summary: QI Detention - FY24-25 - 5 findings

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Orange Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated )
2800 S. Bumby Avenue
Orlando, Florida 32806
Review Date(s): August 13-16, 2024
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Tamara Mahl-Adkins, Office of Accountability and Program Support, Lead Reviewer (Standard
1)
Belinda Alexander, Office of Education, Education Coordinator (Standard 2)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor (Standard
4)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Tyler Mocere, Brevard Regional Juvenile Detention Center, Superintendent (Standard 5)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Interviews)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Orange Regional Juvenile Detention Center MQI Program Code: 247
Provider Name: State Operated Contract Number: N/A
Location: Orange County / Circuit 9 Number of Beds: 95
Review Date(s): August 13-16, 2024 Lead Reviewer Code: 156
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
1.05 Right Interactions (RI) 2.09 Daily Activity Schedule
5.01 Active Supervision of Youth * 2.10 Educational Access*
5.03 Ten-Minute Checks*
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 4 of 56 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Limited
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 5 of 56 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
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 Failed
2.10 Educational Access* Failed
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 6 of 56 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
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 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 56 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
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 8 of 56 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Limited
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Failed
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 56 (Revised July 2023)
Program Overview
The Orange Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Orlando, Florida. The center serves youth in Orange and Osceola
counties in Circuit 9. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the ninety-five 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 Orange County School Board. The center’s
management team includes the superintendent, two assistant superintendents, two
administrative assistants, eleven juvenile justice detention officer (JJDO) supervisors, and
seventy-one JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by one
designated mental health clinician authority, one psychiatrist, three licensed mental health
counselors, and two licensed clinical social workers. Clinical services provided by the center
include mental health and substance abuse evaluations, mental health treatment planning,
individual, group and family therapy, mental health crisis intervention services, on-site
psychiatric services, and availability for substance abuse services for youth with co-occurring
disorders. Medical services are provided by one designated health authority, two advanced
practice registered nurses, four registered nurses, and one licensed practical nurse. The
medical clinic maintains nursing coverage twelve hours a day, seven days a week. Food
services are provided by Department staff and include menus, meal planning, meal schedules,
special diets, nutritional analysis, daily allowance, food preparation, health certifications, food
product standards, sanitation, and cleaning. Staff are responsible for the custody and control of
youth in their care, providing youth supervision twenty-four hours a day, seven days a week.
The center has six living modules which are divided by male and female. There are 154 security
cameras at the center, of which 154 were operational at the time of the annual compliance
review. The living module youth room windows all have scratches; however, do not impede view
inside of the rooms. The entire center has peeling paint on walls in high traffic areas. At the time
of the annual compliance review, the center had twenty-eight vacancies, which included two
food service workers, ten JJDOIs, twelve JJDOIIs, three JJDO supervisors, and one other
personnel service chaplain.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 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 facility operating procedures addressing the requirement of sight and sound
supervision of volunteers, mentors, and interns. The center’s Annual Affidavit of Compliance
with Level 2 Screening Standards was completed and submitted on January 29, 2024, prior to
the January 31st deadline. The affidavit for the teachers was also submitted prior to the
deadline; on January 11, 2024. Ten new staff and three contracted providers were hired since
the last annual compliance review. All thirteen had a background screening completed prior to
contact with youth or confidential youth records, including a criminal history check. One staff
required and obtained an exemption prior to working with youth. Ten of the thirteen staff were
direct care applicants and had a pre-employment assessment tool administered. The pre-
employment assessment passing score was documented in each applicant’s record. The three
contracted provider staff were added to the Clearinghouse employee roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
Five staff were applicable and received a five-year rescreening/renewal completed not more
than twelve months prior and no later than ten days prior to each staff’s five-year anniversary
date.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 56 (Revised July 2023)
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.
A review of Right Interaction Reports, the Department’s Central Communications Center (CCC)
reports, and incident reports indicated management takes immediate action to investigate or
address all allegations or violations of the code of conduct. A review of six violations of the code
of conduct indicated the staff received a verbal or written reprimand, including dismissal based
on the severity of the violation. Each of the six staff signed a code of conduct upon hire. A
review of five staff receiving commendations indicated staff received a certificate of
appreciation, and three staff received a gift card for going above and beyond the job
requirements. Seven youth interviews indicated none had ever been stopped from reporting
abuse to the Florida Abuse Hotline, six youth stated they never had to report abuse. Six of the
youth stated staff are respectful when talking with youth and one reported they are not
respectful, as staff use profanity; however, it is personally not disrespectful. Five youth said the
staff do not use profanity when speaking with youth, one said they have heard them once, and
one more indicated they have heard them often. None of the youth heard staff threaten youth.
Six indicated they feel safe at the center, due to support from staff. One said they do not feel
safe, due to being threatened by other youth, and felt safer at another center. All seven youth
stated they have never exchanged emails, telephone numbers, or social media contact
information with staff. Seven staff interviews indicated the process for allowing staff and youth to
call the Florida Abuse Hotline or the CCC to report suspected abuse is to notify the supervisor
and allow the youth to make the call, six said staff are allowed to call anytime, three stated the
supervisor makes the call, and two would notify the superintendent. The staff described the
process to include taking the youth’s statement, speaking to the Florida Abuse Hotline/CCC
operator to determine if it is reportable or not, noting it in the logbook and documenting it, as
well as the supervisor being with the youth when the call is made. Three staff indicated they
have often observed a co-worker using profanity when speaking to youth, two saying
occasionally, and two never. The staff who stated they have heard co-workers using profanity
also indicated this has happened in conversation, as well as at youth, and one saying they
heard it over a year ago. Six of the staff stated they have never observed a co-worker using
threats, intimidation, or humiliation, when interacting with the youth. One said they have
observed this behavior often, where staff use humiliation and downgrade the youth. Two staff
indicated in the past year the working conditions have been good at this center, two saying fair,
two poor, and one calling the conditions very poor. The interview results were provided to the
superintendent, who stated they are working on changing the center’s culture. The
superintendent interview indicated immediate intervention and an internal investigation are
initiated if there is any physical abuse, threats, or profanity towards the youth, as well as a call
made to the CCC. If a staff uses profanity the Department’s discipline process is followed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 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 had 126 reports made to the Department’s Central Communications Center (CCC)
during the annual compliance review period. Twelve CCC reports were reviewed. All twelve
reports were called into the CCC within the required two-hour time frame. Two of the twelve
were reported by an outside source. Eight were documented in the center’s master control
logbook and the remaining two were missing from being noted in the logbook. The
superintendent interview explained the incident reporting process is for reportable CCC
incidents to be called in within two hours, an email to be sent to the director notifying them of the
incident, and the circumstances surrounding the incident must be documented. Any abuse
observed is immediately reported by the staff member who observed the abuse in accordance
with the mandatory reporting guidelines and a CCC call is then placed within two hours.
1.05 Right Interactions (RI) Limited Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center had a total of 135 Right Interaction (RI) Reports during the annual compliance
review period. A RI Report was completed for each use of countermoves, control techniques,
takedowns, or mechanical restraints. A review of nine RI events was conducted. All nine
included statements of all staff involved. Seven of nine the reports were completed by the end
of the staff’s workday. In two reports there was one staff, for each, who did not complete the
report by the end of their workday; one was two days late, and one was one day late. None of
the incidents resulted in serious injury to youth or staff, or a youth alleging abuse. All nine
reports were reviewed by a supervisor or a RI instructor. In two of the nine, the report was
reviewed by the supervisor/RI instructor two and three days late, respectively. Six of the nine
reports had a post-RI interview conducted with each youth by the administrator/designee no
longer than thirty minutes after the incident. In two of the three remaining the post-RI interview
section was left blank. In the remaining one report the post-RI interview section was completed
three days late. None of the incidents required a medical review or a mechanical restraint
supervision log to be completed. In six of the nine reports the superintendent/designee reviewed
the report within seventy-two hours. Two of the remaining three reports were reviewed eighteen
and thirty-nine days late, respectively. One of the nine reports was not reviewed by the
superintendent/designee. All seven staff interviews indicated staff try to talk to youth prior to
using physical restraints or mechanical restraints. The superintendent interview indicated
mechanical restraints are maintained in intake and the administration conference room on a
shadow board. The inventory can be visually tracked on the shadow board. One of the assistant
superintendents review RI Reports and conducts video reviews. In instances when improper RI
was used, a refresher training and possible discipline is applied on a case-by-case basis.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 56 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
Seven pre-service training records were reviewed. Three of seven staff completed all pre-
service and certification requirements, as well as academy training within 180 days of hire. All
trainings were captured in the Department’s Learning Management System (SkillPro). Three of
the seven staff were still within the first 180 days of hire. The remaining one staff received an
extension. All seven staff received an orientation within thirty days of hire.
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.
A review of seven in-service training records indicated all staff completed a minimum of twenty-
four hours of in-service training, including mandatory topics specified in Florida Administrative
Code. Three of the seven staff were supervisors and completed a minimum of eight hours of
supervisory training in the areas of coaching, leadership, and personal accountability. All
trainings were captured in the Department’s Learning Management System (SkillPro). A review
of girls’ healthcare training including the monitoring, observation, and emergency care of
pregnant youth, indicated a licensed nurse provided the training to all non-healthcare staff
involved in the supervision or treatment of girls. The center maintains an annual in-service
training calendar, which is updated as changes occur, and is approved by the highest-ranking
official at the location, the assistant secretary of detention, and the director for the Department’s
Office of Talent, Leadership, and Culture. The superintendent interview stated he has
completed supervisor training in SkillPro, and his staff have SkillPro training requirements, as
well as code white responses, emergency responses, report writing, and intake paperwork
training.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 56 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures addressing the grievance process. Observations
during the annual compliance review week indicated youth have access to grievance forms. The
center did not have any grievances during the annual compliance review period. The
superintendent explained the center's grievance process in an interview. In the informal phase
the juvenile justice detention officer (JJDO) attempts to resolve the issue. In the formal phase
youth submit a formal grievance, which is addressed by the JJDO supervisor by the end of their
shift. The findings are documented and submitted to the superintendent for review within
seventy-two hours. The youth is provided a copy of the completed grievance which includes the
final decision. The completed grievances are maintained in the Department’s Facility
Management System for one year. All seven youth interviews indicated they had never filed a
grievance. Three youth stated they know the grievance process; they complete a grievance
form and provide it to staff. Two stated they never needed to file a grievance, and two said they
do not know the process. Four of seven staff interviews indicated the center’s grievance process
includes providing the form to the youth and then reviewing the form. Three staff stated they
would notify the supervisor, three said the staff will resolve the issue with the youth, one stating
it will go further up the chain if needed, and one indicated there are time frames for resolution
which have to be adhered to.
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.
A review of seven youth records indicated all alerts were entered into the Department’s Juvenile
Justice Information System (JJIS) as required. During the time when the Department was
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 56 (Revised July 2023)
experiencing system-wide outages, the alerts were shared between the different departments
through email, lists, and verbal contacts. Upon JJIS operating again, all departments entered
the outstanding alerts into the system. A review of documentation indicated all required alerts
were noted in the logbook. A review of ten random dates during the annual compliance review
period indicated the JJIS alert reports were reviewed daily by the supervisors and
administrators. Youth alerts are printed out and provided to staff during shift briefings, as well as
to the kitchen staff. A review of the shift briefing minutes indicated alerts were reviewed, which
was validated during observation of a shift briefing. The alert list is provided to staff with youth
contact. Each of the center’s departments are responsible for entering and updating their
applicable alerts in JJIS. The superintendent interview indicated the medical alerts are entered
during admission or upon return from an outside medical provider. They are entered into JJIS
after being verified by medical staff. Seven staff were interviewed and four stated they are
informed of youth alerts through the logbook, shift briefings, alert forms, and JJIS. Six also
provided other means including through the supervisor, during intake, parental/guardian contact,
census, passed down from other staff, the superintendent’s white board, through master control,
and emails. Six staff stated management informs staff about issues within the center through
staff debriefings, one said through the logbook, and one said through meetings. Other means,
such as the supervisor, passed down from other staff, emails, and logbooks were also
mentioned. Two staff stated the process for communicating information within the center is very
good, one said good, three said fair, and one stated poor.
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 accumulates information like Right Interactions (RI) Reports, the Department’s
Central Communications Center reports, confinement reports, internal incidents, grievances,
contraband search results, and more, then analyzes the data and makes changes to staffing,
rules, and necessary areas within the center. The information is shared with leadership during
leadership meetings, with the supervisors during the monthly supervisor meetings, and with staff
during shift briefings. The center’s practice is to share information with providers and
stakeholders during the quarterly community advisory board meetings, which have not been
held during the annual compliance review period. The center’s staff conducted meetings with
individual providers during the annual compliance review period and provided the information.
Some of the data gathered has affected the center, which has a new administration team who is
working on making a difference in the culture of the center, including safety and security for staff
and youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 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, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures regarding the youth admission process. Seven
youth case management records were reviewed to support they were admitted to the center as
required. A review of the arrest affidavit/custody order, Detention Risk Assessment Instrument
(DRAI), and Suicide Risk Screening Instrument (SRSI) was completed for five of the seven
youth and the admission wizard documented the forms as reviewed. The remaining two youth
records contained Transportation Request Confirmations, which indicated each youth was a
courtesy hold from another detention center, awaiting placement at a residential facility.
Consequently, the arrest affidavit/custody order, DRAI, and SRSI were not included in one
youth record, and the DRAI and SRSI were not included in the other youth record. Reviewed
documentation confirmed all seven youth were searched upon admission, provided a meal, and
received a medical, mental health, and substance abuse screening. Additionally, documentation
indicated six of seven youth made a telephone call; however, the youth refusal of a telephone
call was not documented for the remaining youth. The name of the person called by one youth
was not documented on the admission wizard. A youth admission was not observed during the
week of the annual compliance review week, because there were no admissions while the
annual compliance review team was on-site.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 56 (Revised July 2023)
9. Youth rights.
10. PREA-related information
The center has facility operating procedures regarding the orientation process. Seven youth
case management records were reviewed. Five of seven youth received an orientation within
twenty-four hours of being admitted to the center; however, the center indicated the remaining
two youth came in on the interstate transportation network and the orientation for both youth
was completed on August 13, 2024, during the week of the annual compliance review. All seven
records contained a signed orientation brochure addressing rules and regulations, grievance
procedures, visitation, telephone calls, access to medical, mental health and substance abuse
services, access to the Florida Abuse Hotline and the Department’s Central Communications
Center, behavior expectations and related consequences, possible new law violations for
destruction of property, youth rights, and Prison Rape Elimination Act related information. A
youth admission was not observed during the week of the annual compliance review, because
there were no admissions while the annual compliance review team was on-site. Seven youth
were interviewed, and six youth indicated they were informed about the rules and regulations,
daily schedule, education services, visitation, abuse reporting, and the behavior management
system upon admission to the center; however, the remaining youth stated they were not
informed when admitted to the center.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures addressing the classification process. Seven youth
case management records were reviewed regarding classification. Each of the seven youth
records contained information concerning each youth’s history and status. The classification
process included information from the admission documents, which reflected each youth’s
gender, height, weight, age, level of aggressiveness, mental illness, intellectual disabilities,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 56 (Revised July 2023)
physical disabilities, history of violent behavior, history of human trafficking, gang affiliation,
criminal behavior, history of sexual offenses, the results of the Vulnerability to Victimization and
Sexually Aggressive Behavior form, medical needs, and suicide, escape, and security risks. The
classification process for each of the seven reviewed youth included all required elements. All
reviewed youth room assignments were based on the youth classification procedures, which
include being reclassified if there are any changes in behavior or status. Youth with a history of
committing sexual offenses are placed in a room alone. The superintendent remains informed of
how to identify and address local youth gangs by being out in the community, keeping in contact
with the juvenile probation officers, the chief probation officer, and center staff. The community
advisory board members and other community contacts keep the superintendent informed of
local gangs. A formal interview with the superintendent indicated factors such as mental health
status, physical health status, cognitive performance, age, and prior victimization are all
considered when making room assignments. They added youth are housed together if they are
two years or less apart in age and prior victims are moved to a different dormitory than their
assailant, when possible.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures addressing the exchange of information with the
juvenile probation officer (JPO) designated as the circuit gang liaison. Seven youth case
management records were reviewed. None of the seven records reviewed were applicable for
youth gang involvement. The center indicated there were no youth during the annual
compliance review period who were identified as having newly suspected gang involvement
while at the center. The center indicated the juvenile justice detention officer identified to serve
as the gang representative is on extended leave; therefore, the intake supervisor is the acting
gang representative. The center indicated the gang representative will send an email to the JPO
notifying them of any newly suspected gang involvement, as soon as the center becomes aware
of any potential gang connection.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures addressing admission and storage of youth’s
personal property. Seven youth case management records were reviewed for admission with
personal property. The Property Receipt form was maintained in all seven youth records and
included each youth’s and staff’s signature. The Property Letter of Acknowledgement regarding
unclaimed property was signed by five of the seven youth; however, the center indicated the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 19 of 56 (Revised July 2023)
remaining two youth came in on the interstate transportation network and the Property Letter of
Acknowledgement for both youth was completed on August 15, 2024, during the week of the
annual compliance review. The personal property, including clothing, was placed in an assigned
bag for each youth as documented on the Property Receipt form. Two of the seven youth had
valuable property. All money and personal items of value for both applicable youth were verified
and secured in a clear tamper-proof property bag, which included each youth’s name,
Department of identification number (DJJID), a list of items in the bag, and they were placed in a
drop-safe under video surveillance. A review of the drop-safe bound logbook indicated an entry
for both youth with valuable property including the date, time, each youth’s name, DJJID, printed
name of the officer who secured the property, and the officer’s initials. Each of the two youth
case management records contained copies of the Valuable Property Receipt form.
Observations were made of three valuable and three personal property samples. All six
personal property samples included a bag with a completed inventory form for each youth’s
personal property. A review of the drop-safe logbook confirmed an entry for all three valuable
property samples and observations confirmed they were stored in a clear tamper-proof bag. An
observation of the center receiving youth personal property was not made because there were
no youth admissions conducted during the week of the annual compliance review while the
annual compliance review team was on-site. The center did not have any Department Central
Communications Center incident reports regarding youth property during the annual compliance
review period. The superintendent indicated all youth’s valuable property is placed in a safe
under video surveillance and then removed by intake staff and placed in a locked file cabinet
after being entered in the logbook. Only the intake staff and supervisors have access to the
valuable property stored in the locked file cabinet. Youth clothing and non-valuable property are
stored in a locked room with only intake staff and supervisors having access. Youth are made
aware all unclaimed property will be disposed of after thirty days when the youth leaves the
center. The center sends out a letter to encourage parent/guardians to pick up the property,
prior to disposal. Unclaimed personal property, held more than thirty-days after the
parent/guardian has been notified to either retrieve or make arrangements to retrieve the
property, is deemed abandoned and subject to disposal. The center will donate the abandoned
property to charity or place the property in a property envelope and send it to the regional
detention office. Seven youth were interviewed, and each indicated they signed for their
personal property collected during admission.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures (FOPs) to address youth releases. Three closed
youth case management records were reviewed. Each record had a copy of the Detention
Release form, which documented the on-duty supervisor reviewed all paperwork and court
documents related to each youth’s release. All three youth had their identification verified prior
to their release. The parent’s/guardian’s or responsible adult’s identifications were verified prior
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 20 of 56 (Revised July 2023)
to release for each youth, with a photocopied identification placed in each youth record. None of
the reviewed records identified the youth as an endangered person. Each youth and the person
to whom the youth was released were reminded of future court dates and signed the release
forms, with the exception of one youth, who was transferred to another detention center. The
date of admission and the date of release documented in each youth’s record correlated with
the dates documented in the Department’s Juvenile Justice Information System. An observation
of a youth release during the annual compliance review week validated the staff followed the
center’s FOPs when releasing the youth.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures to ensure each youth’s property is stored securely
during admission and returned to the youth or parent/guardian upon release. Three closed
youth case management records were reviewed. Two of three youth records contained a
Property Receipt form signed by each youth and parent/guardian upon release; however, the
remaining youth record was not applicable because the youth was transferred to another
detention center. Each record contained documentation verifying each youth was released to an
appropriate person to include a copy of their identification. In one applicable record the person
receiving the youth signed the Receipt of Medication form. In all three closed records each
youth and the person to whom the youth was being released were made aware of any health or
welfare issues, such as medical, mental health, substance abuse needs, and pending
appointments. The center had no examples of property held over thirty days during the annual
compliance review period. An observation of a youth being released from the center was
conducted during the week of the annual compliance review. The releasing staff, along with the
on-duty supervisor, verified the youth was allowed to be released to the parent/guardian and the
parent/guardian’s identification was copied for verification purposes. The youth signed for and
received their personal property back.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures 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 Thursday. An observation of the weekly detention
review for youth in secure detention was conducted during the annual compliance review week.
The superintendent, one assistant superintendent, the center’s lead teacher, the clinic manager,
the designated mental health clinician authority, the chief probation officer, the out of home care
manager for the local provider, two commitment mangers, the Department liaison, and the
probation and detention review specialist were present during the detention review meeting.
Participants who attended the detention review meeting signed a meeting roster. Participants
shared information regarding youth court dates, release dates, medical, mental health, and
educational concerns and needs. A review of detention review documentation, since the last
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 21 of 56 (Revised July 2023)
annual compliance review, revealed all required and applicable participants attended the
meetings either in person, telephonically, or by way of video conference. An interview was
conducted with the superintendent who indicated detention reviews are conducted weekly on
Thursday and confirmed the attendees. Youth court dates, release dates, detention hearings,
placement information, and other relevant information are discussed during the detention
review.
2.09 Daily Activity Schedule Failed 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 annual compliance review team observed youth participating in various activities, at various
times of the day, during the annual compliance review week. The daily activity schedule was
posted on each module; however, video review and logbook documentation indicated wake-
up/personal hygiene, mealtimes, visitation, recreation and physical activities, education,
bedtime, and daily groups have not been provided regularly to youth since the last annual
compliance review. Seven youth were interviewed. Five of seven youth indicated the center
does have a daily activity schedule; however, the remaining two youth explained the schedule
was random and sometimes youth don’t come out of their rooms. Seven staff were interviewed.
Four of seven staff confirmed the center has a daily activity schedule, which is followed, the
remaining three staff indicated the youth are not going to school daily, they are short staffed,
and the center attempts to follow the schedule; however, the dynamics of detention cause
interruptions to the schedule.
2.10 Educational Access (Critical) Failed Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. The center
integrates education into the daily schedule to ensure the integrity of the required minimum
instruction time distributed over a twelve-month period. The district approved calendar and daily
school schedule were reviewed, which incorporated the required 250 days of instruction, with
ten days used for teacher planning, and a minimum of twenty-five hours of instruction weekly. A
random sample of three days of video and logbook reviews, since June 5, 2024, when a
deficiency was assigned, showed youth entering class late and leaving early, falling short of the
required twenty-five hours of instruction a week. The youth entered class fifty-six minutes, and
one hour and forty-one minutes late and were released fifty-five minutes and three hours and
forty-six minutes early, with one day not going to class at all. Youth are enrolled in academic
courses through Orange County Public Schools and receive credit, as appropriate, when
courses are completed. Five of the seven youth interviews indicated they attend school Monday
through Friday. The remaining two responded with not having been every day or not going to
school while at the center. Five of the seven youth indicated the program is preparing them well
for the high school equivalency diploma (GED), high school, vocational school, employment
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 22 of 56 (Revised July 2023)
and/or college, and two stated the center was not preparing them well. Responses included
being a virtual student would be a benefit to all youth, as well as youth working with supportive
staff on-site. One youth indicated not having been to school, and another stated completing
lower-level work and there is not much talk about school. Seven staff were interviewed and four
staff stated the center is providing minimal interference of education instruction and three staff
stated the center is not. Staff comments included interference depends on the staffing levels,
youth not going to class daily, and staffing issues. The superintendent interview stated
educational movement occurs as staffing permits youth to be safely moved. On days education
movement is not possible, educational material is provided on the modules and the teachers sit
in sub control to answer any youth questions.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to provide for career education. Career educational
services are provided through the Orange County School District. The center provides
vocational competency development programs to all youth including communication,
interpersonal, and decision-making skills. Six of seven youth interviews indicated receiving math
and reading classes, five also mentioned science, three history and social studies, and one said
life skills classes. Another youth said physical education and English are provided and one
youth stated they are receiving no classes.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 23 of 56 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a contract with VitalCore Health Strategies, LLC to provide mental health
services at the center. The center has a designated mental health clinician authority (DMHCA)
who coordinates services and provides coverage at the center for forty hours each week. The
DMHCA is a licensed mental health counselor (LMHC) and has an active license through the
State of Florida, which expires on March 31, 2025. The center has a back-up DMHCA whose
license expires on March 31, 2025. The DMHCA provides oversight and coordination of mental
health services, including the completion of Assessments of Suicide Risk (ASRs), supportive
services, and individual therapy. The DMHCA also provides supervision of non-licensed staff.
During an interview and as confirmed by sign-in/out logs, the DMHCA confirmed being on-site
forty hours a week and being on call twenty-four hours a day, seven days a week. In addition,
the DMHCA confirmed overseeing mental health and substance abuse services at the center.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has a contract with VitalCore Health Strategies, LLC to provide licensed mental
health staff who deliver mental health and substance abuse services at the center. The center
had three licensed mental health counselors (LMHCs) and two licensed clinical social workers
(LCSWs) since the last annual compliance review, working under the direction of the designated
mental health clinician authority (DMHCA), who is also a LMHC. Both LMHCs and the LCSWs
have clear and active licenses in the State of Florida with expiration dates of March 31, 2025, as
evident by the copies of the licenses provided while on-site. Each licensed mental health staff
was licensed under the appropriate Florida Statutes chapter. The clinical supervisor ensures the
licensed clinical staff under their supervision are providing services they are qualified to provide
based on education, training, and experience.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has facility operating procedures (FOPs) regarding non-licensed mental health and
substance abuse clinical staff. The FOPs included requirements for direct supervision,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 24 of 56 (Revised July 2023)
education, and training. The center reported not having non-licensed mental health and
substance abuse clinical staff since the last annual compliance review.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures regarding the assessment of youth for mental
health and substance abuse needs upon admission. Seven youth mental health records were
reviewed, and each youth was screened using the Suicide Risk Screening Instrument (SRSI)
and each was entered into the Department’s Juvenile Justice Information System (JJIS). Four of
the seven youth were screened using the Massachusetts Youth Screening Instrument, Second
Version (MAYSI-2) and each was entered in JJIS. The remaining three youth’s MAYSI-2s were
completed but were not in JJIS due to Department-wide system outages during their
admissions; however, the staff completed paper MAYSI-2s at the time of admission. All
screenings were completed by trained staff on the date of intake. One youth’s MAYSI-2 was
invalid due to all negative responses. Each of the seven youth had a “YES” response on the
SRSI and each was placed onto suicide precautions. Each youth was referred for and received
a follow-up assessment through administration of an Assessment of Suicide Risk (ASR) by a
licensed clinical staff, as required. Alerts were entered in JJIS for each youth placed on suicide
precautions. Upon the completion of each referral, the superintendent was notified. Each of the
seven youth had an indication of elevated suicide risk upon completion of the MAYSI-2 and or
SRSI, and were referred for an ASR, as required. Each of the youth were noted on the MAYSI-2
and SRSI as needing a follow-up assessment for mental health and substance abuse needs;
each youth was referred for a comprehensive evaluation, and the center and mental health were
notified.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures regarding mental health and substance abuse
evaluations. One of the seven selected youth was applicable; therefore, the center provided two
additional youth mental health records for review. Each of the three applicable youth were
identified as in need of and referred for a mental health and substance abuse evaluation. Two
youth received a new comprehensive evaluation within thirty days of their admission and one
youth had an updated comprehensive assessment. Each of the three comprehensive
evaluations included all required elements. Each evaluation included recommendations which
corresponded with the youth’s diagnosed mental health or substance abuse disorders.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 25 of 56 (Revised July 2023)
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 provides mental health and substance abuse treatment to any youth determined to
need services and any youth who is in the center for more than thirty days. None of the seven
reviewed youth were applicable for treatment plans; therefore, the center provided an additional
three youth mental health records for review. Each youth received a mental health orientation
within fourteen days of their admission. Each applicable youth’s initial treatment plan included
all required elements, was in place within seven days of the onset of treatment and was signed
by all required parties. Each person who signed the plan was involved in the development of the
initial treatment plan. Each of the three individualized treatment plans were developed within
each youth’s thirty-first day of admission and included all required elements. Each youth’s plan
included individual, group, or family therapy prescribed at least weekly. All treatment notes were
documented on the Department’s Counseling/Therapy Progress Notes form. Each of the three
individual treatment plans were signed and dated by all required parties. Two of the three
individual treatment plans required one thirty-day review and the remaining required two
reviews, each review was completed within the required time frame. Each review was
completed and documented on the Department’s Individualized Mental Health/Substance Abuse
Treatment Plan Review form and revisions were documented on the forms. None of the youth
were an alleged victim of a Prison Rape Elimination Act (PREA) event; therefore, it was not
required to be included in the plan. None of the seven reviewed youth were applicable for
Mental Health/Substance Abuse Treatment Discharge Summaries. The center provided three
additional youth mental health records for review. Each of the three youth records included the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form. A copy of
each discharge summary was provided by mail to the juvenile probation officer (JPO),
parent/guardian, and youth. Each youth was released prior to clinical staff having each youth
sign the discharge summary. A mini-treatment team meeting was unable to be observed during
the annual compliance review week, as the center held the meeting the day before the annual
compliance review began.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 26 of 56 (Revised July 2023)
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.
Seven youth mental health records were reviewed for mental health and substance abuse
treatment. Mental health staff have adequate access to youth and confidential space to provide
treatment services. One of the seven youth was applicable; therefore, the center provided two
additional mental health records for review. Each applicable youth was assigned to a mini-
treatment team which consisted of mental health clinical staff, staff from a different service area,
youth, and parent/guardian, if available. Each youth’s plan included individual, group, or family
therapy prescribed at least weekly. A review of progress notes revealed each youth received
counseling according to the frequency required by the plan. All treatment notes were
documented on the Department’s Counseling/Therapy Progress Notes form. A review of group
sign-in sheets confirmed group therapy was limited to ten or fewer youth for mental health and
limited to fifteen or fewer youth for substance abuse treatment groups. None of the selected
youth required substance abuse treatment. One youth signed a form refusing mental health and
substance abuse treatment. The remaining two youth had required consents in their youth
mental health records. A review of group sign-in sheets confirmed groups did not have more
than the required number of youth and were held on the modules for the required time. During
interviews, three of seven youth reported not receiving mental health services, one rated the
services as fair, one rated them as good, and two rated them as very good. If a youth is in need
of treatment and has been in the center more than thirty days, according to the designated
mental health clinician authority interview, an individualized treatment plan is created to address
the youth’s needs.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has a contract with VitalCore Health Strategies, LLC to provide mental health
services, including the provision of a psychiatrist to provide psychiatric services to youth at the
center. During an interview, the designated mental health clinician authority (DMHCA) confirmed
the psychiatrist provides services once a week, youth medication management, initial
assessments, and follow-up on referrals. The psychiatrist holds a clear and active license with
the State of Florida with a specialty in child and adolescent psychiatry, which expires January
31, 2026. The back-up psychiatrist holds a clear and active license with the State of Florida with
a specialty in child and adolescent psychiatry, which expires March 31, 2026. The center does
not have a psychiatric advanced practice registered nurse. The center did not use tele-
psychiatry since the last annual compliance review; however, it is included in the contract. None
of the reviewed youth entered the center on psychotropic medication; therefore, the center
provided three additional youth for review. Each applicable youth received an initial diagnostic
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 27 of 56 (Revised July 2023)
interview within fourteen days of admission. Each of the three youth mental health records
included a completed Clinical Psychotropic Progress Note (CPPN) page three, which was
named psychiatric evaluation. Each initial psychiatric interview included the reason for referral,
medical, mental health and substance abuse history, Mental Status Examination, Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition diagnosis, treatment recommendations,
prescribed medication, frequency of medication monitoring/management, medication name, and
explanation of the need for psychotropic medication. Each youth was applicable for an in-depth
psychiatric evaluation within thirty days and each evaluation included all required elements.
There were no changes to medication for any of the applicable youth. None of the applicable
youth were under the supervision of the Department of Children and Families or eighteen years
of age. Each of the three youth had a signed Authority for Evaluation and Treatment in their
mental health record.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a Suicide Prevention Plan, detailing suicide prevention procedures. The plan
included identification and assessment of youth at risk of suicide, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and review process. The center has an established review process
for every serious suicide attempt or serious self-inflicted injury and a mortality review for a
completed suicide, including all required elements.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has a Suicide Prevention Plan in place which outlines the procedures for youth
identified as at-risk, which includes a review process for any instances of a serious suicide
attempt, self-inflicted injury, or completed suicide. Five of seven interviewed youth reported
being placed on suicide watch and each confirmed staff watched them the entire time they were
on suicide watch. Seven staff were interviewed and indicated when a youth expresses suicidal
ideations, they are to notify mental health and place the youth on constant sight and sound
supervision. Six stated they will search the youth and room, five said they document
supervision, and four would notify a supervisor. Five of seven reviewed youth were identified as
a suicide risk during admission screening, and one was identified through staff observation.
Each of the six youth had alerts entered in the Department’s Juvenile Justice Information
System (JJIS) upon identifying each youth with suicide risk and documenting each youth’s
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 28 of 56 (Revised July 2023)
precautionary observation (PO) status. Each PO log was completed in its entirety for each youth
and all alerts were closed appropriately following each youth’s removal from PO. Each youth
was placed on constant supervision as evident from the Suicide Precaution Observation Logs.
The clinical staff were involved in the process for each youth. Staff submitted a mental health
and substance abuse referral for each youth due to the youth being identified as having a risk of
suicide. The superintendent and clinical staff were notified for each youth. A review of logbooks
and ASRs confirmed each youth had an entry about being placed on and stepped down from
PO, which included instructions on what staff were to do while the youth was on PO. None of
the three youth were released while on PO. An Assessment of Suicide Risk (ASR) was
completed for all six applicable youth. Each of the applicable ASRs were documented on the
Department’s form which included all required elements. All ASRs were completed within
twenty-four hours of each youth being placed on PO. In two of the applicable six records, a
Follow-Up ASR was required due to each youth being stepped down to close supervision. Each
ASR included recommendations for supervision and follow-up services, according to the
center’s suicide prevention plan. Staff entered the date and time each youth was placed on and
discontinued from PO in JJIS. The designated mental health clinician authority (DMHCA) and
the superintendent consulted in regard to each youth being placed on and stepped down from
PO. Each ASR was administered by licensed mental health staff. During an interview, the
DMHCA reported prior to a youth’s level of supervision being changed, they meet with the
center’s administration team and the decision is documented in the center logbooks, ASR, and
Electronic Medical Record.
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
Three of the seven reviewed youth were placed in secure observation. The designated mental
health clinician authority (DMHCA) and superintendent authorized each placement. Two of the
three youth’s parents/guardians were notified of placement, and for the remaining one youth the
notification was not completed. The juvenile probation officer was notified of placement for one
of the three youth; the remaining two youth did not have documentation of notifications. Each
placement had documentation of room assignment. Two of the three youth had an Assessment
of Suicide Risk completed within eight hours of placement, the remaining youth was Baker
Acted before the eight-hour time frame. Each youth had a completed Health Status Checklist
and precautionary observation logs. None of the youth were placed in secure observation
beyond twenty-four hours. Mental health staff provided supportive counseling while each youth
was in secure observation. A conference was held with the superintendent and a licensed
mental health counselor prior to the reduction of supervision level for each youth and
documented in the mental health record by the clinical staff. Each secure observation was
documented in the logbook, as required.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 29 of 56 (Revised July 2023)
3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures for youth placed on suicide precautions. Seven
youth mental health records were reviewed for the completion of Suicide Precaution
Observation Logs. Six of the seven youth had been placed on precautionary observation (PO)
and were applicable for the completion of Suicide Precaution Observation Logs. The center
used the Department’s Suicide Precaution Observation Logs. Each youth had Suicide
Precaution Observation Logs for the duration of their placement. The appropriate level of
supervision and observations of each youth’s behavior was documented in real time and did not
exceed thirty-minute intervals. Each log was reviewed and signed by the shift supervisor and
mental health staff. None of the youth displayed any warning signs while on PO. Five of the six
applicable logs had documentation of safe housing requirements. One youth had eight logs out
of nine which did not document safe housing requirements. Video review of two youth on PO
was conducted and confirmed the log was completed in the increments as required; however, it
was documented on the log the youth was lying down at 10:30 p.m., and the video review
revealed the youth was woken up and removed from the module at 10:23 p.m. to return at 10:36
p.m. It should be noted the clock used to document the time of the checks and the clock of the
video recording device are not set to coordinate.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Seven in-service and seven pre-service staff training records were reviewed and confirmed
suicide prevention training was completed as required. The center conducted suicide drills
quarterly on each shift. The center has a total of seven suicide response kits located on each of
the six modules and one in master control. Each suicide kit is co-located with a first-aid kit.
During interviews with seven staff, it was reported the suicide response kits are located in
master control, medical, sub control, intake, and the dining hall. A review of mock suicide drills
for the last year was conducted. No youth were used in drill simulations. Mock suicide drills
were held no less than quarterly on each shift, for all staff who come in contact with youth, and
were in response to a suicide attempt and/or incident of serious self-injury. Drills are reviewed in
shift briefings and are available for review to ensure staff who did not participate can review the
conducted drill.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 30 of 56 (Revised July 2023)
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a combined Emergency Services Plan, detailing crisis intervention procedures.
The plan included notification and alert system, means of referral, communication, supervision,
documentation, and review.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures regarding the process for emergency mental health
and substance abuse services. The center’s Emergency Care Plan was signed June 7, 2024, by
the superintendent, and is located in master control. The plan included immediate staff
response, notifications, communication, supervision, authorization to transport for emergency
mental health or substance abuse services, transport for emergency mental health evaluation
and treatment, transport for emergency substance abuse assessment and treatment,
documentation, training, and review.
3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures to ensure any youth demonstrating acute
psychological distress receives a detailed evaluation or Crisis Assessment, by a licensed mental
health professional. The center did not have any Crisis Assessments during the annual
compliance review period.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 31 of 56 (Revised July 2023)
3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures to ensure any youth believed to be an imminent
danger to themselves or others because of mental illness or substance abuse impairment is
provided emergency services. Seven youth individual mental health records were reviewed, two
were applicable. One record contained documentation of one Baker Act incident, and one
record contained documentation of two Baker Act incidents. Each of the three incidents had the
youth placed on one-on-one supervision, with documentation of staff maintaining precautionary
observation (PO) until the youth’s release as required. Upon re-admission to the center after the
Baker Act, all three incidents had documentation of the youth being placed on suicide
precautions and a referral was made to mental health. One of three incidents documented the
youth was placed on suicide observation and a Mental Status Examination was completed; the
remaining two incidents the youth was placed on PO and was not applicable for a Mental Status
Examination. All three incidents documented each youth was maintained on a minimum of
constant supervision until properly transitioned to a lower level of supervision, determined by an
assessment completed by a mental health professional and mental health staff conferring with a
licensed supervisor and superintendent or designee. Due to Department-wide system outages
the center could not enter and update suicide and mental health alerts.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 32 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 has a board-certified licensed physician who meets all of the requirements for
independent and unsupervised practice in the State of Florida serving as the designated health
authority (DHA). A review of the DHA’s license revealed it was active and clear expiring on
January 31, 2025. The DHA specializes in internal medicine. A review of the DHA’s sign-in logs
from the time of the last annual compliance review indicated the DHA was on-site at least once
a week as contractually required. The center has a back-up DHA who is a licensed physician
and meets all the requirements for independent and unsupervised practice in the State of
Florida. The back-up DHA holds an active and clear license with an expiration date of January
31, 2025. The back-up DHA was not utilized during the annual compliance review period. The
center utilizes tele-health and has facility operating procedures in place regarding how tele-
medicine is utilized. The center utilized tele-health appointments during the annual compliance
review period and provided tele-health logs which documented the name of the youth, date and
time of service, and the type of service provided. The DHA was interviewed and summarized
their role as conducting medical reviews, periodic evaluations, reviewing Comprehensive
Physical Assessments and sick call, in addition to reviewing medical facility operating
procedures annually or as needed. The DHA advised they communicate with program staff
regarding youth needs in person when on-site, and through email and telephone as needed.
The DHA is available twenty-four hours a day, seven days a week. The DHA provides on-site
clinical services as requested by nursing staff. The DHA ensures off-site records are reviewed
when on-site, or they are briefed by the nurse on the telephone. This call is documented in the
chronological progress notes and signed off on the next visit.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has facility operating procedures (FOPs) governing all healthcare protocols. The
designated health authority (DHA) conducts an annual review of all respective treatment FOPs.
The last review of healthcare FOPs by the DHA was conducted on August 12, 2024, the
superintendent reviewed and signed the FOPs on June 7, 2024, and the psychiatrist reviewed
all FOPs related to psychiatric services and psychotropic medication on August 12, 2024. The
DHA authorized and approved all treatment protocols and standing procedures. All nursing staff
reviewed, signed, and dated a cover page for all FOPs, treatment protocols, and other
procedures on July 2, 2024, as required. Two new healthcare staff were hired since the time of
the last annual compliance review. Documentation was provided which confirmed both staff
received a comprehensive clinical orientation to the Department’s healthcare policies and
procedures, given by a registered nurse or designated, licensed healthcare professional.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 33 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 has facility operating procedures requiring 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. Seven youth Individual Healthcare
Records (IHCRs) were reviewed, and all youth had a valid AET maintained in their IHCR, all of
which were signed prior to providing medical services by a Department representative. Each of
the IHCRs had either the original AET or one which had the word “copy” stamped on the form.
Six of the seven were also signed by the parent/guardian. The remaining youth was over
eighteen years of age and had an AET for youth eighteen years old signed, which did not
require a parent/guardian signature. Three of the seven youth were over the age of eighteen
and each had a documented release of information.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center has facility operating procedures which require the notification of a parent/guardian
when there are significant changes in the youth’s condition and to obtain consent when new
medications and treatments are prescribed. Seven youth Individual Healthcare Records
(IHCRs) were reviewed and four were applicable for parental/guardian notification/consent. The
remaining three youth were over the age of eighteen and did not require parental/guardian
notification. The written notifications were filed in each of the four applicable records utilizing the
required Department form, documentation verified copies were sent to each of the
parent/guardians, and verbal consent was obtained. None of the IHCRs were applicable for
parental/guardian notification regarding over-the-counter medications which were not covered
by the Authority for Evaluation and Treatment. One youth was applicable for taking psychotropic
medication at admission and the IHCR documented a staff witnessed all telephone call attempts
and conversations for psychotropic medications. Four youth received new medications and
contact with the parent/guardian was documented in the progress notes. The written
parent/guardian notifications were documented in the IHCRs, as required. None of the youth
were under the custody of the Department of Children and Families; therefore, a court order
was not required for any treatment procedures. None of the youth received vaccinations at the
center, or had new psychotropic medication prescribed. Immunization records were verified in
five of seven reviewed IHCRs within thirty days of admission. The remaining two youth had not
been at the center thirty days at the time of the annual compliance review. The nurse was
interviewed and advised youth over the age of eighteen are responsible for authorizing their
healthcare, and authorizing release of their healthcare information and records. Youth provide
verbal consent and sign for treatment and/or medication received. The nurse also advised
parental/guardian notification is made to inform the parent/guardian of significant changes in the
youth's condition, to obtain consent when new medications are ordered or stopped, or if a youth
sent off-site for care has treatments prescribed. These notifications are first done verbally and
followed with a letter. In the case of an emergency, 9-1-1 is called for circumstances which
require immediate medical attention or evaluation, and the designated health authority is
contacted. When a new psychotropic medication is prescribed, discontinued, or the drug dosage
is significantly changed, parent/guardian verbal consent is obtained. This consent is
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 34 of 56 (Revised July 2023)
documented on a written Parental Notification/Consent form, showing attempt to obtain the
signed parent/guardian consent. The nurse also advised immunization records are obtained
through Florida Shots and reviewed upon admission.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center has facility operating procedures to ensure youth are screened upon admission for
any healthcare concerns which may need a referral for further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed. All seven contained a
Medical and Mental Health Admission Screening form which was completed, on the date of
admission. All of the Medical and Mental Health Admission Screening forms were completed by
a juvenile justice detention officer (JJDO) or juvenile justice detention officer supervisor
(JJDOS), and six were reviewed by licensed medical staff within twenty-four hours. The
remaining one was reviewed five days late. Five youth were applicable for notification to the
designated health authority (DHA) due to chronic conditions and notifications to the DHA were
documented in each IHCR. Three of the seven youth were applicable for healthcare admission
re-screenings, and all three applicable IHCRs contained a completed rescreening. Each re-
screening was completed by a JJDO or JJDOS and reviewed by the medical staff within twenty-
four hours of screening. None of the youth had a qualitative urine pregnancy screening test. The
nurse was interviewed and said all youth receive a healthcare screening on the day of
admission. If youth arrive after medical staff are gone for the day, the youth are seen by medical
the next day. Supervisors or master control staff notify medical of any new admissions, as well
as receiving medical screening packets for any new youth admission. Admission screenings are
completed by JJDOSs, and the nurse will sign the third page of the screening form. If youth
change physical custody, a new screening is conducted, and the youth is assessed for any
changes in medical conditions. If youth are admitted with serious or chronic conditions, the
nurses will notify the DHA by telephone immediately. This notification is documented on the
intake log and admission form.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures which cover all required health education topics.
These include access to medical care, sick call, what constitutes an emergency and when to
notify staff, medication issuance process with side effect monitoring, the right to refuse care and
how it is documented, what to do in case of sexual assault or attempted sexual assault, the
non-disciplinary role of healthcare providers, and a review of the list of healthcare contacts to
ensure accuracy. Seven Individual Healthcare Records were reviewed, and all indicated each
youth received a general healthcare orientation which was documented on the required
Department form.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 35 of 56 (Revised July 2023)
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center maintains facility operating procedures which require notification to the designated
health authority (DHA) of all youth admitted requiring emergency care. A review of seven
Individual Healthcare Records (IHCRs) reflected five youth were applicable for known or
suspected chronic conditions. Evidence of referrals to the DHA were identified for the five
applicable youth. None of the youth were identified as in-need of emergency care upon
admission. A review of all five applicable youth records confirmed the DHA was notified within
twelve hours of admission, but no later than noon the day following admission. Four youth
records were applicable for being admitted while taking psychotropic medication and the
psychiatrist was notified of each youth’s admission. An interview with the nurse indicated the
nurse contacts the DHA by telephone as soon as a youth with chronic condition is seen at the
clinic. All nursing staff are responsible for notifying the DHA. Notifications to the DHA are
documented on the intake log, as well as the admission form.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center maintains facility operating procedures requiring completion or review and updating
of the Department’s Health-Related History (HRH) form. The center utilizes and completes the
Department’s HRH form for all youth admitted into the center’s physical custody. A review of
seven Individual Healthcare Records (IHCRs) indicated the applicable HRH forms were
completed prior to or at the same time as the Comprehensive Physical Assessment (CPA) for
each youth. Each applicable HRH form was completed by a licensed nurse within seven days of
each youth’s admission to the center. A review of seven IHCRs indicated the designated health
authority reviewed each HRH. A review of seven HRH forms confirmed signatures and dates for
the most current admission. An interview with the nurse indicated the nursing staff are
responsible for completing the HRH and it is completed within seven days.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains facility operating procedures requiring a Comprehensive Physical
Assessment (CPA) to be completed or updated for all youth admitted to the center to determine
the health and wellbeing of each youth, documentation of when any part of the exam is not
conducted or refused by a youth and included the tuberculosis screening and rescreening
process. A review of seven Individual Healthcare Records (IHCRs) indicated four youth were
applicable for physical assessments, the remaining three youth had been at the center for less
than seven days. Each assessment was completed on the Department’s CPA form. All four
records contained a current CPA on file at the time of admission. Each CPA was completed or
reviewed within seven days of the youth’s admission and signed by the designated health
authority (DHA) or the advanced practice registered nurse. Each CPA was completed in full to
include the Medical Grade, tanner stage, cardiovascular, body mass index, visual acuity field,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 36 of 56 (Revised July 2023)
and most recent tuberculosis skin test (TST). The four applicable youth had a current CPA with
no changes in the youth’s medical condition, and it was signed off as reviewed by the DHA. A
focused evaluation for four applicable youth was completed. All sections of the CPA for the
applicable youth were marked with an “O” or “X”. Two of the four applicable youth records
indicated each youth refused part of the exam and the refusal form was signed by each youth.
None of the youth were applicable for an update to the Department’s Problem List. In all four
IHCRs there were verified TST results from within the last year documented on the CPA and
Infectious and Communicable Disease form, and all matched. None of the reviewed youth were
applicable for a new tuberculosis screening or further evaluation. An interview with the nurse
indicated the DHA completes the CPA within seven days of admission. A new CPA is needed
every two years if the youth is Medical Grade one. If the youth’s Medical Grade changes from
one, a new CPA is created. Tuberculosis screenings are completed within seventy-two hours of
admission if not already documented in each youth IHCR within the past year. Youth are given a
TST yearly and results are documented on the CPA, Infectious and Communicable Disease
form and the tuberculosis tracking log. Gynecological exams are not routinely completed for
females.
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 has facility operating procedures to ensure all youth are evaluated and treated for
sexually transmitted infections (STIs) and human immunodeficiency virus (HIV), if necessary.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and three were applicable
for STI screenings. Each of the three applicable youth were clinically screened and evaluated
for STIs. Two of the three youth were tested for STIs. The third youth was waiting to be
scheduled by the designated health authority (DHA), as this youth had recently been admitted.
In all three IHCRs the STI testing results were documented on the Infectious Communicable
Disease (ICD) form and filed in the lab section of each IHCR. A review of all seven youth IHCRs
revealed none of the youth gave consent for a gynecological exam, and none were out of the
Department’s custody and returned with symptoms which required a rescreen. All seven youth
were offered counseling, testing, and if indicated, treatment/referral for HIV. One youth
consented to being tested. The consent was documented, and the HIV test results were filed in
a sealed envelope marked “CONFIDENTIAL” in a manner consistent with Florida Administrative
Code, with confirmation of the DHA review on the sealed envelope. The pre-test/post-test
counseling was documented in the IHCR for the youth and confidentiality for the youth was
protected by not including the HIV status on the internal alert system. Seven youth were
interviewed, and six indicated they can ask for a HIV test, while one youth said they could not
ask for one.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures which require for all youth in the center to be able
to make sick call requests and have their complaints treated appropriately through the sick call
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 56 (Revised July 2023)
system. The center must respond appropriately and in a timely manner and document all sick
call encounters. Seven youth Individual Healthcare Records (IHCRs) were reviewed, and one
was applicable for having requested sick call at the center. Two more examples were provided.
Each of the three applicable youth sick calls were documented on the Sick Call Referral Log.
None of the three applicable youth presented with similar sick call complaints three or more
times within a two-week period or with complaints of severe pain with which medical staff were
unfamiliar and required to be treated as emergencies with an immediate referral. The center
utilized an electronic Sick Call Request form, and all three applicable youth sick call requests
were documented on the electronic Sick Call Request form. The registered nurse (RN)
completed the Sick Call Request form for two of the three youth. The third youth had the sick
call conducted by a licensed practical nurse (LPN), and this was reviewed by the RN within
twenty-four hours. Each Sick Call Request form was filed in the IHCR in reverse chronological
order. None of the youth were in restricted housing. The three applicable sick call encounters
were documented on the Sick Call Index and corresponded with the Sick Call Request forms. A
review of the sick call hours posted on the clinical door showed sick call is conducted daily, as
required or needed. The center has approved treatment protocols for RNs and LPNs. Sick call is
only conducted by licensed staff; however, the center also has procedures in place for shift
supervisors to review all sick call requests as soon as possible and within four hours if there is
not a licensed nursing staff on-site. A review of the center’s policy was completed and showed
the shift supervisor will discuss with youth about medical issues for youth in confinement. If the
sick call complaint is of a non-emergent issue, the shift supervisor will input the sick call request
for the youth to be seen at the next scheduled sick call time when the nursing staff are working.
Nursing staff are required to make daily visits when youth are in confinement. All youth in
confinement will receive all prescribed medication, as required. The nursing staff will evaluate
youth every two hours if a youth in confinement has an active medical condition. A sick call was
not requested during the week of the annual compliance review; therefore, one could not be
observed. The nurse was interviewed about the sick call process and advised when youth notify
staff of a medical complaint, staff then input a sick call through the electronic sick call system.
The nurse further advised nursing staff then retrieve sick call lists twice a day and have twenty-
four hours to see the youth; however, they normally see youth sooner. The nurse also said
youth are seen by either an RN or LPN and if a LPN completes sick call, the RN reviews them
within twenty-four hours. If the RN will not be in within twenty-four hours, the LPN will call the
designated health authority (DHA) to review the sick call. When the DHA is on-site, the DHA will
conduct sick call. The youth are assessed, and vital signs, treatment, education, and follow-up
plans are completed. The nurse also confirmed sick call is conducted daily from 8:00 a.m. to
10:00 a.m., or as needed in the clinic. The nurse also said youth presenting with similar sick call
complaints three or more times within a two-week period are referred to the DHA and will be
added to the list to be seen by the DHA. The nurse confirmed youth in confinement are
assessed and evaluated for medical complaints or distress every twenty-four hours and this is
documented in an episodic note. Seven staff were interviewed, and one said the nurse reviews
sick call requests and conducts sick call. The remaining six said medical staff review sick call
requests and conduct sick call. Seven youth were interviewed, four said they would be seen
within one day if they request a sick call, and three said they did not know because they have
never requested sick call. Three youth said nurses conduct sick call, three said they did not
know because they had not requested sick call yet, and one said they had just submitted their
first sick call request the previous day and did not know how long the process was.
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 has facility operating procedures (FOPs) detailing a comprehensive process for the
provision of episodic and first-aid care. Seven Individual Healthcare Records (IHCRs) were
reviewed and three were applicable for youth who had an on-site first-aid or episodic care event
at the center. Each of the three applicable incidents showed the on-site care provided by the
licensed healthcare staff was documented in problem-oriented charting, which included
subjective, objective, assessment, and plan (SOAP) elements. In all three instances, the nature
of the complaint, findings, treatment rendered, and education/instruction were provided. None
required referral to off-site care, or parental/guardian notification, and two required follow-
up/future care. One youth required to be placed on the alert list because of the medical
encounter. The episodic care events were documented in the Episodic Care Log for each of the
three applicable youth. The center has a total of eighteen first-aid kits. One is in each of the six
housing modules, one is in intake, one is in the training office, one is in the kitchen, one is in
medical, one is in master control, and seven are used for transportation. Three first-aid kits were
checked during the week of the annual compliance review; B-3 module, medical, and master
control. Each was fully stocked with designated health authority approved contents. The nursing
supervisor physically checks each of the first-aid kits monthly, to ensure the contents are
maintained and stored in accordance with guidelines to ensure they are not expired or need
replenishing. The nurse provided documentation which confirmed the checks were conducted
monthly, as required. The center has three automated external defibrillators (AEDs) located in
master control, the east clinic, and the west clinic. The AED procedures are located with each
AED. On-site nursing staff conduct monthly checks for all AEDs and documentation was
provided which verified monthly checks have been conducted during the annual compliance
review period. A review of all three AEDs indicated all batteries expire on May 20, 2027, and
pads expire on October 23, 2024. The AED batteries and pads were last changed on November
7, 2023. A self-test was conducted for each AED, and all were operational. The center provided
documentation which confirmed medical emergency drills were conducted at a minimum
quarterly on each shift for the last year. A total of thirty medical drills were conducted in the past
year. The drills included the use of cardiopulmonary resuscitation (CPR)/AED, which was
practiced annually. Each of the drills simulated an episodic care event which called for
immediate first-aid, administration of CPR techniques, and the initiation of the emergency
procedures to follow when a life-threatening emergency occurs. A comparison of the center’s
staff roster with the drill sign-in sheets revealed all but one direct care staff participated in at
least one drill which included the use of CPR during the past year. A list of emergency numbers,
including the Poison Information Control Center, was posted and accessible for non-licensed
and licensed staff and inaccessible to youth. The center provided documentation which
confirmed supervisory level direct care staff were trained on the administration of the
epinephrine auto-injector by a registered nurse. A review of seven pre-service and seven in-
service staff training records verified each staff completed the required training in episodic, first-
aid, and emergency care. The center has a FOP which details the use, access, and inventory of
Naloxone (NARCAN). The FOP indicates the center will maintain at least one prescribed stock
nasal spray kit for emergency purpose of accidental overdose for youth. During the annual
compliance review week, the center had two doses in stock, in the locked medication cart,
which is kept in the medical office. The FOP indicates NARCAN should not be ordered for each
individual youth. The center maintains NARCAN in the medical office and the nursing and
supervisory staff have access to NARCAN. A review of training documentation verified each
staff with access to NARCAN received training on the use of NARCAN. Documentation
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 39 of 56 (Revised July 2023)
confirmed the nursing staff conducted a weekly count of NARCAN during the annual compliance
review period. The nurse was interviewed and said episodic care is conducted by licensed staff
and notes are entered into the Electronic Medical Record (EMR) in an Episodic Care Progress
Note. The nurse said these notes cover all elements of a SOAP note. In the event episodic care
is provided by non-licensed Department staff, these notes shall be documented on a Report of
On-Site Care by Non-Healthcare Staff form. Episodic care provided by non-healthcare staff
must have a follow-up evaluation by medical staff when they return to the center. The nurse also
said youth who are sent off-site for care are documented in the Off-Site Care Log in the EMR.
The nurse verified and confirmed all of the information regarding the center's three AEDs. The
nurse also said the medical drills are conducted monthly on each shift. Seven staff were
interviewed, and all said they could call 9-1-1 if needed. Seven youth were interviewed and two
said medical services were good, two said they were fair, one said very good, and two said they
have not needed medical services.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures requiring timely referrals, documentation, and
coordination of medical services to an off-site healthcare provider, both emergent and non-
emergent, for youth, as required by the Department. Seven youth Individual Healthcare Records
(IHCRs) were reviewed and one was applicable for off-site care. Two more examples were
requested. Each of the three applicable IHCRs contained documentation which verified the
Summary of Off-Site Care Consultation Report form was utilized. In addition, the off-site care
was also documented on the Episodic Care Log. Parental/guardian notifications were
documented for two youth. The third youth was over the age of eighteen and did not require
parental/guardian notification. All three IHCRs contained discharge and other applicable
documents. The designated health authority (DHA) notification, DHA review and signature of
off-site care findings, and the Department’s Summary of Off-Site Care Consultation Report form
were filed in all the applicable IHCRs. Two of the youth required follow-up appointments and
both had the referrals entered in the center’s referral tracking log. The nurse was interviewed
and advised youth sent off-site for first-aid or emergency care are tracked on the off-site care
log. The nurse also said they review the hospital orders with the DHA and the DHA gives the
orders to follow at the center. The nurse further advised they ensure the DHA reviews and
initials all off-site care findings by placing them in a folder for the DHA to review when the DHA
is on-site. The nurse said nursing staff track follow-up referrals, testing, and appointments by
documenting them on a calendar and sending an email communication to staff. The Summary
of Off-Site Care form is utilized if a youth is sent off-site and follow-up testing, referrals, or
additional appointments are requested by the provider.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center has facility operating procedures which require youth who have chronic conditions to
receive regularly scheduled evaluations and necessary follow-up. Seven youth Individual
Healthcare Records (IHCRs) were reviewed and two were applicable for chronic conditions.
One more youth record was requested for a youth who had been at the center for more than
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 40 of 56 (Revised July 2023)
ninety days. Each of the three applicable youth were identified on the Medical/Mental Health
Screening form with a current chronic condition. None of the youth had a communicable
disease, and none were undergoing treatment for a physical health condition. Two of the
applicable youth were taking prescribed medication on an on-going basis. All three applicable
youth were placed on a chronic list, as required. One of the applicable youth had been at the
center for at least ninety days. The youth had periodic evaluations every ninety days and prior to
renewing prescription medication which was expiring, and the record contained progress notes
indicating the ninety-day periodic evaluation was conducted within the required period. None of
the youth were pregnant nor taking anti-tuberculosis medication; therefore, they did not require
more frequent evaluations. None of the youth had off-site evaluations and there were no
indications of any lapses in care or missed evaluations. In both applicable cases, the problem
list was updated as required. The nurse was interviewed and advised if a youth has a chronic
condition, an alert is entered, the designated health authority (DHA) is notified and sees youth
with chronic conditions, and chronic conditions are listed in the chronic condition binder for
tracking. The DHA was interviewed and indicated youth with chronic medical conditions are
seen for periodic evaluations a minimum of every ninety days. The DHA also said periodic
evaluations may be more frequent based on plan of care established at time of the
Comprehensive Physical Assessment or focused medical evaluations, and the list of youth with
chronic medical conditions and periodic evaluations is maintained by the clinic nurse.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center has facility operating procedures requiring medication to be stored, inventoried, and
provided in a safe and effective manner to youth. Seven youth Individual Healthcare Records
(IHCRs) were reviewed, and all were applicable for medication. Two youth were taking
medication at the time of admission which were verified prior to being admitted to the center.
The prescription verification included utilizing the Department’s Prescription Medication
Verification Checklist form and documentation in the chronological progress note. The
designated health authority (DHA) was contacted to obtain an order to resume the medications,
and this notification was documented in the chronological progress note for each of the youth.
The remaining youth had medications ordered after admission. All medications had a current,
valid order, were administered pursuant to a current prescription, and the DHA placed an order
on the Practitioner Order form for all youth with medications. None of the youth were in
restricted housing; therefore, they did not require nursing staff to completed daily visits. All the
youth required over-the-counter medications not listed on the Authority for Evaluation and
Treatment. The Electronic Medical Record (EMR)/Medication Administration Record (MAR) was
utilized for all youth to document all medication and treatment including start and stop dates.
None of the medications were administered by non-healthcare staff. There were no lapses or
errors noted for any medication administration. The nursing staff documented weekly side effect
monitoring on each MAR. None of the youth refused any medication. The MARs contained all
required elements, to include youth name, Department identification number, date of birth,
allergies, precautions, Medical Grade, medical alerts, and a current picture of the youth. Staff
and youth initialed each administered medication entry. None of the youth were taking any
parenteral medication. Two youth were prescribed psychotropic medication prior to admission
and the DHA and psychiatrist were notified of each youth’s admission, and both received an
initial diagnostic interview within fourteen days of admission. One youth was applicable for
medication monitoring reviews every thirty days, and these were conducted as required. The
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 56 (Revised July 2023)
remaining youth had not been at the center for thirty days at the time of the annual compliance
review week. The center did not have any standing orders, emergency treatment orders, or pro
re nata orders for psychotropic medications. An observation for a medication administration was
conducted during the annual compliance review week. The youth provided verbal consent prior
to observation. The youth was escorted to the medical office by the assigned officer and
approached the nursing staff individually. The nurse identified themself and stated why the
youth was there. The nurse verified the youth’s allergy and alert status, prepared and
administered the medication, and observed the youth to ensure the medication was swallowed.
Both youth and nursing staff signed the MAR, and the medication administration was
documented as required. The nurse did not pre-pour the medication. The nurse was interviewed
and said if a youth arrives with medication, nursing staff review the medication to ensure it is
from a licensed pharmacy with a current, patient specific label intact on the original medication
container to accept the medication. All medications must have a current, valid order, and are
given as ordered on current prescription or the Practitioner Order form. The DHA or psychiatrist
are contacted to obtain the order to resume the specified medications prescribed prior to
admission. The nurse also said the program uses the Department’s MAR form. The nurse said
non-licensed supervisors are trained to assist in medication administration and the approved
staff list is in the front of the medication book. The center’s medication pass times are daily at
7:00 a.m., 12:00 p.m., and 7:00 p.m. Seven youth were interviewed and three said the nurse
administers medication. One said they first requested medication the previous evening and was
awaiting medication administration. Three youth said they do not take medication. Seven staff
were interviewed all said they do not provide medication to youth. The center has a FOP for
medication disposal, this requires a registered nurse to be responsible for the disposal of
medications in conjunction with the pharmacy consultant. Controlled and non-controlled
medications must be disposed of by utilizing the Drug Enforcement Agency (DEA) approved
Drug Buster disposal system in accordance with the state board of pharmacy and DEA disposal
plan.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has facility operating procedures requiring for any medical equipment classified as
sharps and stock medications to be secured and inventoried by using a routine perpetual
inventory with a descending count as each sharp is utilized and disposed of, or when the
medication is utilized. The clinic, including the medication cart, sharps, and medication stock
storage area, was inspected during the annual compliance review week. All medical equipment
classified as sharps were inventoried and secured in a locked cabinet, using a perpetual
inventory with descending count as each item was used and disposed. All medications
inspected were properly identified and secured in the locked medication cart. The medication
cart was clean and organized with stock items separate from youth-specific medications.
Narcotics and controlled medications had individual perpetual descending inventories and were
secured in a separate locked area inside of the medication cart, behind two locks. Injectable,
topical, and liquid medications were stored separately and securely maintained. The oral
medications were stored separate from injectable and topical medications. The center maintains
two refrigerators in medical, which are utilized for medications requiring refrigeration. A review
was conducted of the medical binders for sharps and over-the-counter (OTC) medications which
confirmed a perpetual inventory is maintained for OTC medications. Supervisory floor staff were
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 42 of 56 (Revised July 2023)
trained by the center’s registered nurse on the delivery and oversight of medication
administration. Three different controlled medications, three different sharps, and three different
OTC medications were physically observed and counted. These counts were compared with the
counts listed on the individual inventory sheets for each of these items. All of the physical
inventories matched what was listed on the inventory sheets for each of the items. The nurse
advised any discrepancies in medication inventories are double checked to confirm the
discrepancy. Medical staff would be asked to determine if the medication was administered and
not documented. If unable to determine the location of the missing medication, a report would
be submitted to the supervisor and the Department’s Central Communications Center. The
nurse also advised medical staff utilize destroyer solution to dissolve medications, and if a
controlled substance is being destroyed, the controlled substance is dissolved only when the
pharmacist is on-site. The destruction of any controlled substance is documented in the
pharmacy book. The nurse was interviewed and confirmed all controlled medications are
disposed of by nursing staff and the pharmacy consultant. The nurse also stated all controlled
substances such as narcotics are kept in a locked compartment within the locked medication
cart. The nurse stated the center has a current agreement with a consultant pharmacist, who is
on-site monthly and reviews the medication cart, medication cabinets, medication refrigerators,
helps in the destruction of medications, ensures all items are labeled appropriately, reviews
Medication Administration Records and sharps, and ensures licenses are up to date. The nurse
also confirmed the center maintains a copy of the consultant pharmacy license on-site.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures (FOPs) requiring the implementation of infection
control procedures including prevention, containment, treatment, and reporting requirements
related to infectious diseases, according to the Occupational Safety and Health Administration
(OSHA) federal regulations and the Center for Disease Control and Prevention (CDC)
guidelines. This includes pre-service and in-service training for all staff, and education for youth
on infection control at the time of intake and subsequently when the need is identified. Seven
youth Individual Healthcare Records were reviewed, and all received infection control training
within seven days of admission. This training included hand-washing techniques, universal
precautions, prevention/transmission of communicable diseases, vaccinations, and CDC
guidelines on infection control. A review of the center’s Exposure Control Plan was conducted
and confirmed the plan was written in accordance with OSHA standards. These standards
included all required elements of risk assessments and methods of compliance. A review of the
center’s infection control procedures was conducted and confirmed they included prevention,
containment, treatment, and reporting requirements related to infectious diseases, according to
the OSHA and CDC guidelines. The infection control procedures included common, infectious
childhood diseases, self-limiting, episodic contagious illnesses, viral or bacterial infectious
diseases, Tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus, infectious
diseases caused by bloodborne pathogens, other outbreaks or epidemics caused by another
infectious agent, outbreaks of pediculosis and/or scabies, Methicillin-Resistant Staphylococcus
Aureus, food borne illnesses, bio-terrorist agents, and chemical exposures in the workplace.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 43 of 56 (Revised July 2023)
The FOPs also addressed needle stick post-exposure evaluation. The procedures for needle
stick post-exposure evaluation include identification and status of the source of the individual,
testing of the blood of the individual, documenting route of exposure and circumstances related
to incident, referring the individual for medical attention, offering post-exposure prophylaxis and
counseling, informing the individual on potential illnesses to be alert for, and assuring the
process is effectively carried out. The procedures also contain provisions for staff to have
access to personal protective equipment and Hepatitis B immunizations. The nurse advised the
center did not have any infectious diseases or sexually transmitted infections during the annual
compliance review period which had to be reported to the local health department, the CDC,
and the Department’s Central Communications Center (CCC). The superintendent maintains a
separate file containing all documents of youth and staff who have experienced a
facility/occupational exposure; however, indicated the center has not had any instances of
occupational exposure during the annual compliance review period. A review of seven pre-
service and seven in-service staff training records was conducted and showed each staff
received training on the center’s Exposure Control Plan. The nurse was interviewed and
advised the Infection and Exposure Control Plans are available to staff in the policy binder, and
the registered nurse manager conducts exposure control training for staff and youth. Youth are
trained in infection control procedures during admission. The nurse also said the center
routinely uses health department services to provide immunizations, dental care, and prenatal
care to youth.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures (FOPs) which require access to prenatal care for all
pregnant youth. In addition, the FOP also requires health education to be provided to both youth
and staff. Seven youth Individual Healthcare Records (IHCRs) were reviewed, and none were
applicable for prenatal care/education. The center was able to provide IHCRs for two pregnant
youth who were at the center during the annual compliance review period. A review of the two
applicable IHCRs revealed each youth received prenatal care immediately upon determination
of pregnancy which was continued until discharge. The designated health authority provided
routine, focused medical evaluations of each pregnant youth every thirty days, while each youth
was at the center. One youth was placed on the Department’s Juvenile Justice Information
System (JJIS) alert system for vital nutrition, health awareness, and sleeping arrangements.
The additional youth was placed on a manual alert system due to Department-wide system
outages at the time the second youth was admitted. Neither of the youth complained of issues
related to pregnancy while they were at the center. Reviewed IHCRs revealed each youth
received education related to pregnancy including alcohol and drug use, smoking, nutrition,
sexually transmitted diseases, contraception, prenatal care, birthing process, postpartum care,
basic baby care, child development, and parenting skills. All required topics were documented
on the Health Education Record. Each youth received nutritious food in quantities appropriate
for a pregnant youth. Nursing staff provided routine monitoring of nutritional and weight status
for each youth while at the center. A review of seven in-service and seven pre-service staff
training records confirmed all non-healthcare staff involved in the supervision or treatment of
youth have received training on youth prenatal healthcare. This training included observation
and monitoring of emergency care needs and symptoms of possible miscarriage. The center’s
nursing protocols include treatment plans for pregnant youth. The nurse was interviewed and
advised if a youth is pregnant upon admission, the youth is educated on pregnancy issues by
the nursing manager, issued a special diet, started on pregnancy vitamins, and scheduled for
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 44 of 56 (Revised July 2023)
prenatal appointments. All female youth are given a pregnancy test upon admission if the youth
consent. Seven youth were interviewed, and one said they received prenatal, obstetrical, or
gynecological services when needed at the center. The remaining six youth said they did not
need these services.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 45 of 56 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Limited 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 facility operating procedures to address the supervision of youth. During the
annual compliance review week, supervision of youth was observed each day. Youth and staff
observations were conducted on the module; youth movement was limited during the annual
compliance review week. Youth were always in sight of at least one juvenile justice detention
officer (JJDO). Detention staff always maintained continuous sight and supervision of youth
demonstrating active supervision. Before movement of youth, the JJDO would ask master
control for permission to move to their destination and master control would authorize all
movement throughout the facility. At the time of the on-site review the youth had been moved to
education and there were no staff present on the module. A staff opened one of the rooms and
started to remove blankets from the youth’s room windows. When the blanket was removed it
was noticed a youth was lying in bed sleeping; this was after the other youth had been moved
from the module twenty-four minutes prior. There were no checks conducted while the youth
was alone in the room and module. An incident report was called into the Department’s Central
Communications Center. Seven staff were interviewed and two reported they believe there is
enough staff to provide safety and security for youth and staff. Five staff stated there is not
enough staff to provide proper safety and security, indicating staff shortage and hold over as a
reason.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 46 of 56 (Revised July 2023)
The center maintains facility operating procedures requiring a uniform behavior management
system (BMS) which offers a set of rewards, privileges, and consequences for behavior. The
center has a system of rewards, privileges, and consequences to motivate youth to meet and
exceed the center’s expectations, including rewards for positive behavior and consequences for
inappropriate behavior. During a tour of the center, postings of the BMS were noted in all living
areas which clearly specified appropriate and inappropriate behaviors, rules, norms, and
expectations. A review of point cards was conducted for the annual compliance review period
and confirmed youth are receiving their rewards and being held accountable for their actions
daily. The center prohibits the use of group punishment and there were no instances of
inappropriate use of restrictions or group punishment displayed during the annual compliance
review period. Seven staff were interviewed, and all seven stated they had knowledge of the
BMS and were able to explain the system. Six had positive feedback on the system working.
One stated it does not work; however, they were unable to explain the reasons why. Six staff
indicated weekly food incentives are provided as rewards to the youth, and one stated a later
bedtime. All seven said the staff speak with youth to discuss the consequences being imposed,
giving youth an opportunity to explain their behavior, as well as staff speaking with youth about
alternative acceptable behaviors. Six staff indicated supervisors provide feedback on the
implementation of the BMS as needed and one stated weekly, indicating the incident is
reviewed with them, as well as utilizing debriefings. All seven staff stated points and levels can
be taken away as a consequence and none had ever seen a co-worker take meals, snacks,
clothing, education, or medical care from a youth due to inappropriate behavior. Six staff had
never observed a co-worker encouraging youth to beat up another youth. One staff stated a
couple of different times when youth were engaged in an argument or altercation the staff was
pretending to try to intervene; however, were not. Seven youth were interviewed with four youth
rating the BMS system as fair, two youth stated it was good, and one rated the system as very
good. Six of the seven interviewed youth had a general knowledge of how the system works
with one youth stating they did not know the differences of the level system. One of the seven
youth stated receiving hair products as part of the reward system, five stated snacks/food
incentives, one stated later bedtime, one mentioned movie night, and two stated they do not
remember or did not receive any yet. Six of the seven stated the staff are fair in handing out the
rewards, one said they have not received any yet. Three of the seven youth said they had been
sent to their room for punishment with the door locked, four stated they had not been locked up.
This was addressed during the week of the annual compliance review; it was determined the
youth were behind the doors due to angry outburst or being disruptive and the placement of the
youth in their rooms was used to regain control and calm the youth down. The seven said levels
have been taken away as a consequence, three also stated points, one bedding, and one said
telephone calls while in confinement. Seven reported youth are not allowed to punish other
youth and the consequences they received to be fair. All seven youth stated they never
witnessed handcuffs or restraints being used. The superintendent was interviewed and reported
the center has a weekly BMS in place. On Tuesday level three youth receive extra snacks and
game time in the multipurpose room or a movie. On Wednesdays the level three youth can
enjoy food on the grill and are allowed to stay awake later and Thursday they get extra snacks.
The center has a plan to open a module exclusively for youth with a high level and to conduct a
weekly field day. All youth are made aware of their level daily and encouraged to behave
appropriately, so they can level up.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 47 of 56 (Revised July 2023)
5.03 Ten-Minute Checks (Critical) Failed Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures which require visual checks on youth at least
every ten minutes while they are in their rooms for sleeping purposes, illness, or room
restriction. A review of ten-minute check logs for thirty-minute increments from each shift from
the last twelve months revealed the ten-minute checks/wand reports were not able to be
reviewed from the months of April, May, and June 2024 due to the center’s computer drive
being inoperable. A review of the available ten-minute check logs/wand checks indicated all
checks were conducted as required, other than two checks being three minutes late. A review of
ten-minute check logs/wand checks and coordinating video observation for three days, various
modules, and different times indicated there were no checks conducted while youth were in their
rooms during the day on three occasions, for a period of two hours and twenty-two minutes,
seventeen, and forty minutes, respectively. While youth were sleeping, four ten-minute checks
were not conducted as required being three minutes, ten minutes, twelve minutes, and nineteen
minutes late, respectively. During the annual compliance review week ten-minute checks were
observed. Staff were conducting checks, looking into each youth room. Seven staff were
interviewed and confirmed room checks are to be conducted every ten minutes when a youth is
placed in their room for sleeping purposes. The superintendent was interviewed and stated
juvenile justice detention officers circulate the module looking in the windows of every room. If
youth have blankets covering windows or paper on the ceiling lights they should be removed.
The wand records the ten-minute checks, the data is download and reviewed by administration
daily.
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).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 48 of 56 (Revised July 2023)
The center has facility operating procedures to ensure staff always know the exact number and
location of all youth under their supervision. During the annual compliance review week, a
headcount throughout the center was observed. Master control called for the headcount and
each living module had a juvenile justice detention officer respond with the headcount for the
module. Master control verified the headcount, cleared the count, and documented the findings
in the master control logbook. A review of the master control logbooks for the annual
compliance review period, one full day each month, confirmed the census counts of youth are
written at the beginning and at the end of each shift, prior to and following routine group
movement, and any youth movement. Counts are conducted and documented, at a minimum,
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 and headcounts were recorded in their assigned module logbooks. Six of
seven staff interviews indicated youth counts are conducted at the beginning of the shift, two
stating at the end of the shift, two saying before and after school, and two stated before and
after meals. Three staff also indicated counts are conducted at random, and if the count is
incorrect, master control will check the logbook and four stated they will notify the supervisor,
lock down the center and redo count to reconcile. Two indicated they would call 9-1-1 if a youth
cannot be located. All seven stated emergency counts are conducted when a youth is believed
to be missing, when visibility is hindered, such as an electrical outage, and after a major
disturbance. Three also mentioned after other emergencies, hurricanes, and drills.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures regarding logbooks. The center maintains separate
logbooks in master control, each module, for visitors, and each vehicle. A review of logbooks for
one day each month since the last annual compliance review revealed logbooks were bound
with numbered pages and displayed the date at the top of each page. All entries included the
times of the events, displayed in a.m./p.m. format, the name of the staff and youth involved, a
brief description of the events, and the initials of the staff making the entries. All entries
impacting the safety and security of the center, including medical/special needs and mental
health alerts were highlighted. All errors were struck through with a single line and had void
written after the error followed by the staff’s initials. 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. The entries also had presence
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 56 (Revised July 2023)
of law enforcement, name of youth placed in confinement, including the time confinement began
and the time confinement ended, name of youth placed on precautionary/secure observation,
and the time precautionary/secure observation began, and the time precautionary/secure
observation was discontinued. Furthermore, logbook entries documented receipt of
medical/mental health alerts, population counts throughout shifts as counts change, youth
counts following emergency situations, and searches to include frisk, electronic, and strip
searches. The juvenile justice detention officer supervisors review the logbooks each shift,
including the master control and living unit logbooks when accepting the shift, to document they
are aware of current relevant situations in the center. The superintendent or designee reviewed
the logbooks on a weekly basis, and the staff in charge of the center will tour the youth living
areas at least once during each shift and document the visit in each area’s logbook. The
juvenile justice detention officers assigned to the modules review the logbook upon accepting
the shift. An interview with the superintendent confirmed supervisors are required to document
their reviews and security checks in the center’s logbooks at a minimum of two times during
their shift. The superintendent or designee are required to document their reviews and security
checks at a minimum of once a week on each shift. After a review of the logbook, it was
determined youth were not consistently going to school for education as scheduled. Youth were
also documented arriving to education late and leaving early on multiple occasions. An informal
interview was conducted with the superintendent advised logbooks are reviewed by
administrators on a weekly basis and supervisors are reviewing logbooks daily.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures regarding key control, issuance of keys to staff,
inventory and tracking, key restrictions, storage, missing or lost keys, and reporting and
replacement of damaged keys. A review of the key inventory confirmed the key rings on the
inventory matched the actual key rings in use and included emergency keys. Staff keys are
secured in the supervisor office and are issued to staff during shift change. Emergency keys are
in the superintendent office and all staff have access to them. All facility keys were maintained
on a tamper-resistant key ring and correctly color coded according to policy. The master key
inventory included the ring number, number of keys on each ring, capability of each key, and to
whom the key ring was issued. The issuance of keys and key ring number were documented on
each shift report and included the date and time of issuance, the name of the staff, and the time
the key ring was returned. Based on observations during the annual compliance review week,
staff carried their facility issued keys on them at all times, did not allow youth to handle keys,
and did not remove keys from the facility without approval of the superintendent. The key box
was not easily accessible when locked and could not be opened without a key. Since the last
annual compliance review there was one incident related to missing keys reported to the
Department’s Central Communications Center. The center reported the incident in a timely
manner and since there were no egress keys on the missing key ring the center did not have to
rekey the egress doors. The investigation is still ongoing. Three staff were informally interviewed
about their keys, and all knew the number of keys on their ring and the function of each key in
their possession. An informal interview with the master control operator revealed medical and
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 56 (Revised July 2023)
mental health give their personal keys to the master control operator and then the master
control operator provides medical and mental health staff their assigned facility keys. When
visitors enter the center, they provide their personal keys and then the master control operator
gives a chit with a number on it. Seven staff were interviewed and reported staff personal keys
are securely stored in the supervisor office and visitors’ keys are stored in master control. All
seven staff reported youth do not have access to keys. If keys go missing, they notify master
control and conduct a facility wide search \including youth being searched. All seven staff
interviews indicated the medical records, youth property area, mental health records, case
management records, and kitchen keys are restricted. The staff also stated master control,
classroom, administration, supervisor, dining hall, intake area, outside sheds, and maintenance
have restricted keys. All seven stated the center’s key control process includes personal keys
are securely stored, and a chit or token is provided to the visitors. Six stated a key log is used
and program keys are assigned to staff. Three also mentioned there is a key inventory. The
superintendent was interviewed and reported the superintendent, assistant superintendents,
and administrative assistant have permanent keys issued to them.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures for transportation procedures and operation of
Department owned vehicles. Observations during the annual compliance review week
confirmed each of the six vehicles used to transport youth received an annual vehicle inspection
by a certified mechanic. A review of documentation confirmed maintenance staff were
conducting visual checks of all transport vehicles on a monthly basis, checking the coolant,
lights, oil, emergency equipment, brakes, horn, interior/exterior, cleanliness, tires, battery,
windows, and mirrors. The inspections were documented on the mandatory inspection form and
a copy of the form was maintained by the maintenance staff. All vehicles had the appropriate
number of seatbelts, a seatbelt cutter, a window punch, a fire extinguisher, and a first-aid kit
with items approved by the designated health authority. Logbook documentation for all vans
was reviewed for the annual compliance review period and all included the acknowledgement of
the van being searched before the trip, the destination, the number of youth and staff names,
the name of the officer riding in the back of the van, time the transport began, and the time the
transport ended. During the annual compliance review week, a youth transport was observed.
Before the transport, staff searched the vehicle for contraband, ensured the vehicle had
sufficient gasoline to reach the destination, maintained copies of the current transportation
procedures in the vehicle, ensured the seatbelts were securely anchored, tested the security
cage, had a cellular telephone assigned for the transport, documented the inspection in the
vehicle logbook, and ensured the vehicle was secure at all times. All youth were searched
before entering the vehicle and staff ensured youth wore their seatbelts. After the transport,
observations included confirming the youth and staff wore seatbelts, the vehicle and youth were
searched for contraband, and the vehicle was locked to prevent the introduction of contraband,
of which all were completed. Observations during the annual compliance review week indicated
all vans were secured when not in use. Seven youth were interviewed, and all reported they felt
staff are driving safely during transports. Six youth stated they have never seen anyone place
contraband in a transport vehicle and one youth stated they saw someone place contraband in
a vehicle but did not provide details.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 56 (Revised July 2023)
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures addressing tool inventory and management, youth
access to, and use of tools and cleaning items. The center’s tool policy includes maintenance
tools shall be on a shadow board with a master inventory and the kitchen knives and other
hazardous kitchen sharps shall be stored in a locked cabinet located in the kitchen. An
inspection of the tool room and kitchen determined the tools are secure when not in use. A
review of the tool inventories capturing the issuance and return of tools indicated no tools were
missing on the inventory and there were no tools not listed on the inventory. Kitchen staff
conducted an itemized inventory of all equipment, including knives. An informal interview with
the maintenance staff confirmed all service vendors are always accompanied by designated
center staff. During the annual compliance review week, the maintenance staff was observed
accompanying a vendor throughout the center. The center does not allow youth to use tools,
including kitchen and medical equipment. Youth are allowed to use cleaning items such as
mops, brooms, and other common household items, under direct staff supervision. An informal
interview with maintenance and kitchen staff determined when a tool is damaged or missing the
best practice is to inform the superintendent immediately, secure the broken tool, and begin a
search for the missing tool. The superintendent was interviewed and stated the maintenance
mechanic has access to the tools. Five of seven staff interviews indicated they would notify the
supervisor of damaged or missing tools, four said they would remove the broken tool from use,
one stated get a replacement tool, and two stated they would search for the missing tool. All
seven indicated youth are allowed to use mops and brooms, three also said a scrub brush, and
one said toilet brush, plunger, and dustpan. During the annual compliance review week, a
sample of ten tools was reviewed. All ten tools were secured, had markings for easy
identification, accurate inventory, and the inventory was signed by the superintendent. Six of
seven youth interviews indicated they are allowed to use mops and brooms, the remaining one
stated they are not allowed to use any tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 56 (Revised July 2023)
The center has facility operating procedures to address the inventory of flammable, toxic,
caustic, and poisonous items, including the center’s safety plan. Flammable, toxic, caustic, and
poisonous items are maintained in a shed with limited staff and no youth 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 maintenance mechanic. The SDSs
and inventories were compared to five items on-site and were found to be accurate and
complete. Seven youth were interviewed, and all reported they do not have access to
flammable, toxic, caustic, or poisonous items. One youth indicated they clean with cleaning
agents if the staff spray it. The remaining six stated they do not use cleaning agents. Seven staff
were interviewed, and all stated youth are not allowed to clean with toxic, flammable, or
poisonous substances. During the annual compliance review week, five chemicals were
reviewed, all counts were accurate with no discrepancies, and all SDSs were present for each
item.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures addressing the proper use, storage, and disposal of
all flammables, toxic, caustic, and poisonous items. There have been no instances of a
chemical spill since the last annual compliance review. The center has a container outside of
the kitchen for storage of grease, and it is cleaned monthly by an outside vendor. An informal
interview was conducted with the maintenance staff who advised chemicals are either used or
picked up by a vendor for proper disposal.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains facility operating procedures to address requirements for behavioral
confinement for less than twenty-four hours. The center had 614 confinements lasting less than
twenty-four hours since the last annual compliance review. The center documents confinements
in the Department’s Facility Management System (FMS). Fifteen confinements were reviewed.
Documentation indicated all youth rights were afforded in each instance including three meals a
day, access to mental health care as requested, daily showers, clean clothing, and bedding.
Eight of the fifteen reviewed confinements were applicable for affecting each youth’s attendance
in school. Two youth were provided educational materials while six youth were not provided any
educational materials. All youth were afforded the right to grieve a confinement placement. A
review of FMS indicated the supervisor approved all confinements, staff only placed one youth
in a room, the room was searched, and the search was documented in FMS. All reviewed
documentation of confinement logs indicated each youth in confinement was supervised by
staff. For the first hour, five-minute checks were conducted for all fifteen confinements and then
every ten minute thereafter., The reason of confinement was explained to each youth, and the
supervisor on duty conducted reviews within one hour of each youth being placed in
confinement. All reports were completed by the staff, supervisors conducted additional reviews
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 56 (Revised July 2023)
with each youth at the required minimum of three hours, and youth were continually counseled
by the supervisors and staff. Every effort made to communicate the confinement with the
parent/guardian of each youth was documented in FMS. Superintendent reviews were
completed within the required forty-eight-hour time frame. During a tour of the center, some
minimal scratching was observed on the youth room windows in the living module. The
superintendent was interviewed, and stated confinements are tracked by a supervisor and on
the observation report. The superintendent confirmed checks should be complete every five
minutes for the first hour and every ten minutes after the first hour. Regional detention
management reviews the use of confinement, lockdown, and restraints monthly. Seven staff
interview results were reviewed, and all seven stated staff must search the room before placing
a youth in confinement, complete the incident report, and conduct ten-minute checks on the
youth while in confinement. Four staff stated youth in confinement receive educational material,
and three said no materials are provided, mentioning youth could harm themselves.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not utilize confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures in place which include the Continuity of Operations
Plan (COOP). The center conducted at least two drills and one before the start of hurricane
season as required by the policy. A review of documentation determined both drills contained
the type of drill, date and time, participants, brief scenario, findings, and recommendations. The
superintendent was interviewed, and confirmed drills are conducted monthly, and two COOP
drills are completed each year.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures to address escape drills and escape prevention.
The policy requires the center to conduct quarterly escape drills. The escape drill documentation
for the past twelve months was reviewed. The center completed quarterly escape drills without
exception and documented them in the logbook. Seven staff in-service training records were
reviewed and confirmed staff were trained in escape prevention annually. Seven staff were
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 56 (Revised July 2023)
interviewed, and three of the seven staff reported they participated in an escape drill, the other
four stated they did not.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a fire prevention and evacuation plan which addresses fire prevention and
safety of the center. The plan was reviewed and approved by the local fire official. A review of
documentation since the last annual compliance review supported the center conducts fire drills
every month, on each shift. All drill reporting forms had the logbook notation attached to the drill,
confirming it was documented in the logbook. Fire extinguishers were inspected annually, and
the maintenance staff checked the extinguishers monthly. Seven staff were interviewed with six
staff reported they have participated in fire drills, which are conducted monthly, and one staff did
not. Seven youth were interviewed with five youth stating they have been instructed on what to
do in case of a fire and two youth reported they have not received any instruction.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures regarding searches and contraband procedures. All
searches are documented in the Department’s Facility Management System (FMS). During the
annual compliance review week, observations of searches were conducted. Before a transport
and during contraband room searches staff wore gloves. Since the last annual compliance
review, there were no strip searches conducted by the center outside of the initial strip search at
admission. All visitors entering the facility were searched electronically, all bags, cases, and
jacket pockets were searched, and all personal keys were collected by master control
prohibiting them from entering the secure area. Room searches are completed upon releasing a
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 56 (Revised July 2023)
youth and prior to placing a new youth in a room. Room searches were also conducted on each
awake shift. A review of room searches was conducted for one day each month during the
annual compliance review period and confirmed both awake shifts completed and documented
room searches. Since the last annual compliance review, there have been fifteen instances
where the safety and security of the facility may have been compromised. A review confirmed
all instances were reported immediately to the on-duty supervisor. All visitors entering the facility
are required to complete a contraband attestation statement. A review of nine newly hired staff
training records was conducted, and all nine records contained a signed contraband attestation.
All fifty-four in-service staff training records contained a signed contraband attestation. Nine
instances of contraband entering the center were reviewed. A review of logbook documentation
confirmed the center documented the confiscation of contraband and contacted the
Department’s Central Communications Center (CCC). A review of FMS confirmed all incident
reports regarding contraband were entered into the system. Confiscated items were handed to
the on-duty supervisor and law enforcement was contacted for the illegal contraband entering
the center. Shift supervisors documented the chain of custody of confiscated items. The CCC
and the regional director were notified for all instances of illegal contraband entering the center.
The superintendent was interviewed and confirmed contraband is confiscated, law enforcement
is notified, a search of the modules is conducted, a search of youth is conducted, video review
is completed, and the CCC gets notified. Furthermore, youth are searched every time they leave
the module, when they return from court, when they return from visitation, and randomly.
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

rule: Indicator 1.05

excerpt: Right Interactions (RI)

rating: Limited Compliance

rule: Indicator 2.09

excerpt: Daily Activity Schedule

rating: Failed Compliance

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rule: Indicator 5.01

excerpt: Active Supervision of Youth (Critical)

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)