month requiring sight and sound supervision. The center had an Annual Affidavit of Compliance
with Level 2 Screening Standards signed on January 31, 2024. The school board had an Annual
Affidavit of Compliance with Level 2 Screening Standards signed on January 31, 2024.
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 did not have any staff requiring a five-year background rescreening during the
annual compliance review period. A review of the center’s written facility operating procedures
identified practices required for rescreening staff every five years from the date of hire.
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.
Nine staff records were reviewed for staff code of conduct. Three staff were reviewed for
disciplinary actions, whereas the center addressed each case. Three staff were reviewed for
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 56 (Revised July 2023)
having signed a code of conduct upon hire; each staff had a signed code of conduct contained
in their personnel record. Three staff were reviewed for receiving a commendation; each staff
had a commendation presented to them from the center.
Seven youth were interviewed. All youth reported they had never been stopped from reporting
abuse. All youth stated staff are respectful when talking to youth. Five youth reported they never
heard staff use curse words when speaking with youth. One youth stated occasionally, and one
youth said often, where staff use curse words when speaking to youth. This information was
provided to the center. The center conducted training immediately with each of the three shifts
at the center concerning facility operating procedures (FOPs) pertaining to the staff code of
conduct. The FOP addresses staff adherence to a code of conduct which prohibits any form of
abuse, profanity, threats, harassment, intimidation, or personal relationships with youth. All
seven interviewed youth reported they have never heard staff threaten them or other youth. All
interviewed youth reported they feel safe. All youth stated they have never exchanged emails,
telephone numbers, or social media contact information with any staff at the center.
Seven staff were interviewed. Staff were able to explain what they knew of the abuse reporting
process for allowing staff and or youth to contact the Florida Abuse Hotline and/or the
Department’s Central Communications Center (CCC). Five staff reported they never heard
another staff use curse words when speaking with youth. One staff stated once and another
staff said occasionally, where they had heard staff use curse words when speaking to youth.
This information was provided to the center. The center conducted training immediately with
each of the three shifts at the center concerning FOP pertaining to staff code of conduct. All
interviewed staff reported having never observed a co-worker using threats and/or intimidation
while interacting with any youth. The seven interviewed staff reported in the past year working
conditions have been either fair or good. The superintendent was interviewed and was able to
explain the center’s staff code of conduct and subsequent actions if there were any documented
reports of physical abuse, threats, or profanity used towards youth.
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 had ninety-three total incidents reported to the Department’s Central
Communications Center (CCC) since the last annual compliance review. Nine CCC incidents
were reviewed. All incidents reviewed were reported within a two-hour timeframe. Two of the
nine reviewed incidents were not found documented in the center’s logbook. There were no
indications of any additional internal incidents or grievances which should have been reported to
the CCC. The superintendent was interviewed and was able to identify practices for contacting
either the CCC or Florida Abuse Hotline when necessary.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 56 (Revised July 2023)
1.05 Right Interactions (RI) Limited Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
There was a total of 117 Right Interactions (RI) incidents reported at the center since the last
annual compliance review. Six of the nine sample RI Reports reviewed had some type of
exception. Five of the RI Reports were not completed by the end of the staff’s workday; whereas
four of the five noted reports were missing staff reports completely and the remainder had
reports turned in late. Additionally, two separate reports were not reviewed by a supervisor
and/or a RI instructor. None of the reviewed reports utilized mechanical restraints. Two of the
nine RI Reports were missing documentation of a post-RI interview having been completed.
There were also two of the nine RI Reports which were missing the superintendent/designee
reviews. The center’s RI rate during the previous quarter was 4.80, which is below the statewide
Detention RI rate of 9.79. Seven staff were interviewed, and each stated they try to talk to youth
prior to using any type of RI with youth. The superintendent was interviewed and was able to
identify processes for tracking and monitoring RI incidents at the center.
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.
A total of seven staff training records were reviewed for pre-service and certification
requirements. Five of the staff had completed all pre-service and certification requirements
within 180 days of hire, including the 120 hours of academy training. The two remaining staff
were at the academy and appeared to be meeting all training requirements as required within
the 180 days of hire. Each of the seven reviewed staff records documented new staff orientation
being completed within thirty days of hire. All applicable pre-service trainings were found
documented in the Department’s Learning Management System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
A total of seven staff training records were reviewed for annual in-service training. Each of the
staff completed all mandatory training topics, except for one staff who did not complete human
trafficking. All the reviewed staff did complete a minimum of twenty-four hours of annual in-
service training. A review of three supervisory staff was conducted. Each of the supervisors
completed a minimum of eight hours of either coaching, leadership, and/or personal
accountability training for the calendar year. All applicable in-service trainings were found
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documented in the Department’s Learning Management System (SkillPro), with one exception
as noted above. A review of in-service education on girl’s healthcare for staff was found
documented and having been delivered by a registered nurse (RN) in February 2024 and
August 2024. The annual training included monitoring, observation, and emergency care of
pregnant youth. The center maintains an annual in-service training calendar, which is updated
as changes occur. The annual in-service training calendar was found to be approved by the
superintendent, the assistant secretary for Detention, and the director of the Department’s
Office of Talent, Leadership, and Culture. The superintendent was interviewed and was able to
identify trainings completed by all staff at the center for the calendar year reviewed.
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.
Grievances are available for youth in each of the center’s youth housing areas. The center has
had only one grievance filed during the annual compliance review period. A review of the
grievance found it was reviewed and resolved within the specified time frame. Seven youth were
interviewed. One of the youth filed a grievance and knew the process. The remaining youth
knew a little of the process for filing a grievance or had never filed one. Out of seven interviewed
youth, six said they had never filed one and the remaining stated the process was fair. Seven
interviewed staff interviewed were able to identify and address how the grievance process
works. The superintendent was interviewed and was able to explain how the grievance process
worked.
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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 having alerts entered within the Department’s Juvenile Justice
Information System (JJIS) with a total of eighteen alerts reviewed. Each applicable alert was
either removed and/or updated by appropriate staff in the center. Each applicable alert was also
found either in the center’s logbook and/or shift report when necessary. The center utilizes the
JJIS alert roster to communicate and share youth alert information with all staff. A review of shift
report briefings supported the JJIS alert reports are reviewed by supervisors, administrators,
and staff within the center. A shift briefing was not observed during the on-site annual
compliance review, however, informal discussions held with staff confirmed the practice of
sharing alert information during shift briefings and documentation within logbooks and shift
reports. While on-site, there were no additional alerts found which should have been entered
into the alert system, as specified in the center’s procedures.
The center’s practice for updating alerts is to 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
the supervisors and administrators to ensure it correctly reflects the status of the youth. The
juvenile justice detention officer (JJDO) supervisors shall ensure the detailed alert list is read
aloud during shift briefings. If JJIS is down for any reason, the JJDO supervisor shall ensure the
last hard copy of the alerts shall have a written notification, updates of the recent admissions, or
changes to existing alerts and shall be distributed to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked and
managed. If there are any alerts which require special care of youth on their living unit by staff,
these alerts shall be documented in the initial acceptance of the logbook for each youth’s
designated living area. Seven staff were interviewed and provided input on the practice of
obtaining youth alert information. Staff are in receipt of youth alert information from logbook
entries, debriefings, alerts, meetings, word of mouth, and email. Six staff felt the communication
process was good to very good, whereas one staff stated it was very poor. The superintendent
was interviewed and stated alerts are discussed during shift briefings and given to all floor staff.
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center addresses data trend analysis during pre-shift, weekly, and monthly meetings.
Additionally, information is shared with administration at a minimum of monthly through all-
hands and supervisor meetings. A review of monthly supervisory meeting agendas and notes
support the practice. The center conducts video meetings and disseminates emails quarterly to
stakeholders at a minimum quarterly. A review of quarterly email correspondence and notes
support this practice. Administration provides trainings and meetings to staff on data collected to
assist in improving processes at the center.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
A total of seven youth records were reviewed for admission requirements. All seven youth had a
court order included in the legal section of their record. Each record also included the
Department’s Juvenile Justice Information System (JJIS) Admission Wizard. Four of the seven
Admission Wizard forms documented the court orders were reviewed and three did not notate
the review. Four of the seven applicable records indicated a review of the Detention Risk
Assessment Instrument (DRAI) was completed, three were not applicable for a completion of a
DRAI. All seven reviewed records indicated a review of the Suicide Risk Screening Instrument
(SRSI) was done. Each record noted the youth were searched as required upon admission.
Each also documented the youth’s telephone call made to the parent/guardian, and the meal or
snack received. Each record included documentation of the medical and mental health and
substance abuse screening. Five admissions were conducted during the annual compliance
review week. The youth were observed reviewing the Department-authorized Prison Rape
Elimination Act (PREA) video in the intake screening area. Each youth was searched by a staff
member of the same gender. Youth personal items were taken up and bagged, and youth and
staff were observed signing for the items on the appropriate forms. No valuables were
observed. Youth were given their afternoon lunch. Youth also were observed being allowed to
contact their parent/guardian by telephone as part of the intake process.
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2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
Seven youth records were reviewed for orientation completion requirements. All seven records
had evidence each youth was provided orientation within twenty-four hours of admission to the
center. Each youth signed an orientation acknowledgement form, which was observed in all
records reviewed. Five youth orientations were observed during the annual compliance review -
week. Youth were observed reviewing the Department-authorized Prison Rape Elimination Act
(PREA) video in the intake screening area. Each youth was observed receiving the youth
handbook, which was also provided verbally to them by the intake center staff. The topics
covered all required orientation areas. Six of seven interviewed youth confirmed they were
provided orientation from detention staff when they came to the center. One youth reported they
were not provided the orientation.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
Seven youth records were reviewed for classification requirements. In each youth record there
was evidence staff reviewed information concerning each youths’ history and status including all
documentation required. Classification factors included all required elements for each youth
when determining room assignments. Each youth record also included a completed
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) screening form, as well
as determination of gang affiliation, history of violent behavior, criminal behavior, suicide risk,
escape history, history of human trafficking, and medical status and history. The center’s
superintendent was interviewed and stated the VSAB, Suicide Risk Screening Instrument
(SRSI), Massachusetts Assessment for Youth Screening Instrument, Second Version (MAYSI-
2), and other classification forms are use when considering youth’s room assignments. The
superintendent reported they are notified of any gang activity through a review of alert
information as well as email notification.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity. A referral for youth with suspected
gang involvement shall be shared, by e-mail, with the circuit gang representative, indicating
suspicions of gang activity such as youth flashing gang signs, gang tattoos, gang-related
drawings, or related activity. Center staff should include in the e-mail pictures (when
appropriate), copies of written statements, drawings, graffiti, and a description of what gang
signs the youth was “flashing.”
The center has facility operating procedures which notate referrals for youth with suspected
gang involvement. According to administration, the center does not have a designated circuit
gang representative. Seven youth records were reviewed, and none were applicable for or
required referral for suspected gang involvement. The superintendent was also interviewed and
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reported the center has not had any youth admitted within the annual compliance review period
who have been suspected of gang involvement for required notification to the juvenile probation
officer. The superintendent stated in the event a youth enters the facility and is suspected of
gang affiliation, the center would be responsible to comply with the facility operating procedures,
gather information on the youth, take photographs, and send the information to the assigned
juvenile probation officer who would then notify the local law enforcement.
2.05 Admission and Storage of Youth Personal Property Limited 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.
Seven youth records were reviewed for admission and storage of youth personal property
requirements. Three of seven youth were transfers from another detention center and staff
reported these youth did not have personal items when they were admitted. The remaining four
youth records were reviewed and found each of the four had signed for their personal items on
the Personal Property Receipt form. Three of the four forms had the staff signature, and one did
not. Personal items which are not considered valuable are to be kept in a secured closet. Items
are kept in a mesh bag with the Property Receipt form included. The Property Room was
observed to be secured and inaccessible to youth. The center maintains youth valuables in a
drop safe in the master control room. The drop safe is under video surveillance and has limited
staff access. A drop safe logbook is located on top of the safe. A sample of three valuables in
the drop safe was reviewed. Each was in a tamper-resistant clear bag with all required
information listed. Each was also documented as required in the safe logbook. Each also had
Property Receipt forms included with the bags. Two of the three had staff and youth signatures
on the forms. One of the three did not have the staff and youth signature, however, did have the
youth’s name typed on the bag. Items were present as required. An admission was conducted
during the annual compliance review week. The youth was searched by a staff member of the
same gender. The admitted youth’s personal items were taken up and bagged, and youth and
staff were observed signing for the items on the appropriate forms. No valuables were observed
for this admitted youth.
An observation of a youth release was made during the annual compliance review week.
Detention staff obtained the youth’s property from the property room. Property consisted of the
detention personal items mesh property bag with a property form inside. In addition, the youth
had a book bag in the property room. Inside the book bag was several items which included
twenty-six dollars in cash and a cellular telephone. The cellular telephone was accounted for on
the property sheet; however, the money was not. Both items were not initially placed in the
valuables drop safe when youth was admitted. Prior to the youth release, the youth signed for
the items and confirmed all items were present and accounted for.
The center’s superintendent was interviewed and stated youth’s personal property/valuables are
secured in master control inside a safe, which is logged in the safe’s logbook. For property not
claimed, a letter is mailed to the youth and family, however, if the property is not picked up in
thirty days it is disposed of or donated. Six of seven interviewed youth reported they have had
their personal items checked by staff when they came in. The one youth who stated they did not
was a transfer from another detention center and reported by staff to have not had any
valuables or personal items upon admission. A review of the Department’s Central
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Communication Center (CCC) reports for the annual compliance review period found no
incidents regarding any property valued over fifty dollars reported.
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.
A total of three closed youth records were reviewed for release requirements. Two of the youth
were released to a parent/guardian. One youth was released to a commitment program and was
transported by the Department staff. There was evidence in each of the three records indicating
the on-duty staff verified each youth’s identification prior to release. Detention administration
confirmed on-duty supervisors and staff review all paperwork, including court orders, prior to the
release of the youth. Each of the youth had a completed Release Wizard in their record.
Identification of each parent/guardian responsible was verified and a photocopy of their
identification was included in the youth record for each appliable record reviewed. None of the
reviewed youth were applicable for having an Endangered Person Alert in the Department’s
Juvenile Justice Information System (JJIS). Each youth and parent/guardian to whom the youth
was being released were reminded of any future court dates. Required parties signed all
applicable release forms. A review of each youth’s JJIS face sheet found dates of admission
and releases correlated with JJIS as required. An observation of a youth release was made
during the annual compliance review week. The youth was observed signing for all property.
Each parent’s/guardian’s identification was obtained and photocopied as required. The youth
had no medication. The parent/guardian and youth were observed signing all applicable release
information.
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.
A total of three youth closed records were reviewed for release of youth personal property,
medication, and aftercare instructions requirements. Two of the youth were released to a
parent/guardian and signed a receipt of property upon release. One youth was released to a
commitment program and was transported by the Department staff. Identification of the
parent/guardian responsible was verified and a photocopy identification was included in the
youth record for each appliable record reviewed. Two of the three youth released were not
applicable for release of medications. One remaining youth was released by the detention
transport staff to their commitment program. The detention center completed the Health
Discharge Summary and provided this to the receiving commitment placement as required.
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Each youth had a completed Release Wizard. According to the Release Wizard, each youth and
person to whom the youth was being released were reminded of any health or welfare issues,
including medical, mental health, and/or substance abuse needs and any pending
appointments. According to the detention center administration, there were no incidents
involving properties for youth held for more than thirty days from release during the annual
compliance review period. An observation of a youth release was made during the annual
compliance review week. The youth was observed signing for all property. Each
parent’s/guardian’s identification was obtained and photocopied as required. The youth had no
medication. The parent/guardian and youth were observed signing all applicable release
information.
2.08 Review of Youth in Secure Detention Limited 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.
Observations of weekly detention reviews were made during the annual compliance review
week. Detention center participants included a representative from education, medical, mental
health, and the center administration. Detention reviews were held through video conference,
where outside participants included the juvenile probation officer (JPO) and juvenile probation
officer supervisor (JPOS). Alerts for all youth were discussed during the meetings as well as any
future court dates, youth detention status, and pending placements for each youth. The
detention center maintains all detention review sign-in sheets and meeting information within the
SharePoint system. A review of weekly detention reviews for the annual compliance review
period found a listing of detention reviews uploaded. The list revealed all were uploaded each
week in SharePoint except for five meeting dates; however, the center was able to provide the
five hardcopy sign-in sheets for these dates. A review of one week each month of the annual
compliance review period found the detention center had no representative from education or
medical on October 30, 2024, and no education representative for the week of June 26, 2024.
The superintendent was interviewed and stated attendees for detention reviews include
administration, supervisors, education, medical, mental health, and probation staff. Detention
reviews are conducted in the conference room to address youth releases and commitment
status, as well as any needs for probation, mental health, medical, and the courts. Telephone
contact was made with the Department’s commitment manager supervisor, who confirmed the
center holds detention review meetings weekly as required and has had no issues with
consistency of scheduled meetings.
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.
Daily activity schedules were observed to be posted in the youth living areas and program
areas. Posted activity schedules included activities such as wake up and hygiene times,
mealtimes, visitation occurring a minimum of twice weekly, recreation activities both indoor and
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outdoor, shift changes, groups, and bedtimes. During the annual compliance review week,
youth were observed in education classes, intakes, line movements, and mealtimes. The center
was observed adhering to the daily schedule. Seven interviewed youth confirmed the center has
a daily activity schedule. Six of seven youth reported the center follows the daily activity
schedule regularly. One youth reported it is not consistently followed due to issues at times with
staff shortages. Seven interviewed staff all confirmed the center follows the daily activity
schedule as posted.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has a policy and procedures to provide educational access. The center provides
education services through the Leon County School District and the 250-day calendar, which is
distributed over twelve months, including ten days used for teacher training and planning. A
review of the daily school schedule revealed the center provides three 101 class blocks daily,
fulfilling the weekly requirement of twenty-five hours of instructional time. A review of one
random date for nine months in the logbook showed eight months of daily class schedule being
followed and youth transitioned to and from classes at the correct time. One reviewed month
found the youth were one hour late getting to class due to staff shortage, however, youth were
transitioned from classes on time. Further review of recent logbook entries and video footage for
three days verified the youth were attending school as scheduled. Seven youth were
interviewed. All youth reported they attend school Monday through Friday. Six youth interviewed
felt the school was preparing them either very well or well regarding preparation towards their
high school equivalency diploma (GED), high school, vocational, employment, and/or college,
while one stated not well in their preparation. Seven staff were interviewed. All staff felt there
was minimal interference in educational services. The interview with the superintendent also
reported there is minimal interference with educational services.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to provide career education. An informal interview
with the lead teacher confirmed the facility offers Type 1 career education development which
includes career learning strategies such as interviewing skills, résumé writing, and career
exploration. The career education programming includes communication, interpersonal, and
decision-making skill development. The center also has organizations from the community come
in and give presentations on various careers and educational paths. Seven youth were
interviewed, and all seven reported they were taking core classes such as math, science,
history, reading, and social studies.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a licensed mental health professional working as the designated mental health
clinician authority (DMHCA). The DMHCA is a licensed mental health counselor with an active
and valid license which expires March 31, 2025. The position description for the DMHCA was
available and reviewed. There were no other DMHCAs during the annual compliance review
period. The center does not have a back-up DMHCA. The DMHCA is on-site weekly as required
by contract to ensure coordination and implementation of mental health and substance abuse
services.
The DMHCA was interviewed regarding their job duties and reported to be on-site forty-hours
each week, Tuesday through Friday and weekend hours vary. The DMHCA oversees the daily
operation of all mental health/substance abuse services provided within secure detention for all
youth, as well as ensuring all youth entering secure detention are screened for any mental
health and substance abuse services. All youth are informed on how to access mental health
during their intake process. Any youth entering secure detention who are prescribed
psychotropic medications will be referred to psychiatry and seen within fourteen days and every
thirty days for follow-up or for an emergency until released. All youth will receive weekly mental
health treatment. For those youth who have reached their thirty-days in secure detention, a
Substance Abuse/Mental Health Assessment is completed to determine the needed treatment.
Mental health services include Assessments of Suicide Risk, Crisis Assessments, psychiatric
services, substance abuse treatment and evaluation, individual, and group treatment. The
DMHCA communicates with all clinical staff daily and meets once a week, at a minimum, with
registered interns and student interns for supervision. The DMHCA is in constant
communication with all staff through emails and telephone calls.
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 designated mental health clinician authority (DMHCA) ensures the licensed clinical staff
working under their supervision are performing services they are qualified to perform. All seven
licensed mental health staff are licensed under the appropriate Florida Statute as determined by
a review of the licenses. The licensed staff are on-site thirty-two hours a week, Monday through
Friday. The weekend schedule varies for the mental health staff. The DMHCA reported the
facility does not hold a Chapter 397 license. If a youth is admitted and needs substance abuse
treatment, the licensed staff are assigned to those youth. The DMHCA maintains a white board
in their office which designates what youth are in substance abuse treatment.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The designated mental health clinician authority (DMHCA) assures the non-licensed clinical
staff working under their direct supervision receive a minimum of one hour a week on-site, face-
to-face direct supervision. All reviewed direct supervisions were documented on the
Department’s Licensed Mental Health Professional and Licensed/Certified Substance Abuse
Professional Direct Supervision Log form. The non-licensed clinical staff at the center are on
internships and work the required hours. There were no vacancies for mental health staff during
the annual compliance review period. All non-licensed staff held a master’s-level degree from an
accredited university or college in a related human services field. The non-licensed staff were
trained as required to conduct Assessments of Suicide Risk as evidenced by a review of the
training documentation for each of the staff.
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 and substance abuse records were reviewed for mental health and
substance abuse admission screening. All seven records included documentation a Self-Report
Symptom Inventory (SRSI) was provided to the youth. Two of the youth had a current
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). The remaining youth
had the MAYSI-2 completed at other facilities prior to being transferred to the detention center.
All screening documents were reviewed by detention staff and completed at intake within the
Department’s Juvenile Justice Information System (JJIS). Trained mental health staff completed
the required sections of the SRSI for all seven youth. Six of the seven SRSI results included an
accurate referral selection in the “Screening Results” section. One youth did not require
referrals. All six youth were placed on suicide precautions and mental health referrals were
completed. Six assessment results indicated a need for further assessment. The superintendent
or designee was notified of the six youth who required further assessment. One of the two youth
who had a MAYSI-2 indicated a need for a comprehensive assessment based upon an elevated
score in one or more of the domains and was referred for an assessment.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
Seven youth records were reviewed for mental health and substance abuse evaluations. All
seven youth were identified after admission to be in need of further evaluation and referred to
the center provider. Three youth received an updated evaluation, two youth received new
evaluations, and two youth were still within their first thirty-days of admission. The five
applicable youth had evaluations completed within fourteen days of admission or by the youth’s
thirty-first day of admission. All five evaluations included treatment recommendations. The
designated mental health clinician authority (DMCHA) was interviewed regarding mental health
and substance abuse assessments and reported any youth who is referred for a comprehensive
assessment will receive one within the first thirty days of admission if one has not been
completed by a community provider.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
Seven youth mental health and substance abuse records were reviewed for treatment and
discharge planning. A mental health orientation was completed for all seven youth within
fourteen days of admission. Five of the youth were applicable to receive a treatment plan. Two
of the youth did not have a completed evaluation at the time of the annual compliance review
and were still within their first thirty days of admission. Two youth were applicable for receiving
an Initial Treatment Plan and the remaining three youth did not require an Initial Treatment Plan
due to not coming into detention on medications. Both treatment plans were completed within
seven days of the onset of treatment and were developed on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. The Initial Treatment Plan included the reason
for referral, initial Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V),
initial treatment methods and frequency, initial treatment goals, psychiatric services, and any
medication the youth were taking at admission. The Initial Treatment Plans included youth
signatures and treatment team signatures. The five applicable youth received an Individualized
Treatment Plan. All five Individualized Treatment Plans were developed for youth receiving
mental health and/or substance abuse treatment by the thirty-first day of admission. All five
reviewed treatment plans included DSM-V diagnoses, symptoms which are treatment-focused,
treatment goals, and strengths and needs. Two of the five youth had their psychotropic
medications listed on their Initial Treatment Plan, Individualized Treatment Plan, and all reviews.
A review of all progress notes validated the youth were receiving treatment services as
stipulated on the treatment plans. All reviewed treatment plans were signed and dated by the
youth, mental health clinical staff, and treatment team members. All treatment plans included
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documentation the parents/guardians were notified of the mini-treatment team meetings and a
copy of the treatment plans were mailed as well. Three of the five applicable youth had
Individualized Treatment Plan reviews. Two of the youth were still within the initial thirty days of
completion of the first treatment plan and a review was not yet due at the time of the annual
compliance review. The three applicable youth had one thirty-day treatment plan review
completed on the Department’s Individualized Mental Health and Substance Abuse Treatment
Plan Review form and modifications were clearly identified on each. A review of the
documentation reflected the Individualized Treatment Plan reviews were signed and dated by
the youth, clinical staff, licensed mental health professional, and other treatment team members.
All reviews included documentation the parents/guardians were notified and contacted for the
treatment plan reviews.
Three closed youth records were reviewed for the Mental Health/Substance Abuse Treatment
Discharge Summary. All three records included discharge plans documented on the
Department’s Mental Health/Substance Treatment Discharge Summary form. Copies of the
discharge summaries were provided to the youth, parents/guardians, and juvenile probation
officers (JPOs). All reviewed documentation included the completion of documentation on the
day of service, were signed by the licensed mental health professional, and all uploads were
completed within fourteen days. A mini-treatment team was not held during the annual
compliance review week; therefore, one was not observed. The designated mental health
clinician authority (DMHCA) stated all services are reviewed daily or, at a minimum, once a
week. The DMHCA appropriately summarized the facility operating procedures for
Individualized Treatment Plan reviews.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
Seven youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. Five of the seven youth were applicable for treatment. Two of the
youth were still within their initial thirty days and services had not yet started. All five youth were
assigned a mini-treatment team which consisted of mental health staff, educational staff,
medical staff, and the parents/guardians. All five youth required mental health treatment and
documentation revealed all five youth were receiving individual and group treatment prescribed
to occur weekly. One of the five youth required substance abuse treatment and received
individual counseling weekly. All five youth had current Authorizations for Evaluation and
Treatment (AET). The one youth who required substance abuse treatment had a proper consent
for substance abuse treatment signed. All five records included treatment notes which were
documented on the Department’s Counseling/Therapy Progress notes form. Three groups were
observed on video. The groups were held for forty-one minutes, twenty minutes, and forty-five
minutes. Sign-in sheets for mental health groups were provided for review. The sign-in sheet for
one group did not have an end time noted and one group held ended twenty minutes later than
indicated on the sign-in sheet. Groups were held in an appropriate and confidential space in the
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detention center. The number of youth in the mental health groups was appropriate for the type
of group being held. Seven youth were interviewed regarding mental health and substance
abuse treatment. Five youth reported the services are good and two youth reported the services
are very good. Six youth provided additional information; two youth reported seeing a therapist
every week, two youth reported seeing a therapist when they request a mental health visit, and
one youth reported they do not have individual therapy, however, they meet with a team at a
local mental health facility. The designated mental health clinician authority (DMHCA) was
interviewed regarding mental health and substance abuse treatment services. The services
provided at the center include Assessments of Suicide Risk (ASRs), Crisis Assessments,
psychiatric services, substance abuse treatment, supportive services, Substance Abuse/Mental
Health Assessment, Version Two (SAMH-II) evaluation, individual counseling, and group
treatment. The DMHCA stated the Individualized Treatment Plans are reviewed at least once a
week or more frequently if needed. Any youth evaluated by psychiatry within fourteen days of
entering secure detention on psychotropic medications will have an initial treatment plan
developed within seven days of admission. The Individualized Treatment Plan is developed
according to the SAMH-II by the thirty-first day of admission. A review of the treatment plan
must be conducted every thirty days until the youth is released.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
Psychiatric services are provided by a psychiatrist with a clear and active license which expires
on January 31, 2026. The designated mental health clinician authority (DMHCA) was
interviewed about psychiatric services. The DMHCA and mental health staff meet weekly with
the psychiatrist through tele-health and/or during on-site visits. The psychiatrist is also available
through email and telephone calls as needed for changes in youth treatment. Seven youth
mental health and substance abuse records were reviewed for psychiatric services. Two youth
were applicable for review. One additional youth record was reviewed for the minimum
requirement of three records. All three youth entered the center on psychotropic medications
and two received an initial diagnostic interview within fourteen days of admission. One youth’s
initial psychiatric interview was conducted twenty-one days after the required fourteen days;
however, the center was evacuated during a hurricane at the time the youth was scheduled to
have the initial interview. The interview was conducted after the youth returned to the center.
The initial diagnostic interviews included the reason for referral, history, mental status
examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)
diagnosis, treatment recommendations, prescribed medication, medication name, and
explanation and frequency of the medication. All three youth received an in-depth psychiatric
evaluation conducted within thirty days of admission which was reviewed and included the
stated reasons and factors leading to the referral, developmental history, substance abuse
history, school history, social history, emotional development, peer relations, family
relationships, history of abuse, history of psychiatric illness, medication management, mental
health treatment, substance abuse treatment, mental status examination, identification of
individual, family, and environmental factors, diagnostic formulation, treatment
recommendations, prescribed medications, and an explanation for the need of psychotropic
medications. One of the three youth required laboratory testing for therapeutic serum drug
levels. All three evaluations included the signature of the practitioner conducting the evaluation.
The Clinical Psychotropic Progress Note (CPPN), identified as a psychiatric evaluation, was
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completed for all three youth and included the medications prescribed. The information
documented on all reviewed CPPNs included identifying data, diagnosis, target symptoms,
evaluation, description of effect of prescribed medication on target symptoms, prescribed
medications, side effects, youth’s adherence to the medication regime, height, weight, blood
pressure, telephone contact with the parents/guardians, date and signature of the psychiatrist,
and Tardive Dyskinesia monitoring. All three youth had a current Authority for Evaluation and
Treatment (AET) on file. One youth had a new psychotropic medication prescribed because of
the evaluation and parental/guardian consent was obtained. When tele-psychiatry was provided,
the standard of psychiatric care was delivered the same as if in person. All youth, as well as
parent/guardians, agreed to participate in tele-psychiatry.
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 and procedures. The plan was signed on
December 7, 2024, and is reviewed annually by the superintendent and the designated mental
health clinician authority (DMHCA). The plan was reviewed and included identification and
assessment of youth at risk of suicide, staff training, suicide precautions, levels of supervision,
referral, communication, notification, documentation, immediate staff response, and the review
process as referenced. The plan also includes a review process for every serious suicide
attempt or serious self-inflicted injury which included all 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 mental health and substance abuse records were reviewed for suicide prevention
services. Six of the seven youth were applicable for review. Two of the youth arrived at the
detention center on precautionary observation (PO) and four youth were placed on PO when
they arrived at the center due to prior suicide alerts in the Department’s Juvenile Justice
Information System (JJIS). All six youth received an Assessment of Suicide Risk (ASR) on the
Department’s required form within twenty-four hours. All six ASRs were completed by a licensed
mental health professional and all included recommendations for supervision and follow-up.
Suicide precaution logs were provided for review and were completed correctly for the entire
time the youth were on PO. A qualified mental health professional was involved in the suicide
prevention practice for all six youth. The staff consulted with the designated mental health
clinician authority (DMHCA) and the superintendent immediately of the suicide risk. None of the
youth required a Follow-Up ASR as they were stepped down to standard supervision once the
initial ASR was completed. There was documentation on each of the six ASRs a conference
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was held with the superintendent or designee and the DMHCA to reduce the level of
supervision. A review of documentation revealed the center followed the correct process based
upon the suicide prevention plan. The youth were on PO during their intake process and while
they were in the presence of a mental health professional, therefore, their supervision status
was not required to be documented in the center logbook. A review of JJIS determined the
youth alerts were appropriately entered and closed for each youth. The designated mental
health clinician authority (DMHCA) indicated the mental health professionals and/or the staff on
internships complete the suicide risk screenings. The screening instruments include
Assessment of Suicide Risk (ASR), Suicide Risk Screening Instrument, and the Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2). All mental health referrals are
responded to within twenty-four hours. The DMHCA is available and on-call twenty-four hours a
day, seven days a week. For any youth who appear to be at-risk for suicide, the mental health
staff are notified immediately. If after hours, the DMHCA is notified, and a mental health referral
is completed by the Department staff or medical staff. The youth is to be placed on PO until
mental health staff can evaluate and assist with diminishing further harm. The mental health
staff communicates with security staff in person or through telephone calls and it is documented
on the ASR and in the master control logbook.
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
Seven youth mental health and substance abuse records were reviewed for secure observation
documentation. One youth was applicable for review. Additional files were requested for review.
The center had one additional record. Both youth records included documentation each
placement in secured observation was authorized by the superintendent and the designated
mental health clinician authority (DMHCA). The secure room was designated in writing for each
youth and the Health Status Checklist was completed prior to the youth being placed in the
secure observation room. The Suicide Precaution Observation Log forms were completed in
their entirety. A Follow-Up Assessment of Suicide Risk (ASR) was completed for each youth
within eight hours of placement and the parents/guardians were notified for each youth as
documented on the Follow-Up ASRs. Both assigned juvenile probation officers (JPOs) were
notified of the placements in secure observation. One youth remained on secure observation
more than twenty-four hours. Documentation revealed a mental health professional provided
written support for continuation. The mental health staff provided supportive counseling services
during both secured observations, and this was documented on the observation log. The
supervision for each youth was reduced after a conference with the superintendent and a
licensed mental health professional. Both instances of discontinuation of secured observation
being stepped down to close supervision was documented in the center’s logbook and in each
of the youth records.
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3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Seven youth mental health and substance abuse records were reviewed for documentation of
the suicide precaution observation logs. Six of the seven youth were applicable for review. All
six youth records included documentation the Suicide Precaution Logs were maintained for the
duration the youth was on suicide precaution. The appropriate level of supervision and
observations of behavior was documented in real time and not exceeding thirty-minute intervals.
No warning signs were observed for the youth. The logs were reviewed and signed by each shift
supervisor and the mental health clinical staff and documented safe housing requirements. Two
video observations were completed for precautionary observation supervision. Both youth were
on intake at the time they were on precautionary observation and proper supervision was
maintained for both youth.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Seven staff records were reviewed for both pre-service and in-service training. All staff
completed the required suicide prevention training. Suicide prevention training included suicide
drills held no less than quarterly on each shift. The detention center has four suicide kits co-
located with first-aid kits in each youth dorm and one in master control. Mock suicide drill
documentation was reviewed for the annual compliance review period. The drills were
completed no less than quarterly on each shift for staff who encounter the youth. All drills were
simulated mock mental health drills and in response to suicide attempts and/or incidents of
serious self-injury. No youth were used during the mock suicide drills. The drills included
practicing emergency response procedures at least semi-annually and included
cardiopulmonary resuscitation (CPR). Staff who are not able to participate in the drills have the
opportunity to review each drill scenario and procedures in an effort to understand the process
and receive the necessary training to respond to an incident of a suicide attempt or incident of
serious self-inflicted injury in the facility. Seven staff were interviewed regarding the process
when a youth expresses suicidal thoughts. All seven staff reported they notify the designated
mental health clinician authority (DMHCA). Four staff reported they maintain documentation of
supervision and three staff reported maintaining the youth on constant sight and sound
supervision. Staff reported they are to log in the logbook, notify a supervisor, complete a
referral, talk with the youth, place the youth on precautionary observation, and remove the youth
from their room. The staff were also interviewed on where the suicide kits are in the detention
center. Six staff reported there is one in master control, five staff reported there is one located in
medical, and six reported there are suicide kits on each living module in the secured closet.
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3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a combined written Emergency Services Plan which was provided for review.
The plan included the notification and alert system, means of referral, including self-referral,
communication, supervision, and documentation review.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center maintains a written Emergency Care Plan which was provided for review. The plan
included immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services; Baker Acts and Marchman
Acts, documentation, training, and review. The plan was last approved on December 7, 2024.
The plan is located in the facility operating procedures and is accessible to staff.
3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center did not have any youth applicable for Crisis Assessments during the annual
compliance review period. The center maintains a written facility operating procedures which
include a Crisis Intervention Service and Emergency Care Plan. The plan includes when to
complete a Crisis Assessment and the steps for follow-up.
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3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth mental health and substance abuse records were reviewed for Baker and/or
Marchman Acts. None of the selected youth were applicable for the review of Baker Act
procedures. The center provided three additional records for review. All three youth had an
open suicide risk alert pending off-site transportation. All three youth were placed on one-to-one
supervision, and this was documented on Precautionary Observation (PO) Logs. All three youth
were placed back on PO upon re-admission to the detention center from the Baker Acts.
Documentation revealed a mental health referral was completed for each youth to have a
Mental Status Examination (MSE) completed. All MSEs were completed by a licensed mental
health professional and all three youth were maintained on a minimum of constant supervision
until being transferred to a lower level of supervision once an Assessment of Suicide Risk (ASR)
was completed. All three youth had a Suicide Risk Alert in the Department’s Juvenile Justice
Information System (JJIS), which was discontinued when deemed appropriate.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center’s designated health authority (DHA) is a board-certified physician and a licensed
medical doctor (MD) specializing in internal medicine. The DHA license is unrestricted and
meets all requirements for independent and unsupervised practice in the state of Florida, which
expires on January 31, 2026. The center utilizes an advanced practice registered nurse (APRN)
who has a collaborative practice protocol in place, signed by the DHA and APRN. The APRN’s
license expires on April 20, 2026. The center does not utilize a physician assistant (PA) or had a
need to utilize a backup DHA during the annual compliance review period. A review of sign-in
and sign-out logs indicated the DHA was on-site once each week with no more than nine days
in between on-site visits. No tele-medicine was used during the annual compliance review
period. An interview with the DHA revealed the DHA's role is performing Comprehensive
Physical Assessments, conducting periodic evaluations, sick calls, and policy and procedure
development. The DHA is on-site once a week. The DHA communicates with program staff by
telephone and on weekly visits. The DHA is available by telephone when not on-site. All off-site
care findings, instructions, and information is reviewed during weekly visits. Healthcare staff
contact the DHA by telephone with urgent medical issues and meet weekly during visits.
Periodic chronic medical conditions are completed every ninety days. APRN coverage is
scheduled when youth are on vacation or during scheduled absences. There are no concerns
with the healthcare at this center.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center utilizes facility operating procedures (FOPs) for all health-related procedures and
protocols. During the annual compliance review period, it was found the designated health
authority (DHA) signed the FOPs August 7, 2024, the superintendent signed on August 2, 2024,
and the psychiatrist signed on May 7, 2024.No new policies or changes had been made during
the annual compliance review period. FOPs and nursing protocols were reviewed annually as
required and signed on February 22, 2024. Two new employed healthcare personnel received a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
which was conducted by a registered nurse (RN). Nursing staff reviewed, signed, and dated a
cover page between the dates of February 22, 2024, and November 11, 2024, of all medical
FOPs, treatment protocols, and other procedures. The advanced practice registered nurse
(APRN) did not sign and date the cover page to indicate their review of the FOPs.
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for Authority for Evaluation
and Treatment (AET) requirements. Six of the seven IHCRs included an AET form signed by the
youth and parent/legal guardian. The remaining IHCR included a Limited Consent for Evaluation
and Treatment signed by the superintendent with an Affidavit of Diligent Effort attached. Each
applicable AET was signed by a Department representative. Six of the seven AETs were valid
and were obtained prior to the provision of medical services. The one remaining AET was not
valid, and a court order authorizing physical and mental health care for committed youth was
signed December 11, 2024. There were no youth reviewed over the age of eighteen or under
the care of the Department of Children and Families (DCF) where there had been a termination
of parental/guardian rights. An interview with nursing staff revealed the staff are knowledgeable
in policies and procedures relating to obtaining AETs and gaining consent for youth who are
eighteen and 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/guardian
notification/consent requirements. Three out of seven youth were found to have
parental/guardian notification for over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET). All three youth IHCRs included
documentation of consent provided by the parent/guardian. All three youth IHCRs included
written notification sent utilizing the Department’s Parental Notification of Health-Related Care
form. Two of the seven youth were taking psychotropic medications on admission. The
psychotropic medications were continued, and no parental/guardian notifications were required.
Three of the seven youth received new medication and parent/guardian notifications were
documented in progress notes. Written notification was sent for all three of these youth and a
review of progress notes confirmed an attempt to obtain the parent’s/guardian’s signature. One
youth was prescribed new psychotropic medication and parental/guardian verbal consent for
psychotropic medication was documented on the Clinical Psychotropic Progress Note (CPPN)
and written parental/guardian notice was sent. One of seven youth had an attempt of
parental/guardian notification to change a youth’s psychotropic dosage, however, the
parent/guardian could not be reached; therefore, the dosage remained the same. There were no
youth reviewed under the care of the Department of Children and Families (DCF) where there
had been a termination of parental/guardian rights. Three of seven youth vaccines were verified
within thirty days of the youth’s admission with no additional vaccines needed. The four
remaining youth had vaccines verified within the year on previous admissions with no additional
vaccines needed. There were no youth applicable for Religious Exemption from Immunization.
An interview with nursing staff revealed the staff are knowledgeable in the facility operating
procedures relating to when it is required to notify the youth’s parent/guardian, including consent
for psychotropic medication, the required time frames, emergency medical services, and
vaccinations/immunizations.
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4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for healthcare admission
screenings requirements. All seven youth received a medical and mental health admission
screening completed on the Department’s Facility Entry Physical Health Screening form on the
date of admission by the juvenile justice detention officer (JJDO) with the screening reviewed
with the youth by a licensed nurse within twenty-four hours. Notification was made to the
designated health authority (DHA) for all seven youth and documented in each youth’s IHCR.
None of the reviewed youth changed physical custody since admission to the center. Three
youth were applicable to receive a qualitative urine pregnancy screening test. Two of the three
youth received the qualitative urine pregnancy screening test; however, there was no
documentation of verbal or written consent obtained. Only implied consent was obtained when
the youth voluntarily took the qualitative urine pregnancy screening test. The remaining youth
declined testing and the refusal form was in the youth’s IHCR.
An interview with nursing staff revealed newly admitted youth are generally seen within twelve
hours and always within twenty-four hours. Detention staff provide and complete medical and
mental health screening forms whenever there is a new admission; additionally, the Alpha
Roster is monitored by clinic staff for new youth. If the admission screening is completed by
direct care staff, the nurse will review documentation and follow up with their signature. If the
youth are being detained at the facility for less than twenty-four hours, at a minimum, vital signs
are taken, and the youth is questioned concerning medical needs, chronic conditions,
medications, and any medical complaints. This is followed by contact with the parent/guardian
to verify the information provided by the youth. Depending on the prior facility the youth was
transferred from, there may be a complete intake completed with an event added to the HRH.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for youth orientation to
healthcare services and health education. The center’s facility operating procedures (FOPs)
included access to medical care, sick call access, what constitutes an emergency and when to
notify staff, medication process to include side effect monitoring, the right to refuse care and
how it is documented, what to do in the case of a sexual assault or attempted sexual assault,
the non-disciplinary role of the healthcare provider, and the review of the list of healthcare
contacts to ensure accuracy. All seven youth received a general healthcare orientation within
twenty-four hours of admission and were documented on the Health Education form.
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4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for notification requirements
to the designated health authority (DHA). Four of the seven youth were admitted with known or
suspected chronic conditions, in which a referral was made to the DHA within twelve hours. No
youth were identified as in-need of emergency care upon admission. The notification to the DHA
of all four youth were documented in the youth’s ICHR in the chronological progress notes. Two
of the seven youth were taking psychotropic medications upon admission. The psychiatrist was
also notified within twelve hours of admission for both youth and the notification was
documented in the chronological progress notes section in each youth’s IHCR. An interview with
nursing staff revealed they are knowledgeable in the facility operating procedures (FOPs)
relating to who is responsible, time frames, and documentation for notifying the DHA for youth
admitted with chronic conditions.
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 completion of the Health
Related History (HRH) form. Each youth’s HRH form was updated or completed within seven
calendar days of admission. All seven HRH forms were completed prior to the Comprehensive
Physical Assessment (CPA) or focused evaluation by evidence of a signature and date by a
licensed nurse. The designated health authority (DHA) or advanced practice registered nurse
(APRN) reviewed each HRH, by documenting the review on the HRH form with a date and
signature. All seven HRH forms confirmed signatures and dates for the most current admission.
An interview with nursing staff revealed the HRH shall be completed no later than seven
calendar days following the date of admission and prior to the youth being subjected to extreme
outdoor weather conditions including, but not limited to, high heat indexes and frigid
temperatures.
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 completion of a
Comprehensive Physical Assessment (CPA). All seven youth’s CPAs were completed on the
Department’s CPA form. Four of seven youth had a current CPA on file at admission. There
were no changes in the youth’s medical condition; therefore, each CPA was utilized. All four
CPAs had a focused evaluation completed and were reviewed and signed by the medical doctor
or advanced practice registered nurse (APRN). The remaining three youth had a CPA
completed within seven calendar days. All seven CPAs had a Medical Grade documented and
were completed by the MD or APRN. A review of the CPAs indicated there were no missing or
incomplete elements. All CPAs had sections marked with an “O” or “X” as required. Six of the
seven youth refused part of the exam and the clinician wrote “youth refused” or a similar term.
The refusal forms were found in each of the six IHCRs. The remaining youth’s exam was
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clinically indicated as no concerns; therefore, a refusal was not necessary. The Department’s
Problem List was updated for all seven youth. Six of the seven youth had at least one verified
Tuberculosis Skin Test (TST) documented in the IHCR within the last year. The remaining youth
refused the TST and had a chest x-ray completed within the last year. The results of the TST
documented on the CPA and Infectious and Communicable Disease (ICD) forms matched as
required. All seven youth had the Tier I tuberculosis screening completed within seventy-two
hours and no further evaluation was needed in each case. A review of the center’s facility
operating procedures (FOPs) included policies and procedures on the appropriate
documentation of when any part of the exam is not conducted and/or refused by the youth and
the tuberculosis screening and rescreening process. An interview with nursing staff revealed the
DHA completes a new CPA within seven calendar days of admission. The CPA is current if
performed within the last two years. The center requests the provider complete a new CPA after
one year from the previous new CPA. All youth are required to be screened for tuberculosis and
accurate documentation of results will be maintained by the facility. There will be at least one
verified TST documented in the IHCR in accordance with the Center for Disease Control and
Prevention guidelines. For female youth, gynecological exams are not routinely completed.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. Four out of
seven youth stated they were sexually active and were screened for STIs. Two of the seven
youth records did not indicate whether further evaluation was required or not. Four of the
remaining five required further evaluation; however, two did not have a referral completed for
STI testing. The two youth who had a referral for STI testing refused, and a refusal form was
signed and documented in each youth’s IHCR. None of the seven youth received a
gynecological exam or were ever out of the Department’s physical custody. All seven youth
were offered counseling and testing for HIV. Two of the seven youth received HIV testing and a
consent form was obtained and documented in each youth’s IHCR. The HIV test results were
filed confidentiality in a sealed envelope marked “CONFIDENTIAL” with the practitioner’s
signature documented on the sealed envelope. Pre-test and post-test counseling was
documented on the Individual Health Education Record in each youth’s IHCR. The youth’s
confidentiality was protected by not including the youth’s HIV status or any other STI diagnosis
on the program’s internal alert system as required.
Seven youth were interviewed. All seven-youth indicated they could ask for a HIV test. An
interview with nursing staff revealed youth are screened for STIs by referrals accomplished
using the Department’s most current STI form. If a screening indicates a need for further
evaluation the youth will be referred to the DHA or ARPN to determine if further testing is
needed within seven days. The results of STI tests will be noted on the Infectious and
Communicable Disease (ICD) form and the lab results will be in the IHCR behind the
corresponding tab. Documentation of treatment will also be noted on the ICD form within the
IHCR. Laboratory results should be marked confidential and filed in the IHCR until provided to
the youth at the time of discharge. If HIV testing is performed off-site, the procedures related to
consent should be ensured by the provider. This person may choose to retain the original
consent form in which case a copy of the consent should be provided to the center for the IHCR.
When HIV testing is performed on-site, a signed consent form specific to HIV testing must be
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obtained. The center will offer each youth HIV counseling and subsequent testing when
indicated or requested by youth. A certified HIV counselor must conduct the HIV counseling.
The center will collaborate with the local county health department or other community
providers.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sick call process
requirements. None of the youth were found applicable for having a sick call. Three additional
records were requested, and one was provided. The youth had all sick calls documented on the
Sick Call Referral Log. The youth did not present with a similar sick call complaint three or more
times within a two-week period; therefore, no referral was needed to the designated health
authority (DHA). The youth were not applicable for severe pain which required an emergency or
immediate referral. The youth completed a sick call on the Sick Call Request form and the
nursing staff completed the Sick Call Request form. None of the youths’ sick calls were
conducted by a licensed practical nurse (LPN). The youths’ sick calls were filed in the youth’s
IHCRs in reverse chronological order. The reviewed youth were not in restricted housing during
sick call hours. The youth’s sick call forms were documented in accordance with Florida
Administrative Code. The youth’s sick calls were documented on the Sick Call Index inside the
IHCR with the dates listed on the sick call forms matching the dates of the sick call index. A
review of the posted schedule in the medical clinic area indicated sick call hours are Monday
through Friday 9:00 a.m. to 10:00 a.m. and 3:30 p.m. to 4:30 p.m. On Saturday and Sunday sick
call hours are 2:00 p.m. to 3:00 p.m., or as needed. There are approved treatment protocols for
the registered nursing staff to utilize. Only licensed nurses complete sick calls. When there is
not a licensed nurse on-site, the center has procedures whereby the shift supervisor reviews all
the sick call request as soon as possible, within four hours after the request is submitted and
notifies the DHA. There were no examples of youth in confinement requesting sick calls;
therefore, a review of the center’s policy was completed. The center’s written policy and
procedures indicate youth in restricted housing shall be afforded access to healthcare at equal
or greater intervals of youth who are in regular housing. A sick call was unable to be observed
during the annual compliance review week, as no youth requested a sick call while on-site.
Seven youth were interviewed. Three out of seven interviewed youth stated they were seen
immediately upon submitting a sick call request and the remaining four stated they were seen
within one day. Six youth reported sick call is conducted by the nurse, four youth stated staff,
and one youth reported it could be anybody. Seven staff were interviewed. All seven staff
reported the nurse reviews sick calls. All seven staff reported the nurse conducts sick calls. Two
staff reported the doctor conducts sick calls. An interview with nursing staff revealed the center
will conduct sick call seven days a week. The scheduling of sick call does not preclude the
nursing staff from addressing issues which youth present as they arise. If these complaints are
determined to be of a non-urgent nature, they can be deferred until the following scheduled sick
call. The nursing staff will identify sick calls placed into the Department’s Electronic Medical
Record (EMR) by reviewing the sick call referral log. The sick calls will be triaged and screened
for urgency; emergency conditions are not inappropriately delayed for the next regularly
scheduled sick call session. Only a licensed nurse may conduct sick call. Neither certified
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nursing assistants (CNAs) nor center staff may perform a version of the sick call process. The
DHA conducts sick call if scheduled on-site. Sick call is conducted at the center clinic. Youth
presenting with similar sick call complaints three or more times within a two-week period require
a referral to the DHA, advanced practice registered nurse (APRN), or physician assistant (PA).
The DHA has approved treatment protocols for the center. For youth in restricted housing of any
kind, the supervisor on each shift will question the youth about medical related issues and
document such questioning on the shift report daily. If the youth have an issue which is non-
emergent, the shift supervisor will input the Sick Call Request form into the EMR or take the
youth to the nursing staff if available.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for episodic/first-
aid/emergency care requirements. All seven youth required on-site first-aid or episodic care.
Each youth received episodic or first-aid care by a licensed healthcare staff which was
documented in the subjective, objective, assessment, and plan (SOAP) format. None of the
youth received episodic or first-aid care by a non-healthcare staff. All seven youth complaints
were documented with findings of the person rendering care to include received treatment. One
youth required a referral for off-site care. All seven youth records had education/instruction to
youth documented and plans for follow-up/future care documented. None of the youth required
an alert update. Parental/guardian notification was made for one youth and attempted
parental/guardian notification was attempted for two youth. The remaining four youth did not
have parental/guardian notification documented. All seven youth’s episodic/first-aid care was
documented on the Episodic/First-Aid Care Log. None of the youth required a plan for follow-up
care.
The center has a total of sixteen first-aid kits located throughout program areas, and accessible
to staff in the event of an emergency. The locations of the first-aid kits are one in master control,
one in the administration office, one in maintenance, one in the multipurpose room, one in the
medical office, two in the large classroom, one in the small classroom, one in B1 module, one in
B2 module, one in G1 module, one in the pre-shift room, one in the kitchen, and six are used for
transportation vehicles. Two kits were opened and examined. Both had contents within their
date of expiration. The center has a total of two automated external defibrillator (AED) units with
one located in the medical office and the other in the administration office. Both are inspected
monthly by medical staff and a log is kept documenting any findings or discrepancies fixed with
dates the pads and batteries were changed. The AED procedures are located with each AED.
The batteries and pads of the devices were observed within their date of expiration. A licensed
medical staff was observed performing an inspection and self-test of the AED during the annual
compliance review week. The device was operating as required. The batteries last received an
inspection November 27, 2023. The AED pads on both devices expire on July 28, 2028, and the
batteries on both devices expire on February 14, 2027.
A review of emergency drills revealed they were conducted every month on every shift except
for third shift in April 2024. Each drill simulated an episodic care event which called for
immediate first-aid, AED, and/or administration of cardiopulmonary resuscitation (CPR)
techniques and the initiation of the emergency procedures to follow when a life-threatening
emergency does occur. The center maintains documentation of all emergency drills conducted.
An effort was made by the center to ensure, at a minimum, all staff with direct contact on a day-
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to-day basis could participate in at least one emergency “man-down” drill annually. A list of
emergency numbers was found accessible to licensed and unlicensed staff which included the
number to Poison Information Center. The numbers were in master control and not accessible
to any youth. All authorized direct care staff were appropriately trained by a registered nurse on
the administration of an epinephrine auto-injector. Seven staff records were reviewed which
showed training requirements were met regarding episodic care, first-aid, and emergency care.
The policy on the use, access, and inventory of NARCAN states the center must stock and
inventory of NARCAN for emergency treatment of a known or suspected opioid overdose. The
center stores NARCAN in the medical office which is accessible to medical staff and non-
healthcare supervisory staff. All staff are trained on when and how to use NARCAN; however,
only sergeants and above have access. NARCAN is inventoried by a licensed nurse weekly and
logs are kept in a binder.
Seven youth were interviewed. Five youth rated the medical care at the center good and the
remaining two youth reported the medical care at the center was very good. Seven staff were
interviewed. All seven staff reported they feel comfortable with calling 9-1-1 if it is necessary. An
interview with nursing staff revealed they knew the location of the first-aid kits and AEDs and
are knowledgeable in the center’s facility operating procedures (FOPs) regarding off-site
episodic care, non-healthcare staff providing first-aid or emergency care, and documentation
and tracking of treatment. Nursing staff knew the FOPs for emergency drills and stated drills are
held at least once each quarter or once each shift, every year. A list of emergency telephone
numbers, including the number of the statewide Poison Information Center is posted in the
clinic.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion requirements
concerning off-site care/referrals. Three out of seven youth required off-site care in which the
Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR and was
also documented on the Episodic Care Log. Two of the three youth had parental/guardian
notifications made and documented in the IHCR. The remaining youth did not have
parental/guardian notification efforts documented. All three youth had discharge documents filed
in the IHCRs and the designated health authority (DHA) reviewed the discharge instructions,
findings, and care rendered within seven days from the incidents by evidence of signature and
date. All three youth received non-emergent off-site care. None of the three youth receiving off-
site care required follow-up testing, referrals, or appointments.
An interview with nursing staff revealed following off-site care, youth are added to the providers
log to be evaluated following the care. The Summary of Off-Site Care form shall accompany the
youth to the off-site provider, to be completed and returned to the center for filing in the youth’s
record and uploaded into the Department’s Electronic Medical Record (EMR). Upon the youth’s
return, the documents sent back to the center must be reviewed to ascertain if there are orders
for referrals, lab work, exercise restrictions, alerts, or follow-up appointments. Referrals must be
entered on the centers tracking log. Pertinent information about the referral must be
documented within the progress note. The DHA or advanced practice registered nurse (APRN)
shall initial all orders/information sent back with the youth to the facility. Following off-site care,
the youth’s name, along with records of the visit, are added to the providers log to be evaluated
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following the care. The monthly logbook tracks lab work. The clinic manager maintains a
calendar of appointments. Referrals are completed through orders from the on-site provider.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for chronic
conditions/periodic evaluation requirements. Three youth were identified on the Medical/Mental
Health Screening forms for having a chronic condition. None of the seven reviewed youth had a
communicable disease. None of the seven youth were taking prescribed medication on an on-
going basis. One youth was undergoing treatment for a physical health condition. Three of the
seven youth were classified with a Medical Grade between two and four. None of the seven
youth were identified as pregnant. All three youth were placed on the chronic conditions list as
required. None of the youth have been at the center long enough to receive a ninety-day
periodic evaluation. None of the youth were identified as taking anti-tuberculosis medication.
None of the youth required an evaluation for off-site care. The Department’s Problem List was
updated in accordance with Florida Administrative Code for the three applicable youth. The
center utilizes the Chronic Physical Health Conditions Roster to track periodic evaluations. An
interview with the designated health authority (DHA) revealed periodic evaluations are done
every ninety days. The nurse utilizes a tracking system to ensure periodic evaluations are
conducted every ninety days. An interview with nursing staff revealed the center monitors youth
with chronic conditions by using the chronic conditions log.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication management
requirements. Two of the seven youth were applicable for taking medication at admission. An
additional record was requested; however, none were applicable during the annual compliance
review period. Both youth taking medication at admission had medication verified prior to being
admitted into the center. Prescription verifications for both youth were completed utilizing the
Prescription Medication Verification Checklist form. The physician and psychiatrist were notified
and an order to continue the medications was completed. Both youth entered on psychotropic
medications, the psychiatrist was notified within twelve hours of admission, and an order was
obtained to continue the current prescribed medication documented on a practitioner order form.
One additional youth had new orders for psychotropic medications after admission. The three
psychotropic prescription verifications were noted in the progress notes, IHCR, and Electronic
Medical Record (EMR). None of the seven reviewed youth were in restricted housing during
medication administration hours. Three of the seven youth were given over-the-counter (OTC)
medications which were not listed on the Authority for Evaluation and Treatment (AET) form.
Each of the seven records contained a standard Department Medication Administration Record
(MAR) in the EMR. All seven of the youth’s MARs clearly indicated medication start and stop
dates. Five of the seven youth received medication by a trained non-healthcare staff after hours
when a licensed staff was not on-site. All five had youth and staff documentation when
medications were delivered. No lapses or errors in medication administration were noted. Side
effect monitoring and documentation were noted on all seven youth MARS. Two youth refused
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medication and it was clearly documented on the MAR when applicable and both youth signed
the Refusal of Treatment form indicating the refusal. Each of the seven youth’s MARs contained
all required elements to include the youth’s name, department identification number, date of
birth, youth allergies, precautions, Medical Grade, medical alerts, and current picture of the
youth attached. All seven MARs documented medical staff assisted in medication administration
and each instance was found to have the staff initials and youth’s initials for each medication
given except for one youth on one day. None of the seven youth required parenteral medication.
Two of the seven youth entered on psychotropic medications, and for each youth, the
psychiatrist conducted an initial diagnostic psychiatric interview with the youth within fourteen
days of admission. Both youth received medication monitoring by the psychiatrist every thirty
days, as required. The center’s medical department reported there are no standing orders or
emergency treatment orders for psychotropic medications.
A medication pass was observed. Medication administration was completed by the licensed
medical staff. Youth were escorted to medical by the superintendent. The youth approached the
nurse station individually. The medical provider identified themself and prepared the
medications for each youth as prescribed. The allergy and alert status were verified on the
MAR. Each youth initialed for their medication after receiving it and the nurse indicated they had
given the medication by initialing. A mouth check was completed to ensure the youth had
swallowed the medication. There were no pre-poured medications placed in another container
for subsequent administration. The nurse stated non-healthcare staff can administer medication
if they are trained. A training log with names of staff trained in medication administration is kept
in a binder in the medical clinic area.
Seven youth were interviewed. Four youth reported receiving medication from a nurse, one
youth additionally reported staff, and the remaining three youth reported not taking medications.
Seven staff were interviewed. All seven staff reported never administering medication to youth.
An interview with nursing staff revealed they are knowledgeable regarding verifying youth
medication and all medication procedures.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
An observation of medical equipment classified as sharps confirmed they were secured and
inventoried utilizing a routine perpetual inventory descending count as each sharp was utilized
and disposed. All medications were identified and secured in the locked area designated for
storage of medications. The medication cart was clean and organized with stock items separate
from youth-specific medications. All controlled substances have a perpetual inventory and are
stored separately from other medications. All medications were stored in a separate, secured
area, inaccessible to youth. All narcotics and other controlled medications were stored behind
two locks. There were no injectable or topical medications on-site. Medications required
refrigeration were found inside a secured refrigerator labeled “Medication Only”. There were
perpetual and weekly inventories conducted of all sharps and stock over-the-counter (OTC)
medications as required. All non-healthcare supervisory staff are trained in the delivery and
oversight of medication. The training was delivered by a registered nurse as required. Three
controlled medications samples were reviewed with no discrepancies and counts matched
ending counts. Three OTC medication samples were reviewed with no discrepancies and the
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counts matched ending counts. Perpetual weekly inventories of all sharps and OTC medications
were observed. Observations of inventories confirmed the center’s medical staff conduct
inventories of medications and sharps as required. The procedure for reporting inventory
discrepancies states any medication inventory discrepancy shall require notification to the
superintendent and the Department’s Central Communications Center (CCC).
Medical staff are responsible for all disposal of medications, along with the pharmacy
consultant. Each disposal will be inventoried prior to destruction, with the pharmacy consultant
present. Destruction of medication is completed utilizing the RX drug buster. Any unused
medications are sent back to pharmacy and logged in the logbook. An interview with nursing
staff revealed the center’s controlled substances will be double locked, with daily perpetual
inventories and running balances maintained. The facility has a current agreement with a
pharmacist to come on-site monthly. The facility 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 requirements. Six of the seven reviewed youth received
infection control training on admission to include hand-washing techniques, universal/standard
precautions, prevention/transmission of communicable disease, vaccinations, and the Center for
Disease Control (CDC) guidelines for infection control. The remaining youth had all training with
the exception of infection control training upon admission and hand-washing techniques. The
Exposure Control Plan was written in accordance with Occupational Safety and Health
administration (OSHA) standards and included a risk assessment listing job classifications in
which staff have the potential for occupational exposure, including tasks and procedures which
would cause staff in specific job classifications to have an occupational exposure. A method of
compliance outlining infection control practices and engineering and work practice controls was
also found in the plan. Infection control procedures in place included prevention, containment,
treatment, and reporting requirements related to infectious diseases, according to OSHA, the
Centers for Disease Control and Prevention guidelines. Infection control procedures included all
required elements such as for common infectious diseases of childhood, the common cold, viral
or bacterial infections, tuberculosis, Hepatitis A, B, or C, human immunodeficiency virus (HIV),
other outbreaks or epidemics caused by any other infectious agent, pediculosis and or scabies,
food-borne illnesses, chemical exposure, bio-terrorist agents, and Methicillin-Resistant
Staphylococcus Aureus (MRSA). The facility operating procedures (FOPs) containing the
inflection control plan include processes for needle stick post-exposure evaluation. Hepatitis B
immunizations are made available for staff by referral and are not provided on-site. All staff have
access to protective equipment. The registered nurse stated there have been no instances in
which infectious diseases and sexually transmitted infections needed to be reported to the local
health department as required or the Department’s Central Communications Center (CCC).
There were not three or more cases of reportable infectious diseases which needed to be
reported to the local health department and/or CDC. There were also no hospitalizations or
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quarantining of at least ten percent of the total population for youth or staff. The superintendent
maintains a separate confidential record containing all documents for youth and staff who have
experienced facility/occupational exposure for a ten-year period as required. Seven staff training
records were reviewed. All seven staff received pre-service or in-service training on the center’s
specific Exposure Control Plan by the clinic manager as noted in the nursing interview results
and found in the staff’s training records.
An interview with nursing staff revealed a copy of the Exposure Control Plan is available to all
staff. The infection control training for staff is conducted by the registered nurse (RN). Youth are
trained on infection control by the RN on admission and as needed. The RN is responsible for
providing training to staff on the center’s Exposure Control Plan. The center maintains a
contract with a local clinic for prenatal care.
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 requirements. None of the youth were found applicable for having prenatal care.
Three additional records were requested, and one was provided to being applicable for the
annual compliance review period. The youth received prenatal care immediately upon
determination the youth was pregnant at admission. The youth received routine, focused
medical evaluations every thirty days or sooner, if ordered. Prenatal care was provided at
recommended intervals. The youth was placed on an internal alert system for vital nutrition and
health awareness for staff along with an alert in the Department’s Juvenile Justice Information
System (JJIS). The youth had focused medical evaluations at least every thirty days as
required. The youth complained of issues related to pregnancy and the designated health
authority (DHA) was notified immediately. The youth was not applicable for daily monitoring
related to danger signs of pregnancy complications. There was no plan documented for post-
birth psychological and physical care. Education for the youth was found in the youth’s IHCR
under the education tab to include alcohol and drug use, smoking, nutrition, sexually transmitted
infections, contraception, prenatal care, birthing process, postpartum care, basic baby care,
child/infant development, and parenting skills which was conducted by a licensed staff. The
youth received nutritious food and appropriate servings as ordered by the DHA. The youth
received routine monitoring for nutrition and weight status. A review of in-service training
revealed education on youth’s prenatal healthcare was conducted annually to all non-healthcare
staff involved in the supervision or treatment of youth. Additional training included observation
and monitoring of emergency care needs/symptoms of possible miscarriage. The center has
nursing protocols and treatment plans for pregnant youth.
Seven youth were interviewed and only three were applicable. All three youth reported never
needing to receive prenatal, obstetrical, or gynecological services. An interview with nursing
staff revealed prenatal care shall be provided by an obstetrician and/or perinatologist once it is
determined the youth is pregnant. The DHA shall collaborate with the obstetrician and/or
perinatologist in the oversight and management of the youth’s pregnancy. Each female youth
shall be screened for pregnancy at the time of admission in the center. This screening shall
include any history of pre-existing medical conditions, medication therapy, alcohol use, and
substance abuse. The DHA shall be notified and provided with screening information within
twelve hours of determining a newly admitted youth is pregnant. The DHA or advanced practice
registered nurse (APRN) shall provide a routine, focused medical oversight evaluation of the
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youth’s pregnancy every thirty days. The licensed health care professional staff shall provide
routine monitoring of the pregnant youth’s nutritional and weight status during the course of
pregnancy. The registered nurse (RN) provides non-licensed healthcare staff education on girls'
healthcare. Each pregnant adolescent should be provided prenatal, postpartum, and parenting
education which includes the topics directly related to healthcare issues and medical risk for
pregnant adolescents/teens.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
Visual observations were completed each day of the annual compliance review week to
determine the level of active supervision of youth. Each day of observations substantiated youth
were always being supervised. Youth were observed during line movements to and from
education class as well as during breaks and meals. Visual observations confirmed the center’s
adherence to the activity schedule. Observations yielded positive interactions with staff and
youth, youth were always in in sight and sound of officers, youth were accounted for and always
accompanied by staff, and master control authorized all movements prior to youth being moved.
A review of three full days of therapeutic groups was conducted with no issues observed. An
interview with seven staff was conducted. Five of seven staff reported they believe there are
enough staff to provide for safety and security of youth and staff. The remaining two staff
reported they do not believe there are enough staff to provide for the safety and security of
youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center maintains a policy and procedures addressing the behavior management system
(BMS) and the unauthorized use of punishment. Visual observations confirmed the center has
the BMS posted throughout the facility within each living unit. The BMS clearly specifies
appropriate and inappropriate behaviors, rules, norms, and expectations. The BMS includes
rewards for positive behaviors and consequences for inappropriate behavior. Visual
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observations of daily activities did confirm the implementation of the center’s BMS. The center
was following the components outlined in the policy and procedures based on observation and
review of the facility operating procedures (FOPs). Documentation review confirmed the center
provides positive rewards to youth, and rewards and consequences are given in accordance
with the BMS. There were no instances observed during the annual compliance review week or
any documented occasions which indicated any inappropriate use of restrictions or group
punishment.
Seven staff were interviewed, and each was able to explain the center’s BMS. Six of seven staff
were able to identify the types of rewards the center provides as part of the BMS. Staff reported
examples such as canteen items, snacks, extra telephone calls, level 3 kick back, and the ability
to stay up later during weekends. The remaining staff reported not being sure as they are not
present during rewards time. All seven staff reported they believe the BMS is effective. Each
staff reported staff speak with youth to discuss consequences being imposed and reported
youth are given the opportunity to explain their behaviors as well as speak with youth about
alternative acceptable behaviors. All staff were able to explain how supervisors provide
feedback regarding the implementation of the center’s BMS. Staff provided examples such as
supervisors pulling youth aside and providing feedback during staff briefings. Five of seven staff
reported receiving feedback on implementation of the BMS as needed. Three of seven staff
reported receiving feedback on the implementation of the BMS daily. All seven staff reported
points can be taken away as consequence of violations of the BMS, with additional responses
reporting youth levels can be taken away as a consequence. Each staff reported not seeing a
co-worker take meals, snacks, clothing, education, or medical care from a youth because they
were acting out, and reported they have never observed a staff encouraging youth to beat up
another youth.
Seven youth were interviewed. Three of seven youth rated the center’s BMS as very good.
Three youth rated the center’s BMS as good. The remaining youth rated the center’s BMS as
fair. Each youth was able to explain the difference between each level and how to move from
level to level. Each youth was able to verbalize how youth are rewarded in the center and
provided examples such as extra snacks, phone calls, spa day, special meals, and level parties.
Five of seven youth reported all staff use the rewards system the same. The remaining two
youth reported not all staff use rewards the same. All youth reported no youth are allowed to
punish other youth. Six youth reported they have been sent to their rooms for punishment. The
remaining youth reported never having been sent to their room for punishment. Of the six youth
who reported being sent to their room as punishment, five reported they were sent to their
rooms for purposes of confinement. The remaining youth reported being sent to their room for
timeout. Of the six youth who reported being sent to their rooms, all reported their door was shut
and locked. Five youth reported the consequences they received were fair. One youth reported
the consequence they received was not fair and the remaining youth reported never receiving
any consequences. The level system, clothing, and bedding were responses given for items
taken away as consequences. Three of seven youth reported handcuff or leg irons are not used
on out-of-control youth to prevent them from hurting themselves. The remaining four youth
reported they have never witnessed this. An interview with the superintendent was conducted.
According to the superintendent, the level system authorized by the Department's headquarters
is used within the center.
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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 a policy and procedures addressing ten-minute checks. The center
currently has a total of sixty-three cameras of which all are operational. The center’s camera
system stores footage for approximately thirty days. A sample of security footage as well as
corresponding logs for nine separate days were reviewed for ten-minute checks. Observations
confirmed all checks were conducted in the required frequency with no issues. A sample of ten-
minute check logs for each corresponding month of the annual compliance review period were
observed to verify compliance. Observations confirmed checks were conducted in the required
frequency. The center’s management provides oversight by conducting weekly management
reviews. An interview with the superintendent was conducted and the superintendent reported
staff use the hand wand and visual observation reports to track nine-to-ten-minute visuals to
ensure youth are safe and secure while in their rooms. An interview with seven staff was
conducted. All staff reported room checks are conducted every ten minutes.
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 a policy and procedures addressing census, counts and tracking. An
observation of a head count was conducted. Master control announced the formal headcount to
be conducted and all movement stopped. Each area containing youth indicated the number of
youth present. Master control announced the total number of youth present as well as
accounted for youth who were away from the center. The headcount was cleared and
movement was allowed to proceed. A review of the center’s logbooks for one full day of each
month of the annual compliance review period was conducted. The reviewed logbooks
confirmed counts, census, and tracking is conducted at the beginning of each shift, following an
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emergency, during an evacuation and emergency drills, prior to and following routine group
movement, anytime a population change occurs, and randomly at least once each shift.
An interview with seven staff was conducted. Staff were able to confirm counts are conducted at
the beginning and end of shifts as well as randomly throughout the day. If counts are incorrect,
movement is stopped, and a recount is conducted. Staff were also able to confirm emergency
counts are conducted when a youth is determined to be missing, when visibility is hindered, and
after a major disturbance.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center maintains a policy and procedures addressing logbook maintenance and reviews.
The center maintains a logbook on each living unit as well as in master control and each
transport vehicle. A review of logbooks for one full day of each month of the annual compliance
review period was conducted. One older logbook had become unbound with no missing pages.
All logbooks reviewed were numbered. Each logbook contained a documented date at the top of
the page. All logbook entries included time of events, name of staff and youth involved, a brief
description of events, and the initials of staff making entries. All entries impacting safety and
security were highlighted. There were no logbooks reviewed which contained stricken errors.
Master control logbooks included emergency situations, incidents, drills, documentation of
receipt of medical and mental health alerts, population counts at the beginning and end of each
shift, population counts throughout the shift, youth counts following emergency situations, youth
group movement, admissions and releases, no logbook reviewed had presence of law
enforcement, searches, name of youth in confinement with begin and end times, and name of
youth placed on precautionary or secure observation along with initiated and ending times. The
center’s activity schedule and logbooks did document minimal interference of education
instruction. Education classes were conducted as scheduled. Each logbook reviewed did
document youth arrival and departure time from school. Each logbook indicated logbooks were
reviewed weekly by superintendent or designee. Logbooks maintained in master control were
reviewed by juvenile justice detention officer supervisors (JJDOSs) when assuming duty.
JJDOSs or lead officers reviewed logbooks maintained in each living unit daily as well as
reviewed logbooks in their assigned living areas when accepting responsibility for the living unit.
The superintendent, assistant superintendent, or person in charge of the center toured the youth
living areas at least once during each shift and documented the visit. An interview with the
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superintendent was conducted and the superintendent reported management should review and
sign all logbooks for correction and documentation purposes.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center maintains facility operating procedures (FOPs) addressing key control. A review of
the center’s FOP confirmed it includes key assignment and usage including restrictions on
usage, inventory, daily tracking, and reconciliation of keys, secure storage of keys not in use,
procedures addressing missing or lost keys, and reporting and replacement of damaged keys. A
review of the key inventory did reveal results which indicated the key rings on the inventory
matched the actual key ring in use. Upon entering the facility, staff are searched then proceed to
the key control area of master control. Staff provide their personal keys to the master control
operator who then secures the personal keys. The master control operator documents staff
names on the key log as well as the key ring number assigned. Staff initial the key log and
document the time they received keys. The center’s keys are maintained on a tamper-resistant
ring. Emergency keys are also located in master control and are accessible to administrative
staff and master control staff. Observations of the center’s master control inventory did include
the ring number, number of keys on each ring, the capability of each key, and who the key ring
was issued to. The center’s key rings were color coded as required. A sample of shift reports for
the duration of the annual compliance review period was reviewed and each shift report
documented the issuance of keys and key ring numbers. Documentation also included the date
and time keys were issued, name of staff issuing keys rings, name of staff receiving keys rings,
and the time key rings were returned. Visual observations confirmed keys issued were always
on each staff’s person, no youth were allowed to handle keys, and keys were not removed from
the facility without authorization. The center does maintain FOPs addressing instances when
keys are mistakenly removed from the center. There were no instances during the annual
compliance review period when staff mistakenly removed keys from the center. The key box
located in master control is not easily accessible while locked. A review of the Department’s
Central Communications Center (CCC) did not reveal any instances related to key control
concerns nor were there any deficiencies within the Department’s Program Monitoring and
Management (PMM) system. A sample of five key rings were observed and compared to the
key inventory. No issues were observed. Three staff were informally interviewed about the
number of keys on their key ring and the function of each key. Each staff was able to accurately
provide the number of keys and the function of each key. An informal interview was also
conducted with the master control operator to determine the process for restricted keys.
According to the master control operator, staff will submit their personal keys which are placed
in the lockbox slot replacing the restricted key to be provided to the approved staff. Master
control documents who received/assigned the keys, as well as the time and date. The assigned
staff will initial and document time received. After the end of the shift, restricted keys are
returned to the master control operator and placed back into the lockbox slot replacing the
personal keys to be returned to the approved staff.
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Seven staff were interviewed. Staff were able to confirm the center’s restricted keys as medical
records, youth property area, mental health records, case management records, and kitchen.
Staff were able to explain the center’s key control process. An interview with the superintendent
was conducted and the superintendent reported permanent keys are issued to administrative
staff and maintenance only.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains a policy and procedures addressing vehicles and maintenance of vehicles
used by the center to transport youth. The center has a total of six vehicles which are used to
transport youth. Reviewed documentation confirmed each vehicle had a completed annual
inspection by a certified mechanic. According to documentation provided, monthly visual
inspections were completed on each vehicle and incorporated all the required elements.
Inspections were completed on appropriate forms and a copy was maintained by maintenance.
Each transportation vehicle was equipped with the appropriate number of seatbelts, a seatbelt
cutter, window punch, a current fire extinguisher, and a first-aid kit with items approved by the
designated health authority. Each transport vehicle logbook documented completion of an
inspection of the vehicle, the destination, number of youth and staff names, name of staff riding
in the back of the van, and time the transport began and ended. A youth transport was unable to
be observed during the annual compliance review week. The six center vehicles were checked
which ensured they were locked when not in use. Seven youth were interviewed. All youth
reported they feel staff are driving safely when transporting. Each youth reported they have
never seen anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains a policy and procedures addressing tool inventory, management, youth
access to and use of tools, and cleaning items. The center’s policy states the center ensures all
tools and equipment related to the maintenance and kitchen areas are properly maintained,
stored, and inventoried. A visual inspection of the maintenance tool room and the kitchen did
determine tools were secured when not in use. A sample of ten tools and inventories both from
the kitchen and maintenance office were reviewed for accuracy. All tools were secured and had
markings for easy identification. The inventories were accurate, and the inventories were signed
by the superintendent or designee. There were no tools listed on the tool inventories missing
and there were no tools reviewed not present on the inventories. A review of the inventory within
the center’s kitchen area did confirm staff completed an itemized inventory of all equipment. The
center does maintain a policy and procedures addressing replacement of tools. There were no
instances during the annual compliance review period.
An informal interview with the center’s maintenance manager did confirm service vendors are
always accompanied by staff when in secure areas. A review of documentation confirmed the
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issuance of and return of tools used. An observation of youth using cleaning tools was unable to
be conducted during the annual compliance review week. An informal interview with the centers’
maintenance manager and kitchen staff was conducted to determine the center’s practice for
missing and damaged tools. The center maintains a policy and procedures addressing missing
or lost tools. There were no instances during the annual compliance review period. An interview
with the superintendent was conducted and the superintendent reported only maintenance and
administrative staff have access to center tools. Seven staff were interviewed and were able to
verbalize the center’s practice for damaged or missing tools. Staff responses included telling the
supervisor, the broken item is taken off the living module, make sure the item is secure,
complete a work order, and complete a search if anything is missing. All seven staff reported
youth can use mops and brooms. Seven youth were interviewed. Six of seven youth reported
mops and brooms as tools they have used. The remaining youth reported never having used
any tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center maintains a policy and procedures addressing the inventory of and access to all
flammable, toxic, caustic, and poisonous items. The center’s safety plan is incorporated into
their Continuity of Operations Plan (COOP). Only authorized personnel are permitted to access
flammable, toxic, caustic, and poisonous items. All flammable, toxic, caustic, and poisonous
materials were stored in secure areas which were inaccessible to youth. Five items were
reviewed to be compared with the center’s inventory and Safety Data Sheets (SDS). Review of
all sample items confirmed no discrepancies. All items contained an SDS binder located along
with the items. Actual inventory counts did coincide with ending counts observed on inventories.
Seven youth were interviewed. All seven youth reported they do not clean with any type of
cleaning agent such as bleach, laundry soap, or window or toilet cleaners. All youth reported
they do not have access to flammable, toxic, and caustic, and poisonous materials. Seven staff
were interviewed, and all reported youth are not allowed to clean with substances which are
toxic, flammable, or poisonous.
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5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center maintains a policy and procedures for disposal of flammable, toxic, caustic, and
poisonous items. A review of the center’s facility operating procedures (FOPs) was conducted.
The center’s kitchen does maintain a grease trap and a contractor is used for disposal. An
informal interview with the center’s assistant superintendent was conducted and it was reported
the center had no instances of chemical spills or disposal of flammable, toxic, caustic, and
poisonous items during the annual compliance review period, however, there is a contracted
provider when the need arises.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains a policy and procedures addressing confinements under twenty-four
hours. A sample of fifteen confinements under twenty-four-hours was reviewed for the annual
compliance review period. Documentation reviewed for fourteen of fifteen confinements
confirmed youth were offered meals and snacks, the remaining confinement showed the youth
entered confinement subsequently and prior to respective mealtimes. In each confinement,
youth are offered clean clothing, a mattress and bedding, access to educational materials when
applicable, and notice of their right to grieve confinement. There was no instance where mental
health or showers were requested or needed in any confinement. Documentation for each
confinement further confirmed prior to placing each youth in confinement, supervisors approved
the confinement, with only one youth being placed in a confinement room, and the confinement
room was searched prior to placing the youth in confinement. Each reviewed confinement
confirmed each youth was actively being supervised according to visual observation report
(VOR) logs. There were no instances of physical injury reported in any confinement. A
supervisory initial confinement review confinement was completed within the required time
frame for each confinement. Thirteen of fifteen reviewed confinements showed staff completed
the full report in the required time frame. One confinement report was one day late for two staff,
and one report was not initiated. For fourteen of the fifteen confinements, additional supervisor
reviews were conducted in the required time frame. The remaining confinement did not require
and additional supervisor review. In each confinement, staff continually engaged in counseling
youth to consider removal from confinement. No confinement interfered with visitation. Each
confinement report was reviewed by the superintendent within the required time frame. There
were no instances of pregnant youth being placed in confinement during the annual compliance
review period. Windows and cameras were free of obstruction as to allow adequate supervision
of youth while in confinement.
The superintendent was interviewed and stated confinements are tracked through the
Department’s Juvenile Justice Information System (JJIS) and VOR logs are utilized. Monthly
reviews are conducted by regional staff and forwarded to detention by email. Seven staff were
interviewed and were able to explain the center’s step by step process for placing youth in
confinement. Six of seven staff reported youth who are temporarily placed in confinement are
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provided education materials. The remaining staff reported youth who are in temporary
confinement are not provided education materials, and further stated, if youth refuse educational
materials they document this.
5.12 Confinement Over Twenty-Four Hours and
Satisfactory Compliance
Confinement 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 maintains a policy and procedures addressing confinements over twenty-four hours
and confinement reviews. The center had a total of two instances of confinements over twenty-
four hours for the annual compliance review period. Both youth’s confinement reports and
collateral information were reviewed. Both reports documented supervisory reviews were
conducted as required throughout the duration of the confinement and the supervisor
continuously counseled the youth. The confinement review was chaired by the regional director,
completed at least two hours prior to the youth being in confinement for twenty-four hours, and
the conference was held by telephone. Prior to requesting the extension, the superintendent
and mental health staff visited with the youth and a copy of the report was electronically sent to
the regional director. The regional director’s decision was documented, and mental health staff
counseled the youth regularly thereafter. The youth was removed from confinement as soon as
their behavior was appropriate to do so and did not compromise the safety and security of the
center. A copy of the completed confinement review report was distributed to the assistant
secretary for detention services. There were no pregnant youth confined over twenty-four hours
during the annual compliance review period.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains a policy and procedures addressing Continuity of Operations Plan
(COOP) training. Documentation confirmed the center completed the mandatory two required
drills during the annual compliance review period. The center conducted a hurricane drill on
January 20, 2024, and a severe weather drill on July 18, 2024. Documentation determined the
number of COOP drills, scenarios, and any resulting critique or corrective action. A review of
collateral information confirmed drill documentation contained the type of drill, date and time of
the drill, drill participants, a brief scenario, findings, and recommendations. An interview with the
superintendent was conducted and the superintendent reported the COOP is the
comprehensive safety/emergency program utilized.
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Office of Accountability and Program Support Page 54 of 56 (Revised July 2023)
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains a policy and procedures addressing escape drills. A review of the center’s
escape prevention plan verified the inclusion of the Department’s policy and procedures
regarding escapes. The center conducted escape drills for each corresponding quarter of the
annual compliance review period. Drills were completed as required. Documentation within the
center’s logbooks confirmed drill activity. Seven staff training records were reviewed for escape
drill inclusion for the annual compliance review period. Upon review of the Department’s
Learning Management System (SkillPro), each staff completed escape drill training. Seven staff
were interviewed and reported they have participated in drills during since the last annual
compliance review.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center maintains a policy and procedures addressing fire drills. Reviewed documentation
confirmed the center conducted fire drills monthly on each shift and recorded the drills within the
logbooks. Reviewed documentation and visual observations also confirmed all fire extinguishers
were inspected annually. Seven staff were interviewed. Six of seven staff reported fire drills take
place at least monthly. The remaining staff reported fire drills do not take place monthly. Seven
youth were interviewed. All seven youth reported they have been instructed on what to do in
case of a fire.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
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,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 56 (Revised July 2023)
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 maintains a policy and procedures addressing searches and introduction of
contraband into the center. During the annual compliance review week, observations of youth
searches and a youth room search were conducted. In each instance, staff were observed to be
wearing gloves. The room search was thorough and according to procedure. Youth searches
were conducted and observed between class period change. Visual and pat searches were
conducted according to procedure. No strip search was completed other than during admission
during the annual compliance review week. A review of staff and visitor searches was
conducted. Visitors and staff enter the facility through the electronic metal detector then are
searched by electronic wand and personal items are inspected. Visitors are required to
complete an attestation of contraband prior to signing the visitors log and surrendering personal
keys to master control. The center’s sign in log does not contain a contraband attestation
statement. All visitors are required to complete a contraband attestation form upon entry to the
facility. A review of the center’s visitation logs verified contraband attestation forms did coincide
with visitor presence. A review of room searches for one day of each month of the annual
compliance review period was conducted. Documentation reviewed did validate searches are
conducted as required. A review of the Department’s Central Communications Center (CCC)
confirmed the center had a total of four instances of compromised safety and security and
contraband confiscation. In each instance, the center documented the discovery and
confiscation of contraband within the required time frame. Each incident contained a
corresponding incident report with identifying the finding and disposition of contraband. Law
enforcement was contacted for items considered illegal. All contraband items were confiscated
and secured by the discovering officer and delivered to the superintendent. A documentation
review confirmed the shift supervisor documented the chain of custody of each confiscated item.
The discovery and confiscation of each item of contraband were reported to the CCC within the
required time frame and reported to the regional director or designee. The center had a total of
eighteen newly hired staff during the annual compliance review period. Eighteen staff personal
records were reviewed and documentation within each record confirmed the presence of a
contraband attestation form. The superintendent was interviewed and reported youth are
searched at the Juvenile Assessment Center and in the center’s intake area. The
superintendent further stated depending on the contraband found, law enforcement is
contacted, and the center follows the law enforcement officer’s lead and investigations are
conducted. Youth are placed in confinement and staff are placed on no youth contact. The CCC
is notified along with region’s headquarters and all information regarding the incident will be
documented in the Department’s Juvenile Justice Information System (JJIS) and logbooks.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 56 (Revised July 2023)

source: DJJ

rule: Indicator 1.05

excerpt: Right Interactions (RI)

rating: Limited Compliance

rule: Indicator 2.05

rule: Indicator 2.08

excerpt: Review of Youth in Secure Detention