summary: QI Detention - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Collier Regional Juvenile Detention Center
"Department of Juvenile Justice"
(State-Operated)
3351 E Tamiami Trail
Naples, Florida 34112
Review Date(s): March 5-8, 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:
Andrice Holley, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Dennis Brown, Palm Beach Regional Juvenile Detention Center, Juvenile Justice Detention
Officer Supervisor (Standard 5)
Ebony Evans, Office of Accountability and Program Support, Regional Monitor (Interviews)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Evan Hald, Office of Education, Regional Education Coordinator, South Region (Standard 2-
Education)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Program Name: Collier Regional Juvenile Detention Center MQI Program Code: 1046
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Collier County / Circuit 20 Number of Beds: 40
Review Date(s): March 5-8, 2024 Lead Reviewer Code: 199
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
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 57 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 57 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 57 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 57 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 57 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 57 (Revised July 2023)
Program Overview
The Collier Regional Juvenile Detention Center is a state-owned detention center, operated by
the Department, located in Naples, Florida. The center serves youth in Lee, Hendry, Glades,
and Charlotte counties in Circuit 20. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
forty-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 Collier County School District.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant, seven juvenile justice detention officer supervisors (JJDOSs), ten
juvenile justice detention officer IIs (JJDOIIs), fourteen juvenile justice detention officer Is
(JJDOIs), a training coordinator, a food service director, two food service workers, and one
maintenance mechanic. Mental health and healthcare services are provided through the
contracted provider, VitalCore Health Strategies, LLC. Mental health services are provided by a
licensed clinical social worker (LCSW) who serves as the designated mental health clinician
authority (DMHCA). In addition to the DMHCA, the center has one regional licensed supervisor,
and on-site the center has one non-licensed full-time therapist and one licensed part time
therapist. A licensed psychiatrist provides psychiatric services for applicable youth in the center.
Clinical services provided by the center include mental health and substance abuse evaluations,
mental health treatment planning, individual, group, and family therapy, mental health crisis
intervention services, on-site psychiatric services, and availability for substance abuse services
for youth with co-occurring disorders. Medical services are provided by one medical doctor (MD)
who serves as the designated health authority (DHA), one advanced practice registered nurse
(APRN), one registered nurse (RN), and one licensed practical nurse (LPN). The medical clinic
maintains nursing coverage Monday through Friday from 7:00 a.m. to 7:00 p.m., and on
weekends from 7:00 a.m. to 7:00 p.m. Food services are provided by Department staff and
include menus, meal planning, meal schedules, special diets, nutritional analysis, daily
allowance, food preparation, health certifications, food product standards, sanitation, and
cleaning. Staff are responsible for the custody and control of youth in their care, providing youth
supervision twenty-four hours a day, seven days a week. The center has two living modules
which are divided by male and female. There are sixty-three security cameras at the center, and
all were operational the week of the annual compliance review. Observations of the center
found the exterior was free from debris and the grass was manicured. The lobby area was clean
and had no broken furniture. Observations of the secured area found the floors were clean and
free from insect infestation. The youth rooms revealed the beds were neatly made and the
bathrooms were observed to be clean and functional. There was no graffiti found in the center.
The classrooms, kitchen, and dining area were found to be clean and well organized. At the
time of the annual compliance review, the center had seven vacancies, which included six JJDO
Is and one food service worker.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 57 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures 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) on January
31, 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 31,
2024. A review of twenty-six initial background screenings for newly hired staff, contracted staff,
and volunteers revealed the center received background screening results from the
Department’s BSU/Clearinghouse prior to each staff’s date of hire. At the time of the annual
compliance review, there were four volunteers and eight contracted staff applicable for
background screenings since the last annual compliance review. All completed a background
screening prior to working at the center. None of the twenty-six staff were applicable for a
background screening exemption. All required documentation was reviewed prior to hire for
each staff. The center utilizes a pre-employment assessment tool for all direct care applicants.
Reviewed documentation confirmed the pre-employment assessment passing score was placed
in each staff record. All staff were added to the center’s Clearinghouse roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures requiring all staff, contracted providers, and
volunteers with access to youth undergo a criminal history background check every five years.
At the time of the annual compliance review, the center had no staff applicable for a five-year
rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 57 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures requiring staff adhere to the center’s code of
conduct. A review of five staff personnel records revealed the staff signed a code of conduct
prohibiting any form of abuse, profanity, threats, harassment, or intimidation. The code of
conduct addressed officer professionalism, poor performance, negligence, insubordination,
conduct unbecoming of a public employee, and misconduct. A review of five code of conduct
violations indicated two staff received a verbal reprimand and three received a written
reprimand. In each instance, management took immediate corrective action to address conduct
when staff violated policies and procedures. The center reported two staff were applicable for
commendations since the last annual compliance review. Each staff was awarded employee of
the month. Five youth were interviewed and reported staff are respectful when talking with them
and other youth and they never had to report abuse. Five interviewed youth reported they have
never heard staff use profanity when speaking to them or other youth. Each youth reported they
have never been threatened or heard staff threaten other youth. Each youth reported they feel
safe in the center, and they have never exchanged emails, telephone numbers, or social media
contact information with staff. Five interviewed staff were able to explain the process for
allowing staff and youth to call the Florida Abuse Hotline or the Department's Central
Communication Center (CCC), if the youth is eighteen years or older, to report suspected
abuse. Each staff reported they have never observed a co-worker using profanity when
speaking to youth and never observed a co-worker using threats, intimidation, or humiliation
when interacting with the youth. One staff reported working conditions were fair at the center,
one reported they were good, and three reported conditions were very good. The interviewed
superintendent was knowledgeable of the center’s staff code of conduct. The superintendent
reported staff must adhere to a code of conduct which prohibits any form of abuse, profanity,
threats, harassment, intimidation, or personal relationships with youth. When interacting with
youth, officers must maintain professional behavior and relationships. Officers shall not verbally
abuse, demean or other otherwise humiliate any youth, and shall not use profanity in the
performance of their job. Physical abuse of youth is prohibited by law and a suspicion or
knowledge of such must be reported to both the Florida Abuse Hotline and the CCC. If a youth
is at least eighteen years old and not disabled, physical abuse is to be reported to the CCC
only; however, the youth shall be given the opportunity to file a police report. If a youth is at
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 57 (Revised July 2023)
least eighteen years old and has a disability, both the Florida Abuse Hotline and the CCC must
be notified.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures requiring the response to incidents to be in
accordance with Florida Administrative Code. The center had fifty-four reportable incidents
since the last annual compliance review. Reviewed documentation of five incidents confirmed all
were reported to the Department’s Central Communications Center (CCC) within two hours of
the incident or when staff became aware of the incident. All incidents were documented in the
center’s CCC logbook. A review of the center’s internal incident/grievance reports revealed
there were no additional incidents which should have been reported to the CCC. The
interviewed superintendent explained the process for allowing a youth to call the Florida Abuse
Hotline and/or the CCC. The superintendent stated all reportable incidents must be called in to
the CCC within two hours. Whenever a reportable incident occurs, the detention superintendent
or designee shall notify the CCC within two hours of the incident, or within two hours of
becoming aware of the incident. Incidents shall be called in with basic information to include the
who, what, when, where, and how. If a youth is involved in the incident, a Department
identification number must be provided.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center has a written policy and procedures requiring all staff to use physical intervention
techniques in accordance with Florida Administrative Code. The center had a total of 135
Protective Action Response (PAR)/Right Interactions (RI) incidents since the last annual
compliance review. A review of nine PAR/RI incident reports confirmed all involved staff
completed written statements by the end of their shift. All PAR/RI Reports were reviewed and
processed within seventy-two hours by all required parties. All PAR/RI Reports confirmed a
post-PAR/RI interview was conducted with the youth by the center’s administration within thirty
minutes after the incident. No records were applicable for requiring a post-PAR/RI medical
review. A review of internal incident/grievance reports and logbooks since the last annual
compliance review confirmed there were no additional PAR/RI incidents which did not have a
report. None of the reviewed PARs/RIs resulted in injury. The center’s PAR/RI rate during the
previous quarter was 20.47, which is above the statewide Detention PAR/RI rate of 15.17. Five
interviewed staff reported all staff try to talk to youth prior to using PAR/RI or mechanical
restraints. The interviewed superintendent explained the process of how the use of physical and
mechanical restraints are tracked. Restraints shall be stored in a secure area designated by the
center’s superintendent. Restraints shall be numbered and maintained on a shadow board or a
secure cabinet in a locked area. All restraints shall be inventoried daily and documented on the
restraint log. The superintendent explained the process for monitoring PAR/RI incidents and use
of force is through the Department’s Juvenile Justice Information System (JJIS).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 57 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has a written policy and procedures requiring the completion of pre-service training
for all staff. Phase One consists of instructor-led and web-based courses. Phase Two consists
of 120 hours of academy instructor-led training. A review of five staff training records for pre-
service training confirmed three of the five staff completed all required trainings within 180 days
of hire. The two remaining staff completed the essential trainings; however, one staff was
granted a 180-day extension deadline of January 17, 2024, to complete remediation to prepare
and retake Phase Two training and the other staff took the Phase Two training test on March 8,
2024. All completed pre-service trainings were documented in the Department’s Learning
Management System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures requiring staff complete twenty-four hours of in-
service training each calendar year after completion of pre-service certification training. Five
staff training records were reviewed for in-service trainings, to include three direct care staff and
two supervisory staff. All five staff records confirmed each staff completed twenty-four hours of
the mandatory training topics which must be completed annually. The policy requires
supervisory staff must complete eight hours of supervisory training annually. Two staff were
applicable for a minimum of eight hours of supervisory training and each staff exceeded the
required minimum hours. All trainings were documented in the Department’s Learning
Management System (SkillPro). The center provides in-service training to staff through a
combination of online and instructor-led classes. Reviewed documentation confirmed the center
has a licensed nurse to provide in-service education on girls’ healthcare annually to all non-
healthcare staff involved in the supervision or treatment of girls. Reviewed documentation
confirmed the list of in-service trainings was approved on November 17, 2023, by the
Department’s regional director. The center has an annual in-service training calendar which is
updated as changes occur. An interview with the superintendent confirmed the center’s practice.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 57 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures ensuring each youth has the right to file a
grievance and ensure all youth are treated fairly, respectfully, without discrimination, and their
rights are protected. Grievance forms are filled out and accessible to youth on each module of
the center. The grievance process is posted in each living module and explained to each youth
during the admission and orientation process. Five staff were interviewed, and all were
knowledgeable and could explain the center’s grievance process. The interviewed
superintendent reported the grievance process has an informal and formal phase. The informal
phase, wherein the juvenile justice detention officer (JJDO) attempts to resolve the complaint or
condition with the youth using effective communication skills, and a formal phase, wherein the
youth submit a written grievance which results in a response from a JJDO supervisor by the end
of the shift or within twenty-four hours, are included in the grievance process. Youth shall be
given a grievance form and pencil to complete the grievance. If the youth is exhibiting violent
behavior, filing the grievance will be delayed until the youth is under control. The denial and the
reason shall be documented in the logbook. The supervising officer(s) shall enter the grievance
into the Department’s Facility Management System (FMS) on behalf of the youth. The
completed grievance form shall be submitted to the JJDO supervisor within two hours. The
supervisor shall document their findings on the grievance form and shall advise the youth of
what actions, if any, may be taken. The supervisor shall forward the grievance form to the
superintendent or designee upon completion. The superintendent or designee then reviews the
completed grievance form as quickly as possible, but at a minimum, within seventy-two hours of
receipt and shall take whatever corrective actions deemed necessary. The superintendent’s
decision is final. The youth shall sign a hard copy of the grievance form which will be maintained
in a separate grievance file. During the time of the annual compliance review, the center had no
documented grievances. Five interviewed youth were able to explain the grievance process.
Four youth rated the process very good, and one youth reported never filing a grievance.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 57 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures requiring the center to enter alerts into the
Department’s Juvenile Justice Information System (JJIS) for youth who require an alert which
may not have been previously identified prior to the youth’s admission. Each alert entered in
JJIS is verified by medical staff, juvenile justice detention officer (JJDO) supervisors, or the
mental health staff, as applicable. All JJIS alert reports are reviewed daily, printed out, and
copies are provided to staff daily by the on-duty supervisor during daily briefings on each shift.
An observation of a shift briefing meeting during the annual compliance review week supported
youth alert information was discussed and shared with the JJDOs during the meeting. Each staff
has access to the alert system. Five youth records were reviewed for case management,
medical, mental health, and substance abuse alerts. Each reviewed youth record documented
alert types, and the name/title of staff removing/updating alerts. Each alert was documented in
the logbook and included alert dates. Documented alerts were accurately entered and matched
in JJIS. Reviewed documentation indicated alerts were discussed during shift briefings. All
applicable alerts were downgraded and removed by the medical staff and/or the mental health
staff, as applicable. The interviewed superintendent reported all medical alerts are maintained in
JJIS. Five staff were interviewed and reported they are informed of security, safety, medical,
and mental health alerts which are specific to youth through logbooks, shift debriefings, alert
forms in JJIS, and the alert board. Five staff were interviewed and reported management
informs staff about issues within the center through logbooks, staff debriefings, alerts, meetings,
and emails. One staff reported the process for communicating information within the center is
good, and four staff reported very good.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 57 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a practice in place regarding data trend analysis. The program uses data to
minimize confinements, use of Protective Action Response (PAR)/Right Interactions (RI), and
incidents. This information is shared with staff and administration through monthly supervisory
meetings where data from a shared network drive is used to address incidents, length of
confinements, and the use of PAR/RI. Reviewed documents, such as sign-in sheets and
Detention Review meeting notes confirm the center’s practice. The center conducts weekly
Detention Reviews where information is provided to the juvenile probation officers (JPOs),
medical staff, mental health staff, and lead teachers.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 57 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures regarding youth admission. A review of five active
case management records indicated the Admission Wizard was completed and documented an
arrest affidavit/custody order was reviewed. Each Admission Wizard documented the
completion of a Detention Risk Assessment Instrument (DRAI) and Suicide Risk Screening
Instrument (SRSI). For each of the five reviewed records the Admission Wizard documented
each youth had a full body search conducted by a staff of the same gender, each youth was
offered a phone call to their parent/guardian, and each youth was offered a meal upon
admission. Each record’s Admission Wizard documented a medical/mental health/substance
abuse screening was completed upon admission. During the annual compliance review week,
an observation of a youth admission was conducted. All required procedures of the process
were followed, the youth was afforded the opportunity to make a telephone call to their
parent/guardian, and a meal was offered.
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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 old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures regarding youth orientation. Five youth case
management records were reviewed, and each youth was provided orientation within twenty-
four hours of admission and signed the brochure provided by the center. During the annual
compliance review week, an observation of a youth orientation was observed. The orientation
included all elements as outlined in the center’s policy. The orientation was provided verbally
and in writing which included rules and regulations, grievance procedures, visitation hours,
telephone calls, access to mental health and medical services, access to the Florida Abuse
Hotline and 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. The required PREA video
recording was included for the youth to watch. Five interviewed youth reported when they came
into the center, they were informed of the rules and regulations, daily schedule, education
services, visitation, abuse reporting, and the behavior management system (BMS).
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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;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures regarding classification. Five youth case
management records were reviewed and the classification process for each youth included a
review of information concerning the youth’s history and status. Five youth records were
reviewed and each confirmed the center takes the youth’s gender, height, weight, age, level of
aggression, mental illness, intellectual disabilities, physical disabilities, history of violent
behavior, gang affiliation, criminal history, history of sexual offenses including sexual battery
charges, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB), medical,
identified or suspected suicide risk, escape, and security risks into consideration before placing
a youth in a room. Each of the reviewed records confirmed youth were assigned a room based
on their classification. None of the youth records were reclassified due to changes in behavior.
None of the reviewed youth case management records were applicable for a youth with a
history of committing sexual offenses. The superintendent is informed of how to identify local
gangs through trainings. The superintendent is informed of gang activity and alerts by email.
The interviewed superintendent explained a VSAB screening is completed during the youth's
admission and staff use the information when assigning the youth to a room.
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2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures (FOPs) regarding notifications for gang affiliated
youth. The center’s superintendent acts as the designated gang representative for the center.
During the annual compliance review week, an informal interview was conducted with the
superintendent for the center. The superintendent stated staff are informed of youth involved in
gangs through shift briefings. The center informs the juvenile probation officer (JPO) through
email when a youth is admitted to the center and is involved in a gang. Five youth case
management records were reviewed, and three of the youth were applicable for gang
involvement. Each applicable record contained an email sent from the gang representative to
the proper JPO containing the required information in accordance with the FOPs.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures regarding the admission and storage of youth
personal property. All youth’s personal and valuable property is inventoried and documented in
the Juvenile Justice Information System (JJIS), maintained securely, and returned to the youth
or the parent/guardian in a timely manner upon the youth’s release. Personal items, such as
clothing and shoes, are placed in a property bag and secured in the center’s property room.
Valuable items are listed and placed in a clear tamper-proof property bag, identified with the
youth’s name and Department identification number (DJJID), then secured in the center’s
property safe which always remains in camera view. Five youth case management records were
reviewed, and each record contained youth and staff signatures on the JJIS property sheet.
Each record contained the letter of acknowledgement regarding unclaimed property with youth
and staff signatures. One of five records contained money which was verified and secured in a
clear tamper-proof property bag; however, the money was picked up by the youth’s
parent/guardian upon admission into the center. During the annual compliance review week, an
observation of a youth admission with property was conducted. During the observation, the
youth’s valuable personal property was stored in a clear tamper-proof bag, signed by the staff
and youth, and then dropped into the property safe on camera view. Access of youth personal
property is limited to shift supervisors and administration. A review of the Department’s Central
Communication Center (CCC) reports since the last annual compliance review found no
incidents regarding youth property. Five youth were interviewed, and each youth reported when
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they arrived at the center, staff checked their property and signed a property sheet ensuring
their property was accurate during admission. The interviewed superintendent stated the youth's
property is maintained in a secured room in intake. The superintendent also stated youth's
valuables are placed in a safe which is maintained in the property room in intake under camera
view. The shift supervisors and administration staff have access. Any property which is not
picked up within thirty days will be considered as abandoned. After thirty days, a Notice of
Impending Disposal of Property shall be mailed to the last known address. If the youth is on
supervision, it is also acceptable to have the assigned juvenile probation officer (JPO) sign for
and deliver property to the youth.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center has facility operating procedures regarding the release of youth in secure detention.
Three closed youth case management records were reviewed. Each record had a copy of the
Department’s Detention Release form, which documented the supervisor reviewed all
paperwork related to the youth’s release and court documents. All three youth had their
identification verified prior to release. The parent’s/guardian’s identification was verified prior to
release for each youth, with a photocopy of the parent’s/guardian’s identification being placed in
each youth’s case management record. None of the reviewed records identified the youth as an
endangered person. Each youth and the person to whom the youth was released were
reminded of future court dates and signed the release forms. The date of admission and the
date of release documented in each youth’s record correlated with the dates documented in the
Department’s Juvenile Justice Information System (JJIS). All three case management records
indicated all required parties signed all applicable release forms. During the annual compliance
review week, a release was observed and confirmed the releasing staff was following the
centers procedures in place for a youth release from the center.
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2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures regarding the release of youth personal property,
medication, and aftercare instructions. Three case management records were reviewed. Each
record contained a Property Receipt form signed by the youth and parent/guardian upon
release. Each record contained documentation verifying the youth was released to an
appropriate person and included a copy of their identification. None of the records were
applicable for a youth being released with medication. During the annual compliance review
period there were no examples of abandoned property. During the annual compliance review
week, a youth released with property was observed. The shift supervisor retrieved the youth
property from the safe and the youth and parent/guardian signed the appropriate documentation
for taking custody of the property. The parent's/guardian’s identification was confirmed by the
issued driver’s license and a copy was made. All of the center’s release procedures were
followed during the observation of the youth release.
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 has facility operating procedures regarding the review of youth in secure detention.
The center has an officer assigned as the detention review specialist (DRS). During the annual
compliance review, an observation of the weekly Detention Review meeting was conducted.
The Detention Review meeting was held virtually on Thursday afternoon with no noted issues.
Each week, all youth in the center are discussed during the Detention Review meeting with
mental health, medical, education, and juvenile probation officers (JPOs). A review of the
center’s Detention Review uploads confirmed the center is conducting Detention Review
meetings on a weekly basis with all the required participants attending the meeting. The
interviewed superintendent stated Detention Reviews are conducted on a weekly basis by the
DRS. The superintendent reported the meetings are held every Thursday at two o’clock. Each
youth's release date, court date, behavior, program status, and any pertinent information is
discussed during the review.
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2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures regarding the daily activity schedule. During the
annual compliance review week, a center tour was conducted, and the daily activity schedule
was posted on all the youth living modules. Youth were also observed attending school, during
meals, and at shift change. Logbook documentation confirmed activities such as wake-
up/personal hygiene, mealtimes, visitation, recreation, education, shift change, bedtime, and
groups were conducted, as scheduled. Five youth were interviewed and confirmed the center
has a daily schedule and it is being followed. Five interviewed staff reported the center follows
the daily activity schedule.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to ensure the Collier County School District
provides educational services and approves the 250-day calendar, which incorporates up to ten
days of teacher planning and/or training. Youth earn course credits for the completion of their
education and training experience. Interviews, logbooks, and reviews of video footage
confirmed five-hour daily instruction periods, reliable school schedules with no cancellations of
school, and 250 days of instruction per year, including ten dedicated teacher training days.
Minimal disruptions were documented, with classes occurring as scheduled and youth arriving
and departing as scheduled. There was one exception found on February 8, 2024, where the
group of youth did not arrive to school until 8:37 a.m., which was twenty-two minutes past the
scheduled start time of 8:15 a.m. Five interviewed youth reported the center was preparing them
either well or very well for school and/or employment. Interviews with five staff and five youth
verified the center’s adherence to the daily schedule and minimal interference with learning. The
interviewed superintendent verified minimal interference of education instruction.
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 offers career education programming which meets the requirements of a Type 1
program which incorporates communication, interpersonal and decision-making skills, as well as
life skills and activities through career-related instruction in class. Three interviewed youth
reported they participate in a career course while enrolled at the center.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures requiring a single licensed mental health
professional to serve as the designated mental health clinician authority (DMHCA). The DMHCA
oversees the coordination and implementation of both mental health and substance abuse
services at the center. 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. The contract requires a full-time licensed professional to serve as the DMHCA for forty
hours each week. The previous DMHCA resigned on March 1, 2024. The regional manager is
covering until the position is filled. The center’s interim DMHCA is a licensed mental health
counselor with a clear and active license in the State of Florida which expires March 31, 2025.
The center’s previous DMHCA was a licensed clinical social worker (LCSW), with a clear and
active license in the State of Florida expiring March 31, 2025. The center has a back-up
DMHCA. The back-up DMHCA holds a clear and active State of Florida LCSW licensure which
expires March 31, 2025. The DMHCA’s job description clearly outlines the clinical and
administrative oversight responsibilities for the development, implementation, clinical and or
administrative supervision, and monitoring of the behavioral health delivery system standards.
The DMHCA works with the regional manager, site administrator, medical director, and
psychiatrist to coordinate contracted services. The DMHCA is scheduled to be on-site Monday
through Friday from 8:30 a.m. through 4:30 p.m. and is on-call twenty-four hours each day for
emergencies and as needed, which was confirmed through a review of sign-in logs. An
interview confirmed the DMHCA oversees mental health services at the center. The DMHCA
provides weekly supervision of non-licensed staff, meets weekly with the psychiatrist, holds mini
treatment team meetings, and ensures operational needs are met according to contract. The
interviewed DMHCA reported the mental health staff assesses each youth admitted to secure
detention, provide individual/group therapy, crisis intervention, and supportive services to youth
as required.
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 Department has a contract with VitalCore Health Strategies, LLC. to provide mental health
and substance abuse services to all eligible individuals at the center. The center requires mental
health and substance abuse services be provided by individuals with appropriate qualifications.
The contract requires the center to have a regional mental health director, licensed mental
health professional staff, a psychologist, and mental health clinical staff. The regional director is
a licensed mental health counselor (LMHC) with a clear and active license in the State of Florida
which expires March 31, 2025. The psychologist holds a clear and active license which expires
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March 31, 2024. Reviewed documentation confirmed each staff’s license was clear and active in
the State of Florida and all mental health staff were qualified to provide services based on
education, training, and experience.
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 facility operating procedures requiring non-mental health and substance abuse
clinical services to be provided by individuals with appropriate qualifications. All mental health
services must be administered by either a licensed mental health professional or a non-licensed
mental health clinical staff who is working under the direct supervision of the licensed mental
health professional. The center has one non-licensed mental health staff who holds a master’s-
level degree in psychology. At the time of the annual compliance review week, the center did
not have a Chapter 397 license with the Department of Children and Families. An informal
interview with the DMHCA confirmed only the licensed staff provide substance abuse treatment
at the center. Reviewed documentation verified the non-licensed staff 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 the
Assessment of Suicide Risk (ASR) conducted on-site in the physical presence of a licensed
mental health professional and was documented on the Department’s Non-Licensed Mental
Health Clinical Staff Person’s Training ASR form. All required supervision was completed and
was documented on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log. The non-licensed
staff is scheduled to be on-site Thursdays and Fridays as needed, and for eight hours on
Saturdays and Sundays. The center does not have any vacancies for non-licensed mental
health staff.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures outlining the process for identifying mental health
and substance abuse needs of youth through a comprehensive screening. Upon admission, the
juvenile justice detention officer (JJDO) shall review each youth’s Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2), Face Sheet, critical alerts including closed
suicide risk alerts, and Suicide Risk Screening Instrument (SRSI) located in the Department’s
Juvenile Justice Information System (JJIS). The JJDO shall complete the sections of the SRSI
designated for the JJDO if the need for further assessment is indicated by the SRSI, MAYSI-2,
Face Sheet, critical alerts, closed suicide risk alerts, staff observation, and/or information
collected. A review of five youth mental health and substance abuse records confirmed each
youth had a completed SRSI and a completed MAYSI-2 during the youth’s admission process.
Each form was completed in JJIS. Each of the five SRSIs were reviewed by a mental health
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clinical staff and included their documented recommendation. Each of the SRSIs had completed
entries which also had a summary and recommendations included in the screening results
section. Five youth were reviewed and all were applicable for positive “yes” responses on the
SRSI form. Each applicable youth was placed on suicide precautions, and a mental health
referral was generated. One of five reviewed records was applicable for an elevated suicide
subscale on the MAYSI-2. None of the reviewed youth were applicable for having all negative
responses on the MAYSI-2, invalidating the screening. Reviewed MAYSI-2s indicated two youth
required a comprehensive assessment and the center notified mental health staff and the
superintendent, as required. Three youth were non-applicable.
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 has facility operating procedures outlining the process for identifying the mental
health and substance abuse needs of youth through a comprehensive screening. The center
utilizes the Department’s Mental Health and Abuse Referral Summary form. Youth who are
identified at the Juvenile Assessment Center (JAC) as needing further assessment are referred
for a comprehensive assessment. Five youth mental health and substance abuse records were
reviewed and found two youth were applicable for a referral for mental health and substance
abuse services and three youth were not applicable. One additional applicable record was
requested for review. Each record disclosed the youth was screened, and a referral was made
for each youth to receive a comprehensive mental health evaluation based on the
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). Two of three reviewed
youth mental health records contained an updated Substance Abuse and Mental Health
Assessment (SAMH). One of three reviewed youth records included a new SAMH. Each
reviewed SAMH was completed by the center’s on-site mental health provider within thirty-one
days, as required. All treatment recommendations made corresponded to all diagnosed mental
health and substance abuse disorders. Three youth were applicable for a community provider
assessment since the last annual compliance review. Each of the evaluations were completed
within the required time frame and contained treatment recommendations which corresponded
to all diagnosed mental health or substance-related disorders.
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 has facility operating procedures to ensure each youth needing treatment services
has an initial and/or individual treatment plan created and has a discharge summary completed
when the youth is released from the center. Five youth records were reviewed for mental health
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and substance abuse treatment services. Two of five records were applicable for an initial
treatment plan. One additional applicable record was requested for review. Each reviewed
record documented an initial plan was in place within seven days of the initiation of treatment,
which was developed on the Department’s Initial Mental Health/Substance Abuse Treatment
Plan form. Each reviewed youth record was applicable for treatment with individual or group
counseling. All three initial treatment plans contained the reason for treatment referral, the initial
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, initial
treatment methods and goals, and psychiatric services. Each plan was signed by the youth and
the mini-treatment team members. Each applicable treatment plan was signed and dated by the
youth, clinical staff, and treatment team members. Each reviewed treatment plan had a note
regarding the parent/guardian’s presence over the telephone with the date. Three records had
an individualized treatment plan created within thirty-days of the youth’s admission by mental
health staff. Each of the applicable plans were documented on the Department’s Individualized
Mental Health/Substance Abuse Treatment Plan form. A review of each applicable treatment
plan identified the youth’s individual mental health/substance abuse DSM-5 diagnoses,
treatment-focused symptoms, treatment goals, and strengths/needs. Three youth were
applicable for psychiatric services or pharmacological interventions. Each treatment plan was
signed by the youth, mental health professional, treatment team members, and the
parent/guardian, when applicable. Each applicable record contained progress notes to validate
the services included in the treatment plan were being received. Three of the reviewed youth
records contained thirty-day individualized treatment plan reviews. Each of the applicable
individual youth mental health records contained a thirty-day review completed, as required. All
treatment plan reviews were signed and dated by the youth, clinical staff, and treatment team
members. Each had a note regarding the parent’s/guardian’s presence over the telephone and
each was dated. None of the youth were applicable for having been an alleged victim of a
Prison Rape Elimination Act (PREA) incident. Three closed mental health records were
reviewed for mental health and substance abuse treatment discharge summaries. Each mental
health and substance abuse treatment discharge summary was completed on the required
Department form, and each record indicated a copy of the summary was provided to the youth,
juvenile probation officer, and parent/guardian, if applicable. The center holds treatment team
meetings on Thursdays, each week. Observations of a treatment team meeting were conducted
during the annual compliance review week and all required parties were involved.
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 has facility operating procedures to ensure mental health and substance abuse
treatment planning is provided to applicable youth to reduce or alleviate symptoms of mental
health and substance abuse issues. Five mental health and substance abuse records were
reviewed and two were applicable for receiving initial treatment services. One additional
applicable record was requested for review. Each applicable record contained the properly
executed consents for mental health and/or substance abuse treatment services and each
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youth was assigned to a mini-treatment team as required. Each record contained
documentation of the youth receiving mental health treatment in the form of individual, group,
and/or family counseling as outlined in the treatment plan, at least a minimum of once each
week. Reviewed progress notes confirmed youth were receiving treatment services as
stipulated on their treatment plans. Three of the youth required substance abuse treatment.
Reviewed documentation confirmed the proper consent for substance abuse treatment was
obtained on the Department’s form. Each applicable record contained the proper Authority for
Evaluation and Treatment (AET) consent form. Each reviewed record contained treatment notes
documented on the required Department form with all required elements. A review of video
surveillance was conducted for groups held within the last thirty days. Observations of the video
confirmed mental health groups were held in accordance with the center’s policy. Reviewed
documentation validated mental health staff provide groups at a minimum once a week when
there are enough youth receiving treatment. In the event there are only a few youth, the mental
health staff meet with youth individually. A review of the group sign-in sheets and logbooks,
validated groups were conducted in accordance with policy. Observations and a review of the
documentation indicated the group was held as required and the times noted on the sign-in
sheets matched the video review. An interview with the designated mental health clinician
authority (DMHCA) confirmed mental health staff provide individual therapy, group counseling,
crisis intervention, supportive services, and substance abuse treatment. Five youth were
interviewed, and two youth rated the center’s mental health and substance abuse services as
very good, and three youth stated they were not receiving mental health or substance abuse
services.
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 has established facility operating procedures outlining the process for psychiatric
services provided to youth. Psychiatric services include psychiatric evaluations, consultation,
medication management, and medical supportive counseling. Psychiatric services are provided
to youth in need of services, as indicated by symptoms of a mental disorder or substance-
related disorder, or to youth who are treated with psychotropic medication. The center has a
contract with VitalCore Health Strategies, LLC. for the provision of a licensed psychiatrist to
provide psychiatric services for applicable youth in the center. VitalCore Health Strategies, LLC.
provides a part-time psychiatrist who is contracted to provide services for two hours each week.
The psychiatrist’s license was clear and active in the State of Florida with an expiration date of
March 31, 2026, and the back-up psychiatrist, a licensed medical doctor, holds a clear and
active license with an expiration date of January 31, 2026. The contract was reviewed and
confirmed the inclusion of tele-psychiatry. A review of the center’s Tele-Psychiatry Log and
observations validated the psychiatrist is providing weekly services, as required, through tele-
psychiatry. A review of five mental health and substance abuse records reflected one was
applicable for receiving psychiatric services; therefore, two additional applicable records were
reviewed. Each of the three individual youth mental health records contained documentation of
a psychiatric referral and interview completed within fourteen days of admission. All three youth
had an initial psychiatric interview which included the reason for referral, the youth’s history, a
Mental Status Examination, the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis, treatment recommendations, applicable prescribed medication,
explanation of the need for psychotropic medication, and the frequency of the medication. All
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three youth were applicable for the prescription of medications and each psychiatric interview
documented the most recent applicable therapeutic serum drug levels, signature of the
practitioner, page three of the Clinical Psychotropic Progress Note (CPPN), target symptoms of
each medication, evaluations and description of effect of prescribed medication on target
symptoms, normal dosage range, ordered dosage, frequency and route of administration, side
effects, adherence to medication regime, and whether there was telephone contact with the
parent/guardian to discuss medication. Each youth’s evaluation was documented on the
Department’s CPPN and completed within the required time frame. All three youth records
contained a current Authority for Evaluation and Treatment (AET) form. One youth was
applicable for the monitoring of Tardive Dyskinesia which was documented monthly on the
CPPN for the youth. Two youth were not applicable. All three youth were applicable for
receiving tele-psychiatry, and there was documentation of consent from the youth and
parent/guardian in each case. No reviewed youth were over the age of eighteen or under the
care of the Florida Department of Children and Families (DCF).
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written suicide prevention plan to safely screen, refer, assess, monitor, and
protect youth with elevated risk of suicide in the least restrictive means possible, in accordance
with Florida Administrative Code. The plan details the center’s procedures to address 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 policy and plan were approved by the superintendent
and the designated mental health clinician authority (DMHCA) on August 8, 2023. The plan
includes the identification and assessment of youth at risk of suicide utilizing the Department’s
ASR and Follow-Up ASR forms. 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 and a mortality
review for any completed suicides. The multidisciplinary review is to examine the circumstances
surrounding the event, center procedures relevant to the incident, relevant training received by
involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations for changes in policy, training, the physical plant,
medical or mental health services, and/or operational procedures. The plan outlined emergency
contact telephone numbers to include the superintendent, on-call administrator, DMHCA,
psychiatrist, local emergency room, local sheriff’s department, community crisis stabilization
unit, and Poison Control. The plan is located in master control and is accessible to all staff on
the shared network drive.
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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 has a written Suicide Prevention Plan to safely screen, refer, assess, monitor, and
protect youth with elevated risk of suicide in the least restrictive means possible. The plan
outlines the center’s procedures to address 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). Five
youth mental health and substance abuse records were reviewed, and each youth was
applicable for having been placed on precautionary observation at the time of admission until an
ASR was completed. Documentation revealed an ASR was completed using the Department’s
form. Each youth began on constant supervision based upon the Suicide Risk Screening
Instrument (SRSI) results and after the completion of the ASR. Each youth’s ASR was
completed within twenty-four hours, as required. A review of all five youth’s Suicide Precaution
Observation Logs confirmed each was completed in their entirety to include documented safe
housing areas and all required signatures. All youth records were applicable for a Follow-Up
ASR, which was completed by a licensed staff prior to the removal of the youth from
precautionary observation. Each ASR documented a conference held between the licensed
mental health professional and the superintendent pertaining to reducing the level supervision.
A review of the center’s logbooks and the Department’s Juvenile Justice Information System
(JJIS) alerts it was found the starting and ending times of each youth’s precautions were
documented accordingly. An informal interview with the superintendent and designated mental
health clinician authority (DMHCA) confirmed the center utilizes secure observation; however,
none of the reviewed records were applicable for placement in secure observation; therefore,
three additional records were requested for review. Each applicable record’s documentation
supported the placement was authorized by the superintendent and the DMHCA. The secure
room was designated in writing and the Department’s Health Status Checklist was completed,
as required. The center staff completed the Suicide Precaution Observation Logs in their
entirety and in real time. The youth’s parent/guardian and assigned juvenile probation officer
(JPO) were notified of each youth’s potential suicide risk as indicated by the ASR. Each youth
was removed from secure observation within twenty-four hours of placement. A review of JJIS
indicated the appropriate alerts were entered and removed for each youth. A review of the
center’s logbooks confirmed each youth’s placement on secure observation and discontinuation
and step-down were documented in the logbook. Five youth were interviewed, and each youth
stated they had never been placed on suicide precautions while at the center. Five staff were
interviewed and each confirmed if a youth expresses suicidal thoughts, they are to notify the
mental health authority, search the youth and their room for sharp objects, and document
supervision. Five staff reported having to maintain the youth on constant sight and sound
supervision. Three staff reported if a youth is demonstrating suicidal behavior while on
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precautionary observation then the DMHCA will be notified and if the directive is to place the
youth in a room, then the youth will transition to secure observation.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center maintains a written Suicide Prevention Plan which details the process to safely
screen, refer, assess, monitor, and protect youth with elevated suicide risk in the least restrictive
means possible. The plan outlines the center’s procedures to address 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 the youth’s
behavior documented on the Department’s Suicide Precaution Observation Log. A review of five
mental health and substance abuse records found all five youth were placed on precautionary
observation (PO). In each of the five records, a Suicide Precaution Observation Log was
maintained for the duration each youth was on PO. Each log was reviewed and signed daily by
the shift supervisor and the mental health clinician. Each youth’s log was documented in real
time. No youth were applicable for having warning signs documented on the logs. Each log
documented safe housing requirements. Observations of video surveillance footage on three
random dates and reviewed documentation of youth on PO confirmed the youth was placed on
constant supervision and proper supervision was maintained at all times.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center maintains a Suicide Prevention Plan outlining the requirements to safely screen,
refer, assess, monitor, and protect youth with elevated risk of suicide in the least restrictive
means possible. Five pre-service and five in-service staff training records were reviewed. Each
reviewed staff record documented staff completed suicide awareness and prevention training.
Reviewed documentation of “mock” suicide drills conducted since the last annual compliance
review showed the center completed drills on all three shifts at least quarterly, as required. The
center exceeded the requirement by conducting drills on each shift at least once each month
since the last annual compliance review. The center has four suicide response kits located in
master control, the youth living modules, and in the medical clinic. Suicide response kits are co-
located with the center’s first-aid kits. Reviewed documentation supported the center had thirty-
two applicable staff requiring participation in a suicide drill semi-annually. All thirty-two of the
center’s staff participated as required, and many exceeded the requirement. Documentation
confirmed direct care staff participated in at least one drill which included the use of
cardiopulmonary resuscitation (CPR) annually. Staff who are not present during a drill have the
opportunity to review each drill scenario, procedures, and critique in an effort to understand the
process and receive the necessary training to respond to an incident of a suicide attempt or
incident of serious self-inflicted injury. An interview with five staff was conducted and each staff
reported the suicide response kits are located in master control, sub control, medical, and the
shift supervisor’s office. Two of the five staff reported kits are co-located with the first-aid kits in
the administration area.
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3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a combined Emergency Services Plan which includes all required elements.
Staff response must be 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 was approved by the
superintendent and the designated mental health clinician authority (DMHCA) on August 8,
2023. The center’s procedures require the completion of a Crisis Assessment to evaluate a
youth presenting with acute emotional or psychological distress which is extreme and does not
respond to ordinary interventions. Assessments should be completed by a mental health
clinician to determine the severity of the youth’s distressing symptoms, level of risk to self or
others, and recommendations for treatment and follow-up care. The plan details crisis
intervention procedures including a notification and alert system, means of referral including
youth self-referral, communication, supervision, documentation, review, and requirements for
Prison Rape Elimination Act (PREA) response.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has a written Emergency Care Plan outlining mental health and substance abuse
emergency procedures for youth who are believed to be an imminent danger to themself or
others because of mental illness or substance abuse impairment. The plan was approved by the
superintendent and the designated mental health clinician authority (DMHCA) on August 8,
2023. A copy of the approved plan is maintained in the superintendent’s office, the mental
health office, the medical clinic office, and is accessible to all staff on the shared network drive.
The center’s plan contains procedures for immediate staff response, notifications,
communication, supervision, authorization to transport for emergency mental health or
substance abuse services (Baker Act or Marchman Act), documentation, training, and review.
The center utilizes a local behavioral health center for Baker Act crisis stabilization and
Marchman Act emergency substance abuse assessment and treatment.
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3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has a crisis intervention services and emergency care plan specifying the response
protocols for youth experiencing crisis. Staff response shall be in the least restrictive means
possible to protect the safety of the youth and others while maintaining control and safety of the
center in accordance with Florida Administrative Code. Youth presenting with acute and
extreme emotional or psychological distress are to receive a Crisis Assessment to evaluate
severity of the youth’s distress symptoms, level of risk to self or others, and recommendations
for treatment and follow-up care. The plan was approved by the superintendent and the
designated mental health clinician authority (DMHCA) on August 8, 2023. An informal interview
with DMHCA and superintendent confirmed there were no youth applicable for requiring a Crisis
Assessment since the last annual compliance review. An examination of Assessments of
Suicide Risk (ASRs), logbooks, and the Department’s Central Communications Center (CCC)
incidents did not reveal any events where a Crisis Assessment should have been completed.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has a written Emergency Care Plan detailing mental health and substance abuse
emergency procedures for youth who are believed to pose an imminent danger to themself or
others because of mental illness or substance abuse impairment. A review of five youth mental
health records revealed none were applicable for requiring Baker Act procedures. The
designated mental health clinician authority (DMHCA) provided three additional youth records
which were applicable for a Baker Act since the last annual compliance review. All three youth
were placed on suicide precautions upon re-admission following the Baker Act placement. A
Mental Status Examination was conducted within the administration of the Assessment of
Suicide Risk for all three youth. All three youth were kept on constant supervision until properly
transitioned to a lower level of supervision. Documentation showed supervision levels were
lowered for each youth after an appropriate assessment was conducted by a licensed mental
health professional, and mental health staff conferred with the licensed supervisor and
superintendent or designee. The center had no applicable Marchman Act procedures since the
last annual compliance review.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains facility operating 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 an osteopathic
physician (DO) 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 March 31, 2024. The center utilizes a part-time advanced practice
registered nurse (APRN) whose license expires April 30, 2025. The APRN and the DHA both
signed the Collaborative Practice Protocol agreement in August 2023. The center’s DHA is
contracted to be on-site at least once a week, with a week defined as the seven-day period
beginning on Sunday and ending on Saturday; however, at no time are more than nine days to
pass between on-site visits. The DHA is on-call twenty-four hours a day, seven days a week. A
review of the center’s healthcare staff sign-in sheets since the last annual compliance review
showed the DHA did not consistently sign-in; however, the center’s human resources check-in
and on-call calendar, and orders written by the DHA documented when the DHA was on-site but
did not sign-in. When the DHA was on vacation or on a scheduled absence, one of two back-up
licensed medical doctors was designated by VitalCore Health Strategies, LLC. to provide clinical
services. An interview with the DHA revealed they are on-site at least once every nine days to
provide clinical services, and are available by telephone twenty-four hours a day, seven days a
week for acute medical concerns, emergency medicine, and coordination of off-site care. The
interviewed DHA reported the specific duty of the DHA is to perform Comprehensive Physical
Assessments (CPAs) and CPA updates, provide consultation and advice to nursing staff with
urgent matters, medication questions, medical condition questions, provide consultation to
Department staff when nursing staff are not available, follow up on urgent and acute issues with
detained youth, provide oversight to the APRN when needed for questions, and review and
make recommended changes to policy and procedure development. The providers telehealth
log requires the time in and time out to be logged; however, none of the five instances of
telehealth included on the log during the annual compliance review period noted the time out on
the log.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center maintains written facility operating procedures (FOPs) for all utilized health-related
procedures and protocols. Reviewed documentation reflected the designated health authority
(DHA) reviewed, signed, and dated the FOPs, on January 3, 2024, and the superintendent
signed on January 2, 2024. The psychiatrist reviewed and signed the relevant FOP on February
26, 2024. Reviewed documentation validated the advanced practice registered nurse (APRN)
and nurses reviewed, and respectively signed and dated the FOP cover page treatment
protocols on February 13, 14 and 17, 2024 and March 2, 2024. VitalCore Health Strategies,
LLC. has an established comprehensive clinical orientation for all newly employed healthcare
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staff, which includes the Department’s healthcare policies and procedures, which is provided by
a registered nurse (RN).
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 facility operating procedures requiring parents/guardians to be afforded
the right to give or withhold consent regarding the healthcare provided to the youth. A review of
five youth Individual Healthcare Records (IHCRs) revealed each record had a signed Authority
for Evaluation and Treatment (AET) which was signed by a Department representative. Each
AET was obtained prior to providing medical services for each youth. There were no youth
applicable for being under the care and custody of the Department of Children and Families
(DCF). An interview with the clinical nurse manager indicated the nursing staff obtain a valid
AET upon each youth’s admission into secure detention which may include contacting the
assigned juvenile probation officer (JPO) to assist in obtaining the parent/guardian signature.
When a youth reaches eighteen years of age, the youth will provide consent at the point of
contact for healthcare.
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 facility operating procedures outlining requirements for parental/guardian
notification of significant changes in the youth’s condition and for obtaining written consent from
the parent/guardian when new medications and treatments are prescribed. A review of five
youth Individual Healthcare Records (IHCRs) showed one record contained documentation of
parental/guardian notification for an over-the-counter (OTC) medication beyond those covered
by the Authority for Evaluation and Treatment (AET), as required. Two youth records were
applicable for having a new medication order and one was applicable for significant changes to
existing medications, and each documented the parental/guardian notification was sent, as
required. Five youth IHCRs were reviewed for vaccination status, and four contained a
vaccination record from Florida Shots, all of which were reviewed by medical staff within thirty
days of each youth’s admission. One youth record included a completed Religious Exemption
from Immunization form which was signed by the parent/guardian. The clinical nurse manager
was interviewed and described the center’s process for documenting attempted
parental/guardian notifications.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains facility operating procedures requiring each youth, at the time of
admission, to receive a Facility Entry Physical Health Screening utilizing the Department’s
Medical and Mental Health Admission Screening form. A review of five youth Individual
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Healthcare Records (IHCRs) found each 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. Each youth’s screening form was
completed in the Department’s Juvenile Justice Information System (JJIS), as required.
Reviewed documentation validated the designated health authority (DHA) was notified of each
youth’s admission. The center reported there were no youth applicable for a change in physical
custody since the last annual compliance review; however, all six records documented previous
admissions to the center and a healthcare admission rescreening was completed upon each
admission for each youth. An interview with the clinical nurse manager 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 facility operating procedures requiring all youth to be oriented to the
general healthcare delivery services at the center. A review of five 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 refusals are
documented, what to do in the case of a sexual assault or attempted sexual assault, and the
non-disciplinary role of the healthcare providers. Healthcare staff reviewed 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 facility operating 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 five Individual Healthcare Records (IHCRs), reflected one youth
was applicable for a known or suspected chronic condition upon admission. An interview with
the clinical nurse manager indicated the DHA is notified immediately whenever a youth is
admitted and identified with an emergency or chronic condition. When the DHA is notified by the
nursing staff, it is to be documented in the healthcare record on the chronological progress note.
It is the center’s practice to notify the DHA of all new admissions regardless of medical condition
and the notification is documented in the chronological admission progress note. All five records
documented the DHA was notified of each youth’s admission. One youth record was applicable
for the youth having been admitted while taking psychotropic medication and the psychiatrist
was notified of the youth’s admission, as well.
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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 facility operating procedures requiring completion or review and updating
of the Department’s standard Health-Related History (HRH) form. The center utilizes and
completes the HRH form for all youth admitted into the center’s physical custody. A review of
five youth Individual Healthcare Records (IHCRs) found each contained a new HRH form.
Reviewed documentation indicated each HRH form was reviewed by a licensed nurse and
subsequently by the designated health authority (DHA) or advanced practice registered nurse
(APRN). The HRH form was completed prior to or at the same time as the Comprehensive
Physical Assessment (CPA) for each youth and reflected the most current admission. Each
HRH form was completed by a licensed nurse within seven days of the youth’s admission to the
center. An interview with the clinical nurse manager confirmed the HRH form is completed
within seven calendar days of the youth’s admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains facility operating procedures requiring a Comprehensive Physical
Assessment (CPA) to be completed or updated for all youth admitted to the center to determine
the health and wellbeing of each youth. A review of five Individual Healthcare Records (IHCRs)
was completed and three contained a current CPA on file at the time of admission and two
records required a new CPA. Each CPA was completed or reviewed within seven days of the
youth’s admission and signed by the designated health authority (DHA) or the advanced
practice registered nurse (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 five youth records documented a Tier 1 Tuberculosis (TB)
screening was completed on the Medical and Mental Health Admission Screening form. All five
were completed by the DHA or APRN. Three records had all sections of the CPA completed or
noted by the APRN as not being clinically indicated. The CPAs in two youth records showed
portions of the assessment were not completed, the comment section on those lines noted only
“NA” on each line, and there was no notation of the reason for the deferral. The Department’s
Problem List was updated in each reviewed instance, 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 general population. The center’s policy and procedures for
TB control and screening requires the routine screening of all youth for latent and active TB and
outlines environmental controls in the case of a youth with suspected active TB. An informal
interview with the clinical nurse manager indicated the DHA or designee 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.
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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 facility operating 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 five Individual Healthcare Records (IHCRs) indicated
each youth was clinically screened and evaluated for STIs. One youth record indicated no
further evaluation was required. Four youth records included referrals and ordered testing; while
one record documented the youth declined consent. STI screenings, evaluations, and referrals
were 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 five reviewed records validated each youth was offered
counseling and testing for human immunodeficiency virus (HIV). Three of the five youth declined
consent for HIV testing, while two consented to testing and were provided pre and post-test
counseling which was documented in each youth’s Health Education Record. An informal
interview with the clinical nurse manager indicated the HIV results would be documented on the
youth’s Infectious and Communicable Disease form and stored in a sealed envelope in the
laboratory results section of the IHCR, which a review of the two applicable records validated.
The DHA or APRN documented their review of the test results in the upload library of the
Department’s Juvenile Justice Information System (JJIS) electronic medical records. HIV results
were not included on the center’s internal alerts for either applicable youth. Five youth were
interviewed, and all five-youth reported being able to request a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains facility operating procedures regarding the sick call process and requests.
The center conducts sick call 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 daily from 9:00 a.m. to 10:00 a.m., and 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 required to review the sick call requests in the absence of the
healthcare professionals as soon as possible and within four hours of the submission of the sick
call request. A review of five Individual Healthcare Records (IHCRs) indicated three were
applicable for having submitted a sick call request form. Each of the requests were completed
by the nurse in accordance with Florida Administrative Code and maintained in each youth’s
Electronic Medical Record in the Department’s Juvenile Justice Information System (JJIS).
There were no instances of a youth presenting with a similar sick call complaint three or more
times or youth complaints of severe pain staff were unfamiliar with. Sick calls were conducted
by a licensed nurse either immediately or within twenty-four hours of the sick call request
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submission and documented on the Sick Call Referral Log for each youth. Observations were
made of one sick call during the week of the annual compliance review. The youth’s verbal
consent was obtained prior to observation. The youth was escorted to the medical clinic by a
direct care staff of the same gender as the youth and the direct care staff remained in the
medical clinic but outside the drape screen to allow the youth privacy. An informal interview with
the clinical nurse manager confirmed sick call is conducted by the registered nurse or licensed
practical nurse within twenty-four hours, as well as documented on the Sick Call Referral Log.
All sick calls are conducted in the medical clinic to ensure the youth’s privacy. The center
maintains treatment protocols appropriate to the level of the provider conducting sick call, which
were approved by the designated health authority (DHA). Five youth were interviewed. Two
interviewed youth indicated they could be seen immediately when submitting a sick call, and
three stated they had never requested a sick call.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center maintains facility operating procedures detailing a comprehensive process for the
provision of episodic care, first-aid treatment, and emergency care. The center utilizes an
Episodic Care Log to document episodic care and first-aid treatment. A review of five youth
Individual Healthcare Records (IHCRs) showed three youth were applicable for episodic or
emergency care. In each instance the nature of the complaint was documented, and the
findings of the healthcare staff rendering care were included. One of the three reviewed
instances of episodic care indicated no treatment was needed, while two documented the
treatment which was rendered. None of the reviewed instances of episodic care required
referral to off-site care. Each reviewed instance documented the education/instruction provided
to the youth and an entry in the Episodic Care Log were completed. One instance included a
plan for follow-up care while two did not require any follow-up. The center maintains two
automated external defibrillators (AEDs). The center’s AEDs are located in wall-mounted AED
boxes in the medical clinic and master control. The AED procedures are stored with the AED,
and each AED provides audible instructions when utilized. Nursing staff check the AED
batteries and pads at the end of each month to ensure the AED is operational and the checks
are documented. A review of the center’s AED tracking sheets since the last annual compliance
review documented the center’s practice. The AED was self-tested in front of the annual
compliance reviewer to ensure it was operational, with no issues noted. The batteries in the
AEDs expire December 17, 2024, and the pads expire July 28 and December 28, 2025. An
interview with the clinical nursing manager indicated the date when the AED batteries and pads
were last changed is unknown as it was prior to their promotion to the manager position. AED
maintenance was last conducted by an outside medical equipment company on August 24,
2023. The center maintains a total of eleven first-aid kits which are located in the laundry room
on each of the three living modules, the superintendent’s office, the kitchen, master control, and
in the medical clinic. The first-aid kits for the three transport vehicles are stored within the
medical clinic. The center’s first-aid kits are sealed with breakaway tabs. When a first-aid kit
seal is broken, the kit is inspected and restocked. An informal interview with the clinical nurse
manager indicated the nursing staff check the kits at least monthly. One sealed first-aid kit in the
medical clinic was opened and contained all items approved by the DHA, as required. A review
of five pre-service and five in-service staff training records found each was trained and held
current certifications in cardiopulmonary resuscitation (CPR), first-aid, and AED. All non-
healthcare staff and nursing staff are required to maintain certifications. A review of emergency
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drills since the last annual compliance review supported drills were conducted monthly on each
shift, with mock use of CPR and the AED demonstrated as part of a drill in May and September
2023 on each shift, since the last annual compliance review. Observations confirmed
emergency contact telephone numbers were posted out of the view of youth in the medical
clinic. Only healthcare and trained supervisory non-healthcare staff can administer the
epinephrine auto injector for youth requiring administration, when indicated. A review of five
training records supported each staff received the required training on the center’s Emergency
Care Plan and the designated supervisory staff received training on epinephrine auto injector.
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. Five staff were interviewed, and each indicated they are able to call 9-1-1 if needed.
The center’s medical policy and procedures were revised at the end of last fiscal year. Prior to
the policy revision, NARCAN® training was embedded within the Department’s Learning
Management System (SkillPro) CPR course. Effective April 2024, the center’s nurses will be
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 clinical
nursing manager indicated the center has not utilized NARCAN® since the last annual
compliance review. The clinical nursing manager also indicated emergency drills are conducted
monthly on each shift. A review of drill documentation confirmed two drills on each shift
demonstrated the use of CPR and AED since the last annual compliance review. Five youth
were interviewed and two rated the medical care at the center as very good and three 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 facility operating procedures to provide for referrals and coordination of medical
services to ensure youth have timely access to off-site care services. A review of five youth
Individual Healthcare Records (IHCRs) found there was one youth applicable for off-site care;
therefore, two additional applicable records were selected for review. All three records
maintained discharge paperwork for the youth which was signed by the designated health
authority (DHA); however, none of three reviewed records had a Summary of Off-Site Care form
completed. Progress notes documented the related notification made to each parent/guardian
and the DHA and noted needed follow-up care, when required. The clinical nurse manager
reported the local emergency room/hospital staff do not complete or return the Summary of Off-
Site Care form to the transporting juvenile detention officer’s (JDO). Reviewed documentation
supported the form was sent with the transporting staff for each of the three youth and the blank
forms with youth demographics were uploaded. The clinical nurse manager reported the center
requests and received the hospital records after the youth is discharged, which are reviewed
and signed-off by the designated health authority (DHA) or advanced practice registered nurse
(APRN). The hospital records are then maintained in the youth’s record and in the Department’s
Juvenile Justice Information System (JJIS) Electronic Medical Record (EMR), under the tab for
off-site care. The clinical nurse manager indicated the Episodic Tracking Log is utilized for youth
receiving off-site care, and emergency care progress notes are utilized to document the off-site
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care, which are uploaded into the EMR. The center documented the transport to off-site care for
medical clearance in the admission chronological progress note and the return to the center as
an incidental note. An informal interview with the clinical nurse manager revealed there were no
off-site care logs maintained at the center until the clinical nurse manager established the use of
a log beginning with instances of off-site care in December 2023. A review of the new Off-Site
Care Log indicated three youth had been transported off-site for care on December 13, 19, and
27, 2023; however, a youth medical transport on January 24, 2024, which was reported to the
Department’s Central Communications Center (CCC), was not documented on the Off-Site Care
Log. The January 24, 2024, instance of off-site care was added to the Off-Site Care Log during
the week of the annual compliance review.
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 facility operating procedures to ensure youth identified with chronic
conditions receive regularly scheduled evaluations and necessary follow-up care. A review of
five youth Individual Healthcare Records (IHCRs) found one youth was applicable for the
existence of chronic conditions. The youth was placed on the chronic list; however, did not
remain in secure detention long enough for a periodic evaluation; therefore, three additional
records applicable for chronic conditions were selected for review. All three youth were found to
have been placed on the chronic conditions list for having a food allergy, high body mass index,
or diabetes; however, none of the youth were held in secure detention long enough for a
periodic evaluation to take place. The problem list for each youth was updated to indicate each
youth’s chronic condition upon completion of the Comprehensive Physical Assessment (CPA).
There were no youth applicable for taking anti-tuberculosis medication. An interview with the
clinical nurse manager explained the center utilizes an electronic spreadsheet titled “Medical
Tracker Current” 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. An interview with the clinical nurse manager indicated
all youth who have chronic conditions receive regularly scheduled evaluations and necessary
follow up.
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 facility operating procedures (FOPs) 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 each medication has a current, valid order, and are given according
to a current prescription or practitioner’s order. Nursing staff verify medication with the
parent/guardian when they deliver the medication to the center. A 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. There were no youth
applicable for restricted housing while taking prescribed medications since the last annual
compliance review. The center utilizes a local pharmacy as a back-up for emergency purposes.
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All medication is delivered to the center in blister packs. A review of five Individual Healthcare
Records (IHCRs) showed there was one youth taking medication upon admission; therefore,
two additional applicable records were selected for review. A review of the three applicable
records indicated the designated health authority (DHA), or when applicable the psychiatrist,
were contacted to obtain an order to resume the specified medication prescribed prior to
admission. Each medication had a current, valid order, and was administered pursuant to the
current prescription. When current medications were continued, discontinued, or changed the
reviewed records indicated the DHA placed an order on the Practitioner Order form, as required.
Each reviewed record confirmed prescription verification was completed in the chronological
progress notes in the related IHCRs. Two youth records were applicable for over-the-counter
(OTC) medications not listed on the Authority for Evaluation and Treatment (AET) form, each of
which was administered according to the practitioner’s order. The center utilizes the standard
Department Medication Administration Record (MAR) for each youth receiving either
prescription medications on a routine basis or OTC medications which included all required
elements. The center maintains FOPs to ensure the usage of the MAR by licensed healthcare
staff and non-licensed staff. 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. Five youth records
were reviewed and four were applicable for having MARs documenting administered
medications. Each of the reviewed MARs documented side effect monitoring by the nursing staff
at each medication administration. One youth record was applicable for trained non-healthcare
staff assisting in the delivery of medications when licensed healthcare staff were not on-site.
Reviewed documentation indicated both the youth and the non-licensed staff were present
when staff assisted with the delivery of medication. There were no undocumented explanations
for lapses or errors in medication administration. The center did not have any standing orders
for psychotropic medication, pro re nata (PRN) orders for psychotropic medication, or
emergency treatment orders for psychotropic medication. Two records were for youth on
psychotropic medication who were at the center for more than thirty days. Two of five reviewed
records were applicable for youth entering the center while on prescribed psychotropic
medication. In both instances the psychiatrist was notified upon the youth’s admission and the
psychiatrist conducted an initial diagnostic psychiatric interview within fourteen days of
admission. It is the center’s practice for youth to be seen weekly by the psychiatrist for
medication management rather than every thirty days, as required. A review of the applicable
records confirmed the center’s practice, which exceeds the requirement of medication
monitoring every thirty days. Observations of a medication pass were conducted during the
week of the annual compliance review. Medication delivery was the sole responsibility of the
nurse at the time of administration. Each youth was escorted to the medication administration
area by a direct care staff. Each youth approached the nurse administering medication
individually and the same staff prepared and administered each medication. The nurse
observed each youth’s open mouth after the medication was administered to ensure the
medication was swallowed. The nurse and youth electronically initialed the MAR. An interview
with nursing staff indicated the center has a process for monitoring and tracking youth with
chronic conditions, as well as verifying each youth’s medication regimen once admitted to the
center. Additionally, the center has non-healthcare supervisory staff who are trained by medical
staff to provide OTC medication to youth. An interview with the clinical nurse manager indicated
the center utilizes a chemical pharmaceutical drug disposal system to dispose of expired
medication in the presence of the consultant pharmacist. An interview with five staff regarding
medication administration was conducted, and three non-supervisory staff stated they do not
give medication to youth, while two supervisory staff confirmed they have been trained and they
are able to provide medication to youth. None of the five interviewed youth were taking
medication at the center.
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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 facility operating procedures regarding the requirements for the storage
and inventory of medications and sharps ensuring all medication is inaccessible to youth at the
program. Observations of the medication cart showed it was clean and organized, with stock
items separate from youth specific medications. An observation of the medication cart found all
medications were stored in the locked cart which is kept in the locked medical clinic. All non-
controlled medications were stored in a separate, secure, locked medication cart. Narcotics and
other controlled medications are securely stored and double locked within the medication cart.
Observations found all medications were securely stored in the medical clinic inaccessible to
youth. 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.
Perpetual inventories with running balances are maintained on all controlled substances with a
shift-to-shift inventory conducted by the nurses. The center had one youth prescribed a
controlled medication at the time of the annual compliance review, and the reviewed inventory
was accurate. A review of three over-the-counter (OTC) medications was conducted, each of
which validated the respective inventories were accurate. Syringes and sharps are counted
through a perpetual inventory and are verified weekly. It is the center’s practice for inventory
discrepancies to be reviewed with the clinical nurse manager to determine when and how the
error occurred and to subsequently document the correction on the related inventory.
Observations of a count were conducted with the licensed practical nurse (LPN). A review of
three sharps verified two matched the count on the perpetual inventory; however, the perpetual
inventory recorded one additional one milliliter tuberculosis (TB) test needle in stock than was
observed during the count conducted as part of the annual compliance review. Healthcare staff
determined, at the time of the observation, one youth had a TB test placed on February 27,
2024, for which no documentation was recorded to show the use of a one milliliter TB needle on
the perpetual inventory. Additionally, a weekly sharps count conducted three days later, on
March 1, 2024, continued to report one more needle than was actually present, which was
attributed to a staff miscount. A review of the youth’s Medication Administration Record (MAR)
validated a tuberculosis skin test (TST) was placed on February 27, 2024. The healthcare staff
updated the inventory during the week of the annual compliance review to include the use of
one needle on February 27, 2024, for the youth’s TB test, thereby correcting the inventory to the
correct count.
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 facility operating 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
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diseases. A review of five 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 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 and 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 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) were notified relating to an infectious disease since the last annual compliance review. A
review of five staff training records confirmed each staff completed Exposure Control
Plan/Infection Control Plan training. An interview with the clinical nursing manager indicated
youth are provided with the infection control training upon admission, and nursing staff are
responsible to provide staff with training on the center’s Exposure Control Plan.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center maintains facility operating procedures for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. The center had three
pregnant youth admitted since the last annual compliance review. Two youth transferred from
another detention center, and one was admitted directly. Each youth had the provision of
prenatal care begin immediately, which continued through discharge from the center or through
postpartum. One youth was in the center for more than thirty days, and the designated health
authority (DHA) and/or advanced practice registered nurse (APRN) provided a routine focused
medical evaluation of the youth’s pregnancy every thirty days or sooner. A review of all three
applicable records indicated prenatal care was provided at recommended intervals and each
youth was placed on the center’s internal alert system for the provision of all nutrition and staff
health awareness. Review documentation indicated each youth was monitored daily for signs of
pregnancy complications. One youth was applicable for post-pregnancy psychological and
physical care, and the youth's record included a transitional healthcare plan. Reviewed
healthcare education information showed the three applicable pregnant youth had completed
prenatal education including the topics of alcohol and drug use, smoking cessation, nutrition,
sexually transmitted infections (STIs), contraception, prenatal care, birthing process, postpartum
care, basic baby care, child/infant development, and parenting skills. All youth education was
documented in each youth’s Individual Healthcare Record (IHCR). A review of five staff training
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records validated each staff received training specific to working with pregnant youth. Staff
training documentation reflected training was provided by the APRN at the time of hire and
annually, thereafter. An interview with the clinical nurse manager indicated the center's process
for routine monitoring of pregnant youth includes the provision of a standard bed with adequate
mattress support and requiring staff to report symptoms associated with a medical emergency
to the healthcare staff when they are on-site. All pregnant youth are to have off-site obstetrical
appointments and are to be provided with additional food to meet caloric intake for pregnancy.
The center provides educational topics to pregnant youth including safe pregnancy, nutrition,
dental care, prenatal, and postnatal care.
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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 maintains facility operating procedures to address active supervision of youth.
During the annual compliance review week, youth supervision was observed each day. Youth
and staff observations were made on the living modules, in the classrooms, in the cafeteria, in
the booking area, and line movements throughout the center. 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 and line
movements which supported active supervision. The juvenile justice detention officers (JJDOs)
and master control operators communicated to receive authorization for all movement within the
center. The master control logbooks were reviewed since the last annual compliance review and
verified documentation to support headcounts were conducted on a consistent basis during the
beginning and ending of each shift and prior to youth movement. The center’s method of
tracking daily census is through master control and staff calling counts and documenting in
logbooks. Five staff were interviewed, and each indicated they think there are enough staff at
the center to provide for the safety and security of the youth and staff.
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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 facility operating procedures requiring a uniform behavior management
system (BMS) which offers a predictable set of rewards, privileges, and consequences for
behavior. The center has a system of rewards, privileges, and consequences to motivate youth
to meet the center’s expectations. Observations were conducted during the annual compliance
review week and revealed the center has the BMS posted in all areas in which youth are
housed. The postings describe appropriate behaviors and rewards for such behavior, and
inappropriate behavior and consequences for such behavior. Each youth is informed of the BMS
during the admission process through an orientation. The BMS is a three-tiered level system.
Each youth enters at level 2.1 when admitted, and the level may increase or decrease,
depending on the youth’s behavior in the center. The center has incentives for every youth
earning level three status such as later bedtime, extra telephone calls, extra visitation outside of
the allotted visitation time, participation in special events, and canteen food items. The
incentives can change based on the center’s needs. The center has an incentive calendar
detailing daily incentives for the month. A review of the level sheets and logbooks confirmed the
center’s practice. Five youth were interviewed and one of the five interviewed youth stated the
BMS is good. Four youth stated the BMS is very good. Two youth reported they never received
consequences at the center, and three youth stated the consequences are fair. All five youth
were able to articulate how youth are rewarded in the center. Four of the five youth confirmed all
staff use the rewards the same way, and one youth stated they were unaware. Five staff were
interviewed and four of the five interviewed staff reported they feel the BMS is effective. One
staff stated it is effective when implemented properly. Five 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. Five
staff reported points/levels can be taken away consequently. The center’s BMS prohibits the
use of group punishment and corporal punishment. Each interviewed staff advised
consequences never include loss of meals, snacks, school, or other rights afforded to the youth.
All interviewed staff further indicated they have never witnessed a coworker utilize group
punishment or corporal punishment. All five staff indicated they never witnessed a coworker
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encourage a youth to beat up another youth. Five youth were interviewed, and none reported
having their rights taken away as punishment for inappropriate behavior. Each youth further
indicated losing points or having levels reduced due to inappropriate behaviors. One youth
stated outdoor privileges were taken away due to behavior. Each of the five youth stated they
are not allowed to punish other youth. An interview with the superintendent indicated the center
maintains a BMS tracker which monitors the youth’s level each day. The youth earn incentives
on designated days such as extra phone calls, movie nights, ice cream day, and pizza parties.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures addressing ten-minute checks. Staff utilize an
electronic wand system by tapping it on the check point sensors on the outside of each youth’s
room. The data from the wand is downloaded daily to ensure no data is lost. The juvenile justice
detention officer (JJDO) must observe the youth behind the closed door before the check point
sensor is activated. The center has a total of sixty-three cameras, and all were operational
during the week of the annual compliance review. The center stores all video recordings for
thirty days. A review of the documentation and surveillance coverage was conducted for nine
randomly selected dates and times, across two shifts, on one youth living module with no
issues noted. A review of ten-minute check log samples for each month since the last annual
compliance review reflected checks were consistently conducted at intervals of no more than
ten minutes. Five staff were interviewed, and all were knowledgeable of the requirements and
policy for ten-minute checks and room checks. Each interviewed staff indicated their practice for
room checks are to conduct a check at least every eight minutes when a non-suicidal youth is
placed in their room. The interviewed superintendent reported when youth are placed in a room,
they maintain visual checks every ten minutes with a wand. The staff must look into the room
and then with the wand hit the ring on the door to record the check.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains facility operating procedures requiring staff to always know the exact
number and location of all youth under their supervision. A review of the master control
logbooks confirmed since the last annual compliance review, the census counts of youth were
documented at the beginning and at the end of each shift. Additional counts were conducted
and documented, at a minimum, one extra time randomly on each shift. Counts were
documented after emergencies, disturbances, and drills. Census counts were documented after
any change of population. Living module counts were documented in the assigned module
logbooks. Five staff were interviewed, and all indicated youth counts are conducted at the
beginning of shift, end of shift, before/after school, and before/after meals. All five interviewed
staff confirmed emergency counts are conducted when a youth is believed to be missing, when
visibility is hindered, after any major disturbance, when drills are conducted, after codes, and
after a power surge. Observations of counts being conducted during the annual compliance
review week reflected they were completed in accordance with policy.
5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has facility operating procedures regarding logbooks. The center maintains separate
logbooks in master control, for transportation, and for each living module, as well as one for
visitors, and one for contracted staff. A review of logbooks since the last annual compliance
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review revealed each was bound with numbered pages. A review of three full days of
documentation for each month for the past twelve months reflected 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, medical, special needs, and mental health alerts, which were highlighted.
Reviewed logbooks reflected errors were struck through with a single line and dated and
initialed by the staff correcting the error. The juvenile justice detention officer (JJDO) supervisor
records comments regarding the corrected errors. 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, presence of law enforcement,
and name of youth placed in confinement, including the time confinement began and the time
confinement ended, name of youth placed on precautionary/secure observation, and the time
precautionary/secure observation began and the time precautionary/secure observation was
discontinued. The supervisor reviews the master control logbook when accepting responsibility
for the center and review the living area logbooks daily. The JJDOs review the logbook entries
from the previous shift when accepting responsibility for the living area. Each logbook review
designated the name and position of the reviewer and the date and time the review was
completed.
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has facility operating procedures regarding logbook requirements. Master control
and living module logbooks were reviewed since the last annual compliance review. The
juvenile justice detention officer supervisors (JJDOSs) documented a review of the logbooks
each shift, including the master control logbook when accepting the shift, to document they were
aware of current relevant situations in the center. The superintendent or designee documented
a review of the logbooks on a weekly basis. The juvenile justice detention officer (JJDO)
assigned to each living module documented a review of the logbook upon accepting the shift.
An interview with the superintendent indicated management reviews and signs logbooks weekly
for accuracy.
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5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center maintains facility operating procedures detailing the requirements of the center’s 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
resistant key ring which inhibits the removal of keys and is color coded specific to the position to
which the keys are 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 to. Emergency keys which provide egress through
exterior doors are stored in master control. A review of the Key Control Logs confirmed logs
included the control and use of keys including key assignment and usage including restrictions
on usage, inventory, daily tracking, reconciliation of keys, secure storage of keys not in use,
procedures addressing missing or lost keys, and reporting and replacement of damaged keys. A
review of the Key Control Logs and observations of the distribution and collection of keys,
confirmed the issuance of keys and key rings were documented on the Key Control Logs on
each shift with the date and time of issue, name of staff receiving the key ring, and the time
each key was returned. 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 and youth did not have access to center keys. The center keys carried by three
staff were examined and were confirmed to have the correct number of keys on the ring, as well
as the correct assigned key ring number documented for the shift. Informal interviews
conducted with three staff confirmed all staff knew about the number of keys on their key ring
and the function of each key. A review of the master key control inventory confirmed the
inventory report matched the actual key rings in use. There were no reported incidents of lost
keys since the last annual compliance review. The assistant superintendent confirmed there
were no incidents of a staff taking their keys home with them since the last annual compliance
review. Personal keys are stored in staff lockers, visitor lockers, or master control in the non-
secure area of the center. Five staff were interviewed and all five indicated the keys used to
access the kitchen, medical records, youth property area, case management, and mental health
records are all restricted. All five interviewed staff were able to articulate the daily process for
key control at the center. An interview with the superintendent indicated there are no permanent
keys assigned to staff.
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains facility operating procedures to address transportation procedures and the
maintenance and operation of Department vehicles. The center has three vehicles used to
transport youth. Observations confirmed each of the three center vehicles had the appropriate
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number of seatbelts, a seatbelt cutter, a window punch, a fire extinguisher, and a first-aid kit
containing only approved items. The center’s vehicles are to be securely locked when not in
use. A security check was conducted of three center vehicles not in use and each was found to
be securely locked. Reviewed documentation confirmed each vehicle was inspected prior to
transport. Documentation supported the maintenance mechanic’s completion of weekly and
monthly vehicle checks. A review of the vehicle maintenance invoices revealed all vehicles
received an annual inspection within the previous year. Five youth were interviewed regarding
safety while being transported in center vehicles and all youth indicated they feel staff drive
safely. None of the youth ever observed anyone placing contraband in a transport vehicle.
Observations were conducted and confirmed the transport staff inspected the vehicle for
contraband and made sure the cage area of the vehicle was physically checked for objects
and/or contraband. Staff ensured the vehicle had sufficient gasoline to reach the destination,
maintained copies of current transportation procedures in each vehicle, and verified seatbelts
were securely anchored. Staff tested the security screen/cage to ensure it was secured,
confirmed the vehicle folder contained the vehicle logs, vehicle and mechanical restraint keys,
gas credit card, and vehicle registration. Staff ensured a cellular telephone was assigned to the
vehicle and was charged and turned on prior to departure and ensured the inspection was
documented in the vehicle logbook. Staff ensured the vehicle was secured at all times, ensured
all youth were searched prior to being placed in the vehicle, and ensured youth and staff wore
seatbelts. Observations confirmed the transport staff ensured the vehicle was searched for
contraband and locked to prevent the introduction of contraband. Staff ensured youth were
searched upon return to the center and ensured youth and staff wore seatbelts.
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center maintains facility operating procedures to address tool inventory and management.
All tools used must be signed in and out when removed from respective areas. An inspection of
the tool room and kitchen confirmed there were no tools listed on the inventory which were
missing, and no tools not listed on the inventory. The kitchen staff conducts an itemized
inventory of all equipment, including knives and other implements, upon reporting for duty. An
informal interview with the maintenance staff confirmed service vendors were accompanied by
designated center staff at all times when in a secure area of the center. Following the
completion of a work project, the area is to be cleaned and inspected for contraband prior to
allowing youth access. A review of the inventory confirmed documentation of issuance and
return of tools. An informal interview with maintenance and kitchen staff confirmed the practice
for missing and damaged tools. An interview with the superintendent indicated only staff have
access to center tools. Five interviewed staff indicated the center’s practice for damaged or
missing tools is to contact maintenance, supervisors, and report the missing tools to the
Department’s Central Communications Center (CCC) within two hours. The center maintains a
perpetual inventory of tools. All tools were secured, had markings for easy identification, were
accurately accounted for, and inventories were signed by the superintendent/designee
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5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center maintains facility operating procedures detailing the requirements and restrictions for
youth access to tools and cleaning items. At the center, youth only have access to mops and
brooms. Five youth were interviewed, and all youth responded the staff will apply cleaning
agents such as bleach, laundry soap, window, or toilet cleaner and they will clean the areas
which need to be cleaned and they are only allowed to use mops and brooms with supervision.
Five staff were interviewed, and all five responded level three youth can use mops and brooms
with supervision at all times. An observation of youth using tools was not possible during the
annual compliance review week.
5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center maintains facility operating procedures detailing the proper use, storage, and
disposal of flammable, toxic, caustic, and poisonous items. Flammable, toxic, caustic, and
poisonous items are to be maintained in secure areas of the center to which youth have no
access. Safety Data Sheet (SDS) logbooks are in the same location as the center’s stored
chemicals. Inventories of flammable, toxic, caustic, and poisonous items are maintained by the
maintenance mechanic. A review of documentation maintained during the annual compliance
review period confirmed the center maintained an inventory of all flammable, toxic, caustic, and
poisonous items. A sample of five chemical items were reviewed on-site for which the center
maintained a corresponding SDS and accurate inventories.
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5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center maintains facility operating procedures which prohibit youth access to flammable,
toxic, caustic, or poisonous items. Youth are not permitted to access any materials which are
flammable, toxic, caustic, and/or poisonous. No toxic materials were observed in any place
accessible to youth during the annual compliance review week. All flammable, toxic, caustic,
and poisonous materials are stored in secure areas inaccessible to youth. Five interviewed
youth all indicated they do not use or have access to substances which are toxic, flammable, or
poisonous. Five staff were interviewed, and all five indicated youth are not allowed to clean with
substances which are toxic, flammable, or poisonous.
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center maintains facility operating procedures which address proper use, storage, and
disposal of flammable, toxic, caustic, and poisonous items. The plan details the procedures to
follow in the event of a chemical leak or spill. The maintenance mechanic confirmed chemical
materials are disposed of by evaporation, compaction, or taken to a local waste annex. The
kitchen has a grease trap located outside near the back kitchen door. The grease is taken away
by a local vendor. The interviewed superintendent and maintenance mechanic reported there
have been no instances of chemicals needing disposal or chemical spills since the last annual
compliance review.
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains facility operating procedures to address requirements for behavioral
confinement for less than twenty-four hours. Twenty confinements were reviewed.
Documentation indicated all youth rights were afforded in each instance including three meals a
day, an evening snack, schoolwork, access to mental healthcare as needed, daily shower, clean
clothing, and bedding. The center documents confinements under twenty-four hours in the
Facility Management System (FMS) within the Department’s Juvenile Justice Information
System (JJIS). Twenty reports documented the confinement room was searched prior to each
youth being placed. Twenty reports had the initial confinement reviewed by the juvenile justice
detention officer supervisor (JJDOS) within two hours to determine the appropriateness of the
use of confinement. Each initial confinement was approved by a supervisor, staff placed only
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one youth in the confinement room, and each youth was notified as to their right to grieve the
confinement placement. Documentation indicated all twenty youth were supervised while in
confinement with the supervision documented on the Visual Observation Report (VOR) Log at
least every five minutes for the first hour. The youth were supervised according to how they
were classified on the Detention Supervision Matrix thereafter. Fourteen of twenty reviewed
confinement youth were afforded education materials. Six youth were not applicable. Each of
the twenty reviewed confinements documented a review conducted by the supervisor at least
every three hours, including the reason for continued confinement based on severity of rule
infraction, past disciplinary history, or behavior confinement. All twenty reports were reviewed by
the superintendent or designee within forty-eight hours excluding weekend and holidays.
Reviewed confinements confirmed supervisors/staff continually counsel the youth to consider
removing them from confinement as soon as the youth was able to safely rejoin the population
and there was no threat to safety. None of the reviewed confinements were applicable for
interference with any visitations. All youth were explained the reason for confinement. Five staff
were interviewed, and all stated when placing a youth in confinement, staff must complete a
confinement report and conduct/document checks, and staff must search the confinement room
prior to placing the youth in the room. All five also stated they must conduct five-minute checks
for the first hour of confinement. Five staff also stated when youth are placed in confinement,
educational materials are offered. Observations confirmed windows and cameras were free of
obstructions/scratches so the youth may be visually observed. An interview with the
superintendent indicated when a youth is placed on confinement it is entered in JJIS. The
supervisor conducts a review within the first two hours to ensure the confinement is appropriate.
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains facility operating procedures to manage various emergencies and disaster
events. Two Continuity of Operations Plan (COOP) drills were conducted within the prior year.
Documentation confirmed the center conducted an evacuation on April 14, 2023, prior to
hurricane season and on January 14, 2024, there was an evacuation due to flooding. Five staff
were interviewed, and all staff reported they participated in fire, weather, major disturbances,
bomb threat, hostage situation, chemical spills, flooding, terrorism, and escape drills. An
interview with the superintendent indicated drills are conducted each month to ensure staff are
trained.
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5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures to address escape drills and escape
prevention. The policy requires the center to conduct escape drills at least quarterly.
Documentation for drills conducted since the last annual compliance review was examined. The
center completed quarterly escape drills on April 13, 2023, July 13, 2023, October 26, 2023, and
January 20, 2024. 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 logbooks revealed each mock escape drill was documented in the
logbooks, as required. Five interviewed staff indicated they participated in an escape drill in the
past twelve months. A review of eleven staff training records validated each staff completed
escape prevention training during the previous year.
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center maintains a fire prevention and evacuation plan which details the fire prevention and
safety procedures of the center. The center documented the completion of monthly fire drills on
each shift since the previous annual compliance review. The fire drills were documented in the
master control logbooks. Staff sign-in sheets were used to document staff participation in each
drill. Fire extinguishers are inspected annually. Five staff were interviewed and all five indicated
fire drills take place at least monthly and each participated in fire drills over the prior twelve
months. Five youth were interviewed, and all stated they had been instructed on what to do in
the case of a fire.
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5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) for search and contraband procedures.
Youth frisk searches were conducted prior to admission. Electric and full body searches were
conducted during admission, when there was reasonable suspicion the youth was harboring
contraband, and during center-wide initiatives to reduce the introduction of contraband. All
searches were documented in the logbook and electronically. An observation of a youth and
room search confirmed staff wore gloves during all searches. Staff were observed conducting
searches in the dining hall before youth were called for clearance to return to the living units. An
observation of a staff completing a room search prior to a youth being released was also noted.
Full body searches were conducted with two staff of the same gender of youth, and all searches
of the youth were conducted individually and not in a group setting. Electronic searches were
conducted on all staff, contractors/vendors, and visitors entering the center. All bags, cases,
jacket pockets and other items were searched. All personal keys, personal cell phones, and
other contraband items were prohibited from entering the secure area. Rooms were searched
upon a youth’s release, prior to placing a new youth in a room, and on each awake shift. There
were no instances which may have compromised the safety or security of the center throughout
the annual compliance review period. An interview with the superintendent indicated all
contraband will be confiscated and law enforcement, the Department’s Central Communications
Center (CCC) and regional director will be notified.
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Office of Accountability and Program Support Page 57 of 57 (Revised July 2023)

report_type: QI Detention