state: FL

summary: QI Detention - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Pasco Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
28534 State Road 52
San Antonio, Florida 33576
Review Date(s): September 12-15, 2023
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Tamara Mahl-Adkins, Office of Accountability and Program Support, Lead Reviewer (Standard
1)
Reginald Allen, Pinellas Regional Juvenile Detention Center, Superintendent (Standard 5)
Marvin Bliss, Office of Accountability and Program Support, Operations Review Specialist
(Standard 3)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 2)
Lea Herring, Office of Accountability and Program Support, Operations Review Specialist
(Standard 2)
Gustavo Mazorra, Office of Accountability and Program Support, Operations Review Specialist
(Standard 1)
Bonita Williams, Office of Accountability and Program Support, Operations Review Specialist
(Standard 4)
Program Name: Pasco Regional Juvenile Detention Center MQI Program Code: 363
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Pasco County / Circuit 6 Number of Beds: 36
Review Date(s): September 12-15, 2023 Lead Reviewer Code: 156
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 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 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 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 Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 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 Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 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* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58 (Revised July 2023)
Program Overview
The Pasco Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in San Antonio, Florida. The center serves youth in Pasco County in
Circuit 6. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the thirty-six 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 Pasco 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 thirty-
eight JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore. Mental health services are provided by one designated mental health
clinician authority, two licensed mental health counselors, two licensed clinical social workers
and two non-licensed clinical staff. Clinical services provided by the center include mental health
and substance abuse evaluations, mental health treatment planning, individual, group, and
family therapy, mental health crisis intervention services, on-site psychiatric services, and
availability for substance abuse services for youth with co-occurring disorders. Medical services
are provided by one designated health authority, one advanced practical registered nurse, four
registered nurses and one licensed practical nurse. The medical clinic maintains nursing
coverage seven days a week and sick call from 8:00 a.m. to 10:00 a.m. and when needed. 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-five
security cameras at the center, of which all were operational during the annual compliance
review week. The modules were observed with paint peeling in the main area, as well as the
youth rooms. Bathrooms were observed to be free of mold and mildew; however, had signs of
heavy usage. The floor tiles in the showers and in front of the shower stalls have corroded tile.
Plexiglass on youth dormitory windows was scratched, however, staff were still able to observe
the youth inside the rooms. Floors were swept and mopped; however, showed wear and tear. At
the time of the annual compliance review, the center had thirteen vacancies, which included one
administrative assistant, one food service worker, seven JJDO Is, and four JJDO IIs.
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 addressing initial background screening
requirements, which include a staff being in line of sight of a volunteer who has not been
background screened. The center had volunteers who assisted or interacted with youth on an
intermittent basis for less than ten hours a month who did not need to be background screened.
The center did background screening on all new volunteers, regardless of the amount of time
they volunteered. The center submitted an Annual Affidavit of Compliance with Level 2
Screening Standards on January 19, 2023, by the January 31 deadline. The Annual Affidavit of
Compliance with Level 2 Screening Standards for the teachers, who are school board staff, was
submitted on January 4, 2023. The center had one volunteer, three contracted staff, and eight
new staff hired since the last annual compliance review. All twelve individuals received a
background screening prior to contact with youth or confidential youth records, which included a
criminal history check. None required an exemption, had a break in services as indicated in the
Staff Verification System (SVS), nor were previously employed by a provider or the Department.
All eight of the direct care staff had a pre-employment assessment tool administered and the
passing score was maintained in each employee record. The three contracted staff were each
added to the Clearinghouse staff 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 addressing five-year background rescreening
requirements. In all five applicable staff records reviewed the five-year rescreening was
completed every five years from the agency hire date.
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 addressing the staff code of conduct. The center
had four instances of disciplinary actions since the last annual compliance review. Three of the
four were due to violation of the code of conduct. Three of the four received an oral reprimand
and one a retraining as a management response. Since the last annual compliance review
twelve staff received commendations for doing a great job; all were provided a gift card. Four of
five youth interviews indicated they had never needed to contact the Florida Abuse Hotline and
the one remaining stated never having been stopped from reporting abuse to the Florida Abuse
Hotline while being at the center. Four of the five youth said the staff is respectful when talking
with all youth, and they never heard a staff use curse words when speaking to any youth. The
one remaining youth indicated staff are not respectful and staff use curse words often. None of
the five heard staff threaten any youth, they feel safe at the center and they never have
exchanged emails, telephone numbers or social medical contact information with any of the
staff. All five staff interviews indicated they will notify the supervisor when a youth wants to call
the Florida Abuse Hotline or the Department’s Central Communications Center (CCC) and let
the youth make the call. Four stated the process also includes to have the supervisor make the
call and staff being allowed to call themselves. One also indicated to notify the superintendent.
All five staff stated they have never observed a co-worker using profanity, threats, intimidation
or humiliation when speaking with any youth. Three stated the work conditions at the center
have been good and two stated very good in the past year. The superintendent interview
indicated staff shall provide a role model of socially acceptable behavior to the youth, while
communicating and interacting in a respectful manner. If there is an allegation of abuse made
by a youth the staff is immediately removed from contact, the youth will be afforded the
opportunity to call the Florida Abuse Hotline, and if necessary, law enforcement will be notified,
as well as the CCC.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures addressing the incident reporting process. Five of
the fifty Department’s
Central Communications Center (CCC) reports since the last annual compliance review were
reviewed. All five CCC incidents were reported within two hours of becoming aware of the issue.
Three of five were documented in the logbook. There were no additional incidents which should
have been reported to the CCC. The superintendent interview indicated any reportable incident
must be conveyed to the CCC within the required two-hour time frame. Any allegations of
physical, sexual, or emotional abuse are also called into the Florida Abuse Hotline.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center has facility operating procedures addressing the requirement for Protective Action
Response, Right interactions model (PAR/RI). The center had seventy-eight PAR/RI Reports
since the last annual compliance review. Nine random PAR/RI Reports were reviewed. In five of
nine, the PAR/RI Reports included all statements from staff involved and were completed during
the same shift the PAR/RI incident occurred. In the remaining four PAR/RIs the lead staff
completed the report on time; however, the remaining staff involved did not. There was a total of
forty-six staff involved for the nine reports. In the late reports, one staff completed the report four
days late due to being on sick leave, two were two days late, and two more were one day late.
All PAR/RI Reports included statements of all staff involved, as well as a supervisor or PAR/RI
instructor reviewing each report, and a post-PAR/RI interview being conducted with each youth
by the administrator or designee within thirty minutes. In one of the nine PAR/RIs the staff
completing the report, the supervisor/PAR/RI instructor, and the post-PAR interview were
completed by the same person. In eight of nine the superintendent/designee reviewed the
report, after all other reviews, and made comments within seventy-two hours. In the remaining
one the review was one day late. There were no other incidents, logbook notes, or grievances
which were not documented correctly as a PAR/RI. The center’s PAR/RI rate during the annual
compliance review period was 9.82, which is below the statewide detention PAR/RI rate of
17.52. All five staff interviews indicated staff try to talk to each youth prior to using PAR/RI or
mechanical restraints. The superintendent interview indicated mechanical restraints are only
used in exigent circumstances, not as a means of discipline, and the regional director or
designee must be notified. The officers will complete a mechanical restraint log, conduct ten-
minute circulation checks, and have the handcuff key ready. The handcuffs shall be removed as
soon as it is safe to do so. A PAR/RI Report is completed and submitted for review. An incident
report and PAR/RI Report are entered into the Department’s Juvenile Justice Information
System (JJIS) by staff if a PAR/RI maneuver was conducted. The superintendent or designee is
required to conduct a post-PAR/RI review within thirty minutes. The video is reviewed within
twenty-four hours and the entire PAR/RI Report within seventy-two hours by the superintendent
or designee to ensure compliance.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 58 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures addressing pre-service training requirements. A
review of five staff training records indicated all completed pre-service certification requirements
within 180 days of hire to encompass Phase One and Phase Two training. The five reviewed
staff received orientation within thirty days of hire and the staff training included active shooter
preparedness, human trafficking intervention, cardiopulmonary resuscitation/first-aid/automated
external defibrillator, information security awareness, mental health and substance abuse,
Prison Rape Elimination Act, Protective Action Response, professionalism, interpersonal
communication and ethics, as well as sexual harassment, trauma responsive practices, and
suicide awareness and prevention. All trainings were documented in the Department’s Learning
Management System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures addressing in-service training requirements. A
review of five staff training records indicated four of the five had completed a minimum of
twenty-four hours of in-service training in 2022; they completed between forty-six and seventy-
four and a half hours. The remaining one staff completed twelve of the required twenty-four
hours of training in 2022. All five staff completed infection control training, as well as Protective
Action Response/Right interactions model (PAR/RI) update. Four staff completed human
trafficking intervention, information security awareness, Prison Rape Elimination Act, trauma
responsive practices, sexual harassment, escape prevention, fire prevention plan/disaster
preparedness, cardiopulmonary resuscitation (CPR)/first-aid/automated external defibrillator
(AED), and professionalism, interpersonal communication, and ethics training. Three of the five
completed emergency care plan, mental health and substance abuse training, and two of the
five completed active shooter, and exposure control plan. Two also had the six hours of suicide
awareness and prevention, with another two having only two of the required six hours. All
trainings which were completed were entered into the Department’s Learning Management
System (SkillPro), other than for three staff who completed CPR/first-aid/AED whose hours
were not entered into SkillPro. Two of the five staff were supervisory staff. One of the two
completed the required eight hours of supervisory training in the topics of coaching, leadership,
and accountability. The remaining staff did not complete any supervisory training in 2022. Due
to the 2022 in-service training having been reviewed during the last annual compliance review
and a deficiency having been assigned, the team rated this indicator as satisfactory compliance.
A licensed nurse provided in-service education on girls’ healthcare to all non-healthcare staff
involved in the supervision or treatment of girls, including monitoring, observation, and
emergency care of pregnant youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 58 (Revised July 2023)
The in-service training list was approved by the Department’s regional director prior to the
December 1, 2022 deadline, on November 29, 2022, and included course names, descriptions,
objectives, and training hours. The center maintains an annual training calendar, which can be
updated when changes occur. The superintendent indicated he had completed numerous
management training classes in SkillPro, such as trauma informed care, sexual harassment,
delivering constructive criticism, as well as attending management training at a college and a
university. The superintendent indicated staff are required to attend juvenile justice detention
officer (JJDO) certification training, which consists of two phases. Phase One is 120 hours of
online and instructor led training, including CPR, PAR/RI, first-aid, and mental health. Phase
Two is conducted by staff development and consists of 120 hours. The first forty hours are
conducted at the JJDO academy and the other eighty on the job. Staff are required to complete
twenty-four hours of annual in-service training and supervisory staff an additional eight hours in
the areas of management, leadership, employee relations, communication skills, and fiscal
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 facility operating procedures addressing the grievance process. Grievance
forms are available to youth on each module. The center had two grievances since the last
annual compliance review. Both received a response the same day of the grievance, they were
entered into the Department’s Facility Management System, signed, and resolved within the
required time frame. The superintendent indicated to ensure all youth are treated fairly,
respectfully, without discrimination, they have a right to grieve; they cannot be denied the
opportunity to file a grievance or be punished for it. The grievance process has an informal
phase, wherein the juvenile justice detention officer (JJDO) attempts to resolve the complaint
using effective communication skills. The formal phase is when a youth submits a written
grievance resulting in a response from a JJDO supervisor by the end of the shift, if possible;
however, no later than within twenty-four hours. The last phase is when the superintendent or
designee reviews the completed grievance form within seventy-two hours of receipt and takes
corrective action if deemed necessary. The superintendent’s decision is final. The hardcopy of
the grievance form is maintained in a separate grievance file uploaded into the Facility
Maintenance System. Three of five youth interviews indicated they did not know what the
grievance process was. One stated they had never had to file a grievance; however, knows the
process and one additional explained the process is to fill out a form with the grievance and
submit it to get resolved. One youth rated the grievance process as good and the remaining four
indicated they never had to file one; therefore, did not rate the process. Five staff interviews
indicated the staff were able to describe the center’s grievance process, including youth having
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 58 (Revised July 2023)
the right to grieve, grievance being entered into the computer, trying to resolve the grievance at
lowest level first, then, if unable to resolve, going through the entire process.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures addressing the alert system, including medical,
mental health, and center staff updating youth alerts. A review of five youth records indicated all
youth had alerts entered, updated, and closed as required in the Department’s Juvenile Justice
Information System (JJIS). A logbook review indicated applicable alerts were documented. The
center only utilizes JJIS to document alerts. The JJIS alerts are printed out and discussed
during shift briefings, detention reviews, as well as being maintained in the kitchen and in the
clinic. A review of documentation for five shift briefings indicated the alerts were reviewed with
staff. A review of eight detention review packets indicated alerts were discussed with the
probation circuit, mental health, medical, and detention staff. A shift briefing was observed
during the annual compliance review week. During the shift briefing the youth alerts were
discussed with the staff. The superintendent interview indicated the center’s medical alert
process includes the JJIS alert report being reviewed daily by the supervisors and
administrators to ensure it correctly reflects the status of each youth. During shift briefings the
information is shared with staff and the supervisors notify the staff to update when new
information is received. Three of five staff interviews indicated they are informed of youth alerts
through logbook documentation, and five stated during shift briefings and alert forms. All five
stated management inform the staff about issues with youth through shift briefings and
meetings, three said through the logbook, and one said in email. Three staff indicated this to be
a good communication process and two stated it is very good.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 58 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center collects data in the Department’s Juvenile Justice Information System (JJIS) on a
daily basis, including Protective Action Response/Right Interactions model (PAR/RI) Reports,
the Department’s Central Communications Center (CCC) reports, alerts, confinements, Prison
Rape Elimination Act documentation, and various additional reports. The information is
accessible by all staff, including administration. During the daily shift briefings important
information is shared with the staff to make changes, such as youth behavior and how it can
affect PAR/RI and CCC reports. During the weekly detention reviews all information is shared
with detention, mental health, medical and probation staff to improve services for the youth.
Administration reviews information daily to share with staff, as well as regional personnel to
keep youth safe and secure.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures for admissions. Five youth case management
records were reviewed for youth admission. All five records contained a completed arrest
affidavit/custody order, a Detention Risk Assessment Instrument, and a Suicide Risk Screening
Instrument. All five records had the Department’s Juvenile Justice Information System
Admission Wizard printed and placed in each record. Each of the five Admission Wizards
documented youth were full-body and electronically searched by a staff of the same gender.
Four of the five case management records documented each youth made a telephone call. The
remaining record documented an attempt to contact parent/guardian and no other family
members were listed on the youth’s facesheet. All five youth were offered a snack or meal with
one youth refusing the snack or meal. Screenings were completed to identify medical, mental
health, and substance abuse needs during intake. An admission was observed during the
annual compliance review week. All procedures were followed, the youth was offered something
to eat, and a telephone call to their parent/guardian was made.
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2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures (FOPs) regarding the orientation process which
shall occur within twenty-four hours of the youth being admitted into detention. Five youth case
management records were reviewed for orientation. Documentation indicated orientation was
completed within twenty-four hours of admission and each youth signed an orientation
acknowledgement form. The orientation process included rules and regulations, grievance
procedures, visitation, telephone calls, access to medical/mental health/substance abuse
services, access to the Florida Abuse Hotline and the Department’s Central Communications
Center, behavior expectations and related consequences, possible new law violations for
destruction of property, youth rights, and Prison Rape Elimination Act (PREA) related
information. All five youth records included the signed PREA video acknowledgment form. An
admission was observed during the annual compliance review week and the orientation
documentation included all elements as outlined in the center’s FOP. Four of the five
interviewed youth reported staff provided them with information about the center’s rules and
regulations, daily schedule, education services, visitation, abuse reporting, and the behavior
management system. One youth denied receiving orientation; however, all five youth records
included each youth signature acknowledging their receipt of the center’s orientation.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures to ensure all youth admitted to the center go
through a classification process to provide the highest level of safety and security. Five youth
case management records were reviewed, and all included a review of information concerning
the youth’s history and status to determine a potential safety and security risk. The
Department’s Juvenile Justice Information System Admission Wizard was completed in each
record, which included a review of each youth’s sex, gender, height, weight, age, and level of
aggressiveness. The identified special needs taken into consideration included mental illness,
intellectual disabilities, physical disabilities, history of violent behavior, gang affiliation, criminal
behavior, any history of sexual offenses, including sexual battery charges which were reduced
to a lesser offense, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB),
medical, and identified or suspected suicide, escape, and security risks. All five youth were
assigned to rooms based on classification procedures and four were reclassified when changes
in behavior or status were observed. None of the youth had a history of committing sexual
offenses or were a victim of a sexual offense. The superintendent was interviewed and
explained during the initial intake process the juvenile justice detention officer conducting the
admission looks at several screening instruments such as the Detention Risk Assessment
Instrument, Suicide Risk Screening Instrument, VSAB, Community Assessment Tool (CAT), as
well as past and current charges, and gang affiliation to assist with the classification process
and module/room assignment.
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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 gang affiliation. The
center’s gang representative is a juvenile justice detention officer supervisor, who was on
annual leave the week of the annual compliance review; therefore, could not be interviewed.
None of the five youth case management records reviewed were applicable. A sample of three
was requested. The three applicable youth case management records contained documentation
each youth’s assigned juvenile probation officer, and local law enforcement when applicable,
were contacted. The center emailed pictures, copies of written statements, drawings, graffiti,
and a description of what gang signs each youth was flashing, when applicable. The center staff
entered the appropriate gang related alert into the Department’s Juvenile Justice Information
System (JJIS). All JJIS alerts are provided to staff during shift briefings.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures to ensure a youth's personal property is maintained
securely. Five youth case management records were reviewed, and each record documented
the youth’s property was inventoried by the admitting juvenile justice detention officer and
entered in the Department’s Juvenile Justice Information System. A Property Receipt form was
printed and signed by each youth and a staff in all five records. Three Property Receipt forms
did not have a signature date for the youth and two had no date for the staff; however, the forms
have the date of admission and are dated at the top. All five youth records contained a letter of
acknowledgment regarding unclaimed property, signed by each youth, and a Property Receipt
form listing all personal property which was placed in an assigned locker/bag as documented on
the form. In two of the five records money and additional personal items of value were put in a
clear tamper-proof bag and placed in a drop safe, which is under camera surveillance; the
remaining three youth did not have valuables. The tamper-proof bags were labeled with the
youth’s name, the youth’s Department identification number, and a listing of the items in the bag
and both records contained a Valuable Property Receipt form signed by the youth and staff. A
log is maintained to document items placed in the drop safe and included the date, time, youth’s
name, name of the staff who secured the property, and the staff’s initials. Both youth’s property
items were documented in the safe logbook. Observations during the annual compliance review
week indicated the center received youth personal property, which was stored in a secure area
utilizing the drop safe for valuable belongings and completing all documentation as required. A
review of reports to the Department’s Central Communications Center (CCC) since the last
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annual compliance review indicated there were no incidents reported regarding youth property.
Four of the five youth interviews indicated staff checked the youth’s personal property upon
admission and the youth signed a form indicating it was correct; the remaining one youth denied
staff checking their personal property and signing off on the inventory sheet. The superintendent
interview indicated the property safe is located in master control under camera surveillance, with
supervisors and administration staff only having the combination, and all new and removed
property is logged. Any property which is not picked up within thirty days is considered
abandoned and a Notice of Impending Disposal of Property is mailed to the last known address.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center has facility operating procedures regarding youth release. In all three closed youth
case management records reviewed a juvenile justice detention officer supervisor (JJDOS)
reviewed all paperwork related to each youth’s release prior to release, including paperwork
received from the court. All three records included verification of youth identification prior to
release and a copy of photo identification of the parent/guardian or responsible adult picking the
youth up. In one of the three the youth had previously been identified as an endangered person
and the record contained an alert and email from the youth’s juvenile probation officer
confirming which parent/guardian can pick up the youth. One of the three records required a
reminder of future court dates, which was documented. The three records contained all required
release forms, which were signed and the date of admission and release on each case
management record matched with the dates listed in the Department’s Juvenile Justice
Information System (JJIS). One record had the youth listed at another detention center with the
same dates as the youth’s placement at this center, which was a JJIS error. During the annual
compliance review week, a release was observed. The JJDO conducting the release reviewed
the youth’s court orders to confirm release information. The identifications of the youth’s
parents/guardians were reviewed, photocopied, and placed in the youth’s record.
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2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures regarding the release of personal property and
medication. If a youth does not retrieve their personal property within thirty days, a certified
letter is sent to the parent/guardian stating they have thirty days to retrieve the property. If the
property is not retrieved within thirty days, the center completes an inventory, and the unclaimed
property is donated. Any money is added up, a money order is obtained, and the money is sent
to the regional office. Three closed youth case management records were reviewed, and each
included a Receipt of Property form signed by each youth and their parent/guardian, as well as
a photocopied identification card of the person picking them up, showing each youth was
released to an appropriate person. Two of the three youth were on medication at the time of
release. One of the two records contained a Receipt of Medication signed by the person
receiving the youth. In the remaining record the center staff was unable to locate the form and
speculated the original form was given to the family. A sample of three youth records for
property which had been at the center for more than thirty days beyond release was reviewed.
All three contained a letter sent to each youth’s parent/guardian indicating they had thirty days
to retrieve the property, as well as an inventory of all property, which was donated, and a money
order for all unclaimed currency. During the annual compliance review week, two releases were
observed. The juvenile justice detention officer (JJDO) conducting the release reviewed both
youth’s court orders to confirm release information. The identifications of both youth’s
parents/guardians were reviewed, photocopied, and placed in each youth’s record. Each youth
received their property and a Confirmation of Receipt was signed by both youth and
parent/guardian. One of the two youth was released with valuable property and the JJDO
supervisor retrieved the youth’s property from the drop safe located in master control, signed
out the property on the valuable property logbook, and had the youth review/confirm the receipt
of the property by signing the tamper-proof plastic bag.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures ensuring detention reviews are conducted on a
weekly basis. A review of documentation since the last annual compliance review found the
detention reviews were held weekly with all required participants in attendance. The center’s
assistant superintendent is assigned to coordinate the required weekly detention review. Each
week, a detention review is conducted to inform or address the center’s youth alerts, mental
health or medical concerns, current court order status, release issues or concerns, commitment
placement status, education, confinements, and behavior issues or concerns. During the annual
compliance review week, a detention review was observed, which is conducted weekly by video
conference for all probation staff. The review was led by the detention superintendent, with both
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captains, the facility training coordinator, maintenance personnel, food service specialist and the
center’s mental health, medical, and education staff in-person, and probation and residential
staff participated by video conference. During the review all attendees were actively involved
sharing information and answering questions or concerns about the youth in the center’s care.
During an interview, the superintendent confirmed detention reviews are conducted in the facility
conference room every Wednesday afternoon. Probation staff, detention staff, and the youth
staffing specialist discuss youth court hearings, placements, behaviors, well-being, and
detention status.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures ensuring youth are provided the opportunity to
participate in constructive activities which will benefit them and the center. The center has a
daily activity schedule which outlines each day of the week along with times for each activity.
The daily activity schedule includes times for wake up, personal hygiene, meals, visitation,
educational movement, indoor/outdoor activities, behavior management system (BMS)
activity/incentive, visitation, groups, volunteer programming, shower time, and bedtime. The
center has postings of the activity schedule on all living modules, in the intake area, all
classrooms, dining hall, medical, and the main hallway. Observations were made during the
annual compliance review week at various times of the day, which confirmed daily activities are
conducted as scheduled. Four youth and five staff reported the center follows the daily activity
schedule. The remaining one youth denied the center having a daily activity schedule.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures addressing educational access. The center
provides education services through the Pasco County School Board. A review of the school
calendar indicated 250 days of education are distributed over twelve months, including ten days
used for teacher training and planning. A review of the school schedule revealed the center
provides five sixty-minute class periods daily with a sixty-minute lunch from 11:30 a.m. to 12:30
p.m., fulfilling more than the weekly requirement of twenty-five hours of instructional time. The
lead teacher verified the youth are attending school according to the daily schedule without
interruption. A review of three random dates, over the last thirty days, of logbook entries along
with a video review confirmed the school schedule was being followed. Five youth interviews
indicated they attend school Monday through Friday and felt the school was preparing them
very well or well regarding preparation towards high school equivalency diploma (GED)
platform, high school, vocation, employment, and/or college. Five staff interviews indicated they
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felt there was minimal interference in educational services. The superintendent interview
indicated there is minimal interference in educational services and juvenile probation officers
and other outside agencies are encouraged to see youth during non-educational hours.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures addressing career education. The lead teacher
indicated every youth in the center receives education programming including communication,
interpersonal, and decision-making skills. The center offers Type 1 career education
development which includes career learning strategies, such as career interest, interviewing
skills and techniques, as well as completing employment applications. Five youth interviews
indicated they are taking core classes, such as math, science, history, and social studies, while
at the center, as well as life skills and career choices.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures requiring a single licensed mental health
professional to serve as the designated mental health clinician authority (DMHCA). The DMHCA
is responsible for the coordination and implementation of mental health and substance abuse
services. The DMHCA has a clear and active license in the State of Florida which expires March
31, 2025. The Department maintains a contract with VitalCore Health Strategies, LLC to provide
mental health and substance abuse services to all applicable youth in the center. The contract
requires a full-time licensed professional to serve as the DMHCA forty hours each week. The
center has not utilized a back-up DMHCA since the last annual compliance review; however, the
center has a back-up DMHCA who’s license expires March 31, 2025. Both the DMHCA and
back-up DMHCA are licensed under Chapter 491, Florida Statutes and have active agreements
with the center. The DMHCA’s job description outlines the clinical and administrative oversight
responsibilities of all contractual requirements. The DMHCA is scheduled to be on-site Monday
through Friday from 7:30 am to 3:30 p.m. and is on-call twenty-four hours seven days a week
for emergencies and consultation. The interviewed DMHCA reported being on-site forty-hours
weekly. The DMHCA attends weekly meetings, with an administrator, detention reviews and
mini-treatment teams. The DMHCA went on to explain mental health and substance abuse
services, group and individual therapy, and crisis intervention/prevention services are provided
when needed. When a youth expresses a need, and is inclined to start services, an
Individualized Treatment Plan and a Substance Abuse and Mental Health Assessment (SAMH)
are completed within thirty days.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. The licensed
positions, in addition to the designated mental health clinician authority (DMHCA), include four
full-time licensed mental health professionals. The center identified two licensed mental health
counselors (LMHCs) and two licensed clinical social workers (LCSWs) each with a verified clear
and active license in the State of Florida, expiring on March 31, 2025. The DMHCA is
responsible for ensuring all mental health staff are qualified based on education, training, and
experience. All licenses were maintained on-site.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. A review of the
contract with the Department confirmed the center is not required to have any non-licensed
clinical staff. The center has two non-licensed clinical staff, one of whom is a registered mental
health counselor intern whose certificate expires July 27, 2026. Both are holding master’s-level
degrees from accredited colleges in a required field. The center does not have a Chapter 397
license; however, if any substance abuse services are needed, they are provided by licensed
mental health professionals. A review of the center’s direct supervision log found the non-
licensed clinical staff received weekly direct supervision with the designated mental health
clinician authority (DMHCA). The supervision was recorded on the Department’s Licensed
Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct
Supervision Log. A review of documentation confirmed the non-licensed staff had training in the
facilitation of Assessment of Suicide Risk (ASR) in addition to supervised practice to provide
ASRs to youth.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures to ensure the mental health and substance abuse
needs of youth are identified through a comprehensive screening process in which referrals are
made when youth are identified with mental health and/or substance abuse needs or are
identified as a possible suicide risk in accordance with Florida Administrative Code. Upon
admission, a juvenile justice detention officer (JJDO) reviews each youth’s Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2), facesheet, and alerts. The JJDO then
completes their assigned section of the Suicide Risk Screening Instrument (SRSI). A review of
five mental health and substance abuse records found each youth had a mental health,
substance abuse, and suicide risk screening utilizing the SRSI and the MAYSI-2 completed
during the admission process in the Department’s Juvenile Justice Information System (JJIS) on
the day of admission by trained staff. Each SRSI had completed entries which included a
summary and recommendations in the screening results section. One youth had all negative
responses and did not require further evaluation. Four of five youth were applicable for positive
“yes” responses/hits on the SRSI and MAYSI-2, they were placed on suicide precautions, a
mental health referral was completed, and the mental health staff and superintendent were
notified.
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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.
The center has facility operating procedures for identifying the mental health and substance
abuse needs of youth through a comprehensive screening process. Youth with identified needs
are referred for a further in-depth mental health and/or substance abuse evaluation. The center
utilizes the Department’s Mental Health and Substance Abuse Referral Summary form. Youth
identified with substance abuse and/or mental health needs are assessed within thirty days by
the provider using the Department’s Substance Abuse and Mental Health Assessment (SAMH)
form. Four of five mental health and substance abuse records reviewed were applicable. The
four applicable youth records documented completion of a SAMH within the required time frame
and the treatment recommendations made corresponded to all diagnosed mental health or
substance-related disorders. There were no youth applicable for having a comprehensive
assessment completed by a community provider.
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.
Three of five mental health and substance abuse records reviewed were applicable for
treatment and discharge planning. The two remaining youth did not require a treatment plan. All
three applicable youth were assigned to a mini-treatment team. The three applicable youth
records documented an initial treatment plan was completed on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form within five days of initiation of treatment. Each of
the initial treatment plans documented the reason for referral, initial Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, treatment methods, initial
treatment goals, applicable psychiatric services, and, if applicable, medication received at
admission. All three were completed and signed by the designated mental health clinician
authority (DMHCA). Each plan was signed by treatment team members involved in the
development of the initial treatment plan, youth, and parent/guardian when possible. All three
records contained an individualized treatment plan developed within thirty-one days of
admission. Each of the three individualized treatment plans documented the DSM-5 diagnosis,
symptoms which were the focus of treatment, strengths, needs, and applicable psychiatric
services to include the youth’s prescribed psychotropic medication, dosage, and the frequency
of monitoring rate. A review of the progress notes in all three records indicated each youth was
receiving treatment services as stipulated on the treatment plan. In all three records the
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individualized treatment plan was signed by the youth, mental health/substance abuse clinical
staff, treatment team members, and parent/guardian. Each applicable record contained
treatment plan reviews completed at thirty-day intervals after the development of the
individualized treatment plan on the Department’s Individualized Mental Health/Substance
Abuse Treatment Plan Review form. All modifications documented on the review form were
clearly identified. All treatment plan reviews were dated and signed by each youth, clinical staff,
licensed mental health professional, applicable treatment team members, and the
parent/guardian when possible. Three closed mental health and substance abuse records were
reviewed, and all contained a discharge plan documented on the Department’s Mental
Health/Substance Abuse Treatment Discharge Summary form. Documentation supported a
copy of the plan was provided to each youth, applicable parent/guardian, and the assigned
juvenile probation officer as required. An observation of treatment team was conducted during
the annual compliance review week. Three youth participated in the meeting with all required
treatment team members present, discussing mental health treatment plans.
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.
Three of five mental health and substance abuse records reviewed were applicable for mental
health and substance abuse treatment services. In the three applicable records each youth was
assigned to a mini-treatment team including all required individuals. Each reviewed mental
health and substance abuse record contained the properly executed consents for mental health
and/or substance abuse treatment services and progress notes validated each youth was
receiving treatment services as stipulated on the treatment plan. All progress notes were
documented on the Department’s Counseling/Therapy Progress Notes form. A review of
documentation confirmed mental health groups were limited to ten or fewer youth, and
substance abuse groups to fifteen or fewer youth. Video observations of three groups verified
licensed therapists have adequate access to youth and are conducting groups in a confidential
space, as scheduled. Two of five youth interviews indicated services are good, one stated poor,
and two stated they were not receiving services. The designated mental health clinician
authority (DMHCA) stated youth are provided mental health groups which focus on anger
management, decision-making, and life skills. Licensed mental health staff conduct all
substance services as needed.
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Office of Accountability and Program Support Page 28 of 58 (Revised July 2023)
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The provider’s contract outlines the required psychiatric services provided to youth, which
include psychiatric evaluation, consultation, and medication management. Psychiatric services
are provided to youth in need, as indicated by symptoms of mental disorder or substance-
related disorder, or to youth who are treated with psychotropic medication. The center’s
psychiatrist maintains a clear and active license in the State of Florida, which expires on
January 31, 2024. The psychiatrist is a medical doctor with an American Board of Psychiatry
and Neurology endorsement in child and adolescent psychiatry. The center does not utilize a
psychiatric advanced practice registered nurse (APRN). The center has not needed to utilize a
back-up psychiatrist since the last annual compliance review; however, has one if needed. The
back-up psychiatrist maintains a clear and active license in the State of Florida, which expires
on March 31, 2024. Reviewed documentation and sign-in logs validated the psychiatrist
provided weekly services, as required. A review of five mental health and substance abuse
records reflected one was applicable; two more records were requested. In the three applicable
records each youth was admitted with prescribed psychotropic medications and each youth
received an in-depth psychiatric evaluation which was documented on the Department’s Clinical
Psychotropic Progress Note (CPPN) form and completed within fourteen days of admission.
Each evaluation documented the reason for referral, history, Mental Status Examination,
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis,
treatment recommendations, and prescribed medications. All three also included explanation for
the need of psychotropic medication, frequency of medication management, identification of
factors contributing to youth difficulties, applicable serum drug levels, and the psychiatrist’s
signature and date. Each reviewed evaluation included page three of the CPPN outlining
medication target symptoms, side effect descriptions, medication name, dosage, frequency,
youth adherence to the medication regimen, height, weight, and blood pressure. None of the
three records were applicable for monthly Tardive Dyskinesia monitoring, were under the care
of the Florida Department of Children and Families (DCF), nor received new
medication/significant changes to psychotropic medication requiring parental consent. The three
applicable youth records contained a current Authority for Evaluation and Treatment (AET). The
center did not utilize tele-psychiatry. The interviewed designated mental health clinician
authority (DMHCA) explained the mental health staff meet with the psychiatrist weekly to
discuss youth referred for services.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 29 of 58 (Revised July 2023)
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 Suicide Prevention Plan outlining the center’s procedures to
address the use of suicide precautions, suicide prevention training, and the process by which
any youth identified as having suicide risk factors at any time must be placed on suicide
precautions and receive an Assessment of Suicide Risk (ASR). The policy and plan were signed
by the regional behavioral health director and the designated mental health clinician authority
(DMHCA). The plan includes the identification and assessment of youth at-risk of suicide
utilizing the Department’s ASR and Follow-Up ASR forms. The plan identifies the levels of
supervision, referral process, communication, notification, documentation requirements and
review process. In the event of a life-threatening suicide attempt, staff are to call 9-1-1
immediately. Mental health staff assist in training juvenile justice detention officers in suicide
prevention, including verbal and behavioral cues indicating a suicide risk. The plan outlined
emergency contact telephone numbers to include the superintendent, on-call administrator,
DMHCA, psychiatrist, local emergency room, community crisis stabilization unit, and the Poison
Control Center. The center has an established review process for every serious suicide attempt
or serious self-inflicted injury and a mortality review for a completed suicide. The process
includes review of 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, and recommendations, if any, for
changes in policy, training, physical plant, medical or mental health services, and/or operational
procedures.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
A review of five youth mental health and substance abuse records found documentation of three
youth determined at risk during intake. Each applicable youth was placed on precautionary
observation (PO) until the Assessment of Suicide Risk (ASR) was completed within twenty-four
hours, as required. Each ASR was completed by a licensed mental health clinician on the
Department form. None of the youth were released from the center while on PO. The
conference with the superintendent and the designated mental health clinician authority
(DMHCA) was documented on each ASR in accordance with the center’s approved Suicide
Prevention Plan. A review of the completed Follow-Up ASRs found each youth was stepped
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Office of Accountability and Program Support Page 30 of 58 (Revised July 2023)
down to constant or standard supervision with a documented conference with the
superintendent prior to removal from PO. A review of the Department’s Juvenile Justice
Information System (JJIS) reflected alerts were generated and updated, as required, for all
reviewed youth. A review of the center’s logbook entries and ASRs supported administrative
and supervisory staff provided instructions related to the applicable youth’s elevated suicide risk
levels and precautions, the start of each PO was indicated in the logbook, as well as all
subsequent step-downs and removals were logged for each youth. None of the reviewed youth
were applicable for secure observation. The center has an established review process for
serious suicide attempts or incidents of self-injurious behavior which includes all required topics.
The superintendent was interviewed and advised secure observation (SO) is used when a youth
is either on close watch or precautionary observation and their behavior escalates to where
confinement is needed. The DMHCA makes this determination. Once a youth is placed on SO,
the health status checklist must be completed along with a referral. Five youth were interviewed,
and three youth said they have never been placed on suicide watch while at the center, and two
said they have. The two youth who said they had been placed on suicide watch also said staff
supervised them the entire time they were on suicide watch. Five staff were interviewed, and all
were aware of the steps to take if a youth expresses suicidal thoughts, which include notifying
the mental health authority, searching each youth for sharp objects, documenting supervision,
constant sight and sound supervision, and one staff stated placing a youth in a locked room.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
In three of five reviewed mental health and substance abuse records each youth was placed on
precautionary observation (PO) and the Suicide Precaution Observation Log was maintained for
the duration of PO. Safe housing areas were clearly documented on each reviewed log and
none of the youth displayed any warning signs. All PO logs were reviewed and signed daily by
the shift supervisor and the mental health clinician. Reviewed documentation reflected staff
observations did not exceed the required intervals and were documented in real time for all
three youth. Documentation was provided by the superintendent of a fourth youth, who was on
PO over twenty-four hours. The documentation provided for this additional youth was PO and
secure observation logs for a duration of four days. The youth was placed on PO with Follow-up
Assessments of Suicide Risk being completed every twenty-four hours. A review of the PO logs
indicated a twenty-four hour period of logs were missing. The center staff became aware of the
issue prior to the center’s seven-day notice of the annual compliance review, and provided an
internal corrective action plan, which was completed prior to the annual compliance review
week. A review of video for three youth on PO confirmed the center’s practice of continued sight
and sound supervision.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 31 of 58 (Revised July 2023)
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures requiring all staff working with youth to complete
training to recognize verbal and behavioral cues indicating suicide risk, suicide prevention, and
implementation of suicide precautions. Five pre-service and five in-service staff training records
were reviewed. All five pre-service and three in-service training records documented six hours
of suicide prevention and implementation of suicide precautions training and suicide drills. The
remaining two in-service staff only had two hours of training. During the annual compliance
review period, the center was operating two shifts due to staffing issues. Mental health drills
were conducted on each of the center’s two shifts monthly, exceeding the requirement of
quarterly on each shift. All twenty-nine applicable direct care staff participated in a drill once
every six months. Reviewed drill documentation confirmed direct-care staff participated in at
least one drill which included the use of cardiopulmonary resuscitation (CPR) annually. Staff
who were not present during the drills had the opportunity to review each drill scenario and
procedures. The center maintained five suicide response kits co-located with first-aid kits, one in
each module, the clinic, and the mental health department. Five staff were interviewed and
indicated the suicide kits are located in each module, each vehicle, and the medical office.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a written combined Emergency Services Plan outlining the required response to
youth crisis in the least restrictive means possible to protect the youth and others while
maintaining the control and safety of the center. The center’s plan addresses notification and
alerts, means of completing referrals including self-referrals, communication, supervision,
documentation, and review. The plan was last reviewed and approved on April 24, 2023. The
center utilizes a local mental health center as their crisis stabilization unit.
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Office of Accountability and Program Support Page 32 of 58 (Revised July 2023)
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has a written Emergency Care Plan requiring youth who experience a mental health
or substance abuse emergency with imminent danger to themselves or others to receive
emergency care. The center’s Emergency Care Plan was approved by the superintendent on
April 24, 2023, and includes immediate staff response, notifications, communication,
supervision, authorization to transport for emergency mental health or substance abuse
services, including Baker Acts and Marchman Acts, documentation, training, and reviews. A
copy of the plan, which is accessible to all staff, is located in the mental health offices, master
control, the center’s shared drive, and the superintendent’s office.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures requiring response to youth in crisis and the
administration of a Crisis Assessment. None of the five reviewed mental health and substance
abuse records were applicable for a Crisis Assessment; therefore, three applicable records
were requested. In all three applicable records a Crisis Assessment was completed by a
licensed mental health professional within the required time frame. Each Crisis assessment
included the reason for the assessment, Mental Status Examination, determination of danger to
others or self, initial clinical impression, supervision recommendations, treatment
recommendations, recommendation for follow-up or further evaluation, and notification to
parent/guardian of follow-up treatment. All three youth were alleged victims in a Prison Rape
Elimination Act (PREA) case. In all three mental health and substance abuse records reviewed
a mental health alert was entered in the Department’s Juvenile Justice Information System
(JJIS), as required.
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Office of Accountability and Program Support Page 33 of 58 (Revised July 2023)
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures to ensure youth safety and supervision after
returning from a Baker Act or Marchman Act. None of the five mental health and substance
abuse records reviewed were applicable for a Baker Act or Marchman Act; therefore, three
records were requested. In all three applicable records each youth was placed on suicide
precautions upon re-admission from a Baker Act and maintained on constant supervision until
transitioned to a lower level of supervision. Each youth was referred for a Mental Status
Examination which was completed by a licensed mental health professional. A review of the
Department’s Juvenile Justice Information System (JJIS) indicated in all three records the
mental health/suicide risk alerts were updated based on the outcome of the Crisis
Assessment/Assessment of Suicide Risk. In the three applicable records the supervision levels
were maintained until an appropriate assessment was completed and the licensed mental
health professional conferred with the superintendent.
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Office of Accountability and Program Support Page 34 of 58 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures addressing tele-health. The center has a contract
with VitalCore Health Strategies, LLC to provide medical services which includes the provision
of a physician to serve as the designated health authority (DHA). The DHA has a clear and
active license in the State of Florida, which expires January 31, 2025, and is board-certified in
pediatric medicine. The center has a back-up DHA who is board-certified in pediatric internal
medicine and has a clear and active license in the State of Florida, which expires January 31,
2025; however, the back-up DHA was not utilized during the annual compliance review period.
The DHA has collaborative practice protocols in place with an advanced practice registered
nurse (APRN) to provide clinical services at the center. The APRN is certified in pediatric
nursing and has a clear and active license in the State of Florida which expires April 30, 2025. A
review of sign-in logs since the last annual compliance review found the DHA was on-site
weekly for at least one hour, as required. The center did not utilize tele-health during the annual
compliance review period. An interview with the DHA confirmed their role in reviewing and
approving all policies, conducting clinical duties, as needed, communicating with center staff
regarding the medical needs of youth, and being on call twenty-four hours a day, seven days a
week for consultation. The DHA reported the APRN is responsible for clinical services at the
center; however, the DHA is available to provide any services when on-site and provide
oversight for all medical services.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center has facility operating procedures, as well as nursing protocols in place for all health-
related procedures and services. The designated health authority (DHA) approved all policies
and protocols between July 12, 2023, and September 1, 2023, and the superintendent reviewed
and signed all policies on April 19, 2023. A cover page was found for both the policies and
protocols which was signed by each medical staff on September 1, 2023. The psychiatric
policies were developed, approved, and signed August 11,2023, by the psychiatrist. All
healthcare staff hired during the annual compliance review period received a comprehensive
clinical orientation to the Department’s health care policies and procedures provided by a
registered nurse and all signed the nursing protocols.
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Office of Accountability and Program Support Page 35 of 58 (Revised July 2023)
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Five youth Individual Healthcare Records (IHCRs) were reviewed for the completion of an
Authority of Evaluation and Treatment (AET). Four of the five IHCRs contained a valid AET,
signed by each youth’s parent/guardian and a Department representative. The remaining youth
was eighteen years of age and did not require an AET. Each appliable youth’s IHCR contained
the original AET form and/or was stamped as “copy.” All of the AET forms were obtained prior to
providing medical services to youth. None of the youth were under the supervision of the
Department of Children and Families (DCF).
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 (IHCRs) were reviewed, of which one was applicable
for parental consent and notification of medical services. An additional two youth IHCRs were
provided. One of the three applicable youth had documentation for notifications regarding
psychotropic medications and two were applicable for over-the-counter medications. All three
IHCRs maintained verbal notification documented on each youth’s progress notes, written
notification sent utilizing the Department’s Parental Notification of Health-Related Care: General
or Parental Notification of Health-Related Care: Medications forms, and where applicable the
Clinical Psychotropic Progress Note (CPPN) page three. All three records indicated verbal
consent was witnessed. None of the youth were under the supervision of the Department of
Children and Families (DCF). In all three IHCRs vaccines were verified within thirty days of
admission. The nursing interview indicated parental notification should be made to inform the
parent/guardian of significant changes in the youth’s condition and the center should obtain
consent when new medications are ordered, medications are stopped, youth is sent off-site for
treatment whether scheduled or emergency, and treatments are prescribed. These notifications
are made verbally as soon as an order has been received and followed with a letter. When a
youth’s illness or injury requires emergency medical treatment, 9-1-1 is called and the
designated health authority is notified. The nurse stated whenever a new psychotropic
medication is prescribed, discontinued, or dosage is significantly changed, the parent/guardian
verbal consent is documented on page three of the CPPN, and written consent is documented
on the Department’s Acknowledgment of Receipt of CPPN form. The nurse interview reported
the center’s immunization records are obtained through the Florida Shots website; they do not
provide vaccinations. If the parent seeks exemption, the nurse presents a certified
documentation of exemption to the parent/guardian. Once filled out, it is reviewed by nursing
staff and the designated health authority and uploaded in the Department’s Juvenile Justice
Information System.
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Office of Accountability and Program Support Page 36 of 58 (Revised July 2023)
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.
In all five youth Individual Healthcare Records (IHCRs) reviewed, the Medical and Mental Health
Admission Screening form was completed on the day of admission by a juvenile justice
detention officer (JJDO) and a licensed healthcare staff reviewed the screening form within
twenty-four hours, as required. In all five, the designated health authority was notified of each
youth admission, and this was documented in the IHCR. None of the five youth were applicable
for a change in physical custody; therefore, three additional IHCRs were reviewed. Each of the
three applicable IHCRs contained documentation indicating the rescreening was completed by a
JJDO the day each youth returned to the center and was reviewed by a licensed healthcare
staff within twenty-four hours. None of the three youth were applicable for a qualitative urine
pregnancy screening test. The nurse interview indicated youth are seen on day of admission,
unless the youth arrives after nursing is gone for the day, then they will be seen the following
morning. The supervisors or master control notify the nurses of all newly admitted youth, as well
as receive all admission medical and mental health screening forms/packets in the clinic
mailbox. The JJDO supervisors complete the admission screening and the nurses sign off on
them. When a youth returns to the center, the youth is assessed for any changes in medical
condition since last time in physical custody. Vital signs are also obtained, and the Health-
Related History (HRH) is reviewed with each youth. If there are any changes it is documented in
the HRH.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures including access to medical care, sick call, what
constitutes an emergency and when to notify staff, medication process, the right to refuse care
and how it is documented, what to do in the case of a sexual assault or attempted sexual
assault, the non-disciplinary role of the healthcare providers, and review of the list of healthcare
contacts. Five youth Individual Healthcare Records (IHCRs) were reviewed and all received a
general healthcare orientation, including all required topics documented on the Department
form.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Three of the five Individual Healthcare Records (IHCRs) reviewed were applicable for
notification of the designated health authority (DHA) upon youth admission; the remaining two
were not applicable. In the three applicable IHCRs each youth was admitted with a chronic
condition, the DHA was notified within twelve hours, and this was documented in each IHCR.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 58 (Revised July 2023)
One of the three youth was taking psychotropic medications upon admission and the
psychiatrist was notified. None of the youth were identified as requiring emergency care upon
admission. The nurse interview indicated the DHA is contacted telephonically as soon as a
youth is seen in the clinic, which is documented on the intake log as well as the admission form.
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 reviewed youth Individual Healthcare Records (IHCRs) included a Health-Related History
(HRH) form completed within seven days of admission by a licensed healthcare staff on the
Department’s form. The HRH was completed prior to the Comprehensive Physical Assessment
(CPA), as evidenced by signature and date and the designated health authority (DHA) reviewed
the HRH as indicated by a check mark on the CPA. The nursing interview indicated the HRH is
completed by the nurses within seven days of admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures addressing when any part of the Comprehensive
Physical Assessment (CPA) is not conducted or refused by the youth, as well as Tuberculosis
(TB) screening. In all five Individual Healthcare Records (IHCRs) reviewed the CPA was
documented on the Department form noting each youth’s Medical Grade. Three of five youth
received a new CPA completed by the designated health authority (DHA)/advanced practice
registered nurse (APRN) within seven days of admission, marked with “O” and “X” and missing
no elements. The remaining two youth had an updated CPA wherein the DHA/APRN reviewed,
signed, and dated the CPA after conducting a focused evaluation with each youth. The
Department’s Problem List was updated, as required. All five IHCRs contained a Tuberculosis
Skin Test (TST) completed within the last year with the results having been documented on the
Infectious Communicable Disease (ICD) and the CPA forms. All five youth received a TB
screening within seventy-two hours of admission with no further evaluation required. The nurse
interview indicated the CPA must be completed within seven days of admission. TB screenings
are completed within seventy-two hours of admission, if one is not documented in the youth’s
IHCR within the past year. The results are documented on the CPA, ICD form, and the TB
tracking log. The center does not conduct routine gynecological exams.
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.
In all five Individual Healthcare Records (IHCR) reviewed each youth received a sexually
transmitted infection (STI) screening upon admission. In all five the designated health authority
reviewed the form and two of the youth were referred for further testing. The referral was
documented on the STI form and testing was ordered. In both applicable IHCRs the testing,
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Office of Accountability and Program Support Page 38 of 58 (Revised July 2023)
screening results, clinical evaluations, and diagnosis were documented on the Infectious
Communicable Disease (ICD) form and filed in the lab section of each IHCR. None of the youth
consented to a gynecological exam or were out of the center’s custody. In all five IHCRs each
youth was offered counseling and testing for human immunodeficiency virus (HIV); all five
refused. Each of the five interviewed youth confirmed they are able to request an HIV test at any
time.
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 facility operating procedures indicating when there is not a licensed nurse on-
site the shift supervisor reviews all sick call requests as soon as possible and within four hours
after the request is submitted. The procedure also indicates only licensed nurses conduct sick
call and describes the process when youth are in confinement and have medical issues. Two of
the five Individual Healthcare Records (IHCRs) were applicable for sick call. One more example
was requested. In the three applicable IHCRs each sick call was documented on the Sick Call
Referral Log. One of the three youth was experiencing similar sick call complaints three or more
times in a two-week period and was referred to the designated health authority (DHA). None of
the youth had a complaint of severe pain with which the staff was unfamiliar with or were in
restricted housing. All three youth completed a Sick Call Request form and each was completely
filled out by a nurse. In one of three, a licensed practical nurse (LPN) conducted the sick call
and it was reviewed the same day by a registered nurse (RN) or higher, which was documented
on the form. The Sick Call Request forms were filed in each IHCR and were documented
according to the Health Service Rule. All sick calls were documented on each youth’s Sick Call
Index correlating with the Sick Call Request forms. The center provides sick call every day from
8:00 a.m. to 10:00 a.m., as well as needed, if nurses are on-site. The posted schedule, which
was on the wall next to the clinic door, and nurse interview reiterated this practice. A review of
the approved treatment protocols indicated both the LPN and RN are included. The nursing
interview indicated youth notify Department staff of medical complaints, which are entered into
the electronic system as a Sick Call Request. The nurses review the Sick Call Request Log
twice a day and will youth within twenty-four hours; however, normally sooner. Youth are
assessed by a RN or LPN, or the DHA if on-site. If a LPN completes the sick call, the RN
reviews it within twenty-four hours. All sick calls are conducted in the clinic. Youth presenting
with similar sick call complaints three or more times within a two-week period are referred to the
DHA or APRN and are added to the list to be seen by the provider. If a youth is in restricted
housing/confinement the nursing staff will assess youth for medical complaints or distress every
twenty-four hours and this is documented in an episodic care note. If youth are showing any
distress when medical staff are not on-site, the direct care staff are required to contact their
supervisor and the DHA. Two of the five youth interviews indicated they can be seen within one
day when requesting a sick call, one stated more than three days, and the remaining youth said
they had never requested a sick call. Three youth indicated the doctor conducts sick call, with
two also stating the nurse conducts sick call; two never had to request sick call. All five staff
interviews indicated the doctor and nurse review and conduct sick call.
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Office of Accountability and Program Support Page 39 of 58 (Revised July 2023)
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center has facility operating procedures addressing maintenance and storage of first-aid
kits ensuring contents do not expire or deteriorate. One of the five Individual Healthcare
Records (IHCRs) was applicable for episodic care. Two more examples were requested. In the
three applicable IHCRs each youth required an on-site episodic/first-aid care event. All three
episodic care events were conducted by a licensed nurse on-site and documented in problem-
oriented charting; subjective, objective, assessment, and plan (SOAP) form. The three youth
had nine episodic care events, eight of which were documented in the Episodic Care Log. The
missing one was conducted by the designated health authority (DHA) who forgot to enter the
event into the log. The center had seventeen first-aid kits, one each in the kitchen, girl module,
intake area, both boy modules, teacher lounge, clinic, mental health office, and master control.
Master control also has all eight first-aid kits for the transport vehicles. Observation of three first-
aid kits indicated they were fully stocked with DHA approved contents. Each first-aid kit had the
expiration dates of contents noted on the kit. A review of first-aid kit checks since the last annual
compliance review indicated they were conducted monthly as required. The center had two
automated external defibrillators (AED); one in the clinic and one in master control. In the clinic
the procedures were located on top of the AED box, in master control they were behind the
AED. Both AEDs had a green light and were operational during the annual compliance review
week. A review of AED checks since the last annual compliance review indicated they were
conducted monthly as required by the nursing staff. The AED batteries in both devices expire in
August, 2026 and were changed in August, 2022. The AED pads in both devices expire
November 28, 2024 and were changed January 28, 2023. A review of medical emergency drills
since the last annual compliance review indicated drills simulated an episodic care event which
called for immediate first-aid and/or administration of cardiopulmonary resuscitation (CPR)
techniques and the initiation of the emergency procedures to follow when a life-threatening
emergency does occur. The center practices CPR/AED demonstration at least annually and
conducts drills at least quarterly on each shift. The center maintains a list of emergency
numbers accessible to staff. All authorized direct care staff were appropriately trained on the
administration of the epinephrine auto-injector. All five pre-service and four of five in-service
reviewed training records indicated staff were trained in first-aid, episodic, and emergency care.
One of the in-service staff did not have the training. The center maintains Narcan in the locked
medication cart in the clinic. The Narcan is inventoried weekly, supervisory staff have access
and have been trained to administer the medication. The process when using Narcan was
explained by the nurse, including how much has to be administered and when utilized staff have
to call 9-1-1. The nursing interview indicated episodic care by licensed staff is documented in
the Electronic Medical Record (EMR) in an Episodic Care Progress Note and will cover all
elements of a SOAP note. If non-licensed staff conduct episodic care, it is documented on the
Report of On-Site Care by Non-Healthcare Staff form and a follow-up evaluation is completed
by a nurse when back on-site. Youth who require off-site emergency care are documented in
the Off-Site Care Log in the EMR. All five staff interviews indicated they are able to call 9-1-1 if
necessary. One of five is able to give medication to youth, the remaining four stated they do not.
Four of five youth interviews indicated they rated the medical care at the center as good and the
remaining one said they had never received any medical attention.
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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.
None of the five reviewed Individual Healthcare Records (IHCRs) were applicable for off-site
care; therefore, three additional IHCRs were requested. In the three applicable IHCRs each
youth required off-site care which was documented on the Summary of Off-Site Care form and
on the Episodic Care Log. All parental notification efforts were documented in each IHCR, as
well as notification to the designated health authority (DHA). Discharge instructions and findings
were maintained in each IHCR and the DHA/designee reviewed and signed all off-site
documentation. In one of the three the youth required follow-up care, which was tracked in the
center’s tracking log. The youth was released from the center prior to the appointment. The
nurse interview indicated youth who require off-site care are tracked on the Off-Site Care Log in
the Electronic Medical Record (EMR). All hospital orders from off-site visits are placed in a
folder for the DHA, they are then reviewed with the DHA and the DHA will provide orders to
follow in the center. Any follow-up testing, referrals, and appointments are tracked in a calendar
and through email communication with the center staff and is documented on the Summary of
Off-Site Care form.
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.
One of the five reviewed Individual Healthcare Records (IHCRs) were applicable for chronic
conditions; therefore, two additional IHCRs were requested. In all three applicable IHCRs each
youth had a chronic condition, which was documented on the Medical/Mental Health Screening
form and each was entered on the Chronic Conditions Roster. None were pregnant, took anti-
tuberculosis medication, nor had any communicable diseases. One of the three was at the
center long enough to receive periodic evaluations every ninety days; the remaining two had
been released prior to the ninety days. In all three the Department’s Problem List was updated.
The designated health authority (DHA) interview indicated periodic evaluations are completed
every ninety days. Occasionally there will be serious conditions needing more frequent
monitoring, and those evaluations may be completed every thirty to sixty days. The nurse
interview indicated youth with chronic conditions are noted in the chronic condition binder, alerts
are entered, and the DHA is notified to see the youth.
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4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures addressing medication management and
prohibiting standing orders, emergency treatment orders, and pro re nata orders for
psychotropic medications. One of the five reviewed Individual Healthcare Records (IHCRs) was
applicable for the youth taking medications while at the center; therefore, two additional records
were provided. In all three applicable IHCRs each youth was taking medication at the time of
admission and the medication was verified prior to being admitted to the center utilizing the
Prescription Medication Verification Checklist/Medication Receipt Transfer Disposition form. In
all three the designated health authority (DHA) and psychiatrist were contacted to obtain the
order to continue the medication. Each youth’s medication administration was tracked on the
Department’s Medication Administration Record (MAR), which contained all required
information, utilizing start and stop dates. Every medication administration entry was initialed by
the youth and healthcare staff and the nurses documented weekly side effect monitoring on
each MAR. All medications had a current, valid order and were given pursuant to a prescription.
In two IHCRs, current medications were continued, discontinued, changed, or new ones were
ordered, and the DHA/designee placed an order on the Practitioner Order Form. None of the
youth were in restricted housing, refused medications, nor received over-the-counter or
parenteral medications. All three youth were prescribed psychotropic medications prior to
admission and the psychiatrist was notified. In all three the psychiatrist conducted an initial
psychiatric interview within fourteen days of admission. One of the three youth received
medication reviews every thirty days; the remaining two were released prior to the thirty-day
deadline. Observations of medication pass for two youth during the annual compliance review
week indicated the center staff escorts each youth to the clinic, the nurse administers each
youth’s medication, while the center staff maintain security. Each youth approached the nurse
individually when it was their turn for medication. During the medication pass, the allergy and
alert status were verified for each youth. None of the medication was pre-poured and the nurse
ensured each youth swallowed the medication. The nurse and each youth signed the MAR.
Neither of the two applicable MARs documented administration of medication by a non-
healthcare staff; however, the center provided documentation indicating staff were trained in
assisting in the self-administration of medication in the event healthcare staff are not on-site.
The nurse interview indicated if a youth arrives with medication, a medication receipt is filled
out, the nurse reviews the medication to ensure it is from a licensed pharmacy with a current,
patient-specific label intact on the original medication container in order to accept it into the
center. Medications shall have a current, valid order and are given as noted on current
prescription or Practitioner Order form. The DHA or psychiatrist shall be contacted to obtain the
order to resume the specified medications youth is prescribed prior to admission. The nurse
reported, the center has local pharmacies providing medication for youth while in the center.
During interviews with five staff, it was reported, one administers medication while the remaining
reported not administering medications. During interviews with five youth, it was reported the
doctor or the nurse administer medication.
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4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has facility operating procedures addressing disposal/destruction of medications, as
well as reporting criteria and a process for inventory discrepancies. Observations made during
the annual compliance review week indicated the stock over-the-counter (OTC) medications
and sharps are stored in locked cabinets in the clinic. All youth medications are maintained in
the locked medical cart, as well as the additional OTC medications and sharps which are
separated by topical, injectable, and oral medications. The center did not have any controlled
substances during the observation; however, has a locked box in the locked medical cart
available for those medications, which was confirmed through the nursing interview. The
medical cart was observed to be well organized, clean, and locked. A secured refrigerator in the
clinic is utilized for medications needing to be kept cold. The refrigerator was kept at forty-two
degrees and contained tuberculosis serum, as well as insulin. A review of training
documentation indicated non-healthcare staff were trained in the delivery and oversight of
medication self-administration by a registered nurse or higher. The nurse conducted a count of
three OTC medications and three sharps with all totals matching the inventory numbers. The
nursing interview indicated supervisors are trained and approved to provide medication when
nurses are not on-site. Medication pass occurs daily at 8:00 a.m., 12:00 p.m., 5:00 p.m., and
7:00 p.m. if needed and as ordered. The nurse indicated the process to dispose of controlled
medications is with the pharmacist on-site and nurses present; all other medications can be
disposed of while two nurses are present. The pharmacist is on-site once a month and reviews
the medical cart, medication stock, refrigerator, Medication Administration Records, sharps, as
well as assists with destroying medication and ensures everything is labeled correctly.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures addressing needle stick post-exposure evaluation.
In all five reviewed Individual Healthcare Records (IHCRs) each youth received infection control
training within seven days of admission, as well as hand-washing techniques,
universal/standard precautions, prevention/transmission of communicable diseases, Center for
Disease Control and Prevention (CDC) guidelines for infection control, and immunization
training. The center’s Exposure Control Plan was written in accordance with the Occupational
Safety and Health Administration (OSHA) standards and included all required elements of risk
assessment and methods of compliance. The center’s infection control procedures include
prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to OSHA and the CDC guidelines. The plan also includes common infectious
diseases of childhood, self-limiting, episodic contagious illnesses, viral or bacterial infectious
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diseases, tuberculosis, Hepatitis A, B, C, and human immunodeficiency virus, and infectious
diseases caused by bloodborne pathogens. The infection control plan also addresses other
outbreaks or epidemics caused by any other infectious agent, outbreaks of pediculosis and/or
scabies, Methicillin-Resistant Staphylococcus Aureus, and other antibiotic-resistant micro-
organisms, foodborne illnesses, bio-terrorist agents, and chemical exposures in the workplace.
The center makes Hepatitis B immunizations available to staff, as well as protective equipment.
The center did not have any instances of reportable infectious diseases and sexually
transmitted infections (STIs) or instances involving the quarantining or hospitalization of at least
ten percent of the total population of youth or staff. The center notified the local health
department regarding STIs. The clinic maintains a separate file intended for all documents when
youth and staff have experienced a facility/occupational exposure. Those records are
maintained as confidential for a ten-year period. Two of the five in-service staff had the
exposure control plan training; the remaining three did not. The nursing interview indicated
nurses have access to the Exposure Control Plan, which is maintained in the policy binder. A
registered nurse manager conducts infection control and exposure control plan training with
staff. During the admission process all youth receive infection control training.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has nursing protocols and treatment plans addressing pregnant youth. None of the
five reviewed Individual Healthcare Records (IHCRs) were applicable for prenatal care. The
center was able to provide only two examples since the last annual compliance review. In both
applicable IHCRs each youth received prenatal care immediately upon determination of
pregnancy through release from the center. Both youth were placed on the alert log for vital
nutrition, health awareness for staff, and sleeping arrangements. Neither youth was at the
center long enough to receive a medical evaluation every thirty days. Each youth received
training in alcohol and drug use, smoking, nutrition, sexually transmitted diseases,
contraception, prenatal care, birthing process, postpartum and basic baby care, child/infant
development, and parenting skills. All education was documented on each youth’s Health
Education Record. Both youth received nutritious food in quantities appropriate for pregnant
youth, as well as routine monitoring of nutritional and weight status. A review of five in-service
training records indicated a licensed nurse provided education on youth’s prenatal healthcare,
including observation and monitoring of emergency care needs/symptoms of possible
miscarriage to all non-healthcare staff involved in the supervision or treatment of youth. All five
youth interviews indicated they did not need prenatal, obstetrical, or gynecological services. The
nursing interview indicated after confirming a youth is pregnant obstetric off-site care is
scheduled, the youth is started on a pregnancy diet, educated, prenatal vitamins are provided,
and the youth is seen by the designated health authority (DHA) at least monthly. All DHA orders
are followed. All female youth receive a pregnancy test upon admission, if consent is received.
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Office of Accountability and Program Support Page 44 of 58 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
Observations during the annual compliance review week indicated staff were actively
supervising youth during education, meals, breaks, and line movements. Juvenile justice
detention officers kept youth in sight at all times, accompanying youth during movements which
were authorized by master control, and keeping count of all youth as documented in the
logbooks. Observations indicated positive interactions between youth and staff. A review of
three full days of group video indicated the center followed the group schedule; the center did
not conduct substance abuse groups during the annual compliance review period. All five staff
interviews indicated there are enough staff to provide for the safety and security of the youth
and staff in the center.
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Office of Accountability and Program Support Page 45 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 facility operating procedures (FOPs) outlining the behavior management system
(BMS), including rewards for positive behavior and consequences for inappropriate behavior.
BMS postings were observed hanging in the modules and clearly specified appropriate and
inappropriate behaviors, rules, norms, and expectations, as outlined in the FOPs. BMS
calendars were also posted in the living areas as an incentive to upcoming events which
promoted good behavior by the youth. A review of level cards and daily observations confirmed
rewards and consequences were given in accordance with the BMS. Five staff interviews
indicated the center’s BMS is a point and level system. Two also indicated the BMS is posted
throughout the center and is included in the youth handbook provided during the orientation
process. The five staff were able to describe the BMS, indicating if youth follow rules, attend
school, and do not get in trouble they can level up; if they do not, their level will go down. The
staff indicated youth receive canteen, phone calls, movie night, snacks, extra time out of their
room, and food from outside during visitation as a reward. All five staff stated as a consequence
youth can have level and points taken away from them; however, they are not allowed to take
food, education, medical, mental health, or any other basic rights. The five staff interviews
indicated all believe the center’s BMS is effective, they discuss the consequences imposed with
the youth, youth are given an opportunity to explain their behavior and provide alternative
acceptable behaviors. All five staff indicated supervisors provide feedback to staff regarding the
implementation of the BMS daily and as needed during briefings, two also stated during one-on-
one meetings. All five agreed they have never seen a coworker take meals, snacks, clothing,
education, or medical care from a youth because they were acting out, nor have they observed
any staff encouraging youth to beat up another youth. The superintendent interview indicated
the BMS is a three-level system to reward positive behavior and for youth to earn privileges. All
youth receive basic rights no matter what level they are on. A youth may go up or down one
level for behavior, only law violations will have a youth drop more than one level. A level drop or
freeze must be explained to the youth and documented on the level sheets. Level three youth
receive snacks during the week for good behavior. Four of five youth interviews indicated they
rated the BMS as good, and one fair. The youth stated if they follow rules, go to school, and do
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not get in trouble they will level up and get rewards. Rewards can be canteen, phone calls,
snacks, and food from outside during visitation and all staff provide them the same way. All five
said youth are never allowed to punish other youth. Two youth indicated they had been sent to
their room for punishment, and the door was shut and locked; the remaining three stated they
have not. Two also said they had received consequences, they were fair and consisted of
points/level taken from them. The remaining three never received consequences. All five youth
stated handcuffs or leg irons are not used on out of control youth to prevent them from hurting
themselves or others.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures which address ten-minute checks. The facility has
sixty-five cameras, and all were operational during the annual compliance review week. Video
recording is stored for a period of thirty days. Ten-minute checks are conducted by staff visually
looking in each room to ensure each youth is well, and using a wand system to record the actual
time of the check. A review of video in comparison with wand checks was completed on each
module for random time periods during the dates and times of August 25, 2023, from 9:00 p.m.
to 9:30 p.m., August 27, 2023, from 2:00 a.m. to 2:30 a.m., and September 1, 2023, from 4:00
a.m. to 4:30 a.m. All of the checks reviewed on video were conducted within the ten-minute time
frame, with the exception of one check which was one minute late. The wand checks confirmed
the video observation. One of the assistant superintendents provides management oversight by
conducting weekly reviews of ten-minute checks to ensure fidelity. Five staff interviews indicated
checks are conducted every ten-minutes when youth are placed in their room for sleeping or
non-punishment reasons. One staff added checks are conducted every five-minutes if the youth
are assigned to close watches. The superintendent was interviewed and verified the process of
conducting ten-minute visual observations whenever a youth is placed in a room, whether for
sleeping or other reasons, to ensure safety and security.
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Office of Accountability and Program Support Page 47 of 58 (Revised July 2023)
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).
Observations during the annual compliance review week indicated the master control operator
would call to all staff for a count on an hourly basis. During the shift briefing the count/census
from the previous shift, alerts, and incidents were reviewed. Logbook reviews since the last
annual compliance review indicated counts were conducted at the beginning of each shift, prior
to and following routine group movement, anytime a population change occurred, randomly,
with at least one occurring on each shift, for regular head counts, and during youth movements.
All five staff interviews indicated youth counts are conducted at the beginning of each shift, one
also indicated at the end of each shift. The five staff stated counts are done every hour and if
incorrect they stop all movement, secure youth, and do a recount. If unable to reconcile the staff
will conduct a search and notify the supervisor. All five staff said after visibility has been
hindered as well as after a major disturbance staff will conduct emergency counts, and three
also mentioned when a youth is believed to be missing an emergency count is conducted. Staff
also indicated after every code, fire drill, severe weather, and youth release/admission staff
conduct a count.
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Office of Accountability and Program Support Page 48 of 58 (Revised July 2023)
5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
A review of logbooks since the last annual compliance review indicated there are separate
logbooks in master control, each module, for visitors, and for each vehicle. All were bound with
numbered pages, the date documented at the top of each page and all entries included the time
of the event in a.m./p.m. with the name of the staff and youth involved, a brief description of the
events, and the initials of the staff making the entries. All entries impacting the safety and
security of the center were highlighted, errors were struck through with a single line and the
staff’s initials, as well as the juvenile justice detention officer (JJDO) supervisor making a
comment regarding the corrected errors. The center does not utilize an electronic logbook. The
logbooks documented when the supervisor accepted responsibility of the center and reviewed
the module logbooks, as well as the JJDO reviewing the logbook entries from the previous shift
when accepting responsibility for the module. Each logbook review documented the name and
position of the reviewer and the date and time the review was completed. A review of the master
control logbook entries indicated they included emergency situations, incidents, drills, receipt of
medical/mental health alerts, and population counts at the beginning, throughout, and end of
each shift. The logbooks also documented youth counts following emergency situations, youth
group movement, admissions, releases, presence of law enforcement, names of youth placed in
confinement with the time of confinement began and the time confinement ended, and name of
youth placed on precautionary/secure observation along with the time initiated and time ended.
The activity schedule and logbook documented classes being held as scheduled with minimal
interference of educational instruction.
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5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
A review of logbooks since the last annual compliance review indicated the superintendent or
designee reviews all logbooks on a weekly basis and provides recommendations as to the
completeness and accuracy of the information recorded. The juvenile justice detention officer
(JJDO) supervisors review the master control logbook when assuming center responsibility, as
well as the module logbooks daily. The JJDO reviews logbooks maintained in the assigned
module when accepting responsibility at shift change. Logbooks also documented the
superintendent, assistant superintendent, or staff in charge of the center tour the modules at
least once during each shift and document the visit in each area’s logbook. The superintendent
interview indicated the superintendent or designee reviews all logbooks at least once a week
checking the last seventy-two hours of entries.
5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys.
All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of
keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch.
The key(s) on these rings shall provide egress through facility exterior doors providing access
to evacuation areas.
A key inventory shall be maintained by the Superintendent or designee at all times.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center has facility operating procedures addressing key control. The process includes key
assignment and usage including restrictions on usage, inventory, daily tracking, and
reconciliation of keys, secure storage of keys not in use, procedures addressing missing or lost
keys, as well as reporting and replacement of damaged keys. The key inventory was reviewed
and matched the actual key rings in use. The key inventory included emergency key rings and
documented the ring number, numbers of keys on each ring, capability of each key, and to
whom the key was issued. A review of shift reports during the annual compliance review period
indicated issuance of keys and key ring numbers were documented and included the date and
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Office of Accountability and Program Support Page 50 of 58 (Revised July 2023)
time of issue, name of staff issuing the key ring, name of staff who received the key ring, and
time the key ring was returned. The center contacted the Department’s Central Communications
Center (CCC) for one incident during the annual compliance review period, where a set of keys
went missing; however, were found in a staff’s possession. No corrective action was required.
Observations during the annual compliance review week during shift change, as well as when
the annual compliance review team arrived and departed, indicated personal keys were being
collected and at the end of the day/shift distributed. The key rings observed were on a tamper-
resistant ring, numbered, indicated the number of keys on the ring, as well as being color-
coded, as required. Observations also included staff who were issued keys always carried on
their person, they did not allow youth to handle the keys, and did not remove the keys from the
facility without authorization from the superintendent. Three staff were questioned and were
able to indicate the number and function of each key on their key ring. Observations indicated
keys are in master control in a secure cabinet needing key access. The emergency keys were
color coded with a red key hub and secured in a separate locked box with breakaway glass. The
restricted keys were also in a secured cabinet requiring a key to be accessed. Five staff
interviews indicated medical and mental health record keys are restricted, four stated kitchen
keys are restricted, and two also stated case management record keys are restricted. The staff
mentioned keys for supervisors and maintenance are restricted as well. The staff were able to
explain the center's key control process, which includes staff keys are given to master control
upon entry, personal keys are securely stored, a key log is utilized, as well as a key inventory is
maintained. The staff also indicated the center and youth are searched, and staff have to notify
master control and a supervisor of missing keys and when any damaged key has to be
replaced. If keys are not located, the staff have to lock down the center, search the facility and
call the CCC. The superintendent interview confirmed staff sign a form when issued permanent
keys, indicating they are to maintain control of their issued keys.
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
A review of documentation confirmed all of the center’s eight transport vehicles underwent an
annual vehicle inspection, as well as monthly visual checks performed by the maintenance
staff/designee and included water coolant, lights, oil, emergency equipment, brakes, horn,
interior/exterior, and cleanliness. The documentation also confirmed visual checks documented
the tires, battery, windshield and wipers, windows, mirrors, and any damage. All inspections
were documented on the mandatory inspection form and a copy of the form was maintained by
the maintenance staff. All transport vehicles were equipped with the appropriate number of
seatbelts, a seatbelt cutter, window punch, fire extinguisher, and first-aid kit with items approved
by the designated health authority. Six of the transport vehicles were randomly checked and
were found to be locked. A review of the van logbook indicated staff documented the
acknowledgement of the vehicle being checked, destination, number of youth, staff names, and
time the transport began and ended. A transport did not occur while the annual compliance
review team was on-site; therefore, no transport could be observed during the annual
compliance review week. Four of five interviewed youth had never been transported by the
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center, the remaining one indicated they felt safe being transported. None had ever seen
anyone place contraband in the transport vehicle.
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center has facility operating procedures addressing maintenance and kitchen tools.
Observations during the annual compliance review week indicated the tool storage area and
kitchen maintain tools and the tools are inaccessible to youth. A comparison of the tool
inventory and tools matched. The kitchen staff conduct an itemized inventory of all equipment,
including knives and other kitchen tools, upon reporting for duty. The maintenance staff
interview indicated service vendors are always accompanied by designated center staff when in
a secure area of the center. The food service manager indicated an inventory is completed on
sign-in sheets daily and then again in SharePoint on a weekly basis. The process for missing
tools is to look for the items immediately and notify the supervisor on duty. If the item is not
located the supervisor is notified again along with the administrator, and the missing item shall
be reported to the Department’s Central Communications Center within two hours. If there are
damaged tools, administration is notified, the tool is taken off the inventory until it is replaced,
and the new tool would then be added to the inventory. A review of the tool inventory indicated
tools were signed out and back in and were signed by the superintendent or designee. An
observation of the tool area confirmed all tools were secured and had markings for easy
identification. Five staff interviews indicated the center’s practice for damaged or missing tools is
to notify the supervisor. The five staff also mentioned to notify maintenance, remove the broken
tool, secure and search area for missing tool, and put an out of order sign until
replaced/repaired. The superintendent interview indicated only maintenance and administrative
staff have access to Class A tools.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center prohibits youth to use tools, including kitchen and medical equipment. The youth are
allowed to utilize cleaning items such as mops and brooms under direct staff supervision of
staff. During the annual compliance review week there were no youth observed utilizing any
tools. All five staff interviews indicated youth are allowed to use mops and brooms. Four of five
youth interviews indicated they had never used tools in the center or cleaned with a cleaning
agent. One youth said they utilized mops and brooms and staff put cleaning agent on a rag or
sprayed on the surface for the youth to wipe clean.
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5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center has facility operating procedures addressing the center’s safety plan. A review of
documentation for flammable, toxic, caustic, and poisonous items since the last annual
compliance review indicated the center maintains an up-to-date inventory. Five randomly
selected items were counted and correlated with the inventory, except for two items, which had
been listed right next to each other, with the counts switched on the document. The
maintenance staff immediately fixed the issue. A review of the Safety Data Sheets (SDS)
confirmed they were in a logbook, posted near the items, and available to staff.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
An informal interview with the maintenance staff indicated only the superintendent, the two
assistant superintendents, and the maintenance staff have access to flammable, toxic, caustic,
and poisonous items. Observations during the annual compliance review week indicated all
flammable, toxic, caustic, and poisonous materials are stored in secure areas inaccessible to
youth. All five staff interviews indicated youth are not allowed to clean with substances which
are toxic, flammable, or poisonous. All five youth interviews indicated they no dot have access
to flammable, toxic, caustic, or poisonous items.
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5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures addressing the disposal of flammable, toxic,
caustic, and poisonous items. During the annual compliance review period the center did not
have any instances of chemical spills. The kitchen maintains a container for grease. The center
had one instance of disposing of flammable, toxic, caustic, and poisonous items. A vendor
removed the items from the center with corresponding documentation of proper disposal
techniques.
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
A review of thirteen confinements since the last annual compliance review indicated youth
placed in confinement were afforded three meals a day plus school and evening snack, access
to mental healthcare as requested/needed, daily shower, clean clothing, mattress/bedding,
education materials, and notice of the right to grieve the confinement placement. In all thirteen
instances prior to placing each youth in confinement, the supervisor approved all confinements,
staff placed only one youth in each confinement room, each room was searched, and
documentation of the search was entered into the facility maintenance system (FMS). All
thirteen youth were supervised while in confinement and none had any physical injury or illness.
In all thirteen, the reason for confinement was explained to each youth and the supervisor
conducted an initial confinement review with each youth within one hour from the incident. All
thirteen incidents had a full report completed before the end of the shift and the supervisor
conducted additional reviews with each youth at a minimum of every three hours and
documented the reviews in FMS. In two of thirteen incidents the supervisor conducted one
review late, sixty minutes and ninety minutes respectively. The supervisor/staff continually
counseled each of the youth and considered removing them from confinement as soon each
youth was able to safely rejoin the population and there was no threat to safety. Every effort was
made to communicate the confinement with each parent/guardian of said youth regarding
interference with visitation, and the effort was documented in the FMS. In all thirteen
confinements the superintendent or designee reviewed all confinement reports within forty-eight
hours and determined whether each confinement was appropriate. Observations of the modules
and confinement rooms indicated some of the windows were scratched; however, did not
interfere with visual checks. The five staff interviews indicated the process for youth to be
placed in confinement includes completion of a confinement report, conduct and document
checks (five minutes for first hour and then ten minutes thereafter), search the confinement
room, notify the supervisor, document in logbook, explain to the youth why they are being
placed in confinement, and give youth the right to grieve. All five stated youth placed in
temporary confinement are provided education materials. The superintendent interview
indicated the supervisor shall conduct an initial confinement review with the youth no later than
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two hours after the incident, which includes an appropriate reason for the confinement and must
be completed before the end of the staff’s shift. If a supervisor is unable to have access to a
computer, they shall keep good notes and enter the reviews as soon as possible. A supervisory
review is conducted at a minimum of every three hours and documented in the Department’s
Facility Management System. The Superintendent or designee reviews all confinement reports
within forty-eight hours and determines whether each confinement was appropriate or
inappropriate. The superintendent stated designated headquarter/regional management staff
review the use of confinement monthly to determine areas needing improvement.
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
A review of the drills since the last annual compliance review indicated one Continuity of
Operations Planning (COOP) drill was completed; the center has until the end of the year to
conduct the second drill. The center maintained a copy of the COOP drill which documented the
type of drill, date and time, participants, brief scenario, and any resulting critique or corrective
action. All five staff interviews indicated they have participated in weather, fire, mental health,
and medical drills since the last annual compliance review. Staff also indicated participating in
drills for major disturbances, flooding and escape. The superintendent interview indicated
policies outline conditions and preventive actions needed to ensure safety is a top priority at the
center. There are mechanisms in place to ensure staff know what to do in the event of an
emergency.
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5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures addressing the Escape Prevention Plan. A review
of documentation since the last annual compliance review indicated the center conducted
escape drills on a quarterly basis and they were documented in the logbook. Four of five in-
service training records documented escape prevention training. One staff did not have the
training in the year reviewed.
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
A review of documentation since the last annual compliance review indicated the center
conducted a fire drill monthly on each shift. Each drill was documented in the logbook. All fire
extinguishers had received an annual inspection. All five staff interviews indicated fire drills are
conducted at least monthly. Two of five youth interviews indicated they had been instructed on
what to do in case of a fire; three said they do not recall.
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Office of Accountability and Program Support Page 56 of 58 (Revised July 2023)
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
During the annual compliance review week, a youth admission was observed. A youth frisk
search was conducted prior to admission, and an electronic wand search, as well as a strip
search were done during the admission process as deemed appropriate and necessary. Two
staff of the same gender as the youth were present when the search was conducted, and the
youth was searched individually. A review of documentation indicated searches are noted in the
logbook, as well as electronically. There were no strip searches conducted other than during the
admission process. Observations during the annual compliance review week indicated the
center staff conducted a room search during which the staff wore gloves. The center conducts
electronic/wand searches on all persons entering the facility, with all items entering the secure
area being examined, prohibiting personal keys, personal cell phones, and additional
contraband items. A review of room search documentation since the last annual compliance
review indicated room searches are conducted upon a youth’s release, prior to placing a new
youth in the room, and on each awake shift for contraband. During the annual compliance
review period the center did not have any instances which have compromised the safety or
security of the center. Observations during the annual compliance review week confirmed
searches of staff, visitors, and contractors/vendors were completed prior to entering the secure
area. All members of the annual compliance review team were electronically searched and
physically searched prior to entering the secure area of the center. The annual compliance
review team was also required to read, acknowledge, and sign paperwork regarding the
Contraband Statement of Attestation. The superintendent interview indicated youth searches
shall take place as often as necessary to control contraband and to ensure safety. The results of
any search are documented in the logbook and in the electronic system. Upon discovery and
confiscation of contraband an incident report identifying findings and the disposition of the
contraband are completed, as well as documented in the master control logbook. Law
enforcement is contacted if contraband is considered illegal and items used as evidence are
secured by the discovering staff and hand-delivered to the supervisor. The shift supervisor must
document the chain of custody for the items and give the information to the responding law
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Office of Accountability and Program Support Page 57 of 58 (Revised July 2023)
enforcement officer. The Department’s Central Communications Center and the regional
director or designee must be notified.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 58 (Revised July 2023)

source: DJJ

report_type: QI Detention