state: FL

facility_name: Monroe Juvenile Detention Center

summary: QI Detention - FY24-25 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Monroe Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
5503 College Road
Key West, Florida 33040
Review Date(s): September 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:
Nicos Antonakos, Office of Accountability and Program Support, Lead Reviewer (Standard 1
and interviews)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Douglas Kane, Assistant Detention Center Superintendent II, Saint Lucie Regional Juvenile
Detention Center (Standard 5)
Peter Keelan, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Yvrose Sylvain, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Monroe Regional Juvenile Detention Center MQI Program Code: 1076
Provider Name: Dept. of Juvenile Justice Contract Number: State
Location: Monroe County / Circuit 16 Number of Beds: 10
Review Date(s): September 10-13, 2024 Lead Reviewer Code: 180
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 54 (Revised July 2023)
4 .1 2
L im ite
3 .1 3 S u ic id e P
E p is o d ic /F irs t A
d R a tin g s
re ve n tio n T
id C a re /E m
ra in
e rg
in g *
e n c y C a re
F a ile d R a tin g s
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Non-Applicable
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 54 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 54 (Revised July 2023)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n S a tis fa c
O rie n ta tio n S a tis fa c
C la s s ific a tio n S a tis fa c
N o tific a tio n o f J P O C irc u it G a n g R e p S a tis fa c
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty S a tis fa c
R e le a s e S a tis fa c
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s S a tis fa c
R e v ie w o f Y o u th in S e c u re D e te n tio n a n d H o m e D e te n tio n S a tis fa c
D a ily A c tiv ity S c h e d u le S a tis fa c
E d u c a tio n a l A c c e s s * S a tis fa c
C a re e r E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 54 (Revised July 2023)
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
3 .1 7
* T h e D e p
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
In d ic a t o r R a t in g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
L ic e n s e d M H /S A C lin ic a l S ta ff *
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
M H /S A A d m is s io n S c re e n in g
M H /S A A s s e s s m e n t/E v a lu a tio n
M H /S A T re a tm e n t
T re a tm e n t a n d D is c h a rg e P la n n in g
P s y c h ia tric S e rv ic e s *
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia
m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
L im ite d
S a tis fa c to ry
S a tis fa c to ry
S a tis fa c to ry
N o n -A p p lic a b le
te a tte n tio n if a p ro g ra m o p e ra te s
d ic a to rs . F a ilu re to d o s o w 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 54 (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
In d ic a t o r R a t in g s
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 to ry
F a c ility O p e ra tin g P ro c e d u re s S a tis fa c to ry
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 to ry
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa c to ry
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 to ry
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 to ry
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 to ry
H e a lth -R e la te d H is to ry S a tis fa c to ry
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 to ry
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 to ry
S ic k C a ll P ro c e s s S a tis fa c to ry
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 L im ite d
O ff-S ite C a re /R e fe rra ls S a tis fa c to ry
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 to ry
M e d ic a tio n M a n a g e m e n t S a tis fa c to ry
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 to ry
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 to ry
P re n a ta l C a re /E d u c a tio n N o n -A p p lic a b
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
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 ).
le
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 54 (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
In d ic a t o r R a t in g s
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 N o n -A p p lic a b le
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
The Monroe Regional Juvenile Detention Center is a state-owned detention center, operated by
the Department, located in Key West, Florida. The center serves youth in Monroe County in
Circuit 16. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the ten-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 Monroe County School District. The center’s
management team includes the superintendent, one administrative assistant, five juvenile
justice detention officer supervisors (JJDOSs), one JJDOS who serves as the shift commander,
and seven juvenile justice detention officers (JJDOIIs). Mental health and healthcare services
are provided through the contracted provider, VitalCore Health Strategies, LLC, who sub-
contracts with Guidance Care Center, Inc., which is a local agency located in Key West, Florida.
Mental health services are provided by one designated mental health clinician authority
(DMHCA) and one non-licensed 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, psychiatric services, and
availability for substance abuse services for youth with co-occurring disorders. Medical services,
which are provided by VitalCore Health Strategies, LLC, are provided by one designated health
authority (DHA), one licensed practical nurse (LPN), and one advanced practice registered
nurse (APRN). The medical clinic maintains nursing coverage in accordance with the contract.
Food services are provided by the Monroe County Sheriff’s Office, which is located on the same
property. Meals are prepared by the food service workers in the county jail and delivered to the
center. 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 two youth living
modules. The center was clean and well maintained. There was no graffiti observed during the
annual compliance review week. The elevator was not working; however, vendors were working
on repairing the elevator. There are twenty-seven security cameras at the center, of which
twenty-two were operational during the annual compliance review week. At the time of the
annual compliance review, the center had one detention superintendent, one JJDOS, and one
JJDOII position vacant.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 54 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center maintains a written policy and procedures requiring compliance with the
Department’s background screening requirements. The Annual Affidavit of Compliance with
Level 2 Screening Standards was submitted to the Department’s Background Screening Unit
(BSU)/Clearinghouse on January 30, 2024, meeting the annual requirement. The Annual
Affidavit of Compliance with Level 2 Screening Standards for school district teachers was
submitted to the BSU on January 30, 2024. A review of the initial background screening for the
center’s one applicable newly hired staff found the center received background screening
results from the Department’s BSU/Clearinghouse prior to the staff’s start date and a criminal
history report was reviewed. The center’s reviewed staff was not applicable for a background
screening exemption. The staff was not applicable for a break in service. The center utilizes an
ergometric pre-employment assessment tool for all direct care applicants. A review of the one
direct care staff record indicated the staff completed a pre-employment assessment tool and
received a passing score. A copy of the pre-employment assessment was maintained within the
staff’s record. An informal interview with the juvenile justice detention officer supervisor (JJDOS)
verified the center did not have any volunteers, mentors, or interns during the annual
compliance review period.
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 maintains a written policy and procedures to ensure all staff, contracted providers,
and volunteers with access to youth undergo a criminal history background check every five
years. The center had one staff and one contracted staff applicable for a five-year rescreening
since the last annual compliance review. The staff rescreenings were completed and submitted
to the Department’s Background Screening Unit (BSU)/Clearinghouse within the required time
frames. There were no volunteers applicable for a five-year rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 54 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center maintains a written policy and procedures addressing the staff code of conduct. Staff
are required to adhere to the code of conduct which prohibits any type of abuse, profanity,
threats, harassment, intimidation, horseplay, or personal relationships with youth. A review of
three staff personnel records confirmed each staff had signed a code of conduct prohibiting any
form of abuse, profanity, threats, harassment, or intimidation. The code of conduct also
addressed officer professionalism, poor performance, negligence, insubordination, conduct
unbecoming of a public employee, and misconduct. Right Interactions (RI) Reports and the
Department’s Central Communication Center (CCC) reports were reviewed for violations related
to the code of conduct. The center did not have any staff who received disciplinary actions for
violations of the code of conduct during the annual compliance review period. The center had
one staff who received employee of the month in December 2023. Three youth were
interviewed, and each stated they had never been stopped from reporting abuse since they
have been at the center. Each youth stated staff are respectful when talking to youth and do not
use profanity. Each youth stated they have never heard staff threaten youth at the center. All
three youth stated they feel safe at the center. Each youth stated they have never exchanged
emails, telephone numbers, or social media contact information with staff. Three staff were
interviewed, and each stated they would allow a youth to make a telephone call to the Florida
Abuse Hotline or the CCC if the youth requested to make an abuse call. One staff stated they
would notify the supervisor, and one staff stated they were allowed to call the Florida Abuse
Hotline. Each of the three staff stated they have never heard a co-worker using profanity when
speaking with youth. All three staff stated they have never observed a co-worker using threats,
intimidation, or humiliation when interacting with youth. Three staff were asked about the
working conditions at the center. One staff stated working conditions were very good, and two
stated good. The interviewed juvenile justice detention officer supervisor (JJDOS) stated the
statewide code of conduct is used. If any abuse is alleged towards youth, it is called in to the
Florida Abuse Hotline, the CCC, and the staff is removed from youth contact. An investigation
will be conducted and upon completion of the investigation staff will face disciplinary action if
warranted.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 54 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center maintains a written policy and procedures to ensure when a reportable incident
occurs the center notifies the Department’s Central Communications Center (CCC) within two
hours of becoming aware of the incident. The center has had two reportable incidents since the
last annual compliance review. A review of one incident found the center reported it to the CCC
within two hours of the incident. The second incident involved non-operable cameras which
could not be repaired, and this was reported within the required twenty-four-hour time frame.
Each incident was documented in the center’s logbook. A review of the center’s internal
incident/grievance reports found there were no additional incidents which should have been
reported to the CCC and were not. The center’s juvenile justice detention officer supervisor
(JJDOS) was interviewed and stated whenever a reportable incident occurs, an incident report
is written in the Department’s Juvenile Justice Information System and a call to the CCC is
made.
1.05 Right Interactions (RI) Non-Applicable
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 have been no Right Interactions (RI) incidents during the annual compliance review
period; therefore, this indicator is rated non-applicable.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center maintains a written policy and procedures regarding pre-service training. Staff are
trained in accordance with the Florida Administrative Code. Detention staff satisfy pre-
service/certification requirements specified by Florida Administrative Code within 180 days of
hire. Phase One training consists of instructor-led and web-based courses. Phase Two training
consists of 120 hours of academy instructor-led training. A review of one applicable staff training
record for pre-service training indicated the staff completed all required trainings within 180-
days of hire and new staff orientation was completed within eighteen days of hire. Reviewed
documentation confirmed the applicable staff completed all the trainings required by the
Department prior to having contact with youth. All pre-service trainings were documented in the
Department’s Learning Management System (SkillPro). The center did not have any returning
direct care staff applicable for specified training when returning less than one year from
separation.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 54 (Revised July 2023)
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center maintains a written policy and procedures which require staff to complete twenty-four
hours of in-service training each calendar year after completion of pre-service certification
training. The policy also requires supervisors to complete eight hours of supervisory training
annually. The center provides in-service training to staff through a combination of the
Department’s Learning Management System (SkillPro) and instructor-led classes. Five staff
training records were reviewed for in-service training, including two direct care staff and three
supervisory staff. All five staff records reflected staff completed the mandatory training topics
which included active shooter preparedness, cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED), human trafficking, information security awareness,
mental health and substance abuse, Prison Rape Elimination Act (PREA), Right Interactions
(RI), professionalism, interpersonal communication, and ethics including standards of conduct.
Additionally, staff received training in sexual harassment, suicide awareness and prevention,
trauma responsive practices, the emergency care plan, infection control training, the exposure
control plan, escape prevention, fire prevention, and disaster procedures. Three supervisory
staff records were reviewed, and each staff completed at least eight hours of supervisory
training. All trainings were entered into SkillPro. The center has an annual in-service training
calendar which is updated as changes occur. The in-service training plan was approved by the
center’s superintendent, the assistant secretary for Detention Services, and the director of the
Department’s Office of Talent, Leadership, and Culture. The interviewed juvenile justice
detention officer supervisor (JJDOS) stated detention staff complete twenty-four hours of annual
in-service training, as identified in Florida Administrative Code, beginning the calendar year after
the staff has completed pre-service certification training.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a written policy and procedures to ensure each youth has the right to file a
grievance and ensure all youth are treated fairly, respectfully, without discrimination, and their
rights are protected. The grievance process is posted in each living unit and explained to each
youth during the admission and orientation process. The center did not have any grievances
submitted since the last annual compliance review. An interview with the juvenile justice
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detention officer supervisor (JJDOS) was conducted. The JJDOS explained the grievance
process, indicating there is an informal and formal phase. During the informal phase, the
juvenile justice detention officer (JJDO) attempts to resolve the complaint or condition with the
youth using effective communication skills. During the formal phase the youth can submit a
written grievance resulting in a response from a JJDOS. The completed grievance form is
submitted to the JJDOS within two hours. The JJDOS will give a response by the end of the
shift, if possible, or within twenty-four hours. The JJDOS documents their findings on the
grievance form and advises the youth of what actions, if any, will be taken. The supervisor
forwards the grievance form to the superintendent or designee upon completion. The
superintendent or designee then reviews the completed grievance f as quickly as possible, at a
minimum, within seventy-two hours of receipt, excluding weekends and holidays, and shall take
whatever corrective actions are deemed necessary. The superintendent’s decision is final. The
youth signs a hard copy of the form, which is maintained in a separate grievance binder and
uploaded to the Department’s Facility Management System (FMS). An interview with three staff
was conducted, and all were able to explain the center’s grievance process. Three youth were
interviewed, and each knew how to file a grievance; however, none had filed a grievance to rate
the process.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center maintains a written policy and procedures to address entering an alert into the
Department’s Juvenile Justice Information System (JJIS) for youth who require an alert which
may not have been identified prior to the youth’s admission. The alerts entered into JJIS are
verified by medical staff, juvenile justice detention officer supervisors (JJDOSs), or the mental
health staff, as applicable. Three youth records were reviewed for medical, mental health, and
medication alerts. Each reviewed youth record documented all alerts were accurately entered
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into JJIS. The reviewed youth were applicable for six separate alerts. The JJIS alerts are printed
daily by the on-duty supervisor, copies are provided to all staff during their shift, and all staff
have access to the alert system. Reviewed documentation indicated alerts were discussed
during shift briefings. An observation of a shift briefing meeting verified the JJDOS discussed
youth alerts with the incoming staff and gave the staff a copy of the alerts. All applicable alerts
were downgraded and removed by the medical staff and/or the mental health staff. The
interviewed JJDOS stated the superintendent ensures critical and special alerts are reviewed
and responded to appropriately. Upon completion of the Admission Wizard, staff ensure all
critical and special alerts are listed in JJIS. The JJIS alert report is reviewed daily by the
supervisors and administrators to ensure it correctly reflects the status of the youth. The JJDOS
ensures the detailed alert list is read aloud during shift briefings. Medical and mental health staff
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, alerts are to be documented in
the initial acceptance of the logbook for the youth’s designated living area. When a JJDOS
receives changes to the alert list, they notify the staff affected by changes. Three interviewed
staff stated they are informed of youth alerts during shift briefings, two staff stated they receive a
youth alert form, and one staff stated alerts are entered into the logbook. Each staff stated
management informs them of issues at the center during staff briefings. Additionally, two staff
stated they were informed of issues during meetings, and two staff stated they were informed
by email. All three staff stated communication at the center is very good.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a structured method for analyzing data trends. The Department conducts a
Detention Services Report Card which ensures all centers provide high-quality effective services
for youth and families. The report card is a comprehensive review of policy compliance
conducted through site visit observations and desktop audits. Department headquarters staff
work with centers to identify strengths and areas which need improvement. The report card
includes information based on drills, center inspections, center meetings, and operations. The
report card assigns a grade for the center with recommendations for improvement. The
information is then shared with center staff through monthly management meetings and daily
shift briefings. A review of report cards, surveys, meeting agendas, and data collection software
confirmed the center’s practices. The center also participates in weekly Detention Review
meetings, and information is shared with stakeholders at least quarterly.
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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.
The center maintains a written policy and procedures to ensure all youth are admitted to the
center in accordance with Florida Administrative Code. Three youth case management records
were reviewed. Each reviewed record included an arrest affidavit/custody order, a Detention
Risk Assessment Instrument (DRAI), and a Suicide Risk Screening Instrument (SRSI). All three
youth records included documentation to confirm the youth were full-body and electronically
searched by a juvenile justice detention officer (JJDO) the same gender as the youth. Each
youth record reflected the youth were offered telephone calls and none of the youth refused to
make the call. Two of the three records documented a meal was provided to each youth upon
intake. The third youth was admitted around lunch time and a meal was provided. All youth
received medical, mental health, and substance abuse screenings upon admission. An
observation of one youth intake was conducted during the annual compliance review week. The
youth was full body searched and electronically searched by an officer of the same gender. The
youth was offered a telephone call; however, refused. The youth was given snacks and a drink.
The JJDO stated the youth will be provided a hot meal at dinnertime. During the admission
process, the youth received an orientation to the center verbally and in writing, which included
all required elements. The staff reviewed and followed all the procedures.
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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
The center maintains a written policy and procedures to advise youth of center rules and
regulations, expectations for behavior and related consequences for failing to meet those
expectations, and youth rights within twenty-four hours of a youth being admitted into the center.
A review of three youth case management records found each contained an orientation
acknowledgment form signed by each youth confirming orientation took place within twenty-four
hours of the youth’s admission into the center. Each reviewed record revealed all youth were
advised both verbally and in writing of the orientation process. Each youth signed the orientation
packet acknowledging they received the packet. Each packet included information regarding
rules and regulations, grievance procedures, visitation, telephone calls, access to medical
treatment, mental health and substance abuse services, access to the Florida Abuse Hotline,
the Department's Central Communications Center (CCC), behavior expectations and related
consequences, possible new law violations for destruction of property, youth rights, and Prison
Rape Elimination Act (PREA) related information. During an informal interview, a juvenile justice
detention officer (JJDO) indicated all youth watch a PREA video upon admission. A youth
admission which included an orientation was observed during the annual compliance review.
The staff explained the rules and regulations, expectations for behavior, youth rights, and
policies to the youth. In addition, the youth watched the PREA video. An admission and
orientation were observed which confirmed the orientation included all elements as outlined in
the center’s policy. Three youth were interviewed and each reported receiving information about
the center’s rules and regulations, daily schedule, education services, visitation, abuse
reporting, and behavior management system (BMS) when admitted.
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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.
The center maintains a written policy and procedures regarding classification and orientation to
ensure each youth is protected from harm, violence, and/or victimization. Three youth case
management records were reviewed, and each contained information concerning the youth’s
history and status, as well as all other required information. Considerations on the classification
form included mental illness, intellectual disabilities, physical disabilities, history of violent
behavior, gang affiliation, criminal behavior, history of sexual offenses, Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB) screening results, medical issues,
suicide risk identified or suspected issues, escape, security, and history of human trafficking.
The Department’s Juvenile Justice Information System (JJIS) Admission Wizards were
completed and located in all three youth records. This information is reviewed for room
assignment based on potential safety and security concerns, which included information on the
youth’s gender, height, weight, age, and level of aggressiveness. All three youth records
indicated the youth were assigned to rooms based on classification procedures, and if the youth
had a history of committing sexual offenses or was a victim of a sexual offense they were
placed in a single room. None of the reviewed youth had a reclassification at the time of the
annual compliance review. The center’s practice is to enter all suspected gang affiliation alerts
into JJIS and notify the youth’s juvenile probation officer (JPO) and law enforcement by email.
The center also has a screening process for youth newly admitted into the center to determine if
the youth is a gang member or gang affiliated. None of the three case management records
reviewed were applicable for suspected gang affiliation. The juvenile justice detention officer
supervisor (JJDOS) reported being notified of any related gang information by email, during the
weekly Detention Review meetings, and through the JJIS alert system. An interview with the
JJDOS confirmed all factors are taken into consideration when assigning youth to a room.
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Office of Accountability and Program Support Page 18 of 54 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has a screening process for youth newly admitted into the center to determine if the
youth is a gang member or gang affiliated. The center's gang representative is responsible for
notifying the circuit’s juvenile probation officer (JPO) and law enforcement regarding any
indication of gang activity by email. A juvenile justice detention officer supervisor (JJDOS)
serves as the gang representative who reviews identified youth for suspected gang involvement.
The center’s gang representative enters all suspected gang affiliation alerts into the
Department’s Juvenile Justice Information System (JJIS), when applicable. All staff are made
aware of the alerts during daily shift briefings. A review of three youth case management
records found none were applicable for suspected gang affiliation. The center reported not
having any gang identified or affiliated youth since the last annual compliance review. An
informal interview was conducted with the center’s gang representative. The center’s gang
representative said documented gang members’ information is emailed to local law
enforcement, the youth’s JPO, the center superintendent, and an alert is entered into JJIS, if a
youth is admitted/identified with gang affiliation.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center maintains a written policy and procedures to ensure a youth's personal property is
maintained securely and returned to the youth in a timely manner upon their release. The
youth’s property is itemized and documented on the Property Receipt form in the Department’s
Juvenile Justice Information System (JJIS). Three youth case management records were
reviewed. Each of the three reviewed youth case management records contained a Property
Receipt form and each receipt form documented the youth and staff names and signatures,
Letter of Acknowledgement of Unclaimed Property form, and each surrendered item for the
youth's personal property. None of the three reviewed youth records documented the youth had
valuable property. Three additional records were requested and reviewed for valuable property.
The center maintains a drop safe logbook to document the time, youth’s name, name of the
officer securing the property, and the officer’s initials. Documentation supported all valuable
property is placed in a clear tamper-proof bag, logged into the logbook with date, time, name of
the youth, Department identification number (DJJID), name of the juvenile justice detention
officer (JJDO) securing the property, and the officer's initials. The center's practice is to place
the clear bag into a drop safe, which is under video surveillance twenty-four hours a day. None
of the reviewed youth refused to sign the Property Receipt forms. Personal property such as
clothes and shoes are placed in property bags and placed into the secured property room. The
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information documented on the bag included the date, the youth’s name, the DJJID, and a
listing of items in the bag. Observations of the center’s secured property room during the annual
compliance review week found non-valuable property such as clothing and shoes placed in a
property bag, zipped, and secured in the property room. Observations of three youth’s personal
property revealed each youth’s personal property had the youth DJJID and a completed
inventory form. The center did not have any youth with valuable property during the week of the
annual compliance review. There were no releases available for observation during the week of
the annual compliance review. An observation of a youth’s admission into the center validated
the center’s process for securing and storing youth property. The center’s supervisors are the
designated staff who have access to the youth’s personal property. A review of the
Department's Central Communications Center (CCC) reports since the last annual compliance
review did not document any reported incidents regarding youth property. Three interviewed
youth verified staff checked their personal property upon their admission at the center and had
the youth sign a form stating the personal property was correct. The interviewed juvenile justice
detention officer supervisor (JJDOS) indicated upon a youth’s admission to the center, the youth
property is assigned in JJIS and signed by the officer and the youth. The property is then placed
in the secure property room. The youth property is stored in the property room and only
supervisors have access to the room.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center maintains a written policy and procedures to ensure all releases from the center
occur promptly and accurately. Three youth case management records were reviewed, and one
was applicable for release procedures. Two additional closed records were requested and
reviewed for release. All three closed records documented the on-duty supervisor reviewed all
release paperwork prior to the youth's release. All three closed youth case management records
included documentation the juvenile justice detention officer supervisor (JJDOS) reviewed the
release paperwork received from the court, and the youth’s identification was verified prior to
release. All three youth were released to a parent/guardian. A copy of the parent/guardian's
driver’s license and/or identification card was placed in the record, and the youth and the
parent/guardian were notified, in writing, of the youth's next court date. None of the youth had
an endangered person alert. The date of admission and the date of release were documented in
each youth’s record and correlated with the Department's Juvenile Justice Information System
(JJIS). There were no youth released during the annual compliance review week; therefore, an
observation of a youth being released was not conducted.
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Office of Accountability and Program Support Page 20 of 54 (Revised July 2023)
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center maintains a written policy and procedures to ensure youth's personal property is
maintained securely and returned to the youth in a timely manner upon their release. The
center’s policy also outlines procedures regarding release of youth with prescription
medications. Three closed youth case management records were reviewed. All three closed
records documented the youth and parent/guardian signed the property receipt, acknowledging
receipt of each youth's personal property. Each reviewed record documented the youth was
released to an appropriate person with a copy of their identification. One of the three closed
records was applicable for release from the center with prescription medications.
Documentation verified the receipt of medications was signed by the person receiving the youth
using the Department’s Health Discharge Summary Transfer Note form. The one applicable
closed record documented the youth and the person to whom the youth was released were
reminded of any health or welfare issues, including medical, mental health, and/or substance
abuse needs, and any pending appointments. An informal interview with the juvenile justice
detention officer supervisor (JJDOS) reported the center ensures the youth’s property is
returned safely with verification, and the youth and parent/guardian sign a Property Receipt
form. The center’s JJDOS reported, during visitation, the youth property will be given to their
parent/guardian if the youth is pending Department placement, to prevent the center from
having any property held for more than thirty days. The center did not have any property held for
more than thirty days since the last annual compliance review. There were no youth released
during the annual compliance review week; therefore, an observation was not conducted.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains a written policy and procedures ensuring Detention Reviews are
conducted weekly for youth securely detained to ensure proper management of youth and the
sharing of information. During the annual compliance review week, an observation of a
Detention Review meeting was conducted. All parties were present from all required
departments. The juvenile justice detention officer supervisor (JJDOS) chairs the meetings. The
center’s JJDOS reviews and discusses all securely detained youth, alerts, and waiting lists,
which include youth waiting for placement in a commitment program, and youth being
transported from the center to another center for assessments. During the Detention Review
meeting, the JJDOS discussed all medical and mental health updates. Weekly Detention
Review meetings are attended by the interim superintendent, juvenile probation officers (JPOs),
mental health staff, medical staff, and education staff. Reviewed documentation from October
18, 2023, to September 11, 2024, supported Detention Review meetings are held when there
are youth at the center. An interview with the JJDOS reported education staff, medical and
mental health staff, JPOs, and detention staff participated in the Detention Review meetings,
which are conducted through video conferencing in the center’s conference room. During the
meeting, all aspects of the youth are discussed and include youth releases, legal status,
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detention status, medical and mental health status, and items needed to be completed before
the Department can place the youth on applicable waiting lists.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center maintains a written policy and procedures to address the daily activity schedule.
Youth are provided the opportunity to participate in constructive activities benefiting the youth
and the center. The daily activity schedule is posted in each living area and the dining hall. The
schedule included times for wake-up and personal hygiene, mealtimes, visitation, recreation and
physical activities, indoor activities, shift change, bedtimes, groups, and open program time.
Observations of youth engaged in various activities throughout the week were conducted which
included youth searches, educational programming, snack times, indoor recreation times, and
open programming times. Three interviewed youth reported the center has a daily activity
schedule and the daily schedule is followed. Three interviewed staff reported the center has a
daily schedule which is followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center maintains a written policy and procedures to ensure educational access for youth.
The Monroe County School District provides educational services and approves the 250-day
calendar, which incorporates ten days of teacher planning and/or training. The daily school
schedule reflects five hours of instruction each day, which meets the required minimum of 300
minutes of instruction each day. Three random days of video footage were reviewed for
educational access which confirmed education classes were facilitated as scheduled. One of
the reviewed days reflected an extra hour of education instruction. A review of logbooks for one
random day from each month from October 5, 2023, to September 3, 2024, for start and stop
times was completed. Documentation confirmed the school schedule was followed for eight of
the twelve random days reviewed. For four randomly chosen days school started between
twenty and seventy-five minutes late. Documentation for two of the four days did not reflect why
the school schedule was not followed. The third day was due to the Detention Review and
treatment team meetings for the youth. The fourth day was due to a mandatory school district
meeting. All reviewed school days ended on time or after the scheduled end times. Three staff
and three youth interviews were completed. Both staff and youth confirmed there is minimal
interference in educational instruction. Two of the three interviewed youth indicated the center is
preparing them well for high school, vocational school, employment, and/or college, and one
stated very well. An interview with the juvenile justice detention officer supervisor (JJDOS)
reported there is minimal interference in educational instruction. The JJDOS reported the center
has one teacher assigned from the school district to provide services and the teacher will often
provide instruction past the scheduled end times in addition to Saturday school.
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Office of Accountability and Program Support Page 22 of 54 (Revised July 2023)
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center maintains a written policy and procedures to provide career education. The center
provides career education programming which meets the requirements of a Type 1 program and
incorporates communication, interpersonal and decision-making skills, as well as life skills and
activities through the personal career and social development class. Three interviewed youth
reported taking core classes such as history, the high school equivalency diploma (GED)
practice test, and virtual classes.
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Office of Accountability and Program Support Page 23 of 54 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains a written policy and procedures to ensure there is a licensed mental health
professional in place who is identified as the designated mental health clinician authority
(DMHCA). The policy was approved and signed by the superintendent on August 7, 2023, and
by the DMHCA on August 31, 2023. The Department maintains a contract with VitalCore Health
Strategies, LLC, to provide mental health and substance abuse services to all applicable youth
in the center. VitalCore Health Strategies, LLC subcontracts with Guidance Care Center to
provide a licensed mental health counselor (LMHC) to serve as the center's DMHCA. The
LMHC holds a clear and active license in the State of Florida with an expiration date of March
31, 2025. The DMHCA is scheduled to be on-site, as needed, when there are youth securely
detained at the center. A review of the mental health logbook since the last annual compliance
review confirmed the DMHCA was on-site at least weekly when there were youth in secure
detention. The DMHCA is also available seven days a week, twenty-four hours a day, by way of
telephone for consultation. A review of the DMHCA’s job description determined the DMHCA is
responsible for overseeing all clinical and administrative operations of all contractual
requirements. During an interview, the DMHCA reported being responsible for reviewing and
completing assessments, deliberating with center administration regarding youth supervision
levels, participating in weekly Detention Review meetings, treatment team planning, and case
conceptualizations. The center has one back-up DMHCA in the event of scheduled leave and/or
absences. The back-up DMHCA is a LMHC, licensed under Chapter 491 in the State of Florida,
with an expiration date of March 31, 2025. The back-up DMHCA was used during the annual
compliance review period. The interviewed DMHCA reported they are responsible for
overseeing all mental health and substance abuse services at the center. Detention staff will
enter a referral for mental health services, which generates an email to all mental health staff,
including the DMHCA. The DMHCA also reviews the Department’s Electronic Medical Record to
see each youth’s status and other alerts as needed, which is also discussed at Detention
Review meetings. All discussions are documented in the youth’s chronological notes.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has a contract with VitalCore Health Strategies, LLC, to provide mental health and
substance abuse services to all youth in the center. VitalCore Health Strategies, LLC
subcontracts with Guidance Care Center. The designated mental health clinician authority
(DMHCA) ensures the licensed staff working under their supervision perform services they are
qualified to provide based on education, training, and experience. The center has one DMHCA
who is a licensed mental health counselor (LMHC) with a clear and active license in the State of
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Florida under Chapter 491, with an expiration date of March 31, 2025. The center’s back-up
DMHCA is also a LMHC who holds a clear and active license, which expires on March 31, 2025.
A review of all licensed mental health professionals and qualified professionals verified each
license was clear an active.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has a contract with VitalCore Health Strategies, LLC to ensure mental health and
substance abuse services are provided by individuals with appropriate qualifications. An
informal interview with the designated mental health clinician authority (DMHCA) reported non-
licensed clinical staff working under their supervision are performing services they are qualified
to provide based on education, training, and experience. The center has one non-licensed
master’s-level mental health and substance abuse clinical staff who works under the direct
supervision of the licensed mental health counselor (LMHC). A review of documentation
reflected the non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional received a minimum of one hour a week of on-site, face-to-
face direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the center during the annual compliance
review period. A review of the supervision logs since the last annual compliance review
reflected the DMHCA provided at least one hour of weekly face-to-face supervision which was
documented on a form which included all information required by the Department’s Licensed
Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct
Supervision Log form for all weeks where the staff provided youth services. The center is
operating with a Chapter 397 license which expires on July 10, 2025. The non-licensed
master’s-level clinician held a degree in professional counseling. The non-licensed staff is on-
site Monday through Friday, as needed. Reviewed documentation confirmed the non-licensed
clinician received twenty hours of training and supervised experience in assessing suicide risk,
mental health crisis intervention, and emergency mental health services. The training included
the administration of five Assessments of Suicide Risk (ASRs) or Crisis Assessments conducted
on-site in the physical presence of a licensed mental health professional, which was
documented on the Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment
of Suicide Risk form.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center maintains a written policy and procedures whereby mental health and substance
abuse needs of youth are identified through a comprehensive screening process, in which
referrals are made when youth are identified with mental health and/or substance abuse needs
or are identified as a possible suicide risk. The procedures require a thorough review of each
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youth’s initial screening conducted by juvenile justice detention officers (JJDOs) and existing
documentation of mental health or substance abuse problem needs or risk factors,
administration of the Suicide Risk Screening Instrument (SRSI) upon the youth’s admission,
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) administration, a
review of the Department’s Face Sheet, alerts, and referral to the center’s mental health and
substance abuse clinical staff. A review of three youth records found documentation of each
having a mental health, substance abuse, and suicide risk screening utilizing the SRSI and the
MAYSI-2, which were completed during the admission process in the Department’s Juvenile
Justice Information System (JJIS). Two youth were transferred from another center and the
assessment process began prior to transfer. Each of the three applicable SRSIs were reviewed
by a mental health clinical staff, who documented their summary and recommendations in the
screening results section. None of the reviewed youth were applicable for any positive “YES”
responses on the SRSI; therefore, did not require further evaluation. The results of the MAYSI-2
indicated a need for further assessment for all three youth, which correlated with open or closed
suicide alerts in JJIS. The center’s admission practice is to place each youth on suicide
precautions until they are evaluated by mental health staff. Each of the reviewed SRSIs and
MAYSI-2s were completed by staff trained in screening administration. Three reviewed MAYSI-
2s indicated the need for further assessment, and the center notified mental health staff and the
superintendent or designee, as required. All reviewed MAYSI-2s were valid screenings. Each of
the MAYSI-2s indicated the need for a comprehensive assessment, and the screener referred
the youth as required.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center maintains a written policy and procedures regarding mental health and substance
abuse evaluations. Three youth records were reviewed for a mental health and substance
abuse comprehensive assessment, and each youth was applicable. Youth with identified needs
are referred for a further in-depth mental health and/or substance abuse evaluation. The center
utilizes the Department’s Mental Health and Substance Abuse Referral Summary form. Youth
identified with substance abuse and/or mental health needs are assessed within thirty days by
the provider using the Department’s Substance Abuse and Mental Health Assessment (SAMH)
form. Each applicable youth record documented completion of a SAMH within the required time
frame and the treatment recommendations made corresponded to all diagnosed mental health
or substance-related disorders. There were no youth applicable for having a comprehensive
assessment completed by a community provider.
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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.
The center maintains a written policy and procedures ensuring mental health and substance
abuse treatment planning focuses on the development and review of an initial or individualized
mental health treatment and or substance abuse treatment plan for each youth. Each youth
determined to need mental health treatment, including treatment with psychotropic medications
or substance abuse treatment, while in the center must be assigned to a mini-treatment team.
The informally interviewed designated mental health clinician authority (DMHCA) reported
detention staff enter mental health/substance abuse referrals into the Electronic Medical
Records (EMRs), and youth are offered services within fourteen days of admission, which is
documented on the individual note form. Three youth mental health and substance abuse
records were reviewed for mental health and substance abuse treatment services. One of the
three selected records was applicable for requiring an initial treatment plan completed within
seven days of initiation of treatment; therefore, two additional records were requested and
reviewed. A review of the three applicable records indicated each youth had a treatment plan in
place within seven days of initiation of treatment. Each plan was documented on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. Each initial treatment
plan documented the reason for referral, initial Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5) diagnosis, treatment methods, initial treatment goals, and
applicable psychiatric services. The plans were signed by the youth and treatment team
members involved in the development of the treatment plan. Each applicable youth was
assigned a mini-treatment team and involved in the development of the initial treatment plan.
Two of the three records contained an individualized treatment plan developed within thirty-one
days of admission. One youth was released from the center prior to reaching thirty-one days.
Each of the individualized treatment plans documented the DSM-5 diagnosis, symptoms which
were the focus of treatment, strengths, needs, and applicable psychiatric services to include the
youth’s prescribed psychotropic medication, dosage, and the frequency of monitoring. A review
of the progress notes in each record indicated each youth was receiving treatment services as
stipulated on the treatment plan. None of the applicable youth were at the center long enough to
have an individualized treatment plan review. A review of three applicable youth records
reflected the Department’s Mental Health/Substance Abuse Treatment Discharge Summary
form was completed, and the reviewed documentation confirmed a copy of the discharge
summary was provided to the youth, parent/guardian, and assigned juvenile probation officer
(JPO) upon release. Reviewed documentation practices regarding EMRs adhered to statewide
policies. An observation of treatment team was conducted through video conferencing during
the annual compliance review week. Two youth participated in the meeting with all required
treatment team members present. The team discussed mental health treatment plans and
detention status.
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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.
The center maintains a written policy and procedures ensuring mental health and substance
abuse treatment planning concentrates on providing mental health treatment and/or substance
abuse treatment, which reduces or alleviates the youth’s symptoms of mental disorder or
substance abuse impairment and enables youth to function adequately in the juvenile justice
setting. Each youth identified as needing mental health treatment, including treatment with
psychotropic medication or substance abuse treatment, must be assigned to a mini-treatment
team. Three youth mental health and substance abuse records were reviewed for mental health
and substance abuse treatment services, and each youth was applicable for receiving treatment
services and being assigned to a mini-treatment team. Reviewed documentation confirmed the
mini-treatment team consisted of mental health clinical staff, one staff from a different service
area, youth, and if possible, the youth’s parent/guardian. The informally interviewed DMHCA
reported youth received either individual, group, or family counseling according to the frequency
required by their plan. Each reviewed mental health and substance abuse record contained the
proper consents for mental health and/or substance abuse treatment services and progress
notes documented in the Department’s Electronic Medical Records validated each youth was
receiving treatment services as stipulated on the treatment plan. During the annual compliance
review week, there were no groups conducted within the last thirty days; therefore, group videos
could not be observed. An interview was conducted with three youth during the annual
compliance review week and each youth rated the mental health treatment services as good at
the center. An interview with the DMHCA reported the center offers mental health and
substance abuse assessments, crisis intervention, suicide prevention, and supportive services.
The DMHCA stated youth who are in the center for thirty days or more receive treatment while
detained, unless behavior or requests warrant treatment prior to thirty days. Youth discuss
treatment goals and objectives during treatment team. An individual treatment plan is created,
and goals and objectives are discussed. Substance abuse consents will be signed if youth have
a substance abuse history. Mental health staff will meet with the youth to review the
comprehensive assessment together and process the information. The youth and mental health
therapist will sign and date the comprehensive assessment, the individual treatment plan, and
any reviews to show when it is updated and/or reviewed. All signed documents are saved in the
youth’s record.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center maintains a written policy and procedures to ensure psychiatric services are
provided by a licensed and certified professional. Psychiatric services are provided to youth in
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need of services, as indicated by symptoms of mental disorders or substance abuse related
disorders, or to youth who are treated with psychotropic medication after their admission to the
center. The psychiatrist maintains a clear and active license in the State of Florida, which
expires on March 31, 2026. The psychiatrist is an osteopathic physician with an American Board
of Psychiatry and Neurology commendation in child and adolescent psychiatry. The center has
one back-up psychiatrist whose license is clear and active in the State of Florida, which expires
on January 31, 2026. The center is approved by the Department’s Office of Health Services to
provide tele-psychiatry. The designated mental health clinician authority (DMHCA) reported
meeting with the psychiatrist anytime a youth is referred for psychiatric medication management
and weekly when telepsychiatry occurs. The doctor conducts telemedicine visits each Tuesday
when there are youth on psychotropic medication at the center. These visits are facilitated by
mental health staff. Any concerns are communicated to the doctor during these telehealth
sessions. Three youth records were reviewed, and one was applicable for psychiatric services;
therefore, two additional records were provided for the review of psychiatric services. All three
applicable youth entered the center on psychotropic medications, were seen by the psychiatrist
within the required time frame, and had their medications continued. Each youth had an initial
diagnostic psychiatric interview completed on the Department’s Initial Psychiatric Diagnostic
Interview and Psychotropic Evaluation form within fourteen days of admission which included all
required elements. Each youth’s medication was continued, and all required information was
documented on page three of the Department’s Clinical Psychotropic Progress Note (CPPN).
The psychiatrist signed and dated each CPPN. All three youth had a valid Authority for
Evaluation and Treatment (AET). Each reviewed evaluation included page three of the CPPN
outlining medication target symptoms, side effect descriptions, medication name, dosage, and
frequency. Each record was applicable for the Tardive Dyskinesia monitoring requirement and
each record contained monitoring. No records were relevant for a new prescription or any major
changes which would require parental/guardian consent. No reviewed youth were over the age
of eighteen or under the care of the Florida Department of Children and Families (DCF).
Reviewed documentation reflected the standard of psychiatric care delivered through
telepsychiatry was the same as rendered in person, and each youth agreed to participate in
telepsychiatry at the center. Tele-psychiatry was only utilized for youth who agreed to participate
in the tele-psychiatry session and when the parent/ guardian provided consent.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a written policy and procedures and a Suicide Prevention Plan, which was
approved and reviewed by the designated mental health clinician authority (DMHCA) and the
superintendent. The policy and plan were signed by the superintendent or designee on August
7, 2023, and the DMHCA on August 31, 2023. The plan outlines the center’s procedures
addressing the use of suicide precautions, suicide prevention training, and the process by which
any youth identified as having suicide risk factors at any time must be placed on suicide
precautions and receive an Assessment of Suicide Risk (ASR). The plan identifies the levels of
supervision, referral process, communication, notification, and documentation requirements.
The center has an established review process for every serious suicide attempt or serious self-
inflicted injury. The multidisciplinary review includes the circumstances surrounding the event,
all relevant training received by involved staff, center procedures relevant to the incident,
pertinent medical and mental health services involving the victim, possible precipitating factors,
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and any recommendations for changes in policy, training, physical plant, medical or mental
health services, and/or operational procedures.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center maintains a written policy and procedures and a Suicide Prevention Plan outlining
requirements to safely screen, refer, assess, monitor, and protect youth with elevated risk of
suicide, using the least restrictive means possible. Any youth identified as having suicide risk
factors by screening, information obtained from the youth, or staff observations must be placed
on suicide precautions and receive an Assessment of Suicide Risk (ASR). Three youth mental
health and substance abuse records were reviewed, and each was applicable for having
elevated suicide risk factors during the admission process. Each youth was placed on
precautionary observation (PO) during the admission screening process. Reviewed
documentation confirmed a Suicide Risk Screening Instrument (SRSI) was completed, and an
alert was generated in the Department’s Juvenile Justice Information System (JJIS) as a result
of the SRSI. Reviewed documentation confirmed, prior to the ASR, each youth was on constant
supervision. The Suicide Precaution Observation Logs for the applicable youth were completed
in their entirety, including documenting safe housing areas, and were signed by all required
parties. The superintendent or designee was notified immediately of each applicable youth’s
suicide risk. Each ASR was completed by a licensed mental health professional. No youth were
released prior to receiving an ASR or released while on suicide precautions. Each youth’s ASR
was completed within twenty-four hours, as required. Each assessment included
recommendations for supervision and follow-up. A conference was held between the designated
mental health clinician authority (DMHCA) and the superintendent to reduce the level of
supervision for each youth to standard supervision. A review of the master control logbook,
emails, and the three youth ASRs documented supervisory staff were provided instructions
related to the suicide risk assessment findings and suicide precaution decisions for each youth.
Further review of the logbooks confirmed they documented the beginning and ending times of
each youth placed on precautions. A review of the alerts in JJIS indicated the alert was entered
and removed appropriately. The interviewed DMHCA reported if a youth is placed on PO during
their length of stay, mental health staff will assess the youth immediately or within twenty-four
hours. A referral will be submitted by the center’s officer/staff who placed the youth on PO. If
there is not a referral, mental health staff will complete a referral and close it with assessment
comments. Mental health staff are notified either through a referral, telephone call, or a center
staff member will discuss the youth with mental health staff verbally in person. Mental health
staff and the DMHCA are on call twenty-four hours a day, seven days each week for any
needed support and all crises/emergencies. The superintendent or designee also sends an
email with specifics for step down information to mental health and center staff. This email is
uploaded in the Electronic Medical Record upload library and printed out for the youth’s
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detention chart. Three interviewed youth stated they were never placed on suicide watch while
at the center. Three interviewed staff stated if a youth expresses suicidal thoughts, they are
responsible for notifying the mental health authority, placing the youth on constant sight and
sound and document the supervision. In addition, two staff stated they would search the youth
and their room for sharp objects and notify the supervisor.
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.
The center maintains a written policy and procedures regarding secure observation. Youth
placed on suicide precautions may remain under secure observation if less restrictive methods
are not effective. Three youth mental health and substance abuse records were reviewed, and
none were applicable for secure observation. The center reported they had no youth applicable
for secure observation since the last annual compliance review.
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.
The center maintains a written policy and procedures regarding Suicide Precautions
Observation Logs which details the process to safely screen, refer, assess, monitor, and protect
youth with an elevated risk of suicide in the least restrictive means possible. A review of three
mental health and substance abuse records found each youth was placed on precautionary
observation (PO) upon admission to the center. The Suicide Precautions Observation Logs
were maintained for the duration of each youth’s placement on PO. Reviewed documentation
reflected staff observations did not exceed the required intervals and were documented in real-
time. Each applicable Suicide Precautions Observation Log was reviewed and signed by the
shift supervisor and mental health clinical staff. Safe housing areas were clearly documented on
each log. Observations of camera footage during the week of the annual compliance review
confirmed appropriate supervision of youth on PO was maintained by staff.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Limited Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center maintains a written policy and procedures outlining the process for all staff who work
with youth to be trained in suicide precautions. Staff must participate in “mock” suicide drills
quarterly on each of the three shifts. A review of one pre-service and five in-service staff training
records validated each staff completed at least six hours of annual training on suicide
prevention and implementation of suicide precautions. Reviewed documentation of “mock”
suicide drills completed since the last annual compliance review reflected the center completed
drills on Alpha, Bravo, and Charlie shifts monthly, as required. An informal interview with the
juvenile justice detention officer supervisor (JJDOS) confirmed the center has three suicide
response kits, which are co-located with first-aid kits in master control, the center’s medical
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office, and the youth living units. Each suicide response kit included a knife-for-life, needle nose
pliers, and wire cutters. Reviewed documentation confirmed the center’s “mock” suicide and
mental health prevention drills were not being simulated by the center. The center’s drills are
being discussed during debriefing and are not simulated according to policy. According to the
Department’s Office of Health Services (OHS), it is required for the center to conduct and
simulate the mental health drills as indicated in the policy. Three interviewed staff reported the
suicide kits are located in master control.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center maintains a written policy and procedures and a Combined Emergency Services
Plan, ensuring the center responds 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 center. The
plan outlines the process for handling a notification and alert system, means of referral to
include youth self-referral, communication, supervision levels, documentation, and review, as
required.
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 policy and procedures regarding an Emergency Care Plan
outlining mental health and substance abuse emergency procedures and ensuring youth who
are believed to be an imminent danger to themselves or others because of mental illness or
substance abuse impairment receive emergency mental health or substance abuse services.
The plan addressed immediate staff response, notifications, communication, supervision of
youth, transport for emergency mental health evaluation and treatment under Chapter 394
Florida Statute (Baker Act), transportation for emergency mental health evaluation and
treatment under Chapter 397 Florida Statute (Marchman Act), documentation, training, and
review. The policy and plan were signed by the superintendent on August 7, 2023, and the
designated mental health clinician authority (DMHCA) on August 31, 2023. A copy of the plan is
located within the superintendent’s office, master control office, clinical office, and in the center’s
shared network drive, which is accessible to all staff.
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3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center maintains a written policy and procedures to ensure youth in crisis are administered
a Crisis Assessment. Three youth mental health and substance abuse records were reviewed,
and none were applicable for a Crisis Assessment. The center reported they had no youth
applicable for a Crisis Assessment since the last annual compliance review.
3.17 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center did not utilize Baker Act or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable
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Office of Accountability and Program Support Page 33 of 54 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains a written policy and procedures requiring a contractual agreement with a
licensed physician to serve as the designated health authority (DHA). The center maintains a
contract with VitalCore Health Strategies, LLC, which subcontracts with a medical doctor (MD)
to serve as the center’s DHA. The DHA holds an unrestricted clear and active license, which
meets all requirements for independent and unsupervised practice in the State of Florida, which
expires January 31, 2025. The center utilizes an advanced practice registered nurse (APRN)
whose license is clear and active to practice in the State of Florida, which expires April 30,
2025, and one licensed practical nurse (LPN), whose license is clear and active to practice in
the State of Florida with an expiration of July 31, 2026. The APRN and the DHA both signed the
Collaborative Practice Protocol agreement on November 27, 2023. The center’s DHA is
contracted to be on-site at least once a month and is on-call twenty-four hours a day, seven
days a week. A review of the center’s healthcare staff’s sign-in sheets since the last annual
compliance review showed the DHA was on-site once a month, as required. When the DHA is
on vacation or a scheduled absence, a back-up licensed physician is designated by VitalCore
Health Strategies, LLC, to provide clinical services. The back-up DHA has a clear and active
license in the State of Florida with an expiration date of January 31, 2025. An interview with the
DHA revealed they are on-site once a month to provide clinical services and are available by
email and telephone communication twenty-four hours a day, seven days a week. The DHA is
responsible for communicating with the center’s staff regarding youth medical needs and being
available for consultation by electronic means twenty-four hours a day, seven days a week for
acute medical concerns, emergency medicine, and coordination of off-site care. The DHA has
an APRN who assists with the medical services provided to the youth. The interviewed DHA
reported the specific duty of the DHA is to supervise the medical department and the designated
APRN provides on-site clinical services. Additionally, the DHA indicated they meet with the
medical staff on a weekly basis to review all medical issues at the 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 maintains a written policy and procedures for all utilized health-related procedures
and protocols. Reviewed documentation reflected the designated health authority (DHA)
reviewed, signed, and dated the policies on November 27, 2023, and the superintendent signed
on August 31, 2023. The psychiatrist reviewed and signed the relevant policies on February 26,
2024. Reviewed documentation validated the licensed practical nurse (LPN) and the advanced
practice registered nurse (APRN) reviewed,and respectively signed and dated the cover page
on the policies on September 21 and November 25, 2023. The center’s treatment protocols
were signed and dated by the DHA on November 27, 2023. The center’s non-healthcare staff
protocols were signed and dated by the DHA on June 12, 2024, and June 22, 2024. VitalCore
Health Strategies, LLC has an established comprehensive clinical orientation for all newly
employed healthcare staff, which includes the Department’s healthcare policies and procedures.
The center has had no newly hired medical staff since the last annual compliance review.
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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.
The center maintains a written policy and procedures requiring parents/guardians to be afforded
the right to give or withhold consent regarding the healthcare provided to the youth. A review of
three youth Individual Healthcare Records (IHCRs) revealed two of the three records had a
signed Authority for Evaluation and Treatment. Each applicable signed AET was marked as a
copy on the form if it was not the original AET. There was one youth applicable for being under
the care and custody of the Department of Children and Families (DCF) and the record
contained a signed Limited Consent for Evaluation and Treatment. Each applicable AET,
Limited Consent for Evaluation and Treatment and/or court order was obtained prior to providing
medical services to the youth. Each applicable AET or Limited Consent for Evaluation and
Treatment was valid and was signed by a representative of the Department. Each reviewed
youth was under eighteen years of age. An interview with the licensed practical nurse (LPN)
indicated the nursing staff obtain a valid AET upon each youth’s admission into secure detention
through the assigned juvenile probation officer (JPO) or the nursing staff will contact the
parent/guardian in order to obtain their signature.
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.
The center maintains a written policy and procedures outlining requirements for
parental/guardian notification of significant changes in the youth’s condition and obtaining
written consent from the parent/guardian when new medications and treatments are prescribed.
A review of three youth Individual Healthcare Records (IHCRs) indicated no youth were
applicable for parental/guardian notification and consent. The center indicated there were no
other records applicable for parental/guardian notification or consent since the last annual
compliance review. Three youth IHCRs were reviewed for vaccination status, and each
contained a vaccination record from Florida Shots, which was reviewed by medical staff within
thirty days of each youth’s admission. No Religious Exemption from Immunization forms were
submitted since the last annual compliance review. An interview with the licensed practical
nurse (LPN) indicated the center’s process for documenting attempted parental/guardian
notifications and procedures followed when there is a youth with an illness or injury which
requires emergency medical services. Additionally, the nursing staff explained the procedures
for obtaining the immunization records upon admission.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains a written policy and procedures requiring each youth, at the time of
admission, to have a completed Medical and Mental Health Admission Screening form in the
Department’s Juvenile Justice Information System (JJIS). A review of three youth Individual
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Office of Accountability and Program Support Page 35 of 54 (Revised July 2023)
Healthcare Records (IHCRs) found all three had a Medical and Mental Health Admission
Screening form completed on the date of admission. Each reviewed form was completed on the
date of admission by a juvenile justice detention officer (JJDO), and each indicated the
screening was reviewed by a licensed medical staff within twenty-four hours. Reviewed
documentation validated the designated health authority (DHA) was notified of the applicable
youth at admission, as required. Each youth screening form was completed in JJIS, as required.
The center reported there were no youth applicable for a change in physical custody since the
last annual compliance review. An interview with the licensed practical nurse (LPN) validated
the admission screening practices.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains a written policy and procedures requiring all youth to be oriented to the
general healthcare delivery services at the center. A review of three youth Individual Healthcare
Records (IHCRs) showed each youth received a general healthcare orientation on the day of
admission to the center. Each record contained a completed Department Health Education
Record form documenting youth orientation to the center’s healthcare services within twenty-
four hours of admission to the center. Each youth orientation included topics addressing access
to medical care, sick call, instances which constitute an emergency and when to notify staff, the
medication process and side-effect monitoring, the right to refuse care and how it is
documented, what to do in the case of a sexual assault or attempted sexual assault, and the
non-disciplinary role of the healthcare providers. The healthcare staff also review each youth’s
list of healthcare contacts to ensure accuracy.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center maintains a written policy and procedures which require notification to the
designated health authority (DHA) of all youth admitted with chronic health conditions or youth
in need of emergency care. A review of three Individual Healthcare Records (IHCRs) reflected
one youth was applicable for taking psychotropic medications upon admission. The reviewed
youth record was applicable for the youth having been admitted while taking psychotropic
medication and the psychiatrist was notified of the youth’s admission. The center reported there
were no additional youth with chronic conditions or taking psychotropic medications since the
last annual compliance review, and there were no current applicable youth. An interview with
the licensed practical nurse (LPN) indicated the DHA is notified within six hours whenever a
youth is admitted and identified with an emergency or chronic condition. Additionally, the DHA is
notified by the nursing staff, and it is documented in the healthcare record on the chronological
progress note.
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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.
The center maintains a written policy and procedures requiring completion, or review, and
updating of the Department’s standard Health-Related History (HRH) form. The center utilizes
and completes the standard Department HRH form for all youth admitted into the center’s
physical custody. A review of three youth Individual Healthcare Records (IHCRs) found each
contained a new HRH form. Each HRH form was completed by a licensed nurse within seven
days of the youth’s admission to the center. Reviewed documentation indicated each HRH form
was reviewed by the DHA or the advanced practice registered nurse (APRN). The HRH form
was completed before or at the same time as the Comprehensive Physical Assessment (CPA)
for each youth and reflected the most current admission. A review of the nursing interview
confirmed the HRH is completed by the nursing staff upon the youth’s admission, within forty-
eight hours.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains a written policy and procedures requiring a Comprehensive Physical
Assessment (CPA) form to be completed or updated for all applicable youth admitted
determining the health and wellbeing of each youth. A review of three Individual Healthcare
Records (IHCRs) was completed and each contained documentation of a completed CPA. Two
of the three had a current CPA on record, completed by the medical doctor (MD), and a new
CPA was completed by the advanced practice registered nurse (APRN) for the third youth. For
the youth with current CPAs, documentation supported the CPA was reviewed and a focused
evaluation was completed by the APRN as required. Each reviewed CPA was completed within
seven days of the youth’s admission and signed by the APRN. Each CPA was completed in full
to include the Medical Grade, Tanner Stage, cardiovascular, body mass index, visual acuity
field, and most recent Tuberculosis Skin Test (TST). All three youth records documented a Tier
1 Tuberculosis (TB) screening was completed on the Medical and Mental Health Admission
Screening form. All sections of the CPA were marked with “O”, except for sections which were
noted by the MD/APRN as not being clinically indicated. None of the reviewed records
documented the youth refusal on any part of the exam and the Department’s Problem List was
updated, as required. Each of the reviewed records documented a TST was completed within
the last year. None of the reviewed youth required further evaluation prior to entering the
general population. The center’s policy and procedures for TB control and screening require the
routine screening of all youth for latent and active TB and outline environmental controls in the
case of a youth with suspected active TB. A review of the nursing interview indicated the
designated health authority (DHA) or APRN completes the CPA at the time of admission and
yearly for youth who have not been out of the Department’s custody. Nursing staff indicated TB
screenings are provided to youth within forty-eight hours of arrival to the center if required.
Additionally, gynecological examinations are not routinely completed for female youth.
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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.
The center maintains a written policy and procedures requiring all youth to be evaluated and
treated, if necessary, for sexually transmitted infections (STIs). All sexually active youth are
clinically screened and evaluated for STIs. After the screening, youth are referred to the
designated health authority (DHA) or advanced practice registered nurse (APRN) to determine if
further testing is indicated. A review of three Individual Healthcare Records (IHCRs) confirmed
one youth was sexually active. Two of the three youth records indicated no further evaluation
was required. One youth record included documentation for ordered testing; however, the youth
record documented the youth declined consent. STI screenings, evaluations, and referrals are
documented and maintained in each youth’s IHCR. There were no youth applicable for being
out of the Department’s custody for thirty days or more needing a rescreening since the last
annual compliance review. All three reviewed records validated each youth was offered
counseling and testing for human immunodeficiency virus (HIV). The center had no applicable
youth who consented to HIV testing since the last annual compliance review. The center’s
practice is to obtain counseling and testing orders at the direction of the APRN. An interview
with the nurse indicated the HIV results would be documented on the youth’s Infectious and
Communicable Disease form and the laboratory results section of the record. Additionally, HIV
pre-counseling, testing, and post-counseling are conducted by the nursing staff. Three
interviewed youth reported being able to request an HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains a written policy and procedures regarding sick call processes and
requests. The center conducts sick calls seven days a week to respond to a youth’s medical
illness or injury of a non-emergent nature by a healthcare professional. Postings throughout the
center indicated sick call takes place seven days a week on Monday through Thursday 4:00
p.m. to 5:00 p.m., Wednesday 7:00 p.m. to 8:00 p.m. and Thursday through Sunday 4:00 p.m.
to 5:00 p.m. when youth are securely detained at the center. Shift supervisors are trained in the
center’s sick call procedures and are to review the sick call requests in the absence of
healthcare professionals. A review of three Individual Healthcare Records (IHCRs) indicated
none were applicable for having submitted a sick call. The center reported having no youth
applicable for a sick call since the last annual compliance review. Sick calls are conducted by
the licensed practical nurse (LPN) within twenty-four hours. An interview with the nursing staff
confirmed where the sick call would be conducted by the nursing staff within twelve hours, and
all sick calls are conducted at the nurse’s station. The center maintains treatment protocols
appropriate to the level of the provider conducting sick call, which was approved and signed by
the designated health authority (DHA) on November 27, 2023. Three interviewed staff stated the
nurse conducts sick calls. One staff stated staff can conduct sick calls also. An interview with
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Office of Accountability and Program Support Page 38 of 54 (Revised July 2023)
three youth indicated they have not submitted a sick call. There were no sick calls during the
annual compliance review week; therefore, a sick call could not be observed.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Limited Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center maintains a written policy and procedures detailing a comprehensive process of
episodic care, first-aid treatment, and emergency care. The center utilizes an Episodic Care Log
to document episodic care and first-aid treatment. The log contains information to include the
date, name of youth, the youth’s Department identification number, nature of illness or injury,
treatment rendered, staff initials, nurse initials, verification of who provided episodic care, and if
the youth was recommended for off-site care. A review of three youth Individual Healthcare
Records (IHCRs) showed there were two youth applicable for episodic or emergency care. The
center reported there were no additional records applicable for episodic or emergency care
events since the last annual compliance review. In each applicable record, the nature of the
complaint was documented, and the findings of the healthcare staff rendering care were
included. None of the reviewed instances of episodic care required a referral to off-site care.
Each reviewed instance documented the education/instruction provided to the youth, and an
entry in the Episodic Care Log was completed. There were no youth requiring a follow-up
evaluation. The center maintains eight first-aid kits which are located on each of the two youth
living units, master control, intake, dining room, the medical clinic, and two kits for the
transporting vehicles. The first-aid kits for each of the two transport vehicles are stored within
master control. The center’s policy states first-aid kits shall be inspected and restocked monthly
and are to be sealed with breakaway tabs. Observations of three kits during the annual
compliance review week validated the kits were stocked with the designated health authority
(DHA) approved contents. Informally interviewed nursing staff indicated they conduct weekly
perpetual counts of the contents to ensure the integrity of the contents. The center maintains
one automated external defibrillator (AED). The center’s AED is located on a wall-mounted AED
box in the medical clinic. The AED procedures were in the AED box, as well as audio
instructions. Nursing staff check the AED batteries and pads monthly to ensure the AED is
operational and document their review on a tracking sheet. A review of the center’s AED
tracking sheets since the last annual compliance review confirmed they documented the
center’s practice. The AED was self-tested in front of the annual compliance reviewer to ensure
it was operational, and no issues were noted. The batteries in the AED expire on December 31,
2027, and the pads expire on November 3, 2026. The center’s policy and procedures indicated
emergency drills are to be conducted for each shift on a quarterly basis at a minimum, and
AED/cardiopulmonary resuscitation (CPR) procedures must be demonstrated at least annually.
A review of quarterly emergency drills since the last annual compliance review indicated drills
were being conducted; however, observations of the simulations of the episodic care, first-aid,
AED/CPR techniques could not be made through video. The center reported their drills are
discussed during the staff debriefings; however, the drills are not simulated as required
according to policy. All documented drills included the type of medical event, time the drill/event
occurred, time 9-1-1 was called, if applicable, name of the juvenile justice detention officer
supervisor, healthcare provider in charge, healthcare provider response time, type of medical
care rendered, time the event concluded, clinical manager/medical staff review, and critique.
Observations confirmed emergency contacts and telephone numbers were posted in the
medical clinic and in master control to include the number for the statewide Poison Control
Center. The center has a policy and procedure regarding the use of NARCAN®. Effective April
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Office of Accountability and Program Support Page 39 of 54 (Revised July 2023)
2024, the center’s nurses are responsible for conducting staff training on NARCAN® as a stand-
alone, instructor-led class for the supervisors trained and approved for medication
administration. The center maintains NARCAN® in the locked medication cart which is
accessed only by the licensed nurses and shift supervisors who have completed training on
medication administration. The center maintains a perpetual and weekly inventory of the
NARCAN®. An interview with the nursing staff indicated the center has not utilized NARCAN®
since the last annual compliance review. A review of one pre-service and three in-service staff
training records found each was trained and held current certifications in CPR, first-aid, and
AED. All non-healthcare staff and nursing staff are required to maintain certifications. A review
of three training records supported each staff received the required training on the center’s
Emergency Care Plan, and the supervisory staff received training on the epinephrine auto
injector. Only healthcare and trained supervisory non-healthcare staff can administer the
epinephrine auto injector for youth requiring administration when indicated. Reviewed
documentation supported the designated health authority (DHA), the advanced practice
registered nurse (APRN), and all nursing staff maintained current certifications in CPR and
AED. An interview with the nursing staff indicated all emergency and medical drills are held
monthly. Additionally, the medical staff are responsible for documenting and tracking all
instances of episodic care, first-aid, emergency care, and off-site referrals. Three staff were
interviewed to determine if they are able to call 9-1-1 if necessary, and each staff stated yes, if
needed. Three youth were interviewed, and each youth reported not receiving medical care at
the center.
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.
The center has a written policy and procedures to provide referrals and coordination of medical
services to ensure youth have timely access to off-site care services. A review of three youth
Individual Healthcare Records (IHCRs) found there were no applicable youth for off-site care;
therefore, additional records were requested. The center provided one additional applicable
record and reported there were no additional youth applicable for off-site care since the last
annual compliance review. The reviewed record contained the discharge paperwork, and the
Summary of Off-Site Care Consultation Report form, which was reviewed and signed-off by the
designated health authority (DHA). The signed form was then maintained in the youth’s record
and in the Department’s Juvenile Justice Information System (JJIS) Electronic Medical Record
(EMR). An interview with the nursing staff indicated the Episodic/Medical Tracking Log is utilized
for youth receiving off-site care, and nursing staff ensure all hospital orders are followed.
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.
The center maintains a written policy and procedures to ensure youth identified with chronic
conditions receive regularly scheduled evaluations and necessary follow-up care. A review of
three closed youth Individual Healthcare Records (IHCRs) found no youth were applicable for
the existence of chronic conditions. One youth was taking prescribed medication with a Medical
Grade of five. The youth was placed on the chronic list for the prescription medication; however,
did not remain in secure detention long enough for a periodic evaluation to be completed every
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ninety days. The problem list for the applicable youth was updated to indicate the youth’s
chronic condition upon completion of the Comprehensive Physical Assessment (CPA). There
were no youth applicable for taking anti-tuberculosis medication. There were no youth identified
as pregnant or morbidly obese. The center reported there were no other youth applicable for
chronic conditions since the last annual compliance review. An interview with the nurse
explained the center utilizes the alerts, charts, and a medical tracker to track periodic
evaluations. An interview with the designated health authority (DHA) indicated periodic
evaluations will be addressed and reviewed every thirty days, or more frequently for serious
chronic conditions, and indicated on the youth’s CPA.
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.
The center maintains a written policy and procedures to require all medication and
pharmaceutical products to be procured, dispensed, administered, and stored safely,
accurately, and in accordance with state, federal, and industry standards. The center’s practice
is for nursing staff to verify all medications have a current, valid order, and are given according
to a current prescription or practitioner’s order. Nursing staff verify medications with the
parent/guardian when they deliver the medication to the center. The Department’s Medication
Receipt, Transfer, and/or Disposition form is used to document medication received in the
original packaging from a licensed pharmacy with a current, legible, patient-specific label
affixed. A review of three Individual Healthcare Records (IHCRs) showed there was one youth
taking medication upon admission and there were no additional applicable youth available for
review. A review of the youth record showed the youth was applicable for restricted housing
while taking prescribed medications, since the last annual compliance review. Reviewed
documentation showed nursing staff completed the daily visits and provided all prescribed
medications. There were no applicable records for over-the-counter (OTC) medications not
listed on the Authority for Evaluation and Treatment (AET) form. The center utilizes a local
pharmacy as a back-up for emergency purposes. All medications are delivered to the center in
blister packs. A review of the applicable record indicated the designated health authority (DHA)
and the psychiatrist were contacted to obtain an order to resume the specified medication
prescribed prior to admission. A review of the youth’s medication showed there was a current,
valid order, and medications were administered pursuant to the current prescription. When
current medications were continued, discontinued, or changed the reviewed record indicated the
DHA/APRN placed an order on the Practitioner Order form, as required. The reviewed record
confirmed the center completed a prescription verification and documented the verification in the
chronological progress notes. The center utilizes the standard Department Medication
Administration Record (MAR) for each youth receiving either prescription medications on a
routine basis and/or OTC medications which included all required elements. The center
maintains a written policy and procedures to ensure the usage of the MAR by licensed
healthcare staff and non-licensed staff. Three youth records were reviewed, and one youth was
applicable for having MARs documenting administered medications. The reviewed MARs
documented side effect monitoring by the nursing staff at each medication administration. A
review of the standardized MAR form showed the form included the youth’s name, Department
identification number (DJJID), date of birth, youth allergies, precautions, Medical Grade, medical
alerts, and current picture of the youth. The were no applicable youth records containing a MAR
requiring a trained non-healthcare staff assisting in the delivery of medications when licensed
healthcare staff were not on-site. There were no undocumented explanations for lapses or
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errors in medication administration. There were no youth requiring parenteral medication at the
center since the last annual compliance review. The center did not have any standing orders for
psychotropic medications, no pro re nata (PRN) orders for psychotropic medications, or
emergency treatment orders for psychotropic medications. One reviewed record was applicable
for the youth entering the center while on prescribed psychotropic medication. The psychiatrist
was notified upon the youth’s admission, and the psychiatrist conducted an initial diagnostic
psychiatric interview within fourteen days of admission. The applicable record indicated the
youth was on psychotropic medications at the center for more than thirty days since the last
annual compliance review. A review of the applicable record confirmed medication monitoring
was completed every thirty days. Observations of a medication administration could not be
conducted during the week of the annual compliance review, due to the center not having any
youth taking medication. An interview with nursing staff indicated the center has a process for
monitoring and tracking youth with chronic conditions and medication upon entering the center.
Additionally, the nurse indicated the center has non-healthcare staff who are trained by medical
staff to provide OTC medication to youth. An informal interview with the center’s juvenile justice
detention supervisor (JJDOS) indicated staff were trained by the APRN on January 25, 2024.
An interview with three staff regarding medication administration was conducted. One of the
three staff stated they do not give medication to youth, and two staff indicated they do. An
interview with three youth indicated none of the youth took medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center maintains a written policy and procedures regarding the requirements for the storage
and inventory of medications and sharps ensuring all medication is inaccessible to youth at the
center. The dose-by-dose daily administration and documentation of a medication is
documented utilizing a perpetual inventory process for the daily distribution of non-controlled
prescription medications and over-the-counter (OTC) medications. Documentation of each
individual dosage of medication administered to youth is maintained on the Medication
Administration Record (MAR) to demonstrate the inventory utilizing a routine perpetual inventory
descending count. Observations of the medical clinic were conducted during the annual
compliance review week and found the clinic is secured under lock and key. A locked
medication cart is located in the medical office which stores all oral prescription and OTC
medications prescribed for youth. Narcotics and other controlled medications are securely
stored and double locked within the medication cart. The center did not have any prescription
medications on-site during the annual compliance review week and there were no opened OTC
medications. The center had no medication requiring refrigeration during the annual compliance
review week; however, the center has a refrigerator which is used only for medication, if
needed. A review of three OTC medications was conducted, each of which validated the
respective inventories were accurate. A review of the inventory logs confirmed perpetual and
weekly inventories are conducted on sharps and stock OTC medications. The interviewed nurse
indicated the center conducts perpetual inventories with running balances which are maintained
on all controlled substances with a shift-to-shift inventory conducted by the nursing staff. The
center had no controlled medication on-site during the annual compliance review week. The
center maintains an inventory of all sharps and medical equipment classified as sharps, to
include syringes, butterflies, needles, scissors, and suture removal kits. Syringes and sharps
are counted through a perpetual inventory and are verified weekly. A review of three sharps
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verified each matched the inventory log. Items designated as sharps are stored in a designated
cabinet in the medical clinic and are inaccessible to youth. An interview with the licensed
practical nurse (LPN) indicated the center maintains an extensive inventory of OTC medications
and a perpetual count is conducted as required. The nurse indicated the center’s inventory of
medication is stored securely, and any narcotic medications are maintained behind double
locks. The nurse was able to explain the procedures regarding inventory discrepancies. The
nurse validated the center’s practice and indicated the center utilizes a chemical pharmaceutical
drug disposal system to dispose of expired or discontinued medication. The center has a list of
trained non-healthcare staff who are approved to assist in the administration of medication. The
informally interviewed juvenile justice detention officer supervisor (JJDOS) indicated staff were
trained on the administration of medication by the advanced practice registered nurse (APRN)
on January 25, 2024.
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.
The center maintains a written policy and procedures requiring proper procedures to be followed
to prevent the spread of infectious diseases or illnesses and provide staff with the knowledge of
appropriate prevention, containment, treatment, and reporting requirements of infectious
diseases. A review of three closed youth Individual Healthcare Records (IHCRs) was
conducted. Reviewed documentation indicated each youth received infection control training
within seven days of admission. The infection control training included hand-washing
techniques, universal/standard precautions, prevention/transmission of communicable diseases,
vaccinations, and the Centers for Disease Control and Prevention (CDC) guidelines for infection
control. A review of the center’s Exposure Control Plan/Infection Control Plan documentation
showed the plan was written in accordance with Occupational Safety and Health Administration
(OSHA) guidelines to include risk assessment and methods of compliance. The plan addressed
common childhood infectious diseases, self-limiting, episodic contagious illnesses, viral or
bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus
(HIV), blood-borne pathogens, other outbreaks and epidemics, and outbreaks of pediculosis. In
addition, the plan included Methicillin Resistant Staphylococcus Aureus (MRSA) and other
antibiotic-resistant micro-organisms, food-borne illnesses, bioterrorism agents, chemical
exposures in the workplace, and protocols for needlestick post-exposure intervention and
treatment. The center’s post-exposure process for evaluating needle sticks includes reporting
the stick to the immediate supervisor, documenting the circumstances, route of exposure, and
the source individual and their status. Results of testing are to be made available to the exposed
staff, as well as providing appropriate counseling, and a referral to the nearest medical
center/hospital or Department of Health for post-exposure evaluation through worker’s
compensation. The center ensures Hepatitis B immunizations are made available for staff and
staff have access to protective equipment as needed. There were no reportable incidents for
which the local county health department, CDC, or the Department’s Central Communications
Center (CCC) had to be notified of an infectious disease since the last annual compliance
review. A review of three staff training records found each staff completed Exposure Control
Plan/Infection Control Plan training. An interview with the nurse indicated all infection control
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Office of Accountability and Program Support Page 43 of 54 (Revised July 2023)
education is provided to youth at admission. Additionally, the designated health authority (DHA)
conducts the infection and exposure control training, and the nursing staff are responsible for
providing detention staff with training on the Exposure Control Plan. The nursing staff indicated
a copy of the Exposure Control Plan is available to staff and a copy of the plan is located in the
medical office.
4.18 Prenatal Care/Education [Contract Provider] Non-Applicable
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center did not have any pregnant youth during the annual compliance review period;
therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has a written policy and procedures to address active supervision of youth. During
the annual compliance review week, youth supervision was observed each day. Youth and staff
observations on the living unit and in the classrooms were conducted. Detention staff
maintained continuous sight supervision of all youth in their assigned area. The interactions
between staff and youth demonstrated active supervision. Staff were positioned in the areas
supporting active supervision. The juvenile justice detention officers (JJDOs) and master control
operators communicated to receive authorization for all movement within the center. A review of
master control logbooks since the last annual compliance review verified there was
documentation to support headcounts were conducted on a consistent basis during the
beginning and ending of each shift and prior to youth movement. Three staff were interviewed
and two reported they think there are enough staff at the center to provide for the safety and
security of the youth and staff. One staff reported they do not think there are enough staff at the
center to provide for the safety and security of the youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center maintains a written policy and procedures ensuring there is a uniform behavior
management system (BMS) offering a predictable set of rewards, privileges, and
consequencefor behavior. The center has a system of rewards, privileges, and consequences to
motivate
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youth to meet the center’s expectations. Observations conducted during the annual compliance
review week revealed the center has the BMS information posted in each living module. The
postings specify appropriate behaviors and rewards, and inappropriate behavior and
consequences. Youth are informed of the BMS during the admission process through an
orientation. The BMS is a three-tiered level system. Each youth starts at level two when
admitted, and their level moves up or down, depending on their behavior in the center. There
are incentives for youth obtaining level three status including canteen food items. The incentives
can be changed or updated depending on the center’s needs. A review of the level sheets and
logbooks confirmed the center’s practices. Three youth were interviewed regarding the BMS.
One youth stated the BMS is good. Two youth stated the BMS is very good. All three youth
were able to articulate how youth are rewarded in the center and explain the difference between
the levels. Three youth were interviewed, and two youth reported they have never received a
consequence during their time in the center. One youth stated the consequences received were
fair. All three of the youth stated they are not allowed to punish other youth. All three youth
stated they have not been placed in a room for punishment. All youth stated they have never
witnessed handcuffs or leg irons used on out-of-control youth to prevent them from hurting
themselves or others. Three staff members were interviewed regarding the BMS. All staff were
able to articulate the rewards provided within the BMS, described the BMS as having a point
system, a level system, is posted throughout the center and is included in the youth handbook.
All three interviewed staff members reported the BMS is effective. The staff stated they speak to
the youth to discuss the consequences being imposed and alternative acceptable behavior.
Each interviewed staff stated the youth are provided an opportunity to explain their behavior.
Three staff reported only points/levels can be taken away as a consequence. All staff confirmed
management provides feedback regarding the BMS on a daily basis. The center has a policy
and procedures to address unauthorized use of punishment. The center’s BMS prohibits the use
of group punishment, corporal punishment, or use of drugs to control youth behavior. Three staff
were interviewed, and each advised the consequences never include loss of meals, snacks,
school, or other rights afforded to the youth. All interviewed staff further indicated they had
never witnessed a co-worker take meals, snacks, clothing, education, or medical care from a
youth because they were acting out. All three staff indicated they have never witnessed a co-
worker encourage a youth to beat up another youth. The juvenile justice detention officer
supervisor (JJDOS) was interviewed and stated the statewide BMS is used at the center. Youth
come into the center on level two and, as long as they are earning their points for the day, the
level is moved up until they leave. Once a youth reaches level three status, the youth are
granted additional snacks and other privileges.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has a written policy and procedures addressing ten-minute checks. The center has
twenty-seven cameras with a recording capacity of thirty days. During the week of the annual
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Office of Accountability and Program Support Page 46 of 54 (Revised July 2023)
compliance review, five cameras were not operational. The shift commander indicated a work
order had been submitted and maintenance repaired the cameras; however, they stopped
working a few days later. A new work order has been submitted and is pending. Staff utilize
handwritten Ten-Minute Observation Logs to document ten-minute checks. A review of the
documentation and surveillance coverage was conducted for nine randomly selected dates
across three shifts on the youth living modules. All checks were completed as required, with the
exception of one check which was conducted twenty-five minutes late. Twenty-four handwritten
ten-minute check observation logs were reviewed across the prior twelve months across two
shifts. Documentation verified the superintendent, or designee reviewed the observation logs
weekly. All ten-minute checks were conducted within the required policy. Three interviewed staff
stated they conduct room checks when a youth is placed in their room for sleeping or non-
punishment reasons every ten-minutes. The interviewed juvenile justice detention officer
supervisor (JJDOS) stated ten-minute checks are conducted when any youth is behind a closed
door. Staff will stop and look through the plexiglass to ensure the youth is breathing and safe.
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 has a written policy and procedures in place to ensure staff know the exact number
and location of all youth under their supervision at all times. A logbook review of one full day
from each month throughout the annual compliance review period was conducted.
Documentation confirmed the census counts of youth are written at the beginning and at the
end of each shift. Further, counts are conducted and documented, at a minimum, one additional
time randomly during each shift. Counts were documented following youth movements,
emergencies, disturbances, and drills. Census counts were documented upon any change of
population. Living module counts were recorded in their assigned module logbooks.
Three staff were interviewed, and all three staff reported youth counts are conducted at the
beginning of shift. Two staff reported counts are conducted at the end of shift. Two staff
reported emergency counts are conducted when a youth is believed to be missing. Three staff
reported emergency counts are conducted when visibility is hindered, such as an electrical
outage. Two staff reported emergency counts are conducted after a major disturbance.
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Office of Accountability and Program Support Page 47 of 54 (Revised July 2023)
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has a written policy and procedures regarding logbooks. The center maintains
separate logbooks in master control and for each living module, as well as one for visitors, and
one for contracted staff. A sample of logbooks for one day each month during the annual
compliance review period was reviewed. Documentation revealed each logbook was bound with
numbered pages, all entries included the date and time of the event or incident with the name of
the staff and youth involved, and a brief description of the event and the initials of the staff
making the entry. Entries included safety and security of the center, including medical, special
needs, and mental health alerts which were highlighted. Reviewed logbooks reflected all errors
are struck through with a single line and dated and initialed by the person correcting the error.
Reviewed master control logbooks included emergency situations, incidents, fire and escape
drills, population counts at the beginning and end of each shift, group movements, admissions
and releases, name of youth placed on precautionary/secure observation, and the time
precautionary/secure observation began and the time precautionary/secure observation was
discontinued. The juvenile justice detention officer supervisor (JJDOS) reviews the logbooks
when accepting the shift, to document they are aware of current relevant situations in the
center. The superintendent or designee reviewed the logbooks on a weekly basis. The juvenile
justice detention officer (JJDO) assigned to the modules review the logbook upon accepting the
shift. The interviewed JJDOS verified logbooks are reviewed weekly.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has a written policy and procedures on key control. This policy addresses key
control, issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or
lost keys, and reporting and replacement of damaged keys. All keys are stored on a tamper-
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resistant key ring which inhibits the removal of keys and is color coded specific to the position
the key is assigned. The center maintained a master key inventory which accounts for all key
rings by ring number, the number of keys on each ring, the capability of each key, and to whom
the keys are assigned and issued. Emergency keys which provide egress through exterior doors
are stored in master control. A review of the Key Control Logs confirmed the issuance of keys
and key rings was documented on the Key Control Logs for each shift with the date and time of
issue, name of the person issuing the key, name of person receiving the key ring, and time
returned. In addition, the issuance of keys and key ring numbers were documented on each
shift report. During the annual compliance review week, staff were observed carrying the keys
on their person at all times and youth did not have access to center keys. A review of the master
key control inventory revealed the inventory report matched the actual key rings in use. There
were no reported incidents during the annual compliance review period of lost keys or staff
taking keys home after their shift. If keys were to be taken home by staff, the staff are required
to return the keys to the center within two hours of discovering the keys were taken home.
Personal keys are stored in staff lockers, visitor lockers or secured in master control.
Observations verified staff placed their personal keys in designated lockers prior to entering the
secure area of the center. Master control would issue center keys to staff and document the Key
Control Logs. A random check of five different sets of center keys compared to the inventory list
indicated the keys were accounted for, the key tag matched the number of keys actually on the
key ring, and the ring was documented on the key log. The informally interviewed master control
operator verified keys are restricted only to staff authorized to have each key type and all key
rings are color coded to maintain control of the keys. A random check of three staff verified the
number of keys on their key ring matched the inventory and each staff knew the function of each
key. Three staff were interviewed, and all three reported the restricted keys include keys which
access medical records, the youth property area, mental health records, and case management
records. All three interviewed staff could articulate the daily process for key control at the center.
An interview with the juvenile justice detention officer supervisor (JJDOS) verified if assigned
keys are missing, staff must report the keys were lost or stolen and a search of the center and
youth is conducted.
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 has a written policy and procedures in place for transportation procedures and
operation of Department vehicles. The center has two vehicles used to transport youth. Both
vehicles had the appropriate number of seatbelts, a seatbelt cutter, a window punch, a fire
extinguisher, and a first-aid kit with approved items. A review of documentation since the last
annual compliance review found each vehicle was inspected prior to transports. Documentation
supported the shift supervisor completed weekly and monthly vehicle checks. A review of the
vehicle maintenance invoices revealed both vehicles assigned to the center received an annual
inspection within the previous year. Each of the vehicles had documentation of a visual
inspection conducted, as well as maintenance sheets to inspect the levels for water coolant,
lights, oils, emergency equipment, horn, cleanliness of the vehicle, and the condition of the
interior/exterior. A review of the center’s logbook confirmed youth were searched prior to the
transports, and all youth were securely fastened into their seatbelt. The logbook also contained
the beginning and end time of each transportation, staff and youth names, and the destination
for transport. Further observation of both vehicles found they were secured when not in use.
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Office of Accountability and Program Support Page 49 of 54 (Revised July 2023)
There were two transportations observed during the annual compliance review week. There was
one observation of a youth transported from court being admitted to the center. There was also
an observation of a youth being transported from one center to another center. Observations
verified the vehicles were checked for contraband, the security screen was securely anchored,
all seatbelts were working and securely anchored, staff had a cellular telephone, the inspection
was documented in the logbook, the youth were searched prior to leaving the center, and the
youth were searched after being processed as a new admission. Three interviewed youth
reported not seeing anyone place contraband in a transport vehicle and they felt staff were
driving safely when transporting youth.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has a written policy and procedures addressing tool inventory and management.
Food service and maintenance are provided by the Monroe County Sheriff’s Office and meals
are prepared in the kitchen at the county jail and delivered to the center. There are no kitchen or
maintenance tools stored at the center. Class B tools such as brooms and mops are secured in
the janitor’s closet. The center has one mop and one broom which are used daily. Youth may
use cleaning items such as mops, brooms, buckets, and other common household items under
the direct supervision of the juvenile justice detention officer (JJDO). In an informal interview,
the juvenile justice detention officer supervisor (JJDOS) stated staff accompany service vendors
when entering the secure area of the center. In addition, the work project area is inspected for
lost or missing tools prior to allowing youth access to the area. An observation of two youth
using a broom and dustpan was conducted. Staff monitored the youth while the youth were
using Class B tools. Three youth were interviewed, and one stated they do not use any tools.
Two youth stated they use mops and brooms. Three staff were interviewed, and all three
reported youth are only allowed to use mops and brooms. All three staff were able to articulate
the processes if a tool goes missing. The interview of the JJDOS revealed the center does not
have any Class A tools.
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Office of Accountability and Program Support Page 50 of 54 (Revised July 2023)
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 has a written policy and procedures to address the inventory of flammable, toxic,
caustic, and poisonous items. Flammable, toxic, caustic, and poisonous items are maintained in
secure areas with limited access. Safety Data Sheet (SDS) logbooks are at the location where
the chemicals are stored. Inventories of flammable, toxic, caustic, and poisonous items are
maintained by the center. The SDSs and inventories were compared to a sample of five items
on-site and were found to be accurate and complete. Observations and an informal interview
with the juvenile justice detention officer supervisor (JJDOS) confirmed flammable, toxic, and/or
caustic materials are stored in the janitor’s closet under lock and key and are only accessible to
supervisory staff. Three youth were interviewed and two responded they do not use cleaning
agents such as bleach, laundry soap, toilet, or window cleaner. One youth reported the cleaning
agents are poured into the mop bucket by staff. All three youth responded they do not have
access to flammable, toxic, caustic, and poisonous items. Three staff were interviewed, and two
reported youth are not allowed to clean with chemicals which are toxic, flammable, or
poisonous. One staff reported youth are allowed access to such materials; however, staff apply
the cleaning agent.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has a written policy, and procedures address proper use, storage, and disposal of
flammable, toxic, caustic and poisonous items. The plan addresses what procedure to follow in
the event of a chemical leak, or spill. An interview with the center’s juvenile justice detention
officer supervisor (JJDOS) reported the local waste management department handles all
disposal of flammable, toxic, caustic, and poisonous items and there have been no chemical
spills or leaks within the annual compliance review period.
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Office of Accountability and Program Support Page 51 of 54 (Revised July 2023)
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has a written policy and procedures addressing confinement under twenty-four
hours. A review of the Department’s Juvenile Justice Information System (JJIS) revealed the
center has not had any confinements under twenty-four hours since the last annual compliance
review. Observations of the confinement rooms verified the windows and cameras were free of
obstructions and scratches allowing youth to be visually observed by staff. Three staff were
interviewed, and each reported if a youth is placed in room confinement, a report is written, ten-
minute observations are completed, and the confinement room is searched before placement.
All three staff stated education materials are provided for youth in room confinement. The
interviewed juvenile justice detention officer supervisor (JJDOS) was able to articulate the
process for confinements.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has a written policy and procedures to manage various emergencies and disaster
events. Two Continuity of Operations Plan (COOP) drills were conducted during the annual
compliance review period. Hurricane drills were conducted on April 30, 2024, and on July 31,
2024. One of the drills was conducted prior to the beginning of hurricane season. There were
written scenarios, drill forms, critique forms, and emails used to document the drills. Reviewed
documentation verified drills contained the type of drill, date and time, participants, a brief
scenario, findings, and recommendations. Three interviewed staff reported they have
participated in weather drills, COOP drills, and fire drills. One staff reported they have
participated in a bomb threat drill and a medical drill. The interviewed juvenile justice detention
officer supervisor (JJDOS) stated the center has a COOP which includes emergency plans for
safety and emergencies which may arise.
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Office of Accountability and Program Support Page 52 of 54 (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 has a written policy and procedures to address escape drills and escape prevention.
The policy requires the center to conduct quarterly escape drills. A review of escape drill
documentation since the last annual compliance review was conducted. The center completed
quarterly escape drills without exception. Reviewed documentation verified the center
conducted escape drills on a quarterly basis. The documentation of the drills included scenarios,
as well as the dates and times of the drills. The drill documentation form included the signatures
of the supervisor and the staff coordinating the drill. Recommendations and critiques of the drills
were included in each report. A review of the logbooks revealed all escape drills were
documented in the logbook as required. A review of five staff training records verified each was
trained in escape prevention. Three interviewed staff responded they have participated in
weather drills, COOP drills, and fire drills. One staff responded they have participated in a bomb
threat drill and a medical drill.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a fire prevention and evacuation plan which addresses fire prevention and
safety of the program. The plan was reviewed and approved by the local fire official. A review of
documentation supported the center conducted fire drills every month, on each shift, since the
last annual compliance review. The fire drills were also documented in the master control
logbooks. Staff sign-in sheets were used to document staff participation in the drills. Reviewed
documentation verified fire extinguishers were inspected annually. Three staff were interviewed,
and each reported they have participated in fire drills during the annual compliance review
period. All three staff reported fire drills take place at least monthly. Three youth were
interviewed, and each stated they have been instructed on what to do in the case of a fire.
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Office of Accountability and Program Support Page 53 of 54 (Revised July 2023)
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has a written policy and procedures to address illegal contraband and prohibited
items. Upon admission to the detention center, youth are searched by detention staff. During the
annual compliance review week, a pat-down search was observed, and the staff thoroughly
searched the youth with gloves on and reported the search to master control. There were
observations of searches made for a transport and a new admission during the annual
compliance review week. The search of the youth was conducted individually and not in a group
setting. In-person and video observations confirmed electronic searches were conducted on all
persons entering the center. All bags, cases, jacket pockets, and other items were searched. All
personal keys were collected by master control before entering the secure area. Personal
cellular telephones and other contraband items were prohibited. Room searches are completed
upon releasing a youth and prior to placing a new youth in a room. Room searches were also
conducted on each awake shift. A review of room searches was conducted for one day each
month during the annual compliance review period and confirmed both awake shifts completed
and documented room searches. Since the last annual compliance review there were no
instances which compromised the safety or security of the center. A review of the visitor’s log
confirmed it contained a contraband attestation statement. A review of five in-service records
and one newly hired staff record verified each contained a contraband attestation. A review of
the Department’s Central Communication Center (CCC) incident reports found there have been
no instances of contraband introduction into the center during the annual compliance review
period. The interviewed juvenile justice detention officer supervisor (JJDOS) stated youth are
searched anytime they enter the center or staff believe the youth has contraband. If contraband
is discovered, it is confiscated, and law enforcement is notified.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 54 (Revised July 2023)

source: DJJ

rule: Indicator 3.13

rating: Limited Compliance

rule: Indicator 4.12