summary: QI Detention - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Monroe Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
5503 College Road, 1st Floor
Key West, Florida 33040
Review Date(s): September 19-22, 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:
Rosa Flores, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 2
and interviews)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Rondarrell George, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Peter Keelan, Office of Education, Regional Education Coordinator, South Region (Standard 2)
Duviel Rosello, Office of Detention Services, Superintendent (Standard 5)
Program Name: Monroe Regional Juvenile Detention Center MQI Program Code: 1076
Provider Name: Dept. of Juvenile Justice Contract Number: State
Location: Monroe County / Circuit 16 Number of Beds: 10
Review Date(s): September 19-22, 2023 Lead Reviewer Code: 182
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 56 (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) Non-Applicable
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 56 (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 56 (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 * Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 56 (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 56 (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 Satisfactory
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 56 (Revised July 2023)
Program Overview
The Monroe Regional Juvenile Detention Center is a state-owned detention center, operated by
the Department, located in Key West, Florida. The center serves youth in Monroe County in
Circuit 16. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the ten-bed center. Youth are
provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Monroe County School District. The center’s
management team includes the superintendent, one administrative assistant, four juvenile
justice detention officer supervisors (JJDOSs), one JJDOS who serves as the shift commander,
and five juvenile justice detention officers (JJDOIIs). Mental health and healthcare services are
provided through the contracted provider, VitalCore Health Strategies, LLC, who sub-contracts
with Guidance Care Center, Inc., which is a local agency located in Key West, Florida. Mental
health services are provided by one designated mental health clinician authority (DMHCA) and
one non-licensed staff. Clinical services provided by the center include mental health and
substance abuse evaluations, mental health treatment planning, individual, group, and family
therapy, mental health crisis intervention services, on-site psychiatric services, and availability
for substance abuse services for youth with co-occurring disorders. Medical services, which are
provided by VitalCore Health Strategies, LLC, are provided by one designated health authority
(DHA), one licensed practical nurse (LPN), and one advanced practice registered nurse
(APRN). The medical clinic maintains nursing coverage in accordance with contract. Food
services are provided by the Monroe County Sheriff’s Office, which is located on the same
property. Meals are prepared by the food service workers in the county jail and delivered to the
center. Staff are responsible for the custody and control of youth in their care, providing youth
supervision twenty-four hours a day, seven days a week. The center has two youth living
modules. There are twenty-seven security cameras at the center, of which twenty-two were
operational during the annual compliance review week. At the time of the annual compliance
review, the center had two vacant JJDOII positions.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 56 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has a written policy and procedures requiring initial background screenings in
compliance with the Department’s Background Screening (BSU)/Clearinghouse. The center
utilizes an ergometric pre-employment assessment tool for all direct care applicants. The center
had no new hires, volunteers, or interns since the last annual compliance review. The Annual
Affidavit of Compliance with Level 2 Screening Standards was submitted to the BSU on January
13, 2023, meeting the annual requirement. The Annual Affidavit of Compliance with Level 2
Screening Standards for teachers was submitted to the BSU on January 13, 2023. An interview
with the center’s shift commander confirmed there were no volunteers who required an initial
background screening since the last annual compliance review.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center maintains a written policy and procedures requiring the completion of a five-year
background rescreening for all applicable staff. A rescreening is completed on all Department
staff, contractors, and volunteers every five years based upon their original date of hire. A
review of staff records found the center did not have any staff, contracted staff, or volunteers
applicable for a five-year background rescreening since the last annual compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 56 (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 a written policy and procedures addressing the staff code of conduct. Staff are
required to adhere to the code of conduct, which prohibits any type of abuse, profanity, threats,
harassment, intimidation, horseplay, or personal relationships with youth. A review of three staff
personnel records confirmed staff signed a code of conduct prohibiting any form of abuse,
profanity, threats, harassment, or intimidation. The code of conduct also addressed officer
professionalism, poor performance, negligence, insubordination, conduct unbecoming of a
public employee, and misconduct. An interview with the center’s shift commander stated the
center had no violations of the code of conduct since the last annual compliance review. It was
also reported the center did not have any commendations for staff since the last annual
compliance review. A review of the center’s internal incidents, the Department’s Central
Communications Center (CCC) reports, and Protective Action Response (PAR)/Right
Interactions (RI) Reports determined there were no incidents which should have been
documented as a violation of a code of conduct. An interview was conducted with the center’s
superintendent which confirmed the center adheres to a strict code of conduct inclusive of youth
confidentiality, prohibiting staff horseplay, verbal or physical abuse, and any personal
relationships between staff and youth. There were no youth detained in the center during the
beginning of the annual compliance review week; however, one youth was admitted to the
center during the week. An interview with one youth indicated they have never been denied the
opportunity to call or report abuse to the Florida Abuse Hotline. The youth indicated staff are
respectful when talking to youth and has never heard staff use profanity or threaten other youth.
The youth stated they feel safe while at the center, and have never exchanged e-mails,
telephone numbers, or social media contact information with staff. An interview with three staff
was conducted, and each staff was able to explain the process for calling the Florida Abuse
Hotline and/or the CCC. Each staff stated they have never observed a coworker using profanity
when speaking to youth or observed a coworker using threats, intimidation, or humiliation when
interacting with youth. When asked about the working conditions at the center, two staff stated
the working conditions at the center were good, and one staff indicated they were very good.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 56 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center maintains a written policy and procedures regarding response to incidents in
accordance with Florida Administrative Code. The center notifies the Department’s Central
Communications Center (CCC) within two hours of becoming aware of an incident. The center
had three incidents reported to the CCC since the last annual compliance review. A review of
the internal incidents found two of the three incidents were reported to the CCC within two hours
of the incident, or when staff became aware of the incident, as required. There was one incident
which was reported two hours and twenty minutes after the two-hour reportable time frame, and
after the caller gained knowledge of the incident. Each of the incidents were documented in the
center’s master control logbook. A review of the center’s internal incident/grievance reports
found there were no additional incidents which should have been reported to the CCC. An
interview with the center’s superintendent indicated whenever a reportable incident occurs, the
detention superintendent or designee shall notify the CCC within two hours of becoming aware
of the incident.
1.05 Protective Action Response (PAR) Non-Applicable
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.
There have been no Protective Action Response (PAR)/Right Interactions (RI) incidents during
the annual compliance review period; therefore, this indicator is rated non-applicable.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has a written policy and procedures regarding pre-service training. Pre-service
training is divided into two phases. Phase One consists of instructor-led and web-based courses
and is followed by Phase Two, which consists of 120 hours of academy instructor-led training.
The center did not have any applicable staff for pre-service training since the last annual
compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 56 (Revised July 2023)
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center maintains a written policy and procedures regarding in-service training. Staff are
required to complete twenty-four hours of in-service training each calendar year after completion
of pre-service certification training. The policy requires supervisors to complete eight hours of
supervisory training annually. The center provides in-service training to staff through a
combination of the Department’s Learning Management System (SkillPro) and instructor-led
classes. Three staff training records were reviewed for completion of in-service training.
Reviewed records confirmed the staff completed the required twenty-four hours of in-service
training. Each of the three records contained documentation verifying each staff completed the
required Protective Action Response (PAR)/Right Interactions (RI), cardiopulmonary
resuscitation (CPR), automated external defibrillator (AED), first-aid, mental health, substance
abuse, two hours of web-based suicide prevention training, four hours of instructor-led suicide
training, professionalism, interpersonal communication, and ethics, active shooter training,
human trafficking, information security awareness, Prison Rape Elimination Act (PREA),
interpersonal communication, sexual harassment, and trauma responsive practices. One staff
was applicable for a minimum of eight hours of supervisory training. The applicable staff
completed the required minimum of eight hours of supervisory training in the areas of coaching,
leadership, and personal accountability. All trainings were entered into SkillPro for all staff. The
center maintains an annual training calendar, which was last approved by the Department’s
Office of Talent, Leadership, and Culture on November 29, 2022. An interview with the
superintendent confirmed the required trainings for all staff.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a written policy and procedures to ensure each youth has the right to file a
grievance and ensure all youth are treated fairly, respectfully, without discrimination, and their
rights are protected. The grievance process is posted in each living unit and explained to each
youth during the admission and orientation process. The center did not have any grievances
submitted since the last annual compliance review. An interview with the superintendent was
conducted. The superintendent explained the grievance process, indicating there is an informal
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Office of Accountability and Program Support Page 13 of 56 (Revised July 2023)
and formal phase. The supervising officers shall enter the grievance into the Department’s
Facility Management System (FMS) on behalf of the youth. The informal phase requires the
juvenile justice detention officer (JJDO) to attempt to resolve the grievance with the youth. In the
formal phase, the grievance form is submitted to the juvenile justice detention officer supervisor
(JJDOS), who attempts to resolve the issue, which is to be done by the close of the day or
within twenty-four hours. If a grievance has not been resolved, the JJDOS then forwards the
grievance to the superintendent, in an effort to resolve the grievance within at least seventy-two
hours. The superintendent’s decision is final. The grievance forms are maintained in a separate
file and uploaded into FMS. An interview with three staff was conducted, and all were able to
explain the center’s grievance process. The center had one youth during the week of the annual
compliance review, and the youth was aware of the grievance process; however, the youth
indicated they have never had the need to file a grievance.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center maintains a written policy and procedures regarding entering alerts in the
Department’s Juvenile Justice Information System (JJIS) and the use of an internal alert
system. The alerts entered into JJIS are reviewed by medical staff, juvenile justice detention
officer supervisors (JJDOSs), and/or the mental health staff, if applicable. A review of three
youth records confirmed alerts were documented in accordance with the Department’s policy.
Reviewed documentation reflected alerts were entered, reviewed, and updated, as required, by
an appropriate staff. An interview with the center’s superintendent was conducted and
confirmed medical alerts are entered at the time of admission and updated when necessary. An
interview with the center’s shift commander indicated alerts are printed daily by the on-duty
supervisor, copies are provided to all staff during their shift, and all staff have access to the alert
system. Three staff were interviewed, and each staff reported being informed of youth alerts
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Office of Accountability and Program Support Page 14 of 56 (Revised July 2023)
through the shift debriefing meetings, and one staff stated through the alert forms and e-mails.
Each staff reported management informs staff about issues within the center at shift debriefings,
and two staff indicated through e-mails. All three staff stated the communication at the center is
very good.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a practice in place regarding data trend analysis. An informal interview with the
superintendent and reviewed documentation found the center captures data through various
reports, and changes are made as needed. The center utilizes the Protective Action Response
(PAR)/Right Interaction (RI) Reports, confinement reports, the staff retention report, incident
reports, alert reports, and youth surveys to capture and collect data regarding the center in an
effort to improve their processes. It is the center’s practice to share applicable information with
staff during Department meetings. The center conducts monthly supervisor meetings and daily
staff briefings to ensure all staff are made aware of imperative information regarding the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 56 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures (FOPs) regarding the admission of youth into the
center. At the time of the annual compliance review, the center did not have any youth in
population. Three closed youth case management records were reviewed, and each youth’s
Admission Wizard documented the review of the arrest affidavit/custody order, Detention Risk
Assessment Instrument (DRAI), and Suicide Risk Screening Instrument (SRSI). Each of the
three reviewed case management records documented a youth frisk, full body, and/or electronic
search conducted by same gender staff as the youth, a telephone call was provided, a meal
was provided, and the Department’s Medical, Mental Health, and Substance Abuse Screening
form was completed. There was one youth admission during the annual compliance review
week; however, observations of the admission could not be conducted because the youth was
admitted after the annual compliance review team left the center.
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Office of Accountability and Program Support Page 16 of 56 (Revised July 2023)
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 maintains a written policy and procedures regarding the orientation of youth admitted
to the center. At the time of the annual compliance review, the center did not have any youth in
the population. Three closed youth case management records were reviewed, and each youth
was provided an orientation within twenty-four hours of admission. Each youth signed an
orientation acknowledgement form which discussed the center’s rules and regulations,
grievance procedures, visitation, telephone calls, access to medical services, access to mental
health and substance abuse services, access to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC), behavior expectations and
consequences, Prison Rape Elimination Act (PREA), youth rights, and new law violation
process for destruction of property. There was one youth admission during the annual
compliance review week; however, observations could not be conducted because the youth was
admitted after the review team left the center. The one newly admitted youth was interviewed
during the annual compliance review week. The youth verified when they were admitted to the
center, and staff reviewed the rules and regulations, daily schedule, education services,
visitation, abuse reporting, and behavior management system (BMS).
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Office of Accountability and Program Support Page 17 of 56 (Revised July 2023)
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 maintains a written policy and procedures regarding the classification of youth
admitted to the center. At the time of the annual compliance review, the center did not have any
youth in the population. Three closed youth case management records were reviewed, and
each youth was classified by reviewing the youth’s history, status, and documentation, which
included the Suicide Risk Screening Instrument (SRSI), Detention Risk Assessment Instrument
(DRAI), face sheet, previous alerts, Vulnerability to Victimization and Sexually Aggressive
Behavior (VSAB) screening, parent/guardian information, and the Department’s Mental Health
and Substance Abuse Screening forms. The center considered the youth’s gender, height,
weight, age, level of aggression, mental illness, intellectual disabilities, physical disabilities,
history of violent behavior, gang affiliation, criminal behavior, history of sexual offenses, VSAB,
medical, suicide ideations, threat to escape, and security for each youth when classifying youth.
Each of the three reviewed youth were assigned a room based on their classification. None of
the three youth required a reclassification or had a history of committing sexual offenses. The
shift commander is the gang liaison at the center and informs the superintendent by e-mail on
how to identify and address local youth gangs. The interviewed superintendent verified youth
are assigned to a room based on their classification and are reclassified if changes in behavior
or status are observed.
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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 maintains a written policy and procedures to ensure each youth is screened to
determine if the youth is affiliated or identified as a gang member and to notify the designated
juvenile probation officer (JPO) circuit gang representative if required. The center’s practice is to
document a gang alert in the Department’s Juvenile Justice Information System (JJIS) for all
applicable youth and communicate gang involvement between the center and the circuit gang
representative. The center’s shift commander serves as the gang representative for the center.
An interview with the shift commander confirmed the center’s gang representative
communicates all suspected gang activity with the juvenile probation officer supervisor (JPOS)
for the circuit. The shift commander also reported information is shared with all other pertinent
parties during weekly Detention Review meetings. There was one youth admission during the
annual compliance review week; however, observations could not be conducted because the
youth was admitted after the annual compliance review team left the center. Three closed youth
case management records were reviewed, and none of the youth were identified as suspected
gang members. The center reported not having any gang identified or affiliated youth since the
last annual compliance review.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center maintains a written policy and procedures to ensure the proper safe handling and
security of each youth’s personal property, including valuables, which are collected and secured
at the time of a youth’s admission. Three closed case management records were reviewed.
Each contained a property form, which was signed by the youth and staff. Each of the youth
case management records confirmed three youth’s personal and two youth’s valuable property
was securely stored. The center’s facility operating procedures (FOPs) states all valuable
property is to be stored in a clear tamper-proof bag labeled with the youth’s name, Department
identification number (DJJID), date, staff name, and signatures of the youth and staff. Once
received, the property is placed in a drop safe, which is under video surveillance twenty-four
hours a day. The center’s drop safe logbook documented the time, the youth’s name, the name
of the officer securing the property, and the officer’s initials. A review of the property logbook
confirmed the center’s practice. A review of each case management record confirmed the youth
reviewed and signed an Unclaimed Property Acknowledgement form. The center had one new
youth admitted after hours to the center during the annual compliance review week; therefore,
an observation of the center receiving youth property could not be conducted. A review of the
Department’s Central Communication Center (CCC) reports verified there were no incidents
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regarding youth property during the annual compliance review period. An interview with the
superintendent verified the admission staff are responsible for ensuring all youth personal and
valuable property is inventoried on the Department’s Juvenile Justice Information System (JJIS)
Property Receipt Report and signed by both the youth and admission staff. Valuable property is
placed in a clear tamper-proof bag and placed in a drop safe. This safe is always under video
surveillance. If the youth’s property is moved from the safe to a second location, the new
location must be in camera view as well. One youth was interviewed, and stated when they
arrived at the center, staff checked their personal property and then signed a form stating their
personal property was correct.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center maintains a written policy and procedures to address youth releases. Three closed
youth case management records were reviewed. Each record contained a copy of the detention
release, which confirmed the on-duty supervisor reviewed all paperwork pertaining to the
youth’s release and court documents. Three closed case management records confirmed the
identification of the youth and parents/guardians were verified prior to release, the youth were
reminded of future court dates, and all parties signed the release form. Each reviewed case
management record reflected the date of admission and the date of release correlated with the
Department’s Juvenile Justice Information System (JJIS). None of the reviewed records
identified the youth as an endangered person. There were no youth released during the annual
compliance review week; therefore, a release could not be observed.
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2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center maintains a written policy and procedures regarding each youth’s release from the
center with personal property, medication, and aftercare instructions. A review of three closed
youth case management records confirmed each youth and parent/guardian signed the
Property Receipt form upon release. Each reviewed record documented the youth was released
to an appropriate person with a copy of their identification. Each reviewed record documented
the youth, and the person to whom the youth was released to, were reminded of any health or
welfare issues, including medical, mental health, and/or substance abuse needs and any
pending appointments. A review of three closed records indicated one was applicable for a
release with medication. Documentation verified the receipt of medications was signed by the
person receiving the youth using the Department’s Health Discharge Summary Transfer Note.
The center’s facility operating procedures (FOPs) indicated when property is not returned after
thirty days of a youth’s release, a Notice of Impending Disposal of Property is mailed to the
youth’s last known address. If the personal property is not claimed, it is considered abandoned
and is disposed of according to the center’s policy and Florida Administrative Code. In an
informal interview, the shift commander stated the center did not have any examples of youth
property held for more than thirty days since the last annual compliance review. There were no
youth released during the annual compliance review week; therefore, an observation was not
conducted.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains a written policy and procedures to ensure Detention Reviews are
conducted on a weekly basis for proper management of youth in secure detention and
information sharing. The center holds Detention Review meetings every Wednesday. Detention
Review documentation since the last annual compliance review indicated detention staff,
education staff, mental health staff, medical staff, juvenile probation officers (JPOs), and others
who have responsibilities for the youth attended the meetings either in person, telephonically, or
by way of video conference. Reviewed sign-in sheets since the last annual compliance review
confirmed the center conducted weekly Detention Reviews in accordance with the Department’s
policy. Participants who attended the Detention Review meeting telephonically were reflected on
the sign-in sheet. There was no observation of a Detention Review during the annual
compliance review week due to no youth being in the detention center during the scheduled
meeting. In an informal interview, the shift commander reported the Detention Review is
conducted telephonically, and updates are provided regarding each youth’s behavior while in
the center, release status/date, residential placement status, and next court hearing. In a formal
interview, the superintendent stated Detention Reviews are conducted in the conference room
on a weekly basis, and the status of each youth is discussed.
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2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center maintains a written policy and procedures to ensure the center is adhering to the
daily activity schedule. Youth are provided the opportunity to participate in constructive activities
benefiting the youth in the center. Observations confirmed the daily schedule is posted on each
module and is visible to all youth. One youth was observed attending school and having lunch
during the scheduled times during the annual compliance review week. A review of the daily
schedule verified it contained wake up/personal hygiene, mealtimes, visitation times, recreation
times, indoor activities, shift changes, bedtimes, groups, and program open times. One
interviewed youth reported the center follows the daily schedule. Three interviewed staff
reported the daily schedule is followed.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has a written policy and procedures to provide for educational access. The center’s
educational program is directly supervised and managed by the Monroe County School District.
Instruction shall be provided on a year-round basis with, 250 days of instruction distributed over
twelve months, with a minimum of twenty-five hours of weekly classroom instruction. The annual
academic calendar may allow for the inclusion of up to ten days of teacher planning/professional
development. Reviewed documentation showed the center’s academic and daily class schedule
held 240 days of instruction with two days of teacher and planning/professional development. A
review of the academic schedule shows the schedule offers 300 minutes of daily instruction
which equates to twenty-five hours of instruction each week. The center met the equivalent of
the 1,250 instructional hours to the 250 days of instruction. A review of video observations for
three separate days confirmed classes were being conducted according to the daily schedule
with minimal interruptions or disruptions. A review of logbooks since the last annual compliance
review confirmed classes were being conducted according to the daily schedule, with the
exception of two days, one day in June 2023, the logbooks indicated classes began five minutes
late, and one day in August 2023, when classes began ten minutes late. An interview with the
shift commander indicated the delay was due to the center having one teacher who also attends
the center’s Detention Review meeting each week. It was reported, in the event any delay
occurs, the missing minutes of instruction are made up prior to the conclusion of the day. An
interview with the superintendent stated there is minimal interference of educational instruction.
At the time of the annual compliance review, one youth was available for an interview. An
interview with the youth indicated the center is preparing them well for high school, vocational
school, employment, and/or college. The youth indicated during their time at the center, they
attend school daily, and classes are held Monday through Friday. An interview with three staff
stated there is minimal interference of educational instruction.
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2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has a written policy and procedures for career education. The center provides
appropriate career education to the youth based upon their age as well as assessed education
abilities. The career education curriculum provided is categorized as a Type 1 career and
vocational program. This offering includes activities which focus on creating or improving
individual communication, decision making, interpersonal skills, and decision-making abilities.
This component provides various exploratory exercises which provide the youth with the
opportunity to establish career choices based upon their capabilities, choices, and interests.
One interviewed youth stated education classes are offered at the center and indicated they
were taking math.
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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 maintains a written policy and procedures to ensure there is a licensed mental health
professional in place who is identified as the designated mental health clinician authority
(DMHCA). The policy was approved and signed by the superintendent on August 7, 2023, and
by the DMHCA on August 31, 2023. The Department maintains a contract with VitalCore Health
Strategies, LLC, to provide mental health and substance abuse services to all applicable youth
in the center. VitalCore Health Strategies, LLC subcontracts with Guidance Care Center, which
provides a licensed mental health counselor (LMHC) to serve as the center's DMHCA. The
DMHCA is a LMHC who holds a clear and active license in the state of Florida with an
expiration date of March 31, 2025. The DMHCA is scheduled to be on-site, as needed, when
there are youth securely detained at the center. A review of the mental health logbook since the
last annual compliance review confirmed the DMHCA is on-site at least weekly when there are
youth in secure detention. The DMHCA is also available seven days a week, twenty-four hours
a day, by way of telephone for consultation. A review of the DMHCA’s job description
determined the DMHCA is responsible for overseeing all clinical and administrative operations
of all contractual requirements. During an interview, the DMHCA reported being responsible for
reviewing and completing assessments, deliberating with center administration regarding youth
supervision levels, participating in weekly Detention Reviews, treatment team planning, and
case conceptualizations. The center has one back-up DMHCA in the event of scheduled leave
and/or absences. The back-up DMHCA is a LMHC, licensed under Chapter 491 in the State of
Florida, with an expiration date of March 31, 2025. The back-up DMHCA was not used during
the annual compliance review period. The interviewed DMHCA reported they are responsible
and accountable for ensuring appropriate coordination and implementation of mental health and
substance abuse services in the center. The DMHCA also reviews the Department’s Electronic
Medical Record to see status and other alerts as needed, which is also discussed at Detention
Review meetings.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center maintains a contract with VitalCore Health Strategies, LLC, to provide mental health
and substance abuse services to all applicable youth in the center. VitalCore Health Strategies,
LLC subcontracts with Guidance Care Center. The designated mental health clinician authority
(DMHCA) ensures the licensed staff working under their supervision perform services they are
qualified to provide based on education, training, and experience. The center has one DMHCA
who is a licensed mental health counselor (LMHC) with a clear and active license in the State of
Florida under Chapter 491, with an expiration date of March 31, 2025. The center’s back-up
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DMHCA is also a LMHC who holds a clear and active license, which expires on March 31, 2025.
Copies of the licenses were available on-site.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center maintains a written policy and procedures ensuring mental health and substance
abuse services are provided by individuals with appropriate qualifications. An informal interview
with VitalCore Health Strategies, LLC corporate staff confirmed VitalCore Health Strategies,
LLC is currently operating without the Chapter 397 license and utilizes their subcontractor
Guidance Care Center’s Chapter 397 license, which expires on July 10, 2024. All mental health
services must be provided by a licensed mental health professional (LMHP) or a non-licensed
mental health clinical staff, who is working under the direct supervision of the LMHP. The center
has one non-licensed master’s-level mental health and substance abuse clinical staff who works
under the direct supervision of the licensed mental health counselor (LMHC). The LMHC serves
as the center’s designated mental health clinician authority (DMHCA). The non-licensed
master’s-level clinician held a degree in professional counseling. The non-licensed staff is a
registered mental health therapist with an expiration date of July 14, 2024. The non-licensed
staff is on-site Monday through Friday, as needed. Reviewed documentation confirmed the non-
licensed clinician received twenty hours of training and supervised experience in assessing
suicide risk, mental health crisis intervention, and emergency mental health services. The
training included the administration of five Assessments of Suicide Risk (ASRs) or Crisis
Assessments conducted on-site in the physical presence of a LMHP and was documented on
the Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment of Suicide Risk
form. A review of the supervision logs since the last annual compliance review reflected the
DMHCA provided at least one hour of weekly face-to-face supervision documented on a similar
form which included all information required by the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form for all weeks where the staff provided youth services.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center maintains a written policy and procedures whereby mental health and substance
abuse needs of youth are identified through a comprehensive screening process, in which
referrals are made when youth are identified with mental health and/or substance abuse needs
or are identified as a possible suicide risk. The procedures require a thorough review of each
youth’s preliminary screening conducted by juvenile justice detention officers (JJDOs) and
existing documentation of mental health or substance abuse problem needs or risk factors,
administration of the Suicide Risk Screening Instrument (SRSI) upon the youth’s admission,
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) administration, face
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sheet, alerts, and referral to the center’s mental health and substance abuse clinical staff. Three
youth records were reviewed, finding documentation of each having a mental health, substance
abuse, and suicide risk screening utilizing the SRSI and the MAYSI-2, which were completed
during the admission process in the Department’s Juvenile Justice Information System (JJIS).
Each of the three applicable SRSIs were reviewed by a mental health clinical staff, who
documented their summary and recommendations in the screening results section. All three
applicable youth records had positive responses on the SRSI form and correlated with open or
closed suicide alerts in JJIS. Each youth was placed on suicide precautions, and a mental
health referral was completed, which documented the youth’s need for an Assessment of
Suicide Risk (ASR). Each of the reviewed SRSIs and MAYSI-2s were completed by staff trained
in screening administration. Three reviewed SRSIs and MAYSI-2s indicated the need for further
assessment, and the center notified mental health staff and the superintendent, as required. All
reviewed MAYSI-2s were valid screenings. Each of the MAYSI-2s indicated the need for a
comprehensive assessment, and the screener referred the youth as required. An interview with
the superintendent confirmed all the mental health, substance abuse, and suicide risk
screenings are completed by the JJDOs during intake.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center maintains a written policy and procedures regarding mental health and substance
abuse evaluations. Three youth records were reviewed for a mental health and substance
abuse comprehensive assessment, and none of the youth were applicable. An informal
interview with the designated mental health clinician authority (DMHCA) reported the center did
not have any mental health and substance abuse evaluations during the annual compliance
review period. The DMHCA reported detention staff will put in referrals for any mental health
services which generates an e-mail to all mental health staff. The DMHCA also reviews the
Department’s electronic medical records to see status and other alerts as needed, which is also
discussed at Detention Review meetings. If needed, mental health staff will update and upload
the comprehensive evaluation to the Electronic Medical Records. If the youth does not need a
comprehensive assessment/evaluation or the juvenile probation officer (JPO) does not provide
the assessment, a substance abuse/mental health (SAMH) assessment will be completed by
the thirty-first day of the youth’s admission.
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3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center maintains a written policy and procedures ensuring mental health and substance
abuse treatment planning focuses on the development and review of an initial or individualized
mental health treatment and or substance abuse treatment plan for each youth. Each youth
determined to need mental health treatment, including treatment with psychotropic medications
or substance abuse treatment, while in the center must be assigned to a mini-treatment team.
Three youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment services. One of the three selected records was applicable for
requiring an Initial Treatment Plan completed within seven days of initiation of treatment. The
center did not have any more applicable youth since the last annual compliance review. A
review of the applicable record indicated the youth had a treatment plan in place within seven
days of initiation of treatment. The Initial treatment Plan documented the reason for referral,
initial Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis,
treatment methods, initial treatment goals, and applicable psychiatric services. The plan was
signed by the youth and treatment team members involved in the development of the treatment
plan. The applicable youth was not assigned a mini-treatment team due to the youth not being
at the center long enough to be assigned and/or have a mini-treatment team meeting. None of
the applicable youth were at the center long enough to have an Individualized Treatment Plan.
None of the applicable youth were an alleged victim of a Prison Rape Elimination Act (PREA)
event. A review of the one applicable youth record reflected a Mental Health/Substance Abuse
Treatment Discharge Summary was completed, and the reviewed documentation confirmed a
copy of the discharge summary was provided to the youth, parent/guardian, and assigned
juvenile probation officer (JPO) upon release. There were no youth receiving treatment available
at the center during the on-site review; therefore, the observation of a treatment team meeting
during the annual compliance review week could not be completed.
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3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center maintains a written policy and procedures ensuring mental health and substance
treatment planning focuses on providing mental health treatment and/or substance abuse
treatment, which reduces or alleviates the youth’s symptoms of mental disorder or substance
abuse impairment and 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, must be assigned to a mini-treatment team. The
policy was signed by the superintendent on August 7, 2023, and the designated mental health
clinician authority (DMHCA) on August 31, 2023. An interview with the DMHCA indicated the
center offers mental health and substance abuse assessments, crisis intervention, suicide
prevention, and supportive services. The DMHCA reported detention staff enter mental
health/substance abuse referrals into the Electronic Medical Records (EMRs), and youth are
offered services within fourteen days of admission, which is documented on the individual note
form. The DMHCA ensures youth who are in the center for thirty days or more, unless behavior
warrants mental health (MH) services prior to thirty days, receive MH treatment while detained.
Once the youth is opened for services, the DMHCA tracks the youth utilizing a spreadsheet to
ensure services are provided. This includes what is prescribed on the treatment plan and what
is communicated with the treatment team each week. Three youth mental health and substance
abuse records were reviewed for mental health and substance abuse treatment services, and
one youth was applicable for receiving treatment services; however, none of the applicable
youth were at the center long enough to be assigned to a mini-treatment team for services. The
center had no additional youth applicable for receiving services since the last annual
compliance review. During the annual compliance review week, the center only had one youth
admitted at the center. An interview with the only youth at the center during the annual
compliance review week was conducted, and the youth reported the mental health and
substance abuse services is good.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center maintains a written policy and procedures to ensure psychiatric services are
provided by a licensed and certified professional. Psychiatric services are provided to youth in
need of services, as indicated by symptoms of mental disorders or substance abuse related
disorders, or to youth who are treated with psychotropic medication after their admission to the
center. The center is approved by the Department’s Office of Health Services to provide tele-
psychiatry. The tele-psychiatry policy was signed by the superintendent on May 2, 2022, and
the designated mental health clinician authority (DMHCA) on May 3, 2022. The psychiatrist
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maintains a clear and active license in the State of Florida, which expires on March 31, 2024.
The psychiatrist is an osteopathic physician with an American Board of Psychiatry and
Neurology commendation in child and adolescent psychiatry. The center has one back-up
psychiatrist who is a medical doctor with a clear and active license in the State of Florida with an
expiration date of January 31, 2024. An interview with the administrative staff confirmed the
psychiatrist provides weekly services, as required, through tele-psychiatry. The center has not
needed to utilize a back-up psychiatrist since the last annual compliance review. A review of
three youth mental health and substance abuse records found no youth were applicable for
entering the center on psychotropic medication. In an interview with the DMHCA, it was reported
the center does not offer any type of specialized services. No records were applicable for new
prescriptions or significant changes requiring parental consent since the last annual compliance
review. The center had no youth applicable for receiving a psychiatric evaluation since the last
annual compliance review.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a written policy and procedures and a Suicide Prevention Plan, which was
approved and reviewed by the designated mental health clinician authority (DMHCA) and
superintendent. The policy and plan were signed by the superintendent on August 7, 2023, and
the DMHCA on August 31, 2023. The plan outlines the center’s procedures addressing the use
of suicide precautions, suicide prevention training, and the process by which any youth
identified as having suicide risk factors at any time must be placed on suicide precautions and
receive an Assessment of Suicide Risk (ASR). The plan identifies the levels of supervision,
referral process, communication, notification, and documentation requirements. In the event of a
life-threatening suicide attempt, staff are to call 9-1-1 immediately. Decisions to use extra
precautions are determined on a case-by-case basis based upon the individualized risk factors
and needs of each youth. Clinical staff assist in training detention officers throughout the fiscal
year on 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, emergency room, crisis stabilization unit, and Poison Control Center.
The plan is located in master control and is accessible to all staff on the center’s shared
network. The center has an established review process for every serious suicide attempt or
serious self-inflicted injury. The multidisciplinary review includes the circumstances surrounding
the event, all relevant training received by involved staff, center procedures relevant to the
incident, pertinent medical and mental health services involving the victim, possible precipitating
factors, recommendations, if any, for changes in policy, training, physical plant, medical or
mental health services, and/or operational procedures.
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Office of Accountability and Program Support Page 29 of 56 (Revised July 2023)
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center maintains a written policy and procedures regarding the Suicide Prevention Plan
used to safely screen, refer, assess, monitor, and protect youth with elevated risk of suicide in
the least restrictive means possible. Any youth identified as having suicide risk factors by
screening, information obtained from the youth, or staff observations must be placed on suicide
precautions and receive an Assessment of Suicide Risk (ASR). Three youth mental health and
substance abuse records were reviewed, and each was applicable for having elevated suicide
risk factors. All three youth were placed on precautionary observation (PO) during the admission
screening process. A Suicide Risk Screening Instrument (SRSI) was completed, and an alert
was generated in the Department’s Juvenile Justice Information System (JJIS) as a result of the
SRSI. The Suicide Precaution Observation Logs for the applicable youth were completed in
their entirety, including documenting safe housing areas, and were signed by all required
parties. The superintendent or designee was notified immediately of each applicable youth’s
suicide risk. All three ASRs were completed by a non-licensed clinical staff under the
supervision of the designated mental health clinician authority (DMHCA). Reviewed
documentation supported the non-licensed staff were trained in the completion of ASRs, as
required. Each youth’s ASR was completed within twenty-four hours, as required. Each
assessment included recommendations for supervision and follow-up. A conference was held
between the DMHCA and the superintendent to reduce the level of supervision for each youth.
A review of the master control logbook and the three youth ASRs documented supervisory staff
were provided instructions related to the suicide risk assessment findings and suicide
precaution decisions for each youth. Further review of the logbooks documented the beginning
and ending times of each youth placed on precautions. A review of the alerts in JJIS indicated
the alert was entered and removed following the youth’s removal from PO. None of the youth
were applicable for secure observation. The center reported not having any youth on secure
observation since the last annual compliance review. An interview with the superintendent
indicated the center utilizes secure observation for potentially suicidal youth. The superintendent
reported if a youth has been on precautionary observation and continues to cause harm to
themself, the youth is assessed by mental health staff and, if deemed necessary, the youth will
be placed on secure observation with a staff monitoring the youth from outside of the room. One
interviewed youth indicated they had never been on suicide watch while at the center. In an
interview with the shift commander, it was reported all suicide risk alerts and suicide precaution
updates are shared during the center’s shift briefings. Three interviewed staff were able to
identify the center’s procedure when a youth is identified with an elevated suicide risk. Each
staff indicated they would contact mental health and check the youth’s room for sharp objects.
All three staff reported they would document the supervision and place the youth on constant
sight and sound supervision.
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Office of Accountability and Program Support Page 30 of 56 (Revised July 2023)
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center maintains a written policy and procedures regarding Suicide Precaution Observation
Logs which detail the process to safely screen, refer, assess, monitor, and protect youth with
elevated risk of suicide in the least restrictive means possible. A review of three mental health
and substance abuse records found each youth was placed on precautionary observation (PO)
upon admission while at the center. All three applicable Suicide Precaution Observation Logs
were maintained for the duration of each youth’s placement on PO. Each applicable Suicide
Precaution Observation Log was reviewed and signed by the shift supervisor and mental health
clinical staff. Each reviewed youth displayed warning signs while on PO, which were
documented as required. The reviewed documentation reflected staff observations did not
exceed the required intervals and were documented in real-time. Safe housing areas were
clearly documented on each log. Observations of camera footage were not conducted during
the week of the annual compliance review due to the center not having any youth on PO within
the last thirty days.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center maintains a written policy and procedures outlining all staff who work with youth
must be trained in suicide precautions and emergency response procedures and participate in
“mock” suicide drills quarterly on each of the three shifts. Suicide prevention trainings are
completed and documented in the Department’s Learning Management System (SkillPro). The
center’s designated mental health clinician authority (DMHCA), medical staff, and training
coordinator assist in training juvenile justice detention officers on suicide prevention. The “mock”
drills are designed to practice responses to a suicide attempt or incident of serious self-injury. A
review of three in-service staff training records validated each staff completed at least six hours
of annual training on suicide prevention and implementation of suicide precautions. Reviewed
documentation of “mock” suicide drills completed since the last annual compliance review
reflected the center completed drills on Alpha, Bravo, and Charlie shifts monthly, as required.
Reviewed documentation reflected the center had ten applicable staff requiring participation in a
“mock” suicide drill semi-annually, and all completed the required drills semi-annually. Ten staff
were applicable for a mock suicide drill for the first six months, and none were applicable for the
second six months because the staff were still within the review period. Reviewed
documentation confirmed each of the staff completed at least one drill quarterly, which included
the practice of cardiopulmonary resuscitation (CPR). Staff who are not present for a drill, have
the opportunity to review the drill at the next all-staff meeting. The center has three suicide
response kits, which are co-located with first-aid kits in master control, the center’s medical
office, and the youth modules. Each suicide response kit included a knife-for-life, needle nose
pliers, and wire cutters. Three interviewed staff reported the suicide kits are located in master
control.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 31 of 56 (Revised July 2023)
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 maintains a written combined Emergency Services Plan, ensuring the center
responds to youth in crisis in the least restrictive means possible to protect the safety of the
youth and others while maintaining control and safety of the center. The policy and plan were
signed by the superintendent on August 7, 2023, and the designated mental health clinician
authority (DMHCA) on August 31, 2023. The plan addresses the notification and alert system,
means of referral to include youth self-referral, communication, supervision levels,
documentation, and review, as required.
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 maintains a written policy and procedures regarding an Emergency Care Plan
outlining mental health and substance abuse emergency procedures and ensuring youth who
are believed to be an imminent danger to themselves or others because of mental illness or
substance abuse impairment receive emergency mental health or substance abuse services.
The policy and plan were signed by the superintendent on August 7, 2023, and the designated
mental health clinician authority (DMHCA) on August 31, 2023. The plan addressed immediate
staff response, notifications, communication, supervision of youth, transport for emergency
mental health evaluation and treatment under Chapter 394 Florida Statute (Baker Act),
transportation for emergency mental health evaluation and treatment under Chapter 397 Florida
Statute (Marchman Act), documentation, training, and review. A copy of the plan is located
within the master control office, clinic office and in the center’s shared network drive, which is
accessible to all staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 32 of 56 (Revised July 2023)
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 maintains a written policy and procedures to ensure youth in crisis are administered
a Crisis Assessment. Three youth mental health and substance abuse records were reviewed,
and none were applicable for Crisis Assessment. The center reported they had no applicable
youth since the last annual compliance review.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center did not utilize Baker Act or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 33 of 56 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains a written policy and procedures requiring a contractual agreement with a
licensed physician to serve as the designated health authority (DHA). The center maintains a
contract with VitalCore Health Strategies, LLC, which subcontracts with a medical doctor (MD)
to serve as the center’s DHA. The DHA holds an unrestricted clear and active license, which
meets all requirements for independent and unsupervised practice in the State of Florida, which
expires January 31, 2025. The center utilizes an advanced practice registered nurse (APRN)
whose license is clear and active to practice in the State of Florida, which expires April 30,
2025, and one licensed practical nurse (LPN), whose license is clear and active to practice in
the State of Florida with an expiration of July 31, 2025. The APRN and the DHA both signed the
Collaborative Practice Protocol agreement on August 25, 2023. The center’s DHA is contracted
to be on-site at least once a month and is on-call twenty-four hours a day, seven days a week. A
review of the center’s healthcare staff’s sign-in sheets since the last annual compliance review
showed the DHA was on-site once a month. When the DHA is on vacation or a scheduled
absence, a back-up licensed physician is designated by VitalCore Health Strategies, LLC, to
provide clinical services. The back-up DHA has a clear and active license in the State of Florida
with an expiration date of January 31, 2025. An interview with the DHA revealed they are on-site
once a month to provide clinical services and are available by telephone twenty-four hours a
day, seven days a week. The DHA is responsible for communicating with the center’s staff
regarding youth medical needs and being available for consultation by electronic means twenty-
four hours a day, seven days a week for acute medical concerns, emergency medicine, and
coordination of off-site care. The interviewed DHA reported the specific duty of the DHA is to
supervise the medical department and the designated APRN provides on-site clinical 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 maintains written facility operating procedures (FOPs) for all utilized health-related
procedures and protocols. Reviewed documentation reflected the designated health authority
(DHA) reviewed, signed, and dated the FOPs on August 8, 2023, and the superintendent signed
on August 7, 2023. Reviewed documentation validated the licensed practical nurse (LPN) and
the advanced practice registered nurse (APRN) reviewed, and respectively signed, and dated
the cover page on the FOPs on February 8 and February 19, 2023, with treatment protocols
signed on February 5 and February 9, 2023. The center’s treatment protocols were signed and
dated by the DHA on March 20, 2023. The center’s non-healthcare staff protocols were signed
and dated by the DHA on June 12, 2023. VitalCore Health Strategies, LLC has an established
comprehensive clinical orientation for all newly employed healthcare staff, which includes the
Department’s healthcare policies and procedures. The center had no newly hired medical staff
since the last annual compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 34 of 56 (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.
The center maintains a written policy and procedures requiring parents/guardians to be afforded
the right to give or withhold consent regarding the healthcare provided to the youth. The center
had one youth admitted during the annual compliance review week; however, the AET had not
been signed at the time of the annual compliance review. A review of three closed youth
Individual Healthcare Records (IHCRs) validated all three records had a signed Authority for
Evaluation and Treatment (AET). Each AET was obtained prior to providing medical services for
each youth. There were no youth applicable for being under the care and custody of the
Department of Children and Families (DCF).
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains a written policy and procedures outlining requirements for parental
notification of significant changes in the youth’s condition and obtaining written consent from the
parent/guardian when new medications and treatments are prescribed. A review of three closed
youth Individual Healthcare Records (IHCRs) indicated two were applicable for parental
notification and consent. One record contained documentation of parental notification for an
over-the-counter (OTC) medication beyond those covered by the Authority for Evaluation and
Treatment (AET), as required. The second applicable record documented an order for a newly
prescribed medication, which was administered to the youth for fourteen days in the center;
however, there was no documentation provided to demonstrate any attempts were made to
obtain parental consent, and there was no documentation of obtained parental consent. The
center indicated there were no other records applicable for parental notification or consent.
Three closed youth IHCRs were reviewed for vaccination status, and each contained a
vaccination record from Florida Shots, which was reviewed by medical staff within thirty days of
each youth’s admission. No Religious Exemption from Immunization forms were submitted
since the last annual compliance review. The licensed practical nurse (LPN) was interviewed
and described the center’s process for documenting attempted parental notifications.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains a written policy and procedures requiring each youth, at the time of
admission, to receive a Facility Entry Physical Health Screening form utilizing the Department’s
Medical and Mental Health Admission Screening form in the Department’s Juvenile Justice
Information System (JJIS) Admission Wizard. A review of three youth Individual Healthcare
Records (IHCRs) found all three had a Medical and Mental Health Admission Screening form
completed on the date of admission. Each reviewed form was completed on the date of
admission by a juvenile justice detention officer (JJDO), and each indicated the screening was
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Office of Accountability and Program Support Page 35 of 56 (Revised July 2023)
reviewed by a licensed medical staff within twenty-four hours. Each youth screening form was
completed in JJIS, as required. The center reported there were no youth applicable for a change
in physical custody since the last annual compliance review. An interview with nursing staff
validated the admission screening practice.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains a written policy and procedures requiring all youth to be oriented to the
general healthcare delivery services at the center. A review of three closed youth Individual
Healthcare Records (IHCRs) showed each youth received a general healthcare orientation on
the day of admission to the center. Each record contained a completed Department Health
Education Record form documenting youth orientation to the center’s healthcare services within
twenty-four hours of admission to the center. Each youth orientation included topics addressing
access to medical care, sick call, instances which constitute an emergency and when to notify
staff, the medication process and side-effect monitoring, the right to refuse care and how it is
documented, what to do in the case of a sexual assault or attempted sexual assault, and the
non-disciplinary role of the healthcare providers. Healthcare staff also reviewed each youth’s list
of healthcare contacts to ensure accuracy.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center maintains a written policy and procedures which require notification to the
designated health authority (DHA) of all youth admitted with chronic health conditions or youth
in need of emergency care. A review of three closed Individual Healthcare Records (IHCRs),
reflected two youth were applicable for known or suspected chronic conditions upon admission;
however, one youth’s parent/guardian indicated the youth did not have a confirmed diagnosis of
a chronic condition. An interview with the licensed practical nurse (LPN) indicated the DHA is
notified within six hours whenever a youth is admitted and identified with an emergency or
chronic condition. When the DHA is notified by the nursing staff, it is to be documented in the
healthcare record on the Chronological Progress Note. An informal interview with the LPN
indicated it is the center’s practice to notify the DHA of all new admissions regardless of medical
condition; however, one youth record did not document the DHA was notified of the youth’s
admission. The youth was admitted on May 9, 2023, and the section of the Admission
Chronological Progress Note for documenting notification made to the DHA was left blank by
the LPN. The remaining two records contained documentation the DHA was notified of the
youth’s admission, as required.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 36 of 56 (Revised July 2023)
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center maintains a written policy and procedures requiring completion, or review, and
updating of the Department’s standard Health-Related History (HRH) form. The center utilizes
and completes the standard Department Health-Related History (HRH) form for all youth
admitted into the center’s physical custody. A review of three closed youth Individual Healthcare
Records (IHCRs) found each contained a new HRH form. Reviewed documentation indicated
each HRH form was reviewed by the advanced practice registered nurse (APRN). The HRH
form was completed before or at the same time as the Comprehensive Physical Assessment
(CPA) for each youth and reflected the most current admission. Each HRH form was completed
by a licensed nurse within seven days of the youth’s admission to the center. A review of the
nursing interview confirmed the HRH is completed by the APRN within, or before, seven days of
the youth’s admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains a written policy and procedures requiring a Comprehensive Physical
Assessment (CPA) form to be completed or updated for all applicable youth admitted
determining the health and wellbeing of each youth. A review of three closed Individual
Healthcare Records (IHCRs) was completed and each contained documentation of a current
CPA on file at the time of admission. Each reviewed CPA was completed within seven days of
the youth’s admission and signed by the advanced practice registered nurse (APRN). Each
CPA was completed in full to include the Medical Grade, Tanner Stage, cardiovascular, body
mass index, visual acuity field, and most recent Tuberculosis Skin Test (TST). All three youth
records documented a Tier 1 Tuberculosis (TB) screening was completed on the Medical and
Mental Health Admission Screening form. All three were completed by the APRN, and all
sections of the CPA were marked with “O”, with the exception of sections which were all noted
by the APRN as not being clinically indicated on each. None of the reviewed records
documented the youth refused any part of the exam and the Department’s Problem List was
updated, as required. Each of the reviewed records documented a TST was completed within
the last year. None of the reviewed youth required further evaluation prior to entering general
population. The center’s policy and procedures for TB control and screening requires the routine
screening of all youth for latent and active TB and outline environmental controls in the case of
a youth with suspected active TB. A review of the nursing interview indicated the designated
health authority (DHA) or designee completes the CPA at the time of admission and yearly for
youth who have not been out of the Department’s custody. Nursing staff indicated TB
screenings are provided to youth within forty-eight hours of arrival to the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 56 (Revised July 2023)
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center maintains a written policy and procedures requiring all youth to be evaluated and
treated, if necessary, for sexually transmitted infections (STIs). All sexually active youth are
clinically screened and evaluated for STIs. After the screening, youth are referred to the
designated health authority (DHA) or advanced practice registered nurse (APRN) to determine if
further testing is indicated. A review of three closed Individual Healthcare Records (IHCRs)
confirmed all three youth were sexually active, and each youth was clinically screened and
evaluated for STIs. One youth record indicated no further evaluation was required. Two youth
records included documentation for ordered testing; however, both records documented the
youth declined consent. STI screenings, evaluations, and referrals are documented and
maintained in each youth’s IHCR. There were no youth applicable for being out of the
Department’s custody for thirty days or more needing a rescreening since the last annual
compliance review. The center had no applicable youth who consented to human
immunodeficiency virus (HIV) testing since the last annual compliance review. The center’s
practice is to obtain counseling and testing orders at the direction of the APRN. An informal
interview with the nurse indicated the HIV results would be documented on the youth’s
Infectious and Communicable Disease form and the laboratory results section of the record.
One interviewed youth reported being able to request a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains a written policy and procedures regarding sick call processes and
requests. The center conducts sick call seven days a week to respond to a youth’s medical
illness or injury of a non-emergent nature by a healthcare professional. Postings throughout the
center indicated sick call takes place seven days a week on Mondays and Tuesdays from 9:00
a.m. through 10:00 a.m., Wednesdays and Thursdays from 7:00 p.m. through 8:00 p.m., and
Friday through Sunday from 4:00 p.m. to 5:00 p.m. when youth are securely detained at the
center. Shift supervisors are trained in the center’s sick call procedures and are to review the
sick call requests in the absence of healthcare professionals. A review of three closed Individual
Healthcare Records (IHCRs) indicated each was applicable for submitting a sick call. There
were no instances of a youth presenting with a similar sick call complaint three or more times.
Sick calls were conducted by the (APRN) or licensed practical nurse (LPN) within twenty-four
hours, as well as documented on the Sick Call Referral Log for each youth. An informal
interview with the nursing staff confirmed where the sick call would be conducted by the APRN
or LPN within twenty-four hours, and documented on the Sick Call Referral Log. All sick calls
are conducted at the nurse’s station to ensure the youth’s privacy. The center maintains
treatment protocols appropriate to the level of the provider conducting sick call, which was
approved by the designated health authority (DHA). One interviewed youth indicated they could
be seen immediately when submitting a sick call. There were no sick calls during the annual
compliance review week; therefore, a sick call was not observed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 38 of 56 (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 maintains a written policy and procedures detailing a comprehensive process of
episodic care, first-aid treatment, and emergency care. The center utilizes an Episodic Care Log
to document episodic care and first-aid treatment. The log contains information to include the
date, name of youth, the youth’s Department identification number, nature of illness or injury,
treatment rendered, staff initials, nurse initials, verification of who provided episodic care, and if
the youth was recommended for off-site care. A review of three closed youth Individual
Healthcare Records (IHCRs) showed there were no youth applicable for episodic or emergency
care. The center reported there were no additional records applicable for episodic or emergency
care events since the last annual compliance review. The center maintains one automated
external defibrillator (AED). The center’s AED is located in a wall-mounted AED box in the
medical clinic. The AED procedures were in the AED box, as well as audio instructions. Nursing
staff check the AED batteries and pads monthly to ensure the AED is operational and document
their review on a tracking sheet. A review of the center’s AED tracking sheets since the last
annual compliance review documented the center’s practice. The AED was self-tested in front of
the annual compliance reviewer to ensure it was operational. The batteries in the AED expire in
December 2027, and the pads expire in September 2024. The AED contained the original
batteries and pads. The center maintains six first-aid kits which are located on each of the two
youth modules, master control, and the medical clinic. The first-aid kits for each of the two
transport vehicles are stored within master control. The center’s medical policy requires all first-
aid kits to be sealed with breakaway tabs. If a first-aid kit seal is broken, an incident report must
be submitted in the Department’s Juvenile Justice Information System (JJIS), and an e-mail
must be sent to the shift commander for restocking notification. The center’s policy states first-
aid kits shall be inspected and restocked monthly. An informal interview with the licensed
practical nurse (LPN) indicated the nursing staff restocked the kits weekly and it was not the
center’s practice to seal first-aid kits with breakaway tabs. One unsealed first-aid kit in master
control was opened and did not contain bandages, as required. Two kits, one from each living
module, were both sealed with breakaway tabs, which were snapped for inspection. The kit from
one living module did not contain antiseptic wipes, bandages, antibiotic ointment, or gauze, as
required. The kit from the second living module did not contain antiseptic wipes, antibiotic
ointment, non-adherent pads, gauze, or an eye dressing kit with eye wash, as required. The
contents list attached to each of the first-aid kits differed from each other as different items were
stricken through in ink. During the annual compliance review week, the center removed contents
lists from all first-aid kits and stocked each with the approved list of contents specified in the
center’s approved medical policy. Reinspection of the kits at the end of the annual compliance
review week validated the kits were stocked with the designated health authority (DHA)
approved contents. A review of three staff training records found each was trained and held
current certifications in cardiopulmonary resuscitation (CPR), first-aid, and AED. All non-
healthcare staff and nursing staff are required to maintain certifications. The center’s policy and
procedures indicated emergency drills are to be conducted for each shift on a quarterly basis at
minimum, and AED/CPR must be demonstrated at least annually. A review of quarterly
emergency drills since the last annual compliance review supported drills were conducted, as
required. All documented drills included the type of medical event, time the drill/event occurred,
time 9-1-1 was called, if applicable, name of the juvenile justice detention officer supervisor,
healthcare provider in charge, healthcare provider response time, type of medical care
rendered, time the event concluded, clinical manager/medical staff review, and critique.
Observations confirmed emergency contact and telephone numbers were posted in the medical
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clinic and in master control to include the number for the statewide Poison Control Center. Only
healthcare and trained supervisory non-healthcare staff can administer the epinephrine auto
injector for youth requiring administration when indicated. A review of three training records
supported each staff received the required training on the center’s Emergency Care Plan, and
the supervisory staff received training on the epinephrine auto injector. Reviewed
documentation supported the DHA, the advanced practice registered nurse (APRN), and all
nursing staff maintained current certifications in CPR and AED. Three staff were interviewed to
determine if they are able to call 9-1-1 if necessary, and each stated yes, if needed. The
center’s medical policy and procedures require nursing staff and supervisory staff to be trained
on the administration of Narcan; however, an informal interview with the LPN indicated no
training on Narcan administration has taken place. The center received the NARCAN® nasal
spray training tool curriculum from the Department’s Residential Operations staff on August 30,
2023, in order to share with the center’s nursing staff for training.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has a written policy and procedures to provide for timely referrals and coordination of
medical services to ensure youth have timely access to off-site care services. The center
reported there were no youth applicable for off-site care since the last annual compliance
review. A review of three closed youth Individual Healthcare Records (IHCRs) found there was
one youth applicable for off-site care, and discharge paperwork was maintained; however, the
Summary of Off-site Care form was not utilized for the youth having been transported to a local
hospital on June 5, 2023, due to the youth not having completed the admission to the detention
center prior to being transported off-site. The center documented the transport to off-site care
for medical clearance in the admission chronological progress note and the return to the center
as an incidental program note instead.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center maintains a written policy and procedures to ensure youth identified with chronic
conditions receive regularly scheduled evaluations and necessary follow-up care. A review of
three closed youth Individual Healthcare Records (IHCRs) found one youth was applicable for
the existence of chronic conditions. The youth was placed on the chronic list; however, they did
not remain in secure detention long enough for a periodic evaluation. The Department’s problem
list was updated for this youth. There were no youth identified as pregnant or morbidly obese.
The center reported there were no other youth applicable for chronic conditions since the last
annual compliance review.
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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 maintains a written policy and procedures ensuring all medication and
pharmaceutical products are procured, dispensed, administered, and stored safely, accurately,
and in accordance with state, federal, and industry standards. The center’s practice is for
nursing staff to verify all medications have a current, valid order, and are given according to a
current prescription or practitioner’s order. Nursing staff verify medication with the
parent/guardian when they deliver the medication to the center. A Medication Receipt, Transfer,
and/or Disposition form is used to document medication received in the original packaging from
a licensed pharmacy with a current, legible, patient-specific label affixed. There were no youth
applicable for restricted housing while taking prescribed medications since the last annual
compliance review. One reviewed youth was applicable for over-the-counter (OTC) medications
not listed on the Authority for Evaluation and Treatment (AET) form. The center utilizes a local
pharmacy as a back-up for emergency purposes. All medication is delivered to the center in
blister packs. A review of three closed Individual Healthcare Records (IHCRs) showed there
was one youth taking medication upon admission whose parent/guardian delivered the
medication to the center subsequent to the youth’s admission. The center had no other youth
admitted with prescribed medication during the annual compliance review period. The center
utilizes the standard Department Medication Administration Record (MAR) for each youth
receiving either prescription medications on a routine basis or OTC medications. The center
maintains a written policy and procedures to ensure the usage of the MAR by licensed
healthcare staff and non-licensed staff. A review of the standardized MAR form showed the form
included the youth’s name, Department identification number (DJJID), date of birth, youth
allergies, precautions, Medical Grade, medical alerts, and current picture of the youth. Three
youth records were reviewed, and two were applicable for having MARs documenting
administered medications. Neither of the two reviewed MARs documented side effect
monitoring by the nursing staff at least weekly. One of the two reviewed MARs had incorrect
start/stop dates on the MAR. The advanced practice registered nurse’s (APRN) order on June
8, 2023, was for twice daily oral medication to be administered for fourteen days; however, the
initial typed start/stop dates were incorrectly entered as June 6 to June 12, 2023, which were
stricken through and revised handwritten dates of June 9 to June 15, 2023. All twenty-eight
required doses of the medication were administered from June 9 to June 23, 2023. Additionally,
the MAR indicated one evening dose was missed on June 11, 2023, which was documented by
the LPN in a Chronological Progress Note the next day and one additional dose was
documented on the MAR as having been administered on the evening of June 1, 2023, which
was prior to the youth’s admission and prior to the APRN’s medication order. There were no
youth requiring parenteral medication at the center since the last annual compliance review. The
center did not have any standing orders for psychotropic medications, no pro re nata (PRN)
orders for psychotropic medications, or emergency treatment orders for psychotropic
medications. The designated mental health clinician authority (DMHCA) was notified of the one
youth admission applicable for prior mental health diagnosis. No youth were on psychotropic
medications at the center for more than thirty days since the last annual compliance review;
therefore, no records were applicable for receiving psychiatric medication monitoring every thirty
days. Observations of a medication pass were not conducted during the week of the annual
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compliance review, due to the center not having any youth on medication. An interview with
nursing staff indicated the center has a process for monitoring and tracking youth with chronic
conditions, as well as verifying a youths’ medication regimen once admitted to the center.
Additionally, the center has non-healthcare staff who are trained by medical staff to provide
over-the-counter medication to youth. An interview with the shift commander validated the
center utilizes a chemical pharmaceutical drug disposal system to dispose of expired medication
by placing the expired medication into a container, which is dissolved with the chemical drug
disposal system. An interview with three staff regarding medication administration was
conducted, and all three staff stated they do not give medication to youth. The one interviewed
youth stated they do not take medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center maintains a written policy and procedures ensuring medications and any medical
equipment classified as sharps are secured and inventoried. The dose-by-dose daily
administration and documentation of a medication is documented utilizing a perpetual inventory
process for the daily distribution of non-controlled prescription medications and over-the-counter
(OTC) medications. Documentation of each individual dosage of medication administered to
youth is maintained on the Medication Administration Record (MAR) to demonstrate the
inventory utilizing a routine perpetual inventory descending count as each sharp is utilized and
disposed. Observations of the medical clinic were conducted during the annual compliance
review week and found the clinic is secured under lock and key. A locked medication cart is
located in the clinic which stores oral prescription and OTC medications prescribed for youth. A
locked box within the locked medication cart is used for the storage of controlled medication.
The center did not have any prescription medications on-site during the annual compliance
review week. There were no opened OTC medications. A review of the unopened running daily
inventory of three OTC medications matched the random count. The center had no controlled
medication on-site during the annual compliance review week. The center maintains an
inventory of all sharps and medical equipment classified as sharps, to include syringes,
butterflies, needles, scissors, and suture removal kits. A review of three sharps verified each
matched the inventory list. Items designated as sharps are stored in a designated locked
cabinet in the medical clinic and are inaccessible to youth. An interview with the licensed
practical nurse (LPN) indicated the center maintains an extensive inventory of OTC medication
and all prescribed medications are ordered from a subcontracted pharmacy. The nurse
indicated the center’s inventory of medication is stored securely, and any narcotic medications
are maintained behind double locks. The LPN indicated they provide training for non-healthcare
staff in the administration of medication.
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4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center maintains a written policy and procedures ensuring proper procedures are followed
to prevent the spread of infectious diseases or illnesses and provide staff with the knowledge of
appropriate prevention, containment, treatment, and reporting requirements of infectious
diseases. A review of three closed youth Individual Healthcare Records (IHCRs) was
conducted. The reviewed documentation showed each youth received infection control training
within seven days of admission. The infection control training included hand-washing
techniques, universal/standard precautions, prevention/transmission of communicable diseases,
vaccinations, and the Centers for Disease Control and Prevention (CDC) guidelines for infection
control. A review of the center’s Exposure Control Plan/Infection Control Plan documentation
showed the plan was written in accordance with Occupational Safety and Health Administration
(OSHA) guidelines to include risk assessment and methods of compliance. The plan addressed
common childhood infectious diseases, self-limiting, episodic contagious illnesses, viral or
bacterial infectious diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus
(HIV), blood-borne pathogens, other outbreaks and epidemics, and outbreaks of pediculosis. In
addition, the plan included Methicillin Resistant Staphylococcus Aureus (MRSA) and other
antibiotic-resistant micro-organisms, food-borne illnesses, bioterrorism agents, chemical
exposures in the workplace, and protocols for needlestick post-exposure intervention and
treatment. The center ensures Hepatitis B immunizations are made available for staff and staff
have access to protective equipment as needed. There were no reportable incidents for which
the local county health department, CDC, or the Department’s Central Communications Center
(CCC) were notified of an infectious disease since the last annual compliance review. A review
of three staff training records found each staff completed Exposure Control Plan/Infection
Control Plan training. An interview with the nurse indicated youth are provided with the infection
control training upon admission. Additionally, it was reported the designated health authority
(DHA) provides staff with infection control training, and nursing staff are responsible for
providing staff with training on the center’s Exposure Control Plan.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center maintains a written policy and procedures for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. An interview with the
licensed practical nurse (LPN) confirmed the center had no pregnant youth since the last annual
compliance review. Reviewed healthcare education information showed pregnant youth would
receive prenatal education to include alcohol and drug use, smoking, nutrition, sexually
transmitted infections, contraception, prenatal care, birthing process, postpartum care, basic
baby care, child/infant development, and parenting skills. A review of three staff training records
verified each staff received training specific to working with pregnant youth. Staff training
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documentation reflected training was provided by the advanced practice registered nurse
(APRN) at the time of hire and annually thereafter.
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Office of Accountability and Program Support Page 44 of 56 (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.
The center has a written policy and procedures to address the active supervision of youth.
During the annual compliance review, youth supervision was observed only on the third and
fourth days of the review. This was due to the center having a single youth admitted during the
annual compliance review week. Youth and staff observations on the modules, in the
classrooms, in the cafeteria, and inside the center showed the juvenile justice detention officers
(JJDOs) maintained continuous sight supervision of the youth in their assigned area. The
interactions between staff and youth demonstrated active supervision. Staff were positioned in
the areas supporting active supervision. The JJDO and master control operators communicated
to receive authorization for all movement within the center. The master control logbooks since
the last annual compliance review were reviewed, and there was documentation to support
headcounts were conducted on a consistent basis during the beginning and ending of each shift
and prior to youth movement. Three staff were interviewed, and all stated there is enough staff
to provide for the safety and security of the youth and staff at the center.
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5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations.
Each center shall implement and maintain a behavior management system to meet the needs
of the youth and the center. The system shall include rewards for positive behavior and
consequences for inappropriate behavior.
The behavioral norms and expectations for youth shall be posted in all living areas and shall
clearly specify appropriate and inappropriate behaviors.
The system restricts certain types of penalties on youth who demonstrate negative behaviors.
Group punishment shall not be used. However, corrective action taken with a group of youth
is appropriate when the behavior of a group jeopardizes safety or security, and this should
not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
The use of drugs to control the behavior of youth is prohibited. This does not preclude the
proper administration of medication as prescribed by a licensed physician.
The center maintains a written policy and procedures ensuring there is a uniform behavior
management system (BMS) offering a predictable set of rewards, privileges, and consequences
for behavior. The center has a system of rewards, privileges, and consequences to motivate
youth to meet the center’s expectations. Observations conducted during walk-through tours
revealed the center has the BMS system posted in each living module. The postings specify
appropriate behaviors and rewards for such behavior, as well as inappropriate behavior and
consequences for such behavior. Youth are informed of the BMS during the admission process
through an orientation. The BMS is a three-tiered level system. Each youth enters at level two
when admitted, and their level moves up or down depending on their behavior in the center.
There are incentives for youth obtaining level three status, including canteen food items. The
incentives can be changed or updated based on the center’s needs. A review of the level sheets
and logbooks since the last annual compliance review confirmed the center’s practice. An
interview with the superintendent confirmed the center’s practices regarding the use of the
behavior management system (BMS). An interview with the superintendent also confirmed that
the staff should adhere to a code of conduct prohibiting abuse, profanity, threats, harassment,
intimidation, and personal relationships with youth. One youth was interviewed and stated the
BMS at the center is easy to understand and follow. Youth also stated all staff appear
knowledgeable and consistent in the systems use. The youth stated youth are not allowed to
punish other youth. Three staff were interviewed, and all were able to explain the center’s BMS
and stated they feel the BMS is effective. The three interviewed staff stated youth are provided
snacks, extra food, and a better blanket and/or pillow as part of the BMS. All three staff stated
only levels and points can be taken away from a youth as a consequence, and staff speak with
the youth to discuss the consequences being imposed and allow the youth the opportunity to
explain their behavior. Three interviewed staff stated supervisors provide feedback to staff
regarding the implementation of the BMS daily during briefings. All interviewed staff further
stated they have not witnessed a coworker take meals, snacks, clothing, education, or medical
care from a youth when acting out, and they have never witnessed a coworker encourage a
youth to injure another youth.
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5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has a written policy and procedures addressing ten-minute checks. The center has
twenty-seven cameras with a recording capacity of thirty days. During the week of the annual
compliance review, five cameras were not operational. The shift commander indicated a work
order had been submitted and maintenance was pending. Staff utilize handwritten Ten-Minute
Observation Logs to document ten-minute checks. A review of the documentation and
surveillance coverage was conducted for six randomly selected dates across three shifts and on
the youth living module. The review revealed the ten-minute checks were consistently
conducted at intervals of ten minutes or less for each reviewed sample. Ten-Minute Check Logs
were reviewed for each month of the annual compliance review period and reflected no
exceptions. The interviewed staff were knowledgeable of the requirements and policy for ten-
minute checks and room checks. Reviewed documentation confirmed weekly management
oversight was conducted and documented. Three staff were interviewed, and all responded
room checks are conducted every ten minutes when youth are placed in their rooms for non-
punishment reasons. The interviewed superintendent stated ten-minute checks are to be
conducted in real-time and within ten-minute intervals.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has a written policy and procedures in place to ensure staff know the exact number
and location of all youth under their supervision at all times. A review of the master control
logbooks for one day each month since the last annual compliance review confirmed the census
counts of youth are written at the beginning and at the end of each shift. Counts were
documented, at a minimum, with one additional time randomly each shift. Counts were
documented following emergencies, disturbances, and drills. Census counts were documented
upon any change of population. Living module counts were recorded in their assigned module
logbooks. During the annual compliance review week, the center only had one youth admission.
Observations conducted confirmed counts were conducted. Counts were observed for shift
changes, movements, food service times, and education delivery. Three staff were interviewed,
and each responded youth counts are conducted at the beginning of the shift and at the end of
the shift. Three staff reported emergency counts are conducted after a major disturbance. Three
staff reported emergency counts are conducted following drills.
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5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has a written policy and procedures regarding logbooks. The center maintains
separate logbooks in master control and for each living module, as well as one for visitors and
one for contracted staff. A review of three full days for each of the logbooks since the last
annual compliance review revealed each was bound with numbered pages, all entries included
the date and time of the event or incident with the name of the staff and youth involved, a brief
description of the event, and the initials of the staff making the entry. Entries included the safety
and security of the center, including medical, special needs, and mental health alerts which
were highlighted. Reviewed logbooks reflected all errors were struck through with a single line
and initialed by the staff correcting the error. Reviewed master control logbooks included
emergency situations, incidents, fire and escape drills, population counts at the beginning and
end of each shift, group movements, admissions and releases, and names of youth placed on
precautionary/secure observation, including the time precautionary/secure observation began
and the time precautionary/secure observation was discontinued. Documentation reflected the
master control logbook included all required entries.
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has a written policy and procedures regarding logbooks. The master control and
living unit logbooks were reviewed since the last annual compliance review. The juvenile justice
detention officer supervisor (JJDOS) reviews the logbooks each shift, including the master
control logbook when accepting the shift, to document they are aware of current relevant
situations in the center. Documentation supported the superintendent or designee reviewed the
logbooks on a weekly basis. The shift commander or juvenile justice detention officer supervisor
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(JJDOS) in charge tours the youth living areas at least once during each shift and document
their visit in the living area’s logbook. A review of documentation confirmed the JJDOS assigned
to the modules reviewed the logbook upon accepting the shift. An interview with the
superintendent indicated logbooks are maintained to document all events which occur at the
center in the event other records or sources of information are lost or destroyed.
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 a written policy and procedures on key control. This policy addresses key
control, issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or
lost keys, and reporting and replacement of damaged keys. All keys are stored on a tamper-
resistant key ring, which inhibits the removal of keys and is color-coded specific to the position
the key is assigned. The center maintains a master key inventory which accounts for all key
rings by ring number, the number of keys on each ring, the capability of each key and to whom
the keys are assigned and issued. Emergency keys which provide egress through exterior doors
are stored in master control. A review of the Key Control Logs confirmed the issuance of keys
and key rings were documented on the Key Control Logs on each shift with the date and time of
issue, name of the staff issuing the key, name of staff receiving the key ring, and time returned.
A review of the master key control inventory revealed the inventory report matched the actual
key rings in use. There were no reported incidents since the last annual compliance review of
lost keys or staff taking keys home after their shift. If keys were to be taken home by staff, the
staff would be required to return the keys to the center within two hours of discovering the keys
were taken home. Restricted keys for medical, mental health and education are held in master
control in a locked key box and issued through the master control operator. Emergency keys are
kept in the superintendent’s office in a lock box. Personal keys are stored in staff lockers, visitor
lockers, or master control in the non-secure area of the center. Key inventory and issuance of
keys are documented during each shift to include the date, time, name of staff receiving the
keys, time keys were returned, and name of supervisor issuing the keys. A review of the shift
reports matched the keys in use. Observations indicated keys were with the staff to whom the
keys were issued, and the youth did not have access to center keys. The superintendent was
interviewed and stated no staff are issued permanent keys. An informal interview with the
master control operator confirmed key counts are conducted at the beginning and end of each
shift by the master control operator and supervisor on duty. Three staff were interviewed, and
each staff stated program keys are assigned to staff. Each of the interviewed staff knew the
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number of keys on their key ring and the function of each key. Three staff also indicated the
supervisor assigns the 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.
The center has a written policy and procedures in place for transportation procedures and
operation of Department vehicles. The center has two vehicles used to transport youth. Both
vehicles had the appropriate number of seatbelts, a seatbelt cutter, a window punch, a fire
extinguisher, and a first-aid kit with approved items. A review of documentation since the last
annual compliance review found each vehicle was inspected prior to transport. Documentation
supported the shift supervisor completed weekly and monthly vehicle checks. A review of the
vehicle maintenance invoices revealed both vehicles assigned to the center received an annual
inspection within the previous year. Each of the vehicles had a visual inspection conducted, as
well as maintenance sheets to inspect the levels for water coolant, lights, oils, emergency
equipment, horn, cleanliness of the vehicle, and the condition of the interior/exterior. A review of
the center’s logbook confirmed youth were searched prior to the transports, and all youth were
securely fastened into their seatbelt. The logbook also contained the beginning and end time of
each transportation, staff and youth names, and the destination for transport. Further
observation of both vehicles found they were secured when not in use. There were no
transportations available for observation during the annual compliance review week. There was
only one youth admitted to the center during the week of the annual compliance review. The
interviewed youth reported not seeing anyone place contraband in a transport vehicle and they
felt staff were driving safely when transporting youth.
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 a written policy and procedures addressing tool inventory and management.
Food service and maintenance are provided by the Monroe County Sheriff’s Office, and meals
are prepared in the kitchen at the county jail and delivered to the center. There are no kitchen or
maintenance tools stored at the center. Youth may use cleaning items such as mops, brooms,
buckets, and other common household items under the direct supervision of the juvenile justice
detention officer (JJDO) staff. An interview with the superintendent stated they contact the
county for any issues requiring tools. Three interviewed staff stated the center does not store
any tools.
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5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center has a written policy and procedures addressing youth access to and the use of tools
and cleaning items. Pursuant to the policy and procedures, the youth only have access to mops,
brooms, buckets, and cleaning rags. Three staff were interviewed, and all responded youth are
allowed to use mops and brooms. One interviewed youth reported not using any tools at the
center and not cleaning with any type of cleaning agent such as bleach, laundry soap, window
cleaner, or toilet cleaners. There was no observation of youth using tools conducted during the
annual compliance review week.
5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center has a written policy and procedures to address the inventory of flammable, toxic,
caustic, and poisonous items. Flammable, toxic, caustic, and poisonous items are maintained in
secure areas with limited access. Safety Data Sheet (SDS) logbooks are located where the
chemicals are stored. Inventories of flammable, toxic, caustic, and poisonous items are
maintained by the center. The SDS and inventories were compared to a sample of five items
located on-site at the center and were found to be accurate and complete.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 56 (Revised July 2023)
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center has a written policy and procedures which prohibit youth access to flammable, toxic,
caustic, or poisonous items. Youth are not permitted to access any materials which are
flammable, toxic, caustic, and/or poisonous. The shift commander confirmed flammable, toxic,
and caustic materials are stored in the janitor closet under lock and key and are only accessible
by supervisory staff. Three staff were interviewed, and all three responded youth are not
allowed to clean with substances which are toxic, flammable, or poisonous. One youth was
interviewed and stated youth do not have access to flammable, toxic, caustic, and poisonous
items.
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 a written policy and procedures which address the proper use, storage, and
disposal of flammable, toxic, caustic, and poisonous items. The plan addresses what
procedures to follow in the event of a chemical leak or spill. The center does not have kitchen
services on-site; therefore, the center does not have a grease trap or other liquids to be
disposed of in the center. An informal interview with the center’s shift commander reported the
local waste management handles all disposal of flammable, toxic, caustic, and poisonous items.
There were no reports of any chemical spills or leaks within the annual compliance review
period.
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has a written policy and procedures addressing confinement under twenty–four
hours. The center documents confinements under twenty-four hours in the Facility Management
System (FMS). A review of the Department’s Juvenile Justice Information System (JJIS)
revealed the center has not had any confinements under twenty-four hours since the last annual
compliance review. Observations of confinement rooms showed windows and cameras were
free of scratches and obstructions. An interview with the superintendent confirmed confinement
reports are reviewed by the superintendent or designee to determine whether each confinement
was appropriate or inappropriate. Three staff were interviewed, and all three staff were
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 56 (Revised July 2023)
knowledgeable on the center’s process for placing youth in confinement. All three interviewed
staff indicated youth are provided with educational materials while in confinement.
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has a written policy and procedures to manage various emergencies and disaster
events. One Continuity of Operations Plan (COOP) drill was conducted since the last annual
compliance review. The drill was conducted in April, just prior to the beginning of hurricane
season. A written scenario, drill form, critique form, and e-mails were used to document the drill.
Three staff were interviewed, and all responded they had participated in escape, fire, weather,
hostage situations, chemical spills, and terrorism drills. Two staff stated they participated in
major disturbances, bomb threat, and flooding drills. An interview with the superintendent stated
the center’s comprehensive safety/emergency program ensures the center has a planned and
comprehensive approach to effectively manage emergencies and disaster events, including
those which require the detention center to relocate its youth and staff while maintaining
operations, safety, and security.
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 a written policy and procedures to address escape drills and escape prevention.
The policy requires the center to conduct quarterly escape drills. A review of escape drill
documentation since the last annual compliance review verified the center completed quarterly
escape drills on each of the three shifts. The documentation of the drills included scenarios, as
well as the dates and times of the drills. The drill documentation forms included the signatures
of the supervisor and the staff coordinating the drill. Recommendations and critiques of the drills
were included in each report. A review of the logbooks since the last annual compliance review
revealed all escape drills were documented in the logbook, as required. Three staff were
interviewed, and all responded they had participated in escape, fire, weather, hostage
situations, chemical spills, and terrorism drills. Two staff stated they participated in major
disturbances, bomb threats, and flooding drills.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 56 (Revised July 2023)
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a fire prevention and evacuation plan which addresses fire prevention and
safety of the program. The plan was reviewed and approved by the local fire official. A review of
fire drills since the last annual compliance review supported the center conducted fire drills
every month, on each shift, since the previous annual compliance review. The fire drills were
also documented in the master control logbooks. Staff sign-in sheets were used to document
staff who participated in the drills. A review of the fire extinguishers located throughout the
program confirmed they were inspected annually. Three staff were interviewed, and all three
staff responded fire drills take place at least monthly. One youth was interviewed and stated the
center instructed them on what to do in case of a fire.
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has a written policy and procedures which address searches and contraband for the
prevention of contraband from entering the facility. The center has a policy in place identifying
all items and materials which are considered contraband when found in the possession of youth
and/or staff. The policy lists all items such as 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 has a system in place for the prevention of the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 56 (Revised July 2023)
introduction of contraband and to identify contraband items and materials through searches of
the physical plant, facility grounds, staff, youth, and visitors. All contraband is documented in the
master control logbook. The center documents the confiscation of any illegal contraband and
the manner of disposition. The center’s policy is to complete an incident report identifying
findings for all recovered illegal contraband, notify the regional director, and report any
contraband to the Department’s Central Communication Center (CCC) within two hours. If a
confiscated item is not illegal or prohibited, the center’s superintendent or designee has the
discretion to discard the item, return it to its original owner, mail it to the youth's home, or return
it to the youth upon release. In all instances involving confiscation of illegal or prohibited
contraband, the center shall turn the item over to local law enforcement, and a criminal report
must be filed. The center had one new youth admitted after hours to the center during the
annual compliance review week; therefore, an observation of the center’s search procedure
could not be conducted. A review of CCC reports verified there were no incidents regarding
contraband since the last annual compliance review. An interview with the superintendent
indicated staff should conduct searches for the control of contraband and to ensure safety. The
results of searches are documented in the logbooks as well as electronically. All searches are in
compliance with the Protective Action Response (PAR)/Right Interactions (RI) curriculum
utilized by the center as well as the center's policy. In the event contraband is located, all
contraband will be confiscated and given to administration, and if deemed illegal, law
enforcement will be notified. No observations of a room search were made, as there was only
one admission at the center at the time of the annual compliance review; however, the annual
compliance review team was not on-site at the time of admission.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 56 (Revised July 2023)

report_type: QI Detention

file_name: MonroeRJDC -FINAL-FY2324.pdf