state: FL

summary: QI Detention - FY24-25 - 8 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Bay Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
450 East 11th Street
Panama City, Florida 32401
Review Date(s): August 13, 2024 - August 16, 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:
Jessica Gibson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Cio’nna Allen, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Patrick Brock, Office of Education, Northwest Region Education Coordinator (Standard 2)
Dshombe Flowers, Okaloosa Regional Juvenile Detention Center, Assistant Superintendent
(Standard 5)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
1)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 2,
interviews)
Rebecca Smith, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Bay Regional Juvenile Detention Center MQI Program Code: 33
Provider Name: State Operated Contract Number: NA
Location: Bay County / Circuit 14 Number of Beds: 30
Review Date(s): August 13-16, 2024 Lead Reviewer Code: 210
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* 1.05 Right Interactions (RI)
5.11 Confinement Under Twenty-Four Hours 1.07 In-Service Training
5.15 Fire Drills 5.03 Ten-Minute Checks*
5.07 Vehicles and Maintenance
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 58 (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 Right Interactions (RI) Failed
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Failed
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).
Overall Rating Summary for Standard 1
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be conducted
within six (6) months of publication of the program report.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 58 (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 58 (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 Non-Applicable
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 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 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 58 (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 Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 58 (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* Failed
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Failed
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Limited
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Failed
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Limited
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Limited
5.16 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).
Overall Rating Summary for Standard 5
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be conducted
within six (6) months of publication of the program report.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58 (Revised July 2023)
Program Overview
The Bay Regional Juvenile Detention Center is a state-owned detention facility, operated by the
Department, located in Panama City, Florida. The center serves youth in Bay, Calhoun, Gulf,
Holmes, Jackson, and Washington counties in Circuit 14. Male and female youth who are
detained pending adjudication, disposition, or placement in a residential commitment program
are housed in the thirty-one 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 Bay
County School Board. The center’s management team includes the superintendent, two
assistant superintendents, one administrative assistant, seven juvenile justice detention officer
(JJDO) supervisors, and sixteen JJDOs. Mental health and healthcare services are provided
through the contracted provider, Vital Core. Mental health services are provided by one
designated mental health clinical authority (DMHCA) and four licensed mental health counselors
(LMHC). 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 Vital
Core to include one medical doctor who is the designated health authority (DHA), one advanced
practice registered nurse (APRN), two registered nurses (RN), one licensed practical nurse
(LPN), and a medical records clerk. The medical clinic maintains nursing coverage Monday
through Friday, from 7:00 a.m. to 7:00 p.m., and on weekends, from 7:30 a.m. to 7:30 p.m. Food
services are provided by Department staff and include menus, meal planning, meal schedules,
special diets, nutritional analysis, daily allowance, food preparation, health certifications, food
product standards, sanitation, and cleaning. Staff are responsible for the custody and control of
youth in their care, providing youth supervision twenty-four hours a day, seven days a week.
The center has three living modules which are divided by male and female. There are sixty
security cameras at the center, of which fifty-six were operational. One maintenance issue was
observed while at the center; the air conditioning for the B2 living module was currently not
working. Work orders have been submitted and an air conditioning company has been to the
center multiple times to fix the air conditioning; however, it continues to be inoperable. The
windows of the living module room doors were scratched. Some of the windows were difficult to
see into the rooms. At the time of the annual compliance review, the center had eighteen
vacancies, which included JDO I and II positions.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 58 (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 (FOPs) outlining the process of background
screening for all new staff, volunteers, and contracted staff. An Annual Affidavit of Compliance
with Level 2 Screening Standards was submitted to the Department’s Background Screening
Unit (BSU) on January 5, 2024, meeting the annual requirement. The center employs local
school board teachers and their Annual Affidavit of Compliance with Level 2 Screening
Standards was completed on January 19, 2024, meeting the annual requirement. Since the last
annual compliance review, the center had ten newly hired staff, two volunteers, and one
contracted staff. All thirteen new hires were found to have an eligible background screening
which was completed prior to their hire date. Three of the ten staff required a background
screening exemption and each staff obtained an exemption prior to working with youth. Ten staff
were applicable to complete the pre-employment assessment tool. Six of the ten staff had
passing scores for their pre-employment assessment. The remaining four staff records included
waivers to allow them to be hired. The center had one newly hired contracted staff who had an
eligible screening and was added to the Clearinghouse employee 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 (FOPs) outlining the process of five-year
background rescreening for staff. A rescreening shall be completed every five years from the
date of hire for all staff. Rescreening shall be submitted to the Department’s Background
Screening Unit (BSU). Two staff were applicable and reviewed for five-year rescreening. Both
staff had the five-year rescreening completed every five years, calculated from the agency hire
date. The center did not have any contracted provider staff who required a rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 58 (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 (FOPs) outlining the guidelines of staff code of
conduct. The FOPs state any form of abuse, profanity, threats, harassment, intimidation,
“horseplay,” or personal relationships with youth are prohibited for staff. If the code of conduct is
violated, there is a process in place for management to follow to address each violation. Six
staff records were reviewed for staff code of conduct. All six staff had signed codes of conduct
in their personnel records. Three of the staff were applicable for receiving disciplinary actions for
violations of the code of conduct during the annual compliance review period. Management took
immediate action to investigate and/or address all allegations or violations of the code of
conduct. One staff was terminated from the Department, one staff was demoted, and one staff
was placed on no youth contact until an investigation was completed. The remaining three staff
were applicable for receiving commendations which were documented in their personnel
records. Additionally, five youth were interviewed. All five-youth stated they had never had to
report abuse to the Florida Abuse Hotline since they have been at the center. All five youth
stated staff are respectful when talking to them and other youth at the center. One youth stated
they have never heard staff use profanity toward youth. The remaining four youth stated they
hear staff use profanity occasionally and often, respectively. This information was provided to
the center administrative staff. The review team conducted follow-up interviews with the youth
for more information. The youth reported the staff curse in general conversation and not
directed at youth. Four youth stated they have never heard staff threaten a youth. The
remaining youth stated they have often heard staff threaten a youth. This youth was re-
interviewed about staff threatening youth and the youth could not provide any further details. All
five-youth reported feeling safe at the center. All youth reported never exchanging emails,
telephone numbers, or social media contact information with staff. Five staff were interviewed
and indicated youth are allowed to make the call to the Florida Abuse Hotline or the
Department’s Central Communication Center (CCC) to report suspected abuse. One staff also
indicated the supervisor must be notified. Three staff reported hearing staff use profanity when
speaking to a youth on one occasion. One of the staff indicated this has never occurred and one
staff indicated this has occasionally occurred. Five interviewed staff also indicated they have
never observed a co-worker using threats, intimidation, or humiliation, when interacting with
youth. Three staff interviewed stated, in the past year, the working conditions at the center have
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58 (Revised July 2023)
been good; whereas two staff stated the working conditions have been fair. The superintendent
indicated staff must exhibit behavior prohibiting any form of abuse, profanity, threats,
harassment, intimidation, or personal relationships with youth. Officers shall not verbally abuse,
demean, or otherwise humiliate any youth, and shall not use profanity in the performance of
their job. If staff are found to be in violation of the staff code of conduct, they are immediately
placed on no youth contact status until a management review can be completed. If there is a
suspicion or knowledge of abuse the Florida Abuse Hotline and the CCC are contacted and a
report is made. If the allegations are founded, appropriate disciplinary action is taken.
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 (FOPs) outlining the process of contacting the
Department’s Central Communications Center (CCC). Since the last annual compliance review,
the center had thirty-eight CCC incidents. Five reports were reviewed, and each incident was
reported to the CCC within the required time frame and documented in the center’s logbooks.
During the annual compliance review period, there were no additional incidents/grievances
which should have been reported to the CCC. The superintendent indicated the center will
gather all necessary information regarding an incident and report it to the CCC within two hours
of gaining knowledge of the incident. If an update to the incident is required, it is completed on
the same day or the morning of the next day by 9:00 a.m. An email is also sent to the regional
director and chief of detention.
1.05 Right Interactions (RI) Failed Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures (FOPs) outlining the staff’s use of physical
intervention techniques. The superintendent interview indicated mechanical restraints may only
be used when necessary to prevent harm to the youth or staff. The use of mechanical restraints
requires the regional director or designee to be notified. Additionally, officers will complete the
mechanical restraint log and ensure ten-minute checks are completed and announced over the
radio. The officer supervising the youth should have a handcuff key readily available and the
mechanical restraints should be removed as soon as it is safe to do so. Lastly, a Protective
Action Response (PAR)/Right Interactions (RI) report shall be completed and submitted for
review. Regarding the process for monitoring PAR/RI incidents and use of force, the
superintendent stated incident reports are reviewed by the superintendent, assistant
superintendent, and supervisors to ensure all staff involved in an incident are complying with the
PAR/RI rule. All statements of those involved are entered into the report by the end of their shift.
Incidents are also reviewed on the Closed Circuit Television (CCTV) by all parties involved in
the incident. During five staff interviews, it was indicated staff attempt to talk to youth prior to
any physical intervention being utilized. During the annual compliance review period, the center
had fifty-two PAR/RI incidents. Nine incidents were reviewed. One of the nine incidents did not
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 58 (Revised July 2023)
include a PAR/RI report with statements from all staff involved. One out of nine incidents did not
include a supervisory review of the PAR/RI report. One out of nine incidents did not have a post-
PAR/RI interview conducted with the youth by an administrator or designee within thirty minutes
after the incident. Four of nine youth were applicable for a PAR/RI medical review; however,
one of the four incident documentation did not include a post-PAR/RI medical review when the
post-RI interview indicated a need for one. One of the four records did not include a
documented medical review within the Individual Healthcare Record (IHCR). One youth was
applicable for mechanical restraints. The Mechanical Restraint Supervision Log was not
completed after the result of a Level three PAR/RI response. Five out of the nine youth records
did not include the superintendent or designee’s review of the PAR/RI reports within seventy-
two hours. One report was reviewed forty-five days late, one review was thirty-four days late,
two reports were four days late, and one report was not reviewed at all.
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 facility operating procedures (FOPs) outlining the training requirements for all
new staff. Each of the five reviewed staff completed all required pre-service training within 180-
days of hire. Each of the five staff completed all of the essential skills trainings prior to being in
the presence of youth. Essential skills training includes cardiopulmonary resuscitation (CPR),
first-aid, automated external defibrillator (AED), Child Abuse Recognition, Reporting, and
Prevention, Emergency Procedures, FOPs, Prison Rape Elimination Act (PREA), professional
interpersonal communication and ethics to include standards of conduct, suicide awareness and
prevention, and Protective Active Response (PAR). All trainings were entered in the
Department’s Learning Management System (SkillPro).
1.07 In-Service Training Failed 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 (FOPs) outlining the annual training requirements
for staff. The center has an annual in-service training calendar, which was approved by the
Assistant Secretary of Detention Services on November 17, 2023, and the Director of Talent,
Leadership and Culture (TLC) on December 15, 2023. The annual training calendar was not
approved by the highest ranking official at the facility. The superintendent indicated during an
interview, they have received the following management training: equal employment opportunity
(EEO), fundamentals of coaching, and data analyses. The superintendent also reported staff
are required to complete courses in the Department’s Learning Management System (Skill-Pro),
Protective Action Response, Suicide Prevention, Mental Health Plan, Knife 4 Life, Recognizing
Developmental Disabilities, Recognizing Mental Health and Substance Emergencies, Officer
Protocols, Facility Exposure, and Female Health. Staff are required to complete training which
includes Active Shooter Preparedness, cardiopulmonary resuscitation (CPR), first-aid,
automated external defibrillator (AED), Human Trafficking Intervention, Information Security
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 58 (Revised July 2023)
Awareness, Mental Health and Substance Abuse, Prison Rape Elimination Act (PREA), Right
Interactions Update, Professionalism, Interpersonal Communication, and Ethics, Sexual
Harassment, Suicide Awareness and Prevention, and Trauma Responsive Practices. Two of the
five reviewed staff completed all required in-service training for the annual compliance review
period. One staff was missing Human Trafficking Intervention training. The last training this staff
completed was in 2019.One staff was missing Active Shooter Preparedness, Human Trafficking,
Information Security Awareness, Prison Rape Elimination Act (PREA), Professionalism,
Interpersonal Communication, and Ethics including Standards of Conduct, and Sexual
Harassment. Two supervisory staff were applicable for the annual eight hours of supervisory
training. One of the staff completed eight hours of training. One supervisory staff did not
complete any hours for the annual supervisory training.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a facility operating procedure (FOP) for grievances, which ensures each youth
has the right to grieve, is treated fairly, respectfully, without discrimination, and their rights are
protected. Grievance forms were available for the youth in each youth living module. The center
had three grievances completed since the last annual compliance review. A review of all three
grievances confirmed they were documented in the Facility Management System (FMS) as
required. They were each signed and one was resolved. The remaining two grievances were
not resolved as the response indicated the situation was not an issue appropriate to grieve. The
youth asked for a staff to be moved to a different shift. One of the captains addressed the issue.
During an interview with the superintendent, it was reported the grievance process consists of
an informal phase where the staff attempts to resolve the complaint using effective
communication, the formal phase where the youth submits a written grievance which is
uploaded in The Department’s Juvenile Justice Information System (JJIS) and given to the
supervisor to review and determine the next course of action, and phase three where the
completed grievance form shall be forwarded to the superintendent for review and to
determinate if any disciplinary action is necessary. Each grievance is maintained and uploaded
in the FMS. Four of five interviewed youth indicated they have never filed a grievance but are
knowledgeable of the grievance process. The remaining youth indicated they are
knowledgeable of the grievance process and rated such as poor. Five interviewed staff were
able to summarize the grievance process.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 58 (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 (FOPs) outlining the process of entering and
sharing alerts. All alerts for five reviewed youth were entered by either a mental health clinician
or medical staff. When necessary, the staff verified alerts prior to entering alerts in the
Department’s Juvenile Justice Information System (JJIS). Each staff is notified of alerts during
daily shift debriefings, alert forms, JJIS, school list, radio, detention review, emails, and through
entries in logbooks. The center’s shift briefing minutes are maintained electronically and were
reviewed for identification of youth with alerts. A shift briefing was unable to be observed during
this annual compliance review. The superintendent reported the center screens all youth upon
their intake to determine any necessary medical alerts needing to be documented or
accommodations which may be needed. Each of the five interviewed staff reported being
advised of alerts during daily shift debriefings, alert forms, JJIS, school list, radio, detention
review, emails, and through entries in logbooks. Three of the five staff advised the center’s
process for communicating alerts is very good, two stated it is very good, and one stated it is
fair.
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 maintains all data information in the Department’s tableau Detention site,, the
Detention Services north region SharePoint site, and People First. The information in tableau,
SharePoint, and People First includes vacancies at the center, which is available to
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administrative staff within Detention Services. In addition, information is communicated through
various meetings which are attended by staff and stakeholders. The vacancy report and
meeting minutes were reviewed for documentation which confirmed information is entered and
discussed during staff and quarterly advisory board meetings to ensure compliance and identify
areas which need improvement.
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Office of Accountability and Program Support Page 16 of 58 (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, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures (FOPs) for youth admissions. Five youth case
management records were reviewed for admission documentation. All five youth records had
the Department’s Juvenile Justice Information System (JJIS) Admission Wizard printed and
placed in the youth record. All five youth records indicated the Detention Risk Assessment
Instrument (DRAI) and Suicide Risk Screening Instrument (SRSI) were reviewed. Two of the
five youth did not have their arrest affidavit and custody orders checked on their Admission
Wizards; however, the arrest affidavits and custody orders were observed in the case
management record for each youth. In addition, both youth records included documentation, the
arrest affidavits and custody orders were reviewed in the Admission Chronological Notes. Two
of the five youth had no admission phone call documented on the Admission Wizard; however,
the assistant superintendent provided telephone logs for each youth, which indicated both youth
were provided intake calls upon admission. All five youth records included documentation full-
body searches and electronic searches were conducted by an officer of the same gender. All
five youth records indicated a meal was provided to the youth upon admission, and a medical,
mental health, and substance abuse screening was completed. A youth admission was not
observed due to the center not receiving youth while the review team was on-site.
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2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures (FOPs) to ensure youth orientation occurs within
twenty-four hours of a youth being admitted into the center. Five youth case management
records were reviewed for the center’s orientation process. All five records included
documentation the center provided each youth with an orientation within twenty-four hours of
admission. All youth signed an orientation acknowledgement to document the contents were
discussed with the youth. A copy of the orientation acknowledgement form was located in each
youth record. All five youth case management records included documentation the orientation
included the rules and regulations of the center, grievance procedures, visitation, telephone
calls, access to medical, mental health, and substance abuse services, access to the Florida
Abuse Hotline and/or 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. Additionally, all five
youth records indicated the youth reviewed the PREA video as part of their orientation process.
Five youth were interviewed and each indicated the staff provided them with information
regarding the rules and regulations, daily schedule, education services, visitation, abuse
reporting, and behavior management system. A youth orientation was not observed due to the
center not receiving youth while the review team was onsite.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) to ensure all youth admitted to the center
are classified to provide the highest level of safety and security. Five youth case management
records were reviewed, and each included all required information concerning the youth’s
history and status. All five youth records reviewed did not indicate any history of human
trafficking on their Admission Wizard classification; however, the center administration provided
documentation from the Department’s Juvenile Justice Information System (JJIS) showing youth
records were reviewed for alerts upon admission. One of the five youth records indicated an
alert for Commercially Sexually Exploited Children (CSEC), which the center administration
indicated was a history of human trafficking alert and was taken into consideration during the
classification process. Escape risk was also not identified in the classification system; however,
detention FOPs do not include escape history risk as a consideration for classification. All five
reviewed youth records notated the youth’s sex, height, weight, age, and level of
aggressiveness. Each of the records indicated the youth was assigned to a room based on their
classification. None of the youth records indicated there was a change in classification status
after admission. Two of the youth records indicated the youth was placed into a single
occupancy room due to their history of committing or being victim to sexual offenses. The center
administration advised they had no youth admitted during the annual compliance review period
who had any gang suspicion or affiliation. None of the youth records indicated a gang affiliation.
The assistant superintendent was interviewed and reported the circuit has a juvenile probation
officer (JPO) assigned as a gang liaison. If a youth is identified to have gang affiliation it is
addressed upon admission in the completed Admission Wizard, the gang liaison is then notified
by email, at which time the JPO will notify local law enforcement and place an alert in JJIS. The
superintendent also stated factors such as mental health and physical status, cognitive
performance, age, and prior victimization are considered when assigning youth to rooms in
order to provide the highest level of safety and security.
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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 a screening process for newly admitted youth to determine if the youth is a gang
member or gang affiliate. The circuit has a gang liaison, who is a senior juvenile probation
officer (SJPO). An informal interview was conducted with the SJPO regarding the gang
notification process. All information related to gangs is disseminated through detention reviews
and email. The SJPO reported the detention staff will complete and submit a gang form. If the
youth is identified as a gang member or associate while at the Juvenile Assessment Center
(JAC), this information will be provided to the gang liaison. The detention staff will also review
any gang information during the weekly detention review meetings. The liaison submits the
gang form to the local sheriff’s department and places an alert in the Department’s Juvenile
Justice Information System (JJIS). The gang representative advised there had been no youth
placed in the facility during the annual compliance review period who had any gang affiliations.
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 (FOPs) to ensure a youth’s personal property is
maintained securely. Five youth case management records were reviewed and included
documentation the youth’s personal property was inventoried by the admitting juvenile justice
detention officer (JJDO). Each youth case management record included a personal Property
Receipt Form. All five youth’s personal Property Receipt Forms included a youth signature and
staff signature. Each record included signed letters of acknowledgement regarding unclaimed
property. All five youth had their personal property, including clothes, placed in an assigned
locker and bag, which was documented on the Property Receipt Form. An observation of the
security and storage of personal property was completed. All five youth’s personal property was
observed and included a completed inventory form. An observation of three examples of youth
valuable property was also completed. All three youth had their property documented in the
logbook. All three youth’s valuable property was stored in a clear tamper-proof bag. There were
no observations completed of a newly admitted youth’s property being inventoried due to the
center not having any new admissions during the annual compliance review week. A review of
the Department’s Central Communications Center (CCC) information revealed there were no
incidents regarding youth property valued over fifty dollars for the scope of the annual
compliance review. Five youth were interviewed, and all reported when they arrived at the
center the staff checked their personal property, and they signed a form stating the personal
property was correct. The superintendent was interviewed and reported when a youth is
admitted to the center their valuables or property is placed in the drop safe and/or the secured
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lockers in the sallyport. The receipt will have the youth’s name, the Department Juvenile Justice
Identification number (DJJID), locker location, and room location. All officers have access to the
lockers in the sallyport where all personal youth property is stored. The superintendent was
interviewed and stated the admission staff is responsible to ensure all youth personal and
valuable property is inventoried on the Department’s Juvenile Justice Information System (JJIS)
Property Receipt Report and signed by both the youth and admission staff. Valuable property
shall be placed in a clear tamper-proof bag and placed in a drop safe. This safe shall be under
video surveillance at all times. Lockers in the sallyport area store non-valuables. Any property
not picked up within thirty days will be considered 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 juvenile probation officer (JPO) sign for and deliver
property to the youth.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center maintains facility operating procedures (FOPs) to ensure all releases are verified by
the court’s authorization. Three closed youth case management records were reviewed for
release. All three youth case management records included documentation the on-duty
supervisor reviewed all paperwork related to release prior to the youth being released from the
center. All three youth case management records included documentation the juvenile justice
detention officer (JJDO) supervisor reviewed the release paperwork received from the court and
the youth identification was verified prior to release. Two of the three youth case management
records included a photocopy of the identification (ID) of the parent/guardian or responsible
adult picking up the youth. One of the youth was being transported to a residential program by
staff; therefore no ID was required. None of the youth had an endangered person alert. In all
three reviewed records the parents/guardians were reminded of future court dates. Each record
included documentation the required parties signed all applicable release forms. All admission
and release dates correlated with the Department’s Juvenile Justice Information System (JJIS).
An observation of a youth release was unable to be completed due to there being no releases
during the annual compliance review week. .
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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 maintains facility operation procedures (FOPs) to ensure youth personal property is
maintained securely and is returned to the youth in a timely manner upon their release. Three
youth case management records were reviewed for the release of youth property. All three
records included documentation the parent/guardian signed the receipt of property form. Two of
the three records included a photocopy of the identification (ID) of the parent/guardian or
responsible adult picking up the youth and the ID being verified. One of the youth was
transported to a residential program by staff; therefore, no ID was required. One youth reviewed
was on medications at the time of release from the center. For property held over thirty-days, a
notice of impending disposal will be completed and delivered by certified mail to the parent/legal
guardian to pick up the property within ninety-days of the letter date. The center’s property
disposal process includes any valuables being sent to the Department Headquarters. The
center did not have any examples of property being held more than thirty days during the annual
compliance review period.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures (FOPs) ensuring all youth at the center are
reviewed to ensure proper management of the youth and appropriate sharing of information.
Weekly detention reviews are held each Wednesday at 9:30 a.m. An observation of a detention
review was made during the annual compliance review week. The detention review included
representatives from administration, education, medical, mental health, probation, and
Residential Commitment. All information regarding the youth was shared between participants.
The center maintains documentation of the weekly detention review meetings in a binder kept in
the administrative office. In addition, the Facility Management SharePoint system for Detention
was reviewed and found samples of documentation listed for detention review meetings, as well
as lists of all required participants. The superintendent was interviewed and reported detention
reviews are held on Wednesdays. The youth in secure detention and home detention status are
reviewed. The medical and mental health status, commitment status, court orders, and other
pertinent youth information is discussed. The meetings are typically conducted in the detention
conference room through Teams meetings. Facilitators for these reviews include the detention
assistant superintendent, and participants include all required parties.
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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 maintains a daily activity schedule. An observation of activities and programming
was completed throughout the duration of the annual compliance review week. The youth were
observed in line movements and while in education. Observations confirmed the center was
following the daily schedule. A review of documentation revealed the youth participate in the
following activities regularly: wake up, personal hygiene, meal times, visitation, recreation and
physical activities to include at least one hour of large muscle exercise outdoors, indoor
activities which promote education, problem solving, and life skills, shift change, bed times,
groups, and open program time which includes video games, extra snacks, additional phone
calls, television, movies, and sporting events. Five youth were interviewed regarding the daily
activity schedule. All five youth reported the center has a daily schedule. Four of the five youth
reported the center follows the daily activity schedule and one youth reported the center does
not follow the daily activity schedule. One youth went on to explain the time they are put in their
rooms for the night varies based on what the staff say. The youth also stated they are not able
to have groups sometimes due to staffing. A second youth reported the schedule sometimes
gets mixed up and can be confusing. The youth gave an example of showers taking too long.
Five staff were interviewed regarding the daily activity schedule. All five staff responded the
center’s daily schedule is followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has a facility operating procedure (FOP) to provide educational access. The center
provides education services through the Bay County School District and the 250-day calendar,
which is distributed over twelve months, including ten days used for teacher training and
planning was reviewed. A review of the daily school schedule revealed the center provides six
fifty-minute class periods daily, fulfilling the weekly requirement of twenty-five hours of
instructional time. A review of five random dates in the logbook for October 30, 2023, November
15, 2023, January 22, 2024, April 02, 2024, and May 06, 2024, showed the daily class schedule
was being followed. Further review of recent logbook entries and video footage for July 26th,
July 31st, and August 9th, verified the youth were attending school as scheduled. Five youth
were interviewed, and all five reported they attend school Monday through Friday. Three youth
felt the school was preparing them either very well or well regarding preparation towards
General Education Development platform (GED), high school, vocational, employment, and/or
college, while two stated not well in their preparation. Five staff were interviewed, and all five felt
there was minimal interference in educational services. The interview with the superintendent
also reported there is minimal interference with educational services.
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2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has a facility operating procedure (FOP) to provide career education. An interview
with the lead teacher indicated the facility offers Type 1 career education development. This
includes Career Learning Strategies such as: interviewing skills and techniques,
entrepreneurship, military options, and completing employment applications. The center also
administers the O*Net Interest Profiler by Next Move. Five youth were interviewed, and all five
reported they were taking core classes such as math, science, history, reading, and social
studies.
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Office of Accountability and Program Support Page 24 of 58 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a designated mental health clinician authority (DMHCA) who is a licensed
mental health professional and is responsible for coordination and implementation of mental
health and substance abuse services. The DMHCA is on-site full- time for forty hours a week.
The DMHCA is a licensed mental health counselor with a clear and active license in the State of
Florida under Chapter 491 with a license expiration date of March 1, 2025. There were no other
DMHCAs used during the scope of the annual compliance review period. The center has a
back-up DMHCA who is a licensed mental health counselor. The back-up DMHCA has a clear
and active license which expires March 31, 2025. Copies of the DMHCA’s agreement and
position description were reviewed. The review of the contract confirmed the minimum of forty
hours weekly were met. An interview with the DMHCA was conducted. According to the
DMHCA each youth who enters the center is screened and evaluated by a mental health
counselor within twenty-four hours to determine if mental health and or substance abuse
services are warranted. All youth are informed of how to access mental health while in secure
detention during the intake process. Youth who are prescribed psychotropic medications are
scheduled for an initial evaluation with psychiatry within fourteen days of admission and follow-
up evaluations every thirty days until released. Youth who are not prescribed psychotropic
medication are seen within fourteen days of admission by mental health staff for orientation.
Youth who receive mental health services are seen by mental health staff a minimum of once a
week. No later than the thirty-first day after admission, any youth remaining in secure detention
receives a substance abuse and mental health assessment to determine if services are needed.
The DMHCA reported providing mental health and substance abuse services. The DMHCA
reported communication is daily and as needed both in-person and by telephone.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center currently employs three licensed mental health and substance abuse clinical staff in
addition to the designated mental health clinician authority (DMHCA). The clinical supervisor
ensures the licensed clinical staff working under their supervision are performing services they
are qualified to provide based on their education, training and experience. The licensed mental
health professionals are all licensed under the appropriate Florida statutes chapter. Copies of
licensed professionals were available on-site. All licensed mental health professionals and
licensed qualified professional’s licenses were reviewed with no noted issues.
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3.03 Non-Licensed Mental Health and Substance Abuse Clinical
Non-Applicable
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 does not currently have any non-licensed mental health and substance abuse
clinical staff providing services. Only licensed mental health and substance abuse counselors
provide services at the center.
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.
Five youth records were reviewed for mental health and substance abuse admission screening.
Each record contained screening documents completed upon the youth’s detention screening.
Each record indicated screening documents were reviewed by center staff upon receipt of the
youth. The suicide risk screening instrument (SRSI) was completed at intake. Both the SRSI
and the Massachusetts Youth Screening Instrument (MAYSI-2) were initiated within the
Department’s Juvenile Justice Information System (JJIS); however, due to ongoing systems
issues, the documents were completed manually. In each record, documentation reflected
mental health staff completed the required sections of the SRSI and the completed entries
included accurate referral selections in the screening results section. Each record indicated the
youth had positive responses on the SRSI and each youth was placed on suicide precaution
and a mental health referral was completed which documented the youth’s need for an
Assessment of Suicide Risk (ASR). The SRSI screening in each record included a yes response
when youth had any open or closed suicide risk alerts within JJIS. All MAYSI-2 and SRSI
screenings were completed by trained staff as verified in the Department’s Leaning
Management System (SkillPro). In each record, the results of the MAYSI-2 and SRSI indicated
a need for further assessment. No record was applicable for all negative responses requiring an
invalid marking. Based on the results of the MAYSI-2 assessment in each record, the need for
further assessment was required and the appropriate referrals were made with notification to the
superintendent. The MAYSI-2 assessment results in each record indicated an elevated suicide
risk subscale which prompted the youth to be placed on suicide precautions and referral for an
ASR. The screener for each youth made a referral to the mental health clinical staff for
comprehensive substance abuse and mental health (SAMH) assessment.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
Five youth records were reviewed for mental health and substance abuse evaluations. Each of
the five youth were identified after admission and referred to the center provider for a mental
health and substance abuse evaluation. All Comprehensive Mental Health and/or Substance
Abuse Evaluations completed by the center were classified as new. Four of five evaluations
were completed within the youth’s thirty first day of admission. The remaining youth’s evaluation
was completed five days after the required timeframe. Treatment recommendations were
specified for each of the five youth records reviewed and corresponded with all diagnosed
mental health or substance related disorders. Each of the Comprehensive Mental
Health/Substance Abuse Evaluations consisted of the Substance Abuse and Mental Health
(SAMH) form documented within the Department’s Office of Health Services Electronic Medical
Record. In each record, the SAMH was completed by the contracted provider.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
Five youth records were reviewed for treatment and discharge planning. Five records indicated
the mental health orientation was held within fourteen days of admission. Each record indicated
youth required a treatment plan. Documentation revealed each youth’s initial treatment plans
were in place within seven days of the onset of treatment. Each initial treatment plan was
developed on the Department’s Initial Mental Health/Substance Abuse Treatment Plan form.
The initial treatment plan form in each record included the reason for referral and initial
diagnosis. The initial treatment plan methods included counseling and frequency, psychiatric
services including psychotropic medication and frequency of monitoring. Two of five youth were
admitted to the center with psychotropic medication and in each record the initial treatment plan
included the medication the youth was admitted with in order to compare with the initial
treatment plan goals. The remaining three youth were prescribed medications after admission.
All five records indicated the initial treatment plan contained the remaining elements such as the
mental health and substance abuse professionals’ signature and the youth’s signature. Each
youth was assigned to a mini treatment team and the members were involved in the
development of the initial treatment plan. Documentation confirmed four of five youth
individualized treatment plans were developed by the youth’s thirty-first day of admission. The
remaining youth’s individual treatment plan was developed five days late. All five records
indicated the individualized treatment plan contained a diagnosis, symptoms which are
treatment focused, treatment goals included mental health services and substance abuse
services, strength and or needs, psychiatric services including psychotropic medication and
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frequency of monitoring. Documentation in two of five records supported psychotropic
medications listed in the initial treatment plan matched the psychotropic medication youth was
prescribed at the time the treatment plan was developed. The remaining youth were prescribed
medication after the initial treatment plan; however, the revised plan reflected the addition of
prescribed medications. Records in each youth progress note validated the youth was receiving
treatment services as stipulated on their treatment plans. Each individualized treatment plan
was signed by the youth, mental health and substance abuse professional, treatment team
members, and parent/guardian when possible. Documentation supports a copy of treatment
plans were mailed to parents/guardians. Each of the five records indicated the youth was
applicable for treatment plan reviews. Four of five records indicated treatment plan reviews were
completed and documented on the Department’s Individualized Mental Health and Substance
Abuse Treatment Plan Review form every thirty days. The remaining record indicated one of the
review forms was completed one day late. Three of the five records required modifications on
the review form which were clearly identified. Documentation in each record reflected the
individualized treatment plan reviews forms were signed by the clinical staff, youth, licensed
mental health professional, treatment team members, and parent/guardian when available.
Documentation revealed copies of each plan were mailed to the parent/guardian. In each
record, the treatment plan included treatment and services provided by a licensed psychiatrist.
None of the reviewed records indicated youth had alleged being a victim of a Prison Rape
Elimination Act (PREA) event.
None of the reviewed records indicated youth was applicable for treatment and discharge
summaries. Three additional records were provided to meet the minimum requirement. In each
additional record the discharge plan was documented on the Department’s Mental Health and
Substance Abuse Treatment Summary form. A copy of the discharge summary was provided to
the youth, parent/guardian, and juvenile probation officer (JPO). In each record, all
documentation was maintained as required. In each record, all uploaded additional information
was completed within fourteen days, contained signature of the licensed mental health
professional, and provided the completion date of service. A mini treatment team review was
observed during the annual compliance with no issues.
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.
Five youth records were reviewed for mental health and substance abuse treatment. Each
record indicated the youth was assigned to a mini-treatment team which consisted of a mental
health clinical staff, one staff from a different service area, youth, and parent when available.
Each record indicated youth required mental health treatment and received individual, group, or
family therapy counseling according to frequency required by the plan. Each record indicated
each plan included individual, group, and/or family therapy prescribed at least weekly. Four of
five youth records indicated the youth was in need of substance abuse treatment and received
individual, group or family counseling according to frequency requirements of the plan. The
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remaining youth did not require substance abuse treatment. Each youth’s record contained a
proper Authorization for Evaluation and Treatment (AET). Each youth receiving substance
abuse treatment, the proper consent for treatment was obtained through the signed Department
forms. Each record contained treatment notes documented on the Department’s
Counseling/Therapy Progress Note form. A video review of two groups was conducted with a
verified facilitator. The group duration was forty minutes and thirty minutes, respectively. Mental
health staff had adequate access and confidential space to provide services. Reviewed records
confirmed therapy was limited to ten or fewer youth with mental health diagnosis for mental
health groups and limited to fifteen or fewer for youth with substance abuse diagnosis for
substance abuse treatment. Five youth were interviewed. Three of five youth stated mental
health and substance abuse services are fair. Two of five youth stated mental health and
substance abuse services are good.
An interview with the designated mental health clinician authority (DMHCA) was conducted.The
DMHCA stated facility operating procedures (FOPs) are reviewed once at a minimum. Initial
treatment plans are developed within seven days from the date youth was evaluated by
psychiatry. The individual treatment plan is developed based on the substance abuse and
mental health assessment (SAMH) by the thirty-first day the youth has been in secure detention.
A review of individualized treatment plans, individualized substance abuse treatment plans, or
integrated mental health/substance abuse treatment plans must be conducted every thirty days
or as needed while youth is in secure detention. Each time a treatment plan is prepared or
reviewed, the youth is consulted and encouraged to participate in the development of treatment
plan goals and objectives. Mental health staff conduct the screenings. The Assessment of
Suicide Risk (ASR), suicide risk screening instrument (SRSI) and the Massachusetts Youth
Screening Instrument-2 (MAYSI-2) are used during the screenings. Mental health staff respond
to referrals within twenty-four hours. Mental health professionals are notified by email, telephone
calls, and in-person notification. The DMHCA is on-call twenty-four hours, seven days a week,
for three hundred sixty-five days a year. Mental health staff are notified immediately when on-
site. If after hours, the on-call clinician is notified. Mental health referrals are completed by the
Department’s staff and youth are placed on precautionary observation. The mental health staff
will assess the youth as soon as possible.
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.
Five youth records were reviewed for psychiatric services. All five were applicable for psychiatric
services. Two of the five youth were admitted to the center on psychotropic medications and the
remaining three youth were referred after admission. The initial diagnostic interview for the two
youth who were admitted to the center was completed within fourteen days of admission. The
remaining youth initial diagnostic interviews were completed within fourteen days after referral.
All Initial diagnostic interviews contained the reason for referral, history, mental status
examination, diagnosis, treatment recommendations, prescribed medications, and medication
name. Each record contained the explanation of the need of the psychotropic medication and
the frequency of the medication management. In each record, an in-depth psychiatric evaluation
was completed within thirty days of admission or referral for psychiatric services. The in-depth
psychiatric evaluation in each record included the reason and factors leading to the referral,
history, history of psychiatric illness, psychotropic medication management, mental health
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treatment and or substance abuse treatment, mental status examination, identification of
individual, family and or environmental factors which may potentially account for, influence or
amelioration of difficulties, diagnostic formulation, treatment recommendation and interventions,
prescribed medications and frequency of medication management. Each in-depth psychiatric
evaluation in each record further contained the explanation of the need for psychotropic
medications related to youth’s diagnosis, target symptoms, potential side effects, risk, and
benefits of taking medications. Each in depth psychiatric evaluation contained the most recent
applicable therapeutic serum levels and signature of the practitioner conducting the evaluation.
In each record, page three of the of the clinical psychotropic progress note (CPPN) was
completed and the CPPN was clearly identified. The required information when psychotropic
medications are prescribed, dispensed, or administered by the psychiatrist was present in each
record. Each record contained identifying data, diagnosis, target symptoms, evaluation and
description of effects of prescribed medication on target symptoms, medication name, dosage
and quantity, ordered dosage, frequency and route of administration, reasons for changes in
medications or dosages, side effects, youth’s adherence to medication regime, height, weight,
weight, blood pressure, most recent serum drug levels or laboratory findings, whether telephone
contact with youth or guardian to discuss medication, signature of psychiatrist, date of signature.
In each record, the psychiatrist documented monitoring for Tardive Dyskinesia monthly on the
CPPN. Each record contained an appropriate authorization for evaluation and treatment (AET),
parental notification and verbal consent for prescribed, discontinued, significant dosage
changes was documented on the CPPN form, page three. Each record also contained written
consent documented on the acknowledgement of receipt of CPPN form. One of five youth
required consent provisions of psychotropic medication while under the care of the Department
of Children and Families (DCF). The youth mental health record included a consent for
psychotropic medication for youth under the care of DCF. Two of five youth were responsible
authorizing their health care and release of healthcare records due to being eighteen years of
age. The center currently uses tele-psychiatry. Tele-psychiatry was utilized only for youth who
agreed to participate, and proper consent was obtained for five youth. The standard of
psychiatric care delivered through tele-psychiatry was the same as rendered in person for each
youth. The center has a psychiatrist with a license expiration date of January 31, 2025. The
center does not utilize an advanced practice registered nurse (APRN). The back-up psychiatrist
is licensed under chapter 459 with a license expiration date of March 31, 2026. The back-up
psychiatrist maintains equal education of the psychiatrist. An interview with the designated
mental health clinician authority (DMHCA) reported psychiatric services, mental health services,
and substance abuse services are being provided and the center.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a written plan addressing suicide prevention. The center’s suicide
prevention plan includes the identification and assessment of youth at risk, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and review process. The center maintains an established review
process for every serious suicide attempt or serious self-inflicted injury requiring hospitalization
or medical treatment. The review process contains the circumstances surrounding the event,
center procedures relevant to the incident, all relevant training received by involved staff,
pertinent medical and mental health services involving the victim, possible precipitating factors,
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recommendation for policy change, training, physical plant, medical or mental health services
and operational procedures.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Five youth records were reviewed for suicide prevention services. In each record, a suicide risk
assessment referral was completed. Due to technical issues within the Department’s Juvenile
Justice Information System (JJIS) alerts were unable to be entered. Once technical issues were
resolved, alerts were updated and reflected initial dates of alerts to be entered. In each record,
the Assessment of Suicide Risk (ASR) was completed on the required Department form and
was documented in real time. Each youth was placed on constant supervision prior to the
completion of the ASR. For each record, the suicide prevention logs were completed entirely to
include safe housing areas and required signature and the qualified mental health professional
was involved. In relation to the ASR procedures being followed, each record indicated no youth
was released prior to receiving an ASR. In each record, consultation with the designated mental
health clinician authority (DMHCA) was not required as the ASRs were completed by licensed
clinical staff, the superintendent or designee was notified immediately of suicide risk, the date
and time the referral was made, as well as the time the youth was placed on precautionary
observation. All ASRs were completed within twenty-four hours. No youth required a follow-up
ASR as none were determined to be in crisis. In each record, the date and time the youth were
discontinued from observation was documented. Each youth was stepped down to standard
supervision. All ASRs were completed by a licensed mental health professional with credentials
of licensed mental health counselors (LMHCs). All ARSs provided results of the assessment
including recommendations, there was evidence in the center’s logbook and ASR indicating
staff was provided specific instructions for each youth related to the ASR finding and precaution
decisions. A review of JJIS determined all alerts were entered and removed following the
youth’s removal from precautionary observation. Logbook review determined beginning and
ending time of PO was documented for each youth. An interview with the DMHCA was
conducted. According to the DMHCA, meeting and communication documentation is either in
the mental health office or in the superintendent’s office. Meetings and communication are
documented on the ASR. The superintendent is notified by email, telephone call, and referral.
The shift supervisor notifies the parent/guardian by telephone and the juvenile probation officer
(JPO) is notified by email.
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3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
Five youth records were reviewed for secure observation. One of five records was applicable for
secure observation. A request for additional records to meet the minimum requirement was
made. One additional record was provided. According to the designated mental health clinical
authority (DMCHA) no additional records were applicable for secure observation during the
scope of the annual compliance review period. For the two applicable records, each placement
was authorized by the superintendent and DMHCA, the secure room was designated, and the
health status checklist was completed prior to placement in secure observation. Suicide
prevention observation logs were completed entirely, an appropriate Assessment of Suicide
Risk (ASR) was completed within eight hours, parental and juvenile probation officer (JPO)
notification was completed. Neither record indicated the youth remained on secure observation
beyond twenty-four hours. Mental health staff provided counseling service during secure
observation. The observation log documented supervision and youth’s level was reduced only
after conference with the superintendent/licensed mental health professional. The
discontinuation of secure observation and step-down to close supervision was documented in
the center’s logbook and youth’s mental health record by mental health clinical staff.
3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Five youth records were reviewed for suicide prevention observation logs (PO). For each
record, the PO logs were maintained for the duration the youth was placed on suicide
precaution which included the appropriate level of supervision and the observation of youth’s
behavior documented in real time and did not exceed thirty minutes. Warning signs were
documented and observed when necessary. Each PO log was reviewed and signed by mental
health clinical staff, and the PO logs documented safe housing requirements in each record.
Video footage and corresponding documentation confirmed proper supervision was maintained.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Ten staff training records were reviewed for suicide prevention training. Five records were
reviewed for pre-service and five for in-service training. Documentation supports staff
completion of suicide prevention training. Training records indicated suicide drills are held no
less than quarterly on each shift. The center maintains two suicide response kits which were
observed during the annual compliance review. One kit is in master control and the other is
located within an electrical closet. The suicide kits are co-located with the first aid kits. The
center’s suicide trainings included mock drills for staff who encounter youth, including kitchen
and maintenance staff. All mock mental health drills were in response to a suicide attempt
and/or incident of serious self-injury. No youth were used in drill simulation related to mental
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health or substance abuse care. The center conducted semi-annual training on emergency
response procedures which include mock training in emergency response to a suicide attempt
or incident of serious self-inflicted injury. Staff who were not present during any quarterly drill
had the opportunity to review the drill scenario and procedures to understand the process and
receive necessary training to respond. Five staff were interviewed. Four of five staff stated the
suicide response kits are located electrical closet. One of five staff reported the suicide
response kits are in electrical closet and master control.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center maintains a mental health crisis intervention plan which allows the center to respond
to a youth in crisis in the least restrictive means possible to protect the safety of the youth and
others while maintain control and safety. The center’s crisis intervention plan includes a
notification and alert system, means of referral including self-referral, communication,
supervision, and documentation review.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center maintains an emergency care plan which was approved on August 8, 2024, and last
updated on July 22, 2023. The emergency care plan is available to all staff. One copy of the
plan is in administration and one copy is in the mental health office. The plan includes
immediate staff response, notifications, supervision, authorization to transport for emergency
mental health or substance abuse services, transport for emergency mental health evaluation
and treatment, transport for emergency substance abuse assessment and treatment,
documentation, training, and review.
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3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
Five youth records were reviewed for crisis assessment. One of five was applicable for crisis
assessment. A request for two additional records was made to meet the minimum requirement.
The designated mental health clinician authority (DMHCA) reported there were no other
applicable records to review for crisis assessment. The one applicable record contained all the
required elements. The assessment provided the reason for the assessment, mental status
exam and interview, determination of danger to self and or others, initial clinical impression,
supervision recommendation, treatment recommendation, recommendation for follow-up or
further evaluation, notification to parent or guardian of follow treatment. A mental health alert
was entered into the Department’s Juvenile Justice Information System (JJIS). The youth was
identified by direct care staff as having acute emotional or behavioral problems or acute
psychological distress. The crisis assessment was conducted by a licensed mental health
professional. The crisis assessment was completed immediately or within two hours for
emergencies or within twenty-four hours based on the needs of the youth. There was no
indication the youth was an alleged victim of a Prison Rape Elimination Act (PREA).
3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Five youth records were reviewed for Baker and Marchman Acts. None of the five records were
applicable for Baker and Marchman Acts during the scope of the annual compliance review. A
request for additional records was made in order to meet minimum requirements. Two additional
records were provided. In both records, the youth were placed on one-to-one supervision, and
suicide alerts were opened while pending transport. In both records, youth supervision was
documented on suicide prevention observation logs (PO) until youth’s authorized release. Each
youth was placed on suicide precautions upon re-admission from Baker Act. Each record
contained a completed referral for a mental status examination (MSE) which was completed by
a licensed mental health professional. Each youth was maintained on a minimum of constant
supervision until properly transitioned to a lower level of supervision. Each youth’s supervision
level was maintained until an appropriate assessment was conducted and mental health staff
conferred with the licensed supervisor and superintendent or designee. Each youth had a
suicide alert entered into the Department’s Juvenile Justice Information System (JJIS) and the
discontinuation of the alert and precaution was based upon an assessment of suicide risk
(ASR).
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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 has a contract with VitalCore Health Strategies, LLC. The center has a licensed
physician (MD) who serves as the designated health authority (DHA). The DHA has an
unrestricted license which meets all requirements for independent and unsupervised practice in
Florida. A review of the Department of Health licensure verification portal reveals the DHA
license is clear and active and expires on January 31, 2026. The DHA specialty training is family
practice. The DHA has a collaborative practice protocol in place with the center’s one advanced
practice registered nurse (APRN); the protocol was last reviewed August 9, 2024. The center
does not employ a physician assistant. A review of the sign-in and sign-out logs for the annual
compliance review period confirmed the DHA was on-site at the center once a week at a
minimum of two hours each visit. Pursuant to the contract, the DHA is required to be on-site
weekly for two hours. There were no observed instances of the DHA not being on-site for the
contracted timeframe. The center has not utilized a back-up DHA during the annual compliance
review period. Specific duties outlined for the DHA are denoted within the contract between the
Department and VitalCore Health Strategies, LLC. A review of the provider’s practices
pertaining to tele-medicine was reviewed. There were three instances of tele-medicine being
used during the annual compliance review period. A log is maintained by medical staff for
documenting occurrences of tele-medicine utilized when youth are seen during medical
sessions. Tele-medicine was not used in lieu of regularly scheduled DHA on-site visits. An
interview with the DHA indicated the role performed at the center consists of performing
Comprehensive Physical Assessment’s (CPA), conducting periodic evaluations, seeing any sick
youth, and the development of policies and procedures. The DHA is on-site weekly, has an
APRN who is also on-site weekly, and is available by phone and in person. The DHA ensures
all off-site is reviewed by documentation in the episodic care notes, uploaded medical records,
and follow up calls to the clinic nursing staff. In addition, medical issues and documentation is
reviewed with the medical staff weekly unless a more immediate need which would be
discussed by phone.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center had current written facility operating procedures (FOP) for all health-related
procedures and protocols utilized at the center. The designated health authority (DHA),
superintendent, and psychiatrist each signed the appropriate section(s) of the FOPs. The review
of the health-related FOPs indicated the DHA reviewed and signed on August 6, 2024. The
review of the health-related FOPs indicated the superintendent reviewed and signed on August
6, 2024. The review of the health-related FOPs indicated the psychiatrist reviewed and signed
on June 3, 2024. The review of the health-related FOPs, including treatment protocols, and
other medical procedures, indicated each of the nursing staff last reviewed, signed, and dated a
cover page on August 7, 2024, and August 12, 2024. There was no indication of any new
policies or changes made during the annual compliance review period. At a minimum an annual
review of health-related FOPs and protocols was completed. These reviews were conducted by
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the DHA on August 6, 2024, the superintendent on August 6, 2024, the psychiatrist on June 3,
2024, and the nursing staff on August 7, 2024, and August 12, 2024. The medical department at
the center had one new registered nurse (RN) who was orientated December 11, 2023, through
December 19, 2023. The approval of treatment protocols or standing procedures are authorized
by the DHA only.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of the Authority
for Evaluation and Treatment (AET) form. Three of the five youth records contained an original
AET form filed in the youth’s IHCR. Each of the applicable AET forms were signed by the
youth’s parent/guardian. Additionally, each of the appliable AET forms were valid and signed by
the Department representative. Each of the three applicable AET forms were obtained prior to
providing medical services. One of the remaining two youth was in the custody of the
Department of Children and Families (DCF); therefore, had a limited consent form signed and
had a court order to have medical services provided. The remaining youth was eighteen and an
AET is not required. The eighteen-year-old youth’s record contained a completed release of
information.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for parental notification and
consent when there is significant change to the youth’s condition, new medication, and or
treatments are prescribed. Two of the five youth reviewed were applicable for documentation of
parental notification for over-the-counter (OTC) medication beyond those covered by the
Authority for Evaluation and Treatment (AET) and all notifications were completed as required.
Two youth did not require OTC beyond AET. The remaining youth was eighteen and consent
was not required. Each of the applicable written notifications were made utilizing the
Department’s Parental Notification of Health-Related Care: General or Parental Notification of
Health-Related: Medications forms as required with no observed issues. Two of the five youth
were applicable for taking psychotropic medications for a duration of time while at the center.
Both youth had documentation of staff witnesses to all telephone call attempts for prescribed
psychotropic medication. Four of five youth were ordered new medication and subsequent
notification and documentation of attempted contact made to parent or guardian in the youth’s
IHCR. In addition, written parental notifications were sent regardless of telephone contact. Four
of five youth taking psychotropic medication were applicable for having had a change, added, or
discontinued medication. As a result, there is a verbal consent document on page three of the
Clinical Psychotropic Progress Note (CPPN). Each of the five youth had consent as required
which included written parental notification/consent for three applicable youth and a court order
authorizing all treatment and procedures for one applicable DCF youth. The center obtained
consent prior to administering newly prescribed psychotropic medications or changes to
psychotropic medications. Three of the five youth had vaccines verified within thirty days of the
youth’s admission to the center. The fourth youth was not verified within the thirty-day time
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frame; the record is from out of state. The fifth youth was not applicable due to being eighteen
years of age. None of the youth required any vaccinations.
An interview with the nurse indicated parental notification of care shall be accomplished by
attempting verbal contact with the parent/guardian to notify them of care in the following
instances and shall be followed by written notification utilizing one of the appropriate parental
notification forms. The center will inform the parent/guardian of significant changes in the
youth’s condition and obtain consent when new medication and treatments are prescribed.
Written parental consent is required in certain circumstances. The appropriate parental
notification of health-related form(s) will be used for consent purposes. Verbal attempt at
consent shall be documented in the chronological progress notes. Notifications or attempts are
completed and documented at the time of episode. When reviewing for psychotropic medication
consent, medical staff complete the CPPN, which will be sent to the parent/guardian to provide
consistent, updated information concerning the youth’s progress and/or recommendations for
changes in medications. The nurse confirmed vaccinations are not provided on-site.
Immunizations are found and reviewed through Florida Health. Should a parent/guardian claim
exemption and does not consent to vaccinations for religious reasons, then they must complete
the religious exemption from immunization form provided by the Health Department, have it
signed, authorized, then submit to the center. Copies of the exemption will be filed in the youth’s
IHCR.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of a medical and
mental health screening form. All the medical and mental health screening forms reviewed were
completed on the date of admission. Each of the screenings were completed by a juvenile
justice detention officer (JJDO). Two of five screenings were subsequently reviewed by a
registered nurse (RN) and three of five screenings were subsequently reviewed by a licensed
practical nurse (LPN) within twenty-four hours. All youth had documentation within the IHCR
where the designated health authority (DHA) was notified of the youth's admission. There was
no indication there had been a change in physical custody since the youth’s arrival to the center
for any of the five reviewed youth. The sample of the youth reviewed were all males, therefore,
a qualitive urine pregnancy screening test was not required.
An interview with the nursing staff indicated medical will see newly admitted youth within twenty-
four hours of admission. Medical staff are notified by receiving the medical/mental health
screening forms and the court first appearance schedule. At the time of admission to the center,
each youth will receive a facility entry screening by the intake officer. This screening is to be
performed using the medical and mental health admission form. A healthcare admission
rescreening is to be completed each time the physical custody of the youth changes and
subsequently returned or re-admitted to the center. A change in physical custody within secure
detention requires a complete rescreening by the receiving center, whenever they are moved
from one to the other with an anticipated stay of twenty-four hours or more; however, does not
require full completion of the intake process.
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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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of an orientation
to healthcare services at the center. All youth received a general healthcare orientation at the
center. Healthcare education topics were found documented in each youth’s IHCR on the
appropriate Department form. A review of the provider’s facility operating procedures,
documented at a minimum the following were included: access to medical care, sick call
practices, emergency situations, medication process, right to refuse care, what to do in case of
sexual assault or attempt sexual assault, non-disciplinary role of healthcare staff, and a list of
healthcare related contacts.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed to ensure the designated
health authority (DHA) is notified for a youth admitted requiring emergency care or routine
notification. All five youth were applicable for notification of a known or suspected chronic
condition. Five youth were reviewed and found notification to the DHA documented in the
youth’s IHCR Chronological Progress Notes. Each notification to the DHA was completed within
twelve hours of the youth’s admission to the center. None of the youth were identified as in need
of emergency care upon admission. Two of five youth were taking psychotropic medication
upon admission and the psychiatrist was notified. An interview with the nursing staff indicated
the timeframe for notifying the DHA is no longer than twenty-four hours after admission. In no
case will notification exceed 12:00 p.m. of the following day. Medical staff are responsible for
notifying the DHA of newly admitted youth during clinic hours, and non-healthcare staff notify
after clinic hours. Notifications are documented in the youth’s chronological progress notes.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of a Health-
Related History (HRH) form. All youth had an HRH completed within seven calendar days of
admission. The HRH was completed and updated prior to completion of the youth’s
Comprehensive Physical Assessment (CPA) form. Each of the HRHs were completed by a
licensed nurse or practitioner. A review of the HRH forms for all five youth confirmed the
signature and dates for each youth’s current admission. An interview with the nursing staff
indicated the HRH shall be completed no later than seven calendar days following the date of
admission and prior to the youth being subjected extreme outdoor weather conditions including,
but not limited to, high heat indices and frigid temperatures.
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Office of Accountability and Program Support Page 38 of 58 (Revised July 2023)
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of a
Comprehensive Physical Assessment (CPA) and tuberculosis skin test (TST). Each of the youth
had documentation completed on the Department’s CPA form. All youth had a CPA completed
within seven calendar days of admission. Each CPA documented the youth’s medical grade. All
sections for each of the CPA’s reviewed were appropriately marked. In all five youth records,
each youth refused the genital exam, subsequently, the clinician indicated the youth’s refusal on
the form. A refusal form was found in each youth’s IHCR. All youth were applicable for inclusion
of documentation within the Department’s Problem List form. Each youth had at least one
verified TST documented on the CPA and Infectious and Communicable Disease (ICD) form.
None of the reviewed youth required further evaluation prior to entering general population. A
review of the facility operating procedures (FOP) found the FOPs address appropriate
documentation when any part of the exam is not conducted and/or refused by the youth; each
reviewed record reflected the documentation is maintained as required. In addition, the center’s
FOP was reviewed for tuberculosis screening and rescreening process, which was completed
for each of the five youth in accordance with the FOP. An interview with the nursing staff
indicated the CPA is current if performed within the last two years and no identified chronic
health conditions exist. If a CPA has not been performed or is not current, or there are changes
to the health condition of the youth, then the youth shall have a CPA as soon as possible, but no
longer than within seven calendar days of admission. The Department’s medical and mental
health screening form will be utilized for a youth’s initial TST symptom screening.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of sexually
transmitted infection (STI) and human immunodeficiency virus (HIV) screening and testing. Two
of the five youth were applicable for screening and evaluation of STI’s; therefore, one additional
youth record was requested to get a minimum sample size of three records. The three
applicable youth were sexually active and applicable for being subsequently screened and
evaluated for STI’s. Two of the three youth required further evaluation and had been referred to
the designated health authority (DHA). Both referrals were documented on the Department’s
STI form. Testing for both youth were ordered, and screening results documented on the
Department’s Infectious and Communicable Disease (ICD) form. The remaining applicable
youth had a previous admission and was screened at this time; however, was found to not need
further evaluation by the DHA. Five reviewed youth and one additional youth record provided for
STI screening/testing, were reviewed for and offered counseling, testing, and if indicated,
treatment and or referral for HIV. Four of the six youth refused testing and signed a refusal form.
The remaining two youth consented to HIV testing. Both youth had a documented consent
obtained by the center. The HIV results were placed in a sealed envelope marked
“Confidential”, reviewed by the practitioner, and filed in the youth’s IHCR for both youth. Both
youth had documentation of pre and post-test counseling indicated on the youth’s Health
Education Record. Both youth’s confidentiality was protected by not including the HIV status on
the center’s internal alert system.
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Office of Accountability and Program Support Page 39 of 58 (Revised July 2023)
Five youth were interviewed, each confirmed they can ask for an HIV test at the center.
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 has not had any youth requiring sick calls during the annual compliance review
period. The center addresses youth medical needs on an episodic basis. When a youth needs
to be seen by medical, staff notify nursing staff, the youth is escorted to medical and treated. A
review of the facility operating procedures (FOP) confirmed the FOP includes a process for
youth to complete a sick call if needed. Observation of the center’s posted schedule and review
of FOP, aligns with having sick call available daily, seven days week, to include holidays. The
sick call hours were observed to be posted just outside the center’s medical clinic, in the main
hallway. The posted hours are documented to be at 7:00 a.m. and 4:00 p.m. daily, or
immediately following medication pass. A review of the medical clinic found approved treatment
protocols for both registered nurses (RN) and licensed practical nurses (LPN). The center’s
FOP addresses practices necessary when non-licensed medical staff are not on-site, whereby
the shift supervisor shall review all applicable sick call requests. Two of the five reviewed youth
were applicable for instances of room confinement. A review of each individual health care
record (IHCR) for youth in confinement revealed the nursing staff completed daily visits and
provided medication as needed. There was no sick call request during the on-site portion of the
annual compliance review; therefore, an observation of sick call was unable to be completed.
An interview with nursing staff indicated the center follows facility operating procedures when
addressing youth needs for sick calls. Five youth were interviewed. Two youth stated they could
be seen for a sick call within a day. The remaining three youth stated they had never requested
a sick call. Each of the youth were asked who conducts sick calls; all five youth indicated the
nurse. Five staff were interviewed. Three staff stated the nurse reviews sick calls. One staff said
staff review sick calls. The remaining one staff said either administration, supervisor, or medical
reviews sick calls. Two of the five staff indicated the doctor conducts sick calls. Four of the staff
said nursing would conduct sick calls. One staff went on to say, supervisory staff conducts sick
call when medical staff are not present.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for the completion of episodic,
first-aid, or emergency care incident. Four of the five youth reviewed needed either first aid or
episodic care. None of the youth required any emergency care. Out of the four applicable youth,
there was a total of thirty-four episodic or first aid incidents reviewed. All thirty-four incidents
were conducted on-site, and care was rendered by licensed healthcare personnel. None of the
incidents were completed by non-healthcare staff. Each incident documented the nature of the
complaint. In addition, the findings of the person rendering care along with treatment was
included within the IHCR. When applicable, parental notifications were made and documented
accordingly. The center’s episodic care log was completed as needed for each incident. There
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Office of Accountability and Program Support Page 40 of 58 (Revised July 2023)
were twelve first-aid kits located throughout the facility. The first aid kits were kept in the
following locations: one in master control, one in medical, one in the kitchen, one in the
supervisor office, one in the courtyard closet, four for transportation, and one for each of the
three mods. Three first-aid kits were observed. Each of the kits were found to be fully stocked
with designated health authority (DHA) approved contents. The kits have a content list on the
back, which identifies expiration dates. Medical staff check kits monthly, should an item be
observed in needing to be changed, medical would change out contents. Documentation
confirmed first aid kits are checked monthly. There were two automated external defibrillators
(AEDs) located within the facility. One of the AED’s was in the common area courtyard and the
other was in the medical office. The AED procedures are with each of the AEDs. Each of the
AED batteries and pads are checked by medical staff at the center. Documentation revealed
AEDs are checked monthly. A self-test of the AED was conducted in front of the monitoring and
quality improvement team during the on-site review; no issues observed. The AED batteries and
pads for both units were up to date. The center has completed announced and unannounced
emergency medical drills at a minimum of quarterly for each shift. The emergency medical drills
included first aid, cardiopulmonary resuscitation (CPR), and AED demonstration practiced
annually. Drill documentation is available for all staff to review and discuss if not present during
an actual drill scenario. A list of emergency numbers is accessible for all staff at the center. The
list of emergency numbers is inaccessible to youth. Emergency numbers are in medical and
master control. A review of staff training for those staff authorized to administer an epinephrine
auto-injector was conducted. This training is conducted by the on-site registered nurse (RN). A
review of five training records revealed staff are trained in episodic, first-aid, and emergency
care. The center has a facility operating procedure (FOP) pertaining to naloxone nasal spray
(Narcan). The center stores Narcan in medical in the medication cart. Trained supervisory staff
and medical staff have access to the Narcan. The Narcan is counted weekly and documented
as part of the medication cart inventory log. An interview with nursing staff indicated the medical
department maintains first aid and AED counts monthly. Additionally, emergency medical and
dental care will be available twenty-four hours a day. The center will track all
episodic/emergency events using the Department’s Episodic Care Log form. Non-Healthcare
staff episodic care documentation will utilize the Report of Healthcare by non-healthcare staff. If
on-site episodic care (first aid/emergency care) is provided by a licensed health care
professional, documentation shall be in such a manner which conforms to professional
standards. All youth will receive a follow-up evaluation by licensed healthcare staff after each
episodic/emergency event provided by non-healthcare staff. Documentation will conform to
professional standards in the youth’s chronological progress notes. Five staff were interviewed
and stated they feel as though they may call 9-1-1 if it is necessary. Five youth were
interviewed. Two youth rated the medical care fair, one youth said good, and two others stated it
was very good.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
referrals for off-site care. Three of the five records were applicable for this indicator. The three
records had documentation within the IHCR of each youth requiring off-site care. In each of the
cases, a summary of off-site care consultation report form was completed. None of the youth
required any emergency care. Each of the IHCR records had parental notifications documented.
Two of the three youth were applicable for having discharge instructions required to be filed in
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Office of Accountability and Program Support Page 41 of 58 (Revised July 2023)
the IHCR. Both youth required the designated health authority (DHA) or designee to review and
sign the off-site care findings. One of the two youth was missing the DHA signature on the off-
site care findings. None of the youth required any follow-up testing, referral, or appointments.
An interview with the nursing staff indicated following off-site care, youth are added to the
provider’s log to be evaluated following the care. The Summary of Off-Site Care accompanies
the youth to the off-site provider to be completed and returned to the center for filing in the
youth’s IHCR and uploaded into the electronic medical record (EMR). The documents sent back
must be reviewed to ascertain if there are orders for referrals, lab work, exercise restrictions,
alerts, or follow-up appointments. If there are any referrals, they must be entered on the center’s
tracking log. The DHA or designee shall initial all orders/information sent back with the youth to
the center. The clinic manager maintains a calendar of appointments. Referrals are completed
through orders from the on-site provider.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Five youth Individual Healthcare Records (IHCR) were reviewed for care of youth with chronic
conditions. All five youth records reviewed were applicable for this indicator. Each of the five
reviewed youth records identified the youth with a chronic condition. None of the youth were
diagnosed with a communicable disease. None of the youth were taking medication on an on-
going basis. None of the youth were classified with a medical grade of either two, three or four.
None of the youth were identified as being pregnant. All five of the youth reviewed were placed
on the chronic condition list. Three of the five youth were taking prescribed psychotropic
medication on an on-going basis. Only three of the five youth had been at the center long
enough to receive periodic ninety-day evaluations. The three youth were in receipt of periodic
evaluations as required. None of the youth reviewed were taking tuberculosis medication. None
of the youth required a periodic evaluation prior to renewing a prescription medication which had
expired. None of the youth required an evaluation be conducted off-site. There was no
indication of any youth having a lapse in care of missed periodic evaluation. The Department’s
Problem List form was updated as required. The center maintains a tracking log for all youth
identified with a chronic condition and or requiring a periodic evaluation. An interview with the
nursing staff indicated a tracking sheet is maintained of youth with chronic conditions as well as
the youth identified in the clinic logbook.
An interview with the DHA indicated youth with chronic conditions are seen for periodic
evaluations every ninety days and are tracked through a logbook in the clinic. The logbook is
reviewed and updated daily by the nursing staff in the clinic.
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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for medication
management. Two of the five youth were taking prescribed psychotropic medication at
admission to the center. The designated health authority (DHA) and the psychiatrist were
notified for the two youth upon admission to the center. All five youth were taking medication at
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Office of Accountability and Program Support Page 42 of 58 (Revised July 2023)
some point while at the center. The five youth had a prescription verification which was included
in chronological progress notes. Additionally, all medications had a current, valid order, and
were administered pursuant to a current prescription. Each youth had current medications which
were either continued, discontinued, changed, or new ones ordered. In each of these instances,
there was an order documented on the practitioner order form. Only two of the five youth were
documented to have been in restricted housing. Each of these youth had documentation where
nursing staff completed visits, provided medical services, and administered medications. All five
youth had appropriate standardized Department medication administration records (MAR) filed
in the IHCR and electronic medical record (EMR) system. The reviewed MARs clearly
annotated medication start and stop dates. There were no observed instances where non-
healthcare staff administered medications to youth during the annual compliance review period.
There were no instances of any undocumented explanations for lapses or errors in medication
administration. At a minimum, nursing staff documented side effect monitoring weekly on each
of the youth’s MARs. There were no instances of youth having refused any medications. All
reviewed MARs contained all required elements. There were no instances of any youth
requiring parenteral medications. Two of the five youth entered the center on prescribed
psychotropic medications, subsequently, the youth were in receipt of an initial diagnostic
psychiatric interview within fourteen days of admission. The remaining three youth were later
assessed and prescribed psychotropic medications. All five youth were in receipt of
psychotropic medication monitoring every thirty days as required.
There was no indication there were standing orders for psychotropic medications. There was no
indication there were any emergency treatment orders for psychotropic medications. There was
no indication of any pro-re nata orders for psychotropic medications. Medication administration
pass is scheduled for 7:00 a.m. and 7:00 p.m. daily; therefore, was not able to be observed
during the annual compliance review. Non-licensed healthcare staff are designated by name
and title and were trained by a registered nurse (RN) to conduct medication administration if
necessary. The provider utilizes Rx Destroyer for destruction of medications.
An interview with the nursing staff indicated upon admission to the center, the youth and
parent/guardian (if available) will be interviewed about the youth’s current medications. This will
be conducted as part of the Medical and Mental Health Screening Form. Medication verification
will also occur during the completion of the review of the Medical and Mental Health Screening
Form, the initial medical admission screening completed within twenty-four hours of admission,
the Health-Related History form, and the Comprehensive Physical Assessment. Only
medications from a licensed pharmacy, with a current, patient-specific label intact on the original
medication container may be accepted in the center. Further medication verification requires
DHA or physician designee notification and a completed medical evaluation of the youth, with
documentation in the Chronological Progress Notes. After medication verification, the
Medication Receipt, Transfer, and Disposition Form shall be completed, with copy of the form
provided to the parent/guardian (when parent/guardian is available). The licensed nurse must
call to obtain an order from the DHA or designee to resume the specified medications. This
telephone order must be documented in the youth’s Individual Health Care Record and co-
signed when the ordering practitioner is on-site. The medication will subsequently be
administered according to the instructions on the label. For situations when youth are admitted
and medical staff is not on duty, staff will refer to the physician’s protocol for trained non-
healthcare staff to receive and verify medications and assist the youth with self-administration. A
telephone order must then be obtained and documented by the incoming nurse on the next
shift. The protocol should only apply to critical medications for which a missed dose would
compromise the youth’s health. The protocol will list which specific medications to which this
would apply. The need for any further verification requires the notification of the DHA who then
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Office of Accountability and Program Support Page 43 of 58 (Revised July 2023)
must evaluate the youth. This is of particular importance if a youth is on medication for a chronic
condition for which a dose should not be missed. Documentation of prescription verification
must occur in the chronological progress notes in the IHCR.
Five staff were interviewed. Two stated they give medication to youth, three staff stated they do
not give medication to youth.
Five youth were interviewed. One youth said the doctor gives medication; the remaining four
youth said the nurse gives them medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
A review of the center’s medical clinic was conducted for the inventory of medications, sharps,
and storage process. Observations confirmed the medical equipment classified as sharps were
secured and inventoried utilizing a routine perpetual inventory descending count as each sharp
was utilized and disposed. A review of medications was observed to be secured in a locked
area designated for storage of medications. Observations found the medication cart at the
center to be clean and organized, with stock items separate from youth-specific medications. A
review of controlled substances confirmed a perpetual inventory is completed and stored
separately from other medications. The medications in the center were observed to be stored
separately, in a secured area, and inaccessible to youth. The controlled medications were
observed to be stored behind two locks. There were no injectable medications to be observed
during this on-site review. A refrigerator is available to store medications if necessary. The
refrigerator is also equipped with a lock and is used for medication only. A review of perpetual
and weekly inventories of all sharps and stock over-the-counter (OTC) medications was
conducted. Two controlled medications, three OTC medications, along with three sharps were
observed. Each of the final counts from each of the inventories matched the observed count
with no issues.
An interview with the nursing staff described the process for disposal of outdated medications to
include removing and segregating the medications from regular stock and placing them in a
designated secure locked quarantine area. Outdated medications shall be destroyed at least
monthly. Any non-expired pharmaceutical product which has been subjected to improper
storage condition, contaminated in any way, adulterated, or deemed to be unusable for any
reason shall be placed in the designated area and destroyed. A secured and designated
quarantine medication storage area shall be clearly marked and designated separate and apart
from usable medications. Any medication not procured by a youth’s parent/guardian, after a
youth’s discharge from the center, shall be destroyed after thirty days under the supervision of
the licensed pharmacy consultant. A registered nurse (RN) shall be responsible for the disposal
of medications. Controlled and non-controlled medications for disposal shall be inventoried prior
to disposal and disposed in the presence of the pharmacy consultant. Controlled and non-
controlled medications must be disposed of by utilizing the drug buster disposal system and in
accordance with the state board of pharmacy disposal plan. Documentation of the disposal of all
medication shall be maintained.
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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.
A review of five youth Individual Healthcare Records (IHCR) was conducted for completion of
infection/exposure control and education. Each youth was in receipt of infection control training
and education within seven days of admission to the center. The center has an exposure and
infection control plan which is written in accordance with Occupational Safety and Health
Administration (OSHA) guidelines. The center’s process for needlestick post-exposure
evaluation is to document route of exposure and identify source. Staff would be sent to the local
hospital for further evaluation. The center offers post-exposure prophylaxis precautions and
counseling if necessary. The Hepatitis B immunization is available for staff through a referral to
the local health Department. Observations on-site found staff using protective equipment to
include gloves. There were no observed incidents during the annual compliance review period
where the local health department, or the Department’s Central Communications Center (CCC)
needed to be notified. There were no observed cases of three or more incidents of any
reportable infectious diseases which needed to be reported to the local health department or the
centers for disease control (CDC). A separate file is maintained by the superintendent for any
youth and or staff who have experienced a center or occupational exposure. All records are
maintained as confidential for a period of ten years. A review of five staff pre-service and in-
service training records confirmed staff have completed training on the center’s exposure
control plan.
4.18 Prenatal Care/Education [Contract Provider] Non-Applicable
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has not had any pregnant youth throughout the annual compliance review period;
therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
Observations were made of youth supervision during the annual compliance review week. Staff
accounted for all youth with mandatory line counts and staff remained in proximity for
supervision of the youth. Active supervision was observed during class, dining hall, and line
movement functions. Master control authorized all movement of youth and staff prior to being
moved. Five staff were interviewed about staffing for youth supervision, two staff responded
there are enough staff to provide adequate supervision and three staff felt there were not
enough staff. The three staff who did not feel there were enough staff for proper supervision
reported the following: the center needs more staff and it is hard to stay within the Prison Rape
Elimination Act (PREA) ratio, there are times staff from administration must be pulled in order to
help out on the floor, staffing is fine on certain days, and there are not enough staff to provide
for the safety and security of the youth. During youth movement in the center observations
found youth were in sight of at least one detention officer at all times, with the exception of when
placed in sleeping rooms or in a secure placement. All youth were observed to be accompanied
by staff at all times. Master control authorized all movement of youth prior to the youth being
moved.
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Office of Accountability and Program Support Page 46 of 58 (Revised July 2023)
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has a behavior management system (BMS) which specifies appropriate and
inappropriate behaviors, rules, norms, and expectations for youth. The system includes rewards
for positive behavior and consequences for inappropriate behaviors. The center’s BMS
guidelines were observed posted in all living areas and main hallways. Level books were
observed in youth living areas. The books were maintained by detention center staff to
document youth points earned and levels according to the center’s BMS. A review of the
documentation confirmed rewards and consequences are given according to the BMS. An
informal interview with the detention administration revealed incentives for youth are typically
given out during the weekend for youth who earn these privileges. No incidents of group
punishment were observed during the annual compliance review. Three of five interviewed
youth rated the center’s BMS as fair. One rated it poor, and one rated it good. All five were able
to summarize the BMS process. Youth gave examples of incentives they were able to receive
such as snacks, candy, level parties, radios, and extra phone calls. None of the five interviewed
youth reported a youth is not allowed to punish another youth in the center. All five youth
reported they have been sent to their room for punishment in the past. Four of five reported this
was due to confinement, one reported this was done at shift change prior to dinner time to be
given time to calm down. All five youth reported consequences they have received have been
fair. Youth gave examples of items which can be taken away as a result of a consequence, to
include points, level, and radios. Youth also reported everything is taken out of their room when
placed in confinement. None of the five youth reported ever witnessing handcuffs or mechanical
restraints being utilized for out of control youth. Five staff were interviewed regarding the BMS.
Each summarized the process and gave examples of rewards youth may earn in the center. All
five reported they felt the BMS was effective. All five reported staff speak with youth to discuss
consequences being imposed and give the youth the opportunity to explain their behaviors,
while discussing with them alternative acceptable behavior to use. All five interviewed staff
reported they are given feedback on their implementation of the BMS through areas such as
shift briefings and one on one discussions. One staff reported nothing is taken from a youth as a
result of a consequence. Four staff gave examples of things which could be taken such as
levels or items which were given to them when reaching a higher level, such as radios. None of
the staff reported seeing a staff taking a youth meal, education, clothing, or medical care. None
of the interviewed staff reported witnessing a staff encourage another staff to beat up a youth.
The detention superintendent was interviewed and was able to summarize the center’s BMS.
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Office of Accountability and Program Support Page 47 of 58 (Revised July 2023)
5.03 Ten-Minute Checks (Critical) Failed 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.
Ten-Minute checks were reviewed for the annual compliance review period. The center had
fifty-six out of sixty cameras operational at the time of the annual compliance review. The video
system stores video recordings for thirty-days. The center was operating on twelve-hour shifts at
the time of the annual compliance review. A review of nine separate dates and times of video
observations across all living modules was made to confirm the fidelity of the ten-minute checks
Nine checks were observed during video review and six checks were completed utilizing wand
report observations for a total of fifteen checks of thirty-minute increments for each shift on each
dorm. All samples reviewed had late checks completed. The center utilizes an electronic wand
system in which staff touch the wand to the door when conducting the checks. The electronic
wand system captures the time and date as to when the check was conducted on each room.
Corresponding wand logs were provided for review. The center was on a corrective action plan
for ten-minutes checks which closed on January 29, 2024. Six days of wand check reports were
reviewed. All six days of checks reviewed had checks completed between one and forty-five
minutes late. A review of the documentation revealed weekly reviews by management were not
completed. Observations of ten-minute checks did not reflect checks were conducted in the
required frequency to ensure the checks are met with fidelity. Five staff were interviewed
regarding how often room checks are completed when a youth is placed in their rooms for
sleeping. All five staff reported the room checks occur every ten minutes during sleeping hours
or if a youth is placed in their rooms, with the exception of suicidal youth. The superintendent
was interviewed regarding ten-minute checks. The superintendent reported any time a youth
placed in a room, a visual observation report (VOR) is placed on the on the door outside of the
youth’s room. The first check entered on the door would be when the ten-minute checks start.
Then, every ten minutes a certified officer will complete a check by looking into the room at the
youth and placing their initial and the time the check was completed.
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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 (FOPs) to address census, counts, and
tracking which require staff to know the exact number and location of all youth under their
supervision at all times. Counts were observed to be conducted by the master control operator
calling for and clearing a daily formal headcount over the radio. Five staff were interviewed
regarding the census and counts. All five staff reported counts are conducted at the beginning
and end of shifts. Three of the five staff reported if a count is incorrect there is a recount, all
youth are secured, and staff conduct a room-to-room search in the building. Two staff reported
the times counts are completed daily. Five staff were interviewed regarding when emergency
counts are conducted. One staff reported when a youth is believed to be missing. One staff
reported when visibility is hindered, such as an electrical outage. Three staff reported an
emergency count is conducted after a major disturbance. Other answers included when drills
are completed, during any codes called, when someone is admitted or released, and randomly.
A sample of logbooks for ten of the twelve months, one full day a month, was reviewed for the
annual compliance review period. All ten months reviewed months included documentation
counts were conducted at the beginning of each shift, following any emergency, emergency
drills, prior to and following routine group movement, anytime a population change occurs,
randomly, at least once on each shift, and head counts. Eleven out of the twelve months had
documentation of counts being conducted during and after youth movements. The remaining
sample was missing youth movement.
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5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) for logbook maintenance. The center has
separate logbooks for master control, each living module, visitors, and vehicles. All but one
logbook was found to be bound with numbered pages. One of the logbooks did not have a cover
but was still bound. Logbooks were observed to not have dates documented at the top of each
page. One logbook was missing December 25, 2023, from the logbook. These pages were not
located. All entries included the times of events in a.m. and p.m. with the name of the youth and
staff involved, a brief description of events, and the initials of the staff making the entries. The
logbooks reviewed did not include all of the incidents which impacted the safety and security of
the center. All errors were struck through with a single line and “void” written after the error
followed by the staff’s initials. Three full days were reviewed each month during the annual
compliance review period. The following elements were observed in the master control logbook:
emergency situations, incidents, documentation of receipt of medical and mental health alerts,
population counts at the beginning and end of each shift, population counts throughout shifts as
counts change, youth counts following emergency situations, youth group movement,
admissions and releases, and the presence of law enforcement. Samples from the master
control logbook and living module logbooks were reviewed for one day each month of the
annual compliance review period for eleven months. The activity schedule provided, and the
logbook documented minimal interference of educational instruction. A review of the logbooks
indicated education classes were conducted as scheduled and youth arrived and departed
school on time. Some of the fire drills, names of youth placed in confinement with the beginning
and ending times, and the name of youth on precautionary/secure observation along with the
time it was initiated and ended were not consistently documented in the logbooks reviewed. A
review of the logbooks showed evidence of the superintendent or designee reviewed all
logbooks on a weekly basis and provided recommendations as to the completeness and
accuracy of the information recorded. A review of the logbooks revealed a juvenile justice
detention officer supervisor reviewed the center logbooks maintained in master control when
assuming center responsibility, in each living area daily, and maintained the logbooks in
assigned living areas when accepting responsibility at shift change. There was documentation
observed in the logbooks of the superintendent, assistant superintendent, or staff in charge of
center toured the youth living areas at least once during each shift. The superintendent was
interviewed regarding the management’s role in regard to logbooks. The superintendent
reported the superintendent or designee shall review the logbooks weekly for the last seventy-
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two hours. Once reviewed, acknowledgement of the review will be completed in blue ink and
signed by the person completing the review.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures (FOPs) describing the center’s process for key
control, issuance of keys to staff, key restrictions, inventory and tracking, storage, missing or
lost keys, and reporting and replacement of damaged keys. The reviewed key inventory
revealed the key rings on the inventory matched the actual keys in use. The key storage area
was observed in master control. The keys are kept in a storage box in master control. The lock
was damaged on the key storage box. There was documentation the keys were signed in and
out by master control staff in a key logbook. The distribution of keys and collection of keys was
observed. The staff asked for the keys needed. Then prior to the staff entering the secured
area, the staff are searched with a wand to ensure no contraband is introduced into the center.
Restricted keys are maintained in master control which is secured with locked doors. All center
keys were observed to be maintained on a tamper-resistant ring. Emergency keys are
maintained in the captain’s office in the administration section of the building. The keys are kept
in two locked boxes. It was reported only administrative staff and maintenance have access to
the keys. Emergency key rings were included as part of the center key inventory. The master
key inventory included the following information: ring number, number of keys on each ring, who
each key ring was issued to, and the capability of each key. The center keys were placed on
key ring hubs and color coded according to function, officer keys were blue, supervisor keys
were yellow, administration keys were black, medical and mental health keys were white, food
service keys were green, education keys were brown, and emergency keys were red. Issuance
of keys were documented in the center logbook. The reviewed documentation included date and
time of issue, name of staff issuing the key ring, name of staff who received the key ring, and
the time the key ring was returned. Staff who were issued keys were observed to carry the keys
on their person at all times and did not allow youth to handle center keys. The key box was
observed to not be easily accessible. There were no incidents regarding keys during the annual
compliance review period reported to the Department’s Central Communications Center (CCC)
or Program Monitoring and Management (PMM) deficiencies related to key control concerns.
Five samples of key rings were observed and compared to the inventory key log with no
discrepancies noted. Three staff were informally interviewed about the number of keys on their
key ring and the function of each key with no discrepancies noted. An observation was
completed with the master control operator regarding key control. The master control operator
recognized the staff and looked at the key tag the staff had in their possession. This information
was then documented in the logbook by the master control operator. Five staff were interviewed
regarding key control. Two staff reported the restricted keys include medical records, one staff
reported youth property area keys, and one staff reported mental health record keys were all
restricted. The staff also included emergency keys, egress keys, red keys, exit keys,
maintenance keys, supervisor keys, and yellow keys. Five staff were interviewed regarding the
center’s key control process and all five were able accurately describe the key control process.
The superintendent was interviewed regarding permanent issued keys. The superintendent
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Office of Accountability and Program Support Page 51 of 58 (Revised July 2023)
reported permanent issued key rings are defined as key rings assigned to specific personnel at
the discretion of the superintendent which authorizes the individual to remove keys from the
center or the center grounds. The superintendent also reported these keys are maintained by
the maintenance mechanic.
5.07 Vehicles and Maintenance Failed Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has a facility operating procedure (FOP) requiring the center vehicles to be properly
maintained, contain safety and emergency equipment, and be operated in a safe manner. The
center ensures any vehicle used to transport youth is properly maintained and documentation
regarding the use and maintenance of each vehicle is maintained. Each vehicle used for
transporting youth shall pass an annual safety inspection. Each vehicle used to transport youth
is to be equipped with the appropriate number of seat belts, a seat belt cutter, a window punch,
a fire extinguisher, and an approved first-aid kit. At the time of the annual compliance review,
the center had seven operable vans used for transportation of youth. None of the seven vans
had yearly maintenance conducted. There was no documentation of the vans having monthly
visual checks being completed as required. The assistant superintendent advised the
maintenance manager left employment as of May 2024. All seven transportation vans had
safety screens and were equipped with a fully charged fire extinguisher, a window punch, and
the appropriate number of seatbelts for each passenger; however, only six of the seven
transportation vans had a seat belt cutter. The vehicle first-aid kits are stored in center
administration to be checked out each time a vehicle is in use. The center maintains a log which
had documentation of completed vehicle inspections for each transport. The results of the
inspections are documented and stored in the center’s vehicle maintenance log/binder. A review
of the inspections showed all were completed, as required. A check of the center’s
transportation vehicles was conducted during the annual compliance review and each vehicle
was found to be locked. There were no youth transports during the annual compliance review
week, therefore an observation of transport process was unable to be observed. Five youth
were interviewed, and each reported they feel staff drive safely when transporting. None of the
youth had ever seen anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use of
Limited Compliance
Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains a facility operating procedure (FOP) for tool inventory, tool maintenance,
youth access to tools, and use of tools and cleaning items. The level of security for the tool
room and kitchen was observed when tools were not in use. A review of ten tools throughout the
center was conducted. Three tools were not included on the inventory sheet. Additionally, the
center did not maintain a consistent inventory for all mops and brooms in their custodial cabinet
and the inventory for the maintenance tools has not been updated for the previous three
months. Further, the superintendent or designee has not signed off on the kitchen and custodial
inventory for the duration of the annual compliance review period. There was documentation the
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Office of Accountability and Program Support Page 52 of 58 (Revised July 2023)
kitchen staff conducted inventory of all equipment, including knives and other implements upon
reporting for duty. No tools were lost during the annual compliance review period. The perpetual
inventories for the custodian closet and tools had not been reviewed or updated for
approximately three months. All tools were observed to be secure and had tool markings for
easy identification. Three tools were missing from the perpetual inventory: tin snips, lock cutters,
and a putty knife. According to the assistant superintendent, the previous maintenance manager
bought these tools and did not add them to the inventory. The youth are not permitted to use
tools, including kitchen and medical equipment. The youth are permitted to use cleaning items
such as mops, brooms, and other common household items, under direct staff supervision. An
observation of youth using cleaning tools was unable to be conducted. The administrative staff
informed the review team their maintenance staff left employment in May 2024. The
superintendent was interviewed and reported the maintenance mechanic is the staff who has
access to the center tools. Five staff were interviewed regarding the center’s practice for
damaged or missing tools. The staff reported damaged tools are disposed of outside of the
center. If a tool is lost the youth are secured in the center and staff conduct a search for the lost
item.
5.09 Inventory of and Access to all Flammable, Toxic, Caustic,
Failed Compliance
and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has an Emergency Care plan which is incorporated into the Continuity of Operations
Plan (COOP). The center has facility operating procedures which prohibits youth from handling
chemicals, toxic items, and cleaning agents. Only authorized personnel are permitted to handle
these items. Five interviewed youth denied directly handling any chemicals at the center. All five
interviewed staff also confirmed only staff handle cleaning agents and chemicals. The center
had a total of five locations which were observed to contain some supplies of chemicals and
poisonous items. Each of these locations were observed to be secured and inaccessible to
youth. A review of five items within each of these separate locations was completed, for a total
of twenty-five items reviewed, and compared with a chemical inventory log. The outdoor tan
storage shed, outdoor blue storage shed, and maintenance office all had a supply of chemicals,
but none of these had an updated inventory of the items present. The inventory reviewed in the
outdoor shed did not include five chemicals. All listed chemicals were observed in the outdoor
shed. The inventory reviewed in the maintenance office did not include four items stored in the
office. All listed chemicals were observed in the maintenance office. The custodial closet had an
updated inventory. The kitchen chemical closet and the custodial closet both had a current
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Office of Accountability and Program Support Page 53 of 58 (Revised July 2023)
inventory of the items located within those two areas; however, the kitchen inventory noted nine
bottles of one chemical, but only six were discovered in the closet. The dietary staff reported this
was due to a miscount. All items observed had a corresponding Safety Data Sheet (SDS), with
the exception of one item, which was a bottle of lighter fluid located in the outside tan storage
shed. The center maintains a master SDS book in the master control room and the conference
room. Items used within the living module for cleaning are located in the custodial closet in the
courtyard area, which contains the SDS book for those items present.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has a facility operating procedures which indicates the disposal of all flammables,
toxic, caustic, and poisonous items. A review of the Department’s Central Communications
Center (CCC) revealed the center had no incidents involving chemical spills. The center’s
administration reported any grease is disposed of in a grease vat located outside the facility
building. A contracted company comes quarterly, or as needed, to dispose of any grease.
Dietary and other staff were also interviewed and stated any dirty mop water is disposed of
through pouring into standard drains and mop sinks. The registered nurse was also interviewed
and stated all biohazardous waste is disposed of through and agreement with biohazardous
disposal company, who comes to the center monthly to pick up and discard of any biohazardous
waste. A disposal log for biohazardous waste, including copies of invoices, was also observed
which confirmed the practice. All biohazardous waste is kept secured in the medical office within
marked containers.
5.11 Confinement Under Twenty-Four Hours Limited Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains facility operating procedures (FOPs) ensuring confinements under twenty-
four hours are used as an immediate, short-term response to incidents which effect the physical
safety of youth or others. The center had 140 confinements under twenty-four hours during the
annual compliance review period, ten of which were reviewed.
Seven of the ten youth were applicable for receiving three meals a day plus school and evening
snacks. Four of the seven youth received their meals and snacks. Three of the youth did not
receive their required meals and snacks. Two youth were applicable for access to mental health
care. One of the two youth received documented mental healthcare when requested or needed.
Seven youth were applicable for requiring a daily shower while in confinement. Four of the
seven youth received their shower. The remaining three did not, according to reviewed
documentation. Nine of the ten youth were applicable for receiving a mattress and bedding. One
youth did not have a completed visual observation report (VOR) completed; therefore, it is
unknown if the youth received these items. The youth remained in confinement for twenty hours
and forty-five minutes according to the confinement report. Six youth were applicable for
receiving education materials. Two of the six youth received the required education materials.
Documentation showed nine of the ten youth received a notice of rights to grieve a confinement
placement.
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Prior to the youth being placed in confinement, a supervisor approved all confinements. Each
youth was placed into a room with no other youth. According to documentation within the
Department’s Facility Management System (FMS), all rooms were searched prior to the youth
being placed in confinement. Reviewed documentation indicated nine of the ten youth were
supervised for the duration of their time in confinement, as required. One youth did not have a
VOR completed. None of the youth sustained physical injury, for which medical care was
needed. Documentation in FMS indicated all ten youth were provided the reason confinement
was necessary. A supervisor conducted an initial confinement review with the youth within one
hour of the youth being placed in confinement. A full report was completed before the end of the
shift according to a review of confinement reports in FMS. A supervisor completed additional
interviews with the youth at a minimum of every three hours, counseled the youth, and was
documented in FMS. Five out of ten confinement reports were reviewed and signed off by the
superintendent or designee within forty-eight hours, excluding weekends and holidays. Five
superintendent reviews were not completed within forty-eight hours. One review was twenty-two
days late, one was seventeen days late, and one was twenty-six days late. Two superintendent
reviews were not completed according to documentation in FMS. The cameras were free from
obstructions and scratches in order for the youth to be visually observed. Some of the living
module windows in the dorms were observed to be heavily scratched. These windows were
observed during the facility tour. The superintendent was interviewed regarding confinement
documentation and reviews. The superintendent reported all confinement reports are reviewed
within forty-eight hours excluding holidays and weekends. Regional detention management
conducts a weekly review of confinements, lockdowns, and restraints. Five staff were
interviewed regarding the processes for placing a youth in confinement. Three staff reported a
confinement report is completed, one staff reported they are to conduct and document ten-
minute checks, and three reported the confinement room is to be searched. Additional
information by the staff was provided, which included: the youth are to be searched and all
items are to be removed from the room until bedtime, provide the youth with their rights and
their right to grieve the incident, the youth are taken to a dorm and placed in their room, the
supervisor starts the confinement paperwork, and the staff are to complete five minute checks
for one hour and then ten-minute checks are to be conducted. Five staff were interviewed
regarding providing the youth education materials. Four staff reported education materials are
provided. One staff reported education materials are not provided. The staff also shared the
teachers bring papers to the youth with no pencils, just the materials for the youth to read.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated not applicable.
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Office of Accountability and Program Support Page 55 of 58 (Revised July 2023)
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains facility operating procedures (FOPs) establishing a procedure for
conducting drills to address the Continuity of Operations Plan (COOP). The center conducted
two drills during the annual compliance review period which included severe weather, major
disturbances, hostage situations, chemical spills, flooding, or terrorist threats/acts. The reviewed
drills did not result in a critique or corrective action. All drills reviewed included the type of drill,
date and time, participants, a brief scenario, and findings or recommendations. The
superintendent was interviewed regarding the center’s comprehensive safety/emergency plan.
The superintendent reported the plan describes how to respond to emergency situations
including fire and fire prevention/evacuation, severe weather, major disturbances, pandemics,
bomb threats, taking of hostages, chemical spills, flooding, or terrorism threats or acts.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains an Escape Prevention Plan to include the Department’s policies and
procedures regarding escapes. The center completed quarterly escape drills for the annual
compliance review period. Two out of the five staff reviewed for training did not complete the
annual escape training. The logbooks were reviewed for documentation of escape drills. Three
drills were not documented in the logbook to include the second quarter first shift and third
quarter first and second shift.
Five staff were interviewed regarding escape drills. One staff reported participating in a major
disturbance drill, two staff reported participating in an escape drill, and all five staff reported
participating in fire drills. The staff also reported participating in suicide drills, medical drills, code
blue or fight drills, and Continuity of Operations Plan (COOP) drills.
5.15 Fire Drills Limited Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a disaster plan, fire prevention plan, and an evacuation plan addressing fire
prevention and safety in the center. Twenty-four fire drills were required for the annual
compliance review period. It should be noted the center changed the amount of shifts
throughout the annual compliance review period. For the months of October 2023 and January
2024 through May 2024 the center was on three shifts. For the months of November 2023,
December 2023, and June 2024 through August 2024 the center ran on two shifts. Twenty-three
out of twenty-eight drills were completed. Two drills were missing for October 2023 and one drill
for December 2023. One drill was missing for January 2024 and one for May 2024Three of the
fire drills reviewed were not in the center’s logbook.
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Five staff were interviewed regarding fire drills and all five staff reported the fire drills take place
at least monthly. Five youth were interviewed regarding receiving instruction in case there is
afire and all five youth reported being instructed.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) for search and contraband procedures.
Staff shall wear gloves when conducting a frisk or room search. An electronic search consists of
the use of an electronic walk-through or hand-held wand device to locate metal objects. This
search shall be conducted during admission and following any transport. Staff and visitor
searches are to be conducted by the juvenile detention officer supervisors (JDOS)Any person
coming into the secure area shall be searched using an electronic wand and their pockets shall
be emptied. Searches shall be conducted in an area under video surveillance. All bags, cases,
jacket pockets, and any other items shall also be searched. Observations of visitors to the
center were conducted throughout the week. The center was observed to follow the facility
operating procedures for searches of visitors.
There were no instances of a strip search being conducted at any other time than admission.
Every sleeping room shall be searched for contraband on each awake shift. In addition, every
room is to be searched when a youth is released, prior to placing a newly admitted youth into a
room, and prior to confinement. A room search was unable to be observed during the annual
compliance review. A review of documented room searches for one day of each month of the
annual compliance review period for each awake shift was completed. Twenty-four room
searches were completed. Fourteen out of twenty-four searches were conducted on the awake
shifts Ten required room searches were not documented as required. There were no instances
which may have compromised the safety or security of the center throughout the annual
compliance review period. All searches of all staff, visitors, and contractors/vendors completed
prior to entering the secure area. The center’s visitor log contains does not contain a contraband
attestation statement; however, the center does have separate visitor contraband attestation
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 58 (Revised July 2023)
forms. A review of the attestation forms and visitors’ log revealed no discrepancies. Fifteen staff
records were reviewed, and all contained a contraband attestation form. There was no
documentation of a strip search being conducted at any other time than admission.
The superintendent was interviewed regarding contraband and searches at the center. The
superintendent reported searches shall take place no more frequently than necessary to control
contraband or to ensure safety. The results of any search shall be documented in the logbook
and electronically. The staff are to utilize gloves and verbal instructions to put the youth at ease.
All contraband must be documented in the master control logbooks, an incident report must be
completed, and the Department’s Central Communications Center (CCC) notified. If the
confiscated item is illegal, law enforcement is to be notified and can be disposed of at the
discretion of the superintendent or designee. At the time of the annual compliance review
period, the center had no CCC’s relating to contraband reported.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 58 (Revised July 2023)

source: DJJ

rule: Indicator 1.05

excerpt: Right Interactions (RI)

rule: Indicator 1.07

excerpt: In-Service Training

rule: Indicator 5.07

excerpt: Vehicles and Maintenance

rule: Indicator 5.08

rule: Indicator 5.09

rule: Indicator 5.11

rule: Indicator 5.15

excerpt: Fire Drills