state: FL

facility_name: Alachua Academy

summary: QI Detention - FY23-24 - 5 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Alachua Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3440 NE 39th Avenue
Gainesville, Florida 32609
Review Date(s): February 27 - March 1, 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:
Kristine Harshaw, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Patrick Brock, Office of Education, North Central Education Coordinator (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Shandricka Felton, Assistant Superintendent, Detention Services, (Standard 5)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Ines Parker, Circuit 4 Probation, Juvenile Probation Office Supervisor (Standard 2)
Program Name: Alachua Regional Juvenile Detention Center MQI Program Code: 89
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Alachua County / Circuit 8 Number of Beds: 42
Review Date(s): February 27- March 1, 2024 Lead Reviewer Code: 187
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
5.09 Tool Inventory and Management
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items
5.14 Confinement Under Twenty-Four Hours
5.15 Confinement Over Twenty-Four Hours
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 57 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 57 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 57 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 57 (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 7 of 57 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Failed
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Failed
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Failed
5.15 Confinement Over Twenty-Four Hours Failed
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Failed
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 57 (Revised July 2023)
Program Overview
The Alachua Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Gainesville, Florida. The center serves youth in Alachua, Baker,
Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwanee, and Union
counties in Circuit 8, and is co-located with the Juvenile Assessment Center (JAC). Male and
female youth who are detained pending adjudication, disposition, or placement in a residential
commitment program are housed in the forty-two-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 Alachua County School Board. The center’s management team includes the
superintendent, two assistant superintendents, one administrative assistant, seven juvenile
justice detention officer (JJDO) supervisors, and forty-two 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 (DMHCA), two
licensed clinical staff, and one non-licensed staff. Clinical services provided by the center
include mental health and substance abuse evaluations, mental health treatment planning,
individual, group, and family therapy, mental health crisis intervention services, on-site
psychiatric services, and availability for substance abuse services for youth with co-occurring
disorders. Medical services are provided by one designated health authority (DHA), one
advanced practice registered nurse (APRN), two full-time registered nurses (RNs), one part-
time RN, and one licensed practical nurse (LPN). The medical clinic maintains nursing coverage
Monday through Friday, from 7:00 a.m. to 7:30 p.m., and on weekends, from 7:00 a.m. to 5:30
p.m. Food services are provided by Department staff and include menus, meal planning, meal
schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has three living modules which are divided by male and female.
There are eighty-two security cameras at the center, of which eighty were operational. The
center was clean and free of clutter or debris. At the time of the annual compliance review, the
center had eighteen vacancies, which included two JJDO supervisors, six JJDO Is, five JJDO
IIs, one maintenance staff, one other personnel services (OPS) maintenance staff, one OPS
staff, and two food service workers.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 57 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has a facility operating procedure to ensure all staff, contracted providers,
volunteers/interns, and mentors with access to youth undergo a criminal history background
check prior to hiring or providing services. A review of the center’s staff roster showed the
center hired twenty-five new Department staff since the last annual compliance review. There
were no contracted staff or volunteers applicable for an initial background screening during the
annual compliance review period. A review of personnel records for all newly hired staff showed
a background screening reflecting each received clearance from the Department’s Background
Screening Unit (BSU) for Department staff prior to each staff’s hire date and/or contact with
youth and confidential youth records. Twenty-four direct care staff were applicable for a pre-
employment assessment tool to be administered. Twenty-one staff earned a passing score. The
three staff who did not receive a passing score were provided remedial training prior to contact
with youth. A copy of the pre-employment assessment was maintained within each staff record.
One Department staff had a break in service and was previously employed by center. A new
background screening was completed on the staff prior to hiring. The center’s Annual Affidavit of
Compliance with Level 2 Screening Standards was completed and submitted on January 4,
2024, meeting the annual requirement. The Annual Affidavit of Compliance with Level 2
Screening Standards for school board teachers was submitted to the BSU/Clearinghouse on
January 8, 2024.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures to ensure all staff, contracted providers, volunteers,
mentors, and interns with access to youth undergo a criminal history background check every
five years. A review of staff personnel records found six center staff were applicable for the
completion of a five-year rescreening since the last annual compliance review. Five of the six
staff had a five-year rescreening submitted to the Department’s Background Screening Unit
(BSU)/Clearinghouse at least ten days prior to the five-year anniversary date, as required. One
was completed sixty-nine days late.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 57 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures addressing the code of conduct. At hire, each staff
signs the code of conduct acknowledging they have read and understood all expectations and
consequences of any violations. There have been five substantiated conduct violations by staff
during the annual compliance review period according to an informal interview with the
superintendent and a review of reports to the Department’s Central Communication Center
(CCC). All five of the reviewed incidents resulted in the termination of the staff. No staff have
received commendations during the annual compliance review period, as the current
superintendent has been at the center for less than five months. The interview with the
superintendent indicated the center follows facility operating procedures regarding the staff code
of conduct. If the policy is violated, the documented disciplinary standards are followed, based
on the severity of the situation, starting at re-training up to termination.
Seven staff were interviewed, and each indicated youth are allowed to call the Florida Abuse
Hotline or CCC when it is requested. Four staff indicated they contact the supervisor to take the
youth to make the call. Two staff stated they have never heard other staff using profanity, four
staff stated they have heard other staff use profanity once, and one staff reported occasionally.
When asked the four staff reported the cursing was a slip and not directed towards the youth,
and one staff reported the staff who cursed is no longer at the center. None of the seven staff
stated they have observed staff using threats or intimidation when interacting with youth. Two of
seven staff stated the working conditions were good at the center during the annual compliance
review period, two stated they were fair, and three staff stated the working conditions were poor.
Six of seven interviewed youth stated staff at the center are respectful, with one youth reporting
it depends on the staff. Six of the seven youth reported they have heard staff use curse words
when speaking with youth occasionally. One youth stated they have never heard staff use curse
words when speaking with youth. Six youth stated they have never heard staff threaten youth,
and one stated they have heard it once. Six of seven youth reported they feel safe at the center,
with one youth stating the other youth make them feel unsafe. Each of the interviewed youth
reported they have never asked for an abuse call, and none have ever exchanged telephone
numbers, emails, or social media contact with staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 57 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has a facility operating procedure in place regarding incident reporting. A tour of the
center was conducted, and observations reflected there were signs posted throughout the
center of the Florida Abuse Hotline and the Department’s Central Communications Center
(CCC) telephone numbers. The center had 102 incidents reported to the CCC during the annual
compliance review period, of which ten were reviewed. Each of the ten incidents reflected being
reported to the CCC within the mandatory two-hour time frame and in accordance with the CCC
reporting procedures. A review of internal incidents/grievances for the past twelve months
determined there were no incidents which should have been reported to the CCC but were not.
The center documents all incidents, whether accepted or not accepted by the CCC, in the
master control logbook. A review of the master control logbook reflected all ten CCC reports
were documented. An interview with the center’s superintendent confirmed within two hours of
being notified of an incident, a supervisor or above will call CCC or the Florida Abuse Hotline to
report incidents.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center has a facility operating procedure to ensure staff use physical intervention
techniques in accordance with the Florida Administrative Code requirements. The center had
252 Protective Action Response Right Interactions model (PAR/RI) incidents since the last
annual compliance review. A review of nine PAR/RI Reports was completed, and six of the nine
were completed the same day as the PAR/RI incident. Each report contained statements from
all the staff involved. Each report was reviewed by a supervisor, PAR/RI instructor, and the
assistant superintendent within the required time frame with the exception of two. Two of the
nine reports were not reviewed by the superintendent within seventy-two hours. Each PAR/RI
Report documented a post-PAR/RI interview was conducted with the youth by the center’s
superintendent and/or designee within thirty minutes after the incident. A review of internal
incident reports, grievances, and logbooks indicated there were no additional PAR/RI incidents
which did not have a report. None of the reviewed PAR/RI incidents were applicable for
mechanical restraints, a medical review, or a post-PAR/RI medical review. An interview with the
superintendent indicated PAR/RI incidents are reviewed daily. The assistant superintendent
reviews reports daily to check for incidents, reviews videos and staff written narratives, and
ensures PAR/RI Reports are completed and are in compliance. The superintendent conducts
reviews of incident reports for PAR/RI compliance, addresses incomplete reports, and ensures
PAR/RI Reports are completed.
A review of seven pre-service and seven in-service training records verified staff were trained in
the use of PAR/RI. Seven staff were interviewed, and each indicated staff utilize verbal
interventions before the use of physical restraints or PAR/RI techniques on a youth. The
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 57 (Revised July 2023)
center’s PAR/RI rate during the previous quarter was 13.33 which is below the statewide
Detention PAR/RI rate of 15.17.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has a facility operating procedure to ensure pre-service training is in accordance
with Florida Administrative Code. The center abides by the detention center statewide annual
training plan. The annual training plan serves as a written list of training curricula for all state-
operated secure detention centers in Florida. A review of seven staff training records indicated
five have completed pre-service certification requirements within 180 days of hire to encompass
Phase One and Phase Two training. Two staff have completed the first phase of training and
were beginning Phase Two at the time of the annual compliance review. The nine reviewed staff
received orientation within thirty days of hire and the staff training included active shooter
preparedness, human trafficking intervention, cardiopulmonary resuscitation/first-aid/automated
external defibrillator, information security awareness, mental health and substance abuse,
Prison Rape Elimination Act, Protective Action Response Right Interactions model,
professionalism, interpersonal communication and ethics, as well as sexual harassment, trauma
responsive practices, and suicide awareness and prevention. Reviewed documentation
confirmed each applicable staff completed all trainings required by the Department prior to
having contact with youth. All pre-service trainings were documented in the Department’s
Learning Management System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center maintains a facility operating procedure to ensure staff successfully complete
ongoing in-service training, as required. The center requires twenty-four hours of in-service
training for staff through a combination of the Department’s Learning Management System
(SkillPro) and instructor-led classes. The policy requires supervisors to complete an additional
eight hours of supervisory training annually. Seven staff training records were reviewed for in-
service trainings including four direct care staff and three supervisory staff. Each reviewed
record reflected staff exceeded the required twenty-four hours of in-service training. All seven
included all the required topics with the exceptions including one staff missing professionalism,
interpersonal communication, and ethics, and one was missing four of the six hours of suicide
prevention training. This was shared with the center superintendent. Three staff were applicable
for a minimum of eight hours of supervisory training. Two of the three reviewed supervisors
exceeded the required eight hours of supervisory training in the required topics. One supervisor
had not received any supervisory training for the reviewed year. All trainings were entered into
SkillPro. The center’s licensed nursing staff provide in-service training on girls’ healthcare
annually to all non-healthcare staff involved in the supervision or treatment of girls. The center’s
annual training plan was approved on November 17, 2023. The center has an annual in-service
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 57 (Revised July 2023)
training calendar which is updated as changes occur. The superintendent indicated their
supervisory training included Certified Public Manager (CPM), leadership training, supervisor
training, and peer reviewer training.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a facility operating procedure to ensure each youth has the right to grieve and
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. The policy indicates each youth has the right to grieve the actions of the center staff,
and youth cannot be punished for filing a grievance, whether it is substantiated or
unsubstantiated. The grievance process is explained to the youth during orientation. The
grievance process consists of three phases. The first is the informal phase which is completed
by staff whereby the youth and staff attempt to resolve the youth’s issue. A written grievance is
submitted to the juvenile justice detention officer supervisor (JJDOS). If the staff is unable to
resolve the issue, this begins the formal grievance process. The appeal phase requires a
response from the superintendent or designee. Grievance forms are electronically maintained in
the Department’s Facility Management System (FMS). Each grievance is forwarded to the on-
duty JJDOS within the required time frame, through FMS, and the youth is informed of the
findings. The superintendent or designee then reviews the completed grievance form within
seventy-two hours of receipt, excluding weekends and holidays. Grievance forms were
observed to be posted and accessible to the youth in each living module. The center had two
formal grievances during the annual compliance review period. Both of the formal grievances
were reviewed, and each was resolved as required. Neither entered into the appeal phase. A
formal interview with the superintendent confirmed when a youth completes a grievance form, it
is submitted to the staff for review. If they are unable to resolve/correct the issue, it is forwarded
to the shift supervisor. If the situation is unable to be resolved on the supervisor level, it is
forwarded to administration. Seven youth were interviewed, and all of the youth stated they
have never filed a grievance. Seven staff were interviewed, and each indicated they understood
the grievance process and procedures.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 57 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has a facility operating procedure to ensure critical or special alerts are documented,
reviewed, and responded to appropriately. Alerts are entered into the Department’s Juvenile
Justice Information System (JJIS), as well as the internal alert system. Internal alerts and JJIS
alert reports are distributed and reviewed daily by the juvenile justice detention officer
supervisors and administration. Alerts are entered, downgraded, or discontinued in JJIS by the
appropriate staff on the date identified and/or when the alert is no longer applicable. All alerts
regarding youth medication or medical information are confirmed and verified between the
medical staff and youth’s parents/guardians. The center's practice is to have a copy of the
detailed alert list for all juvenile justice detention officers (JJDOs) during each shift briefing. An
observation of a shift briefing during the annual compliance review week supported youth alert
information was consistently discussed with the JJDOs at the meeting, and JJIS was updated
by medical, mental health, and other staff, as needed. Seven reviewed youth records were
applicable for case management, medical, and mental health alerts. Each applicable record
documented all alerts were accurately entered into JJIS. Logbooks were reviewed and reflected
alert documentation included gang affiliation, medical status, Prison Rape Elimination Act
(PREA) status, security alerts, mental health alerts, dietary restrictions, and activity/sports
restrictions. The center’s superintendent stated youth alerts are added by staff during the
admission process based on information given at the time. Medical staff then verify the alerts.
Seven staff were interviewed, and each reported being informed of alerts; seven reported
learning of alerts through the shift briefing, four staff stated learning from alert lists, and three
staff reported they are informed of youth alerts from reading the logbook. Seven staff reported
management informs staff about issues within the center during shift briefings and one stated
through alert listings. One of seven interviewed staff stated communication is very good, four
reported it is good, three reported good, two reported it is fair, and one reported poor.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 57 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center collects data in the Department’s Juvenile Justice Information System (JJIS) on a
daily basis, including Protective Action Response/Right Interactions model (PAR/RI) Reports,
the Department’s Central Communications Center (CCC) reports, alerts, confinements, Prison
Rape Elimination Act documentation, and various additional reports. Supporting documentation
reflected regular data collection and discussion during management and shift meetings. The
center superintendent is still working on building up a community advisory board and preparing
a meeting with community members, providers, and stakeholders.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 57 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has a policy and procedures for admissions. Seven youth case management records
were reviewed for admission procedures. All seven case management records contained an
arrest affidavit/custody order, a Detention Risk Assessment Instrument (DRAI), and Suicide
Risk Screening Instrument (SRSI). All seven case management records contained a printed
copy of the Admission Wizard. Each of the seven youth were electronically searched, full body
visual searched, and screenings were completed to identify medical, mental health, and
substance abuse needs. All seven of the Admission Wizards documented each youth was
offered a snack or meal. Six of the seven case management records reviewed were provided a
telephone call or refusal was documented. An observation of an admission was not conducted
as there were no youth available being admitted; however, all documents and interviews related
to the admissions process were reviewed.
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Office of Accountability and Program Support Page 17 of 57 (Revised July 2023)
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has a policy and procedures to advise youth of the center rules and regulations,
expectations for behavior and related consequences for failing to meet those expectations, and
youth rights within twenty-four hours of being admitted into the center. Seven youth case
management records were reviewed for orientation. The documentation revealed an orientation
was completed within twenty-four hours of admission for each youth and all seven youth
acknowledged the orientation by signature. The orientation process included 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 (CCC), behavior expectations and related consequences,
possible new law violations for destruction of property, youth rights, and Prison Rape
Elimination Act (PREA) information. Documentation reviewed in each of the seven youth case
management records contained all elements as outlined. The videotape of the Prison Rape
Elimination Act (PREA) guidelines is initiated immediately during the orientation process. Seven
youth were interviewed, and six of the seven youth reported staff provided them with information
of the grievance procedure. Five of the seven interviewed youth reported staff provided them
information about the center’s rules and regulations, daily schedule, education services,
visitation, abuse reporting, and the behavior management system upon admission. Five of the
seven interviewed youth reported the center has a daily activity schedule. Three of the seven
interviewed youth reported the daily activity schedule is followed. The superintendent advised all
youth are provided orientation information during the intake process and signed documentation
is placed in youth’s case management record. An observation of a youth orientation was not
conducted as there were no youth available being admitted; however, all documents and
interviews related to the orientation process were reviewed.
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Office of Accountability and Program Support Page 18 of 57 (Revised July 2023)
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has a policy and procedures to ensure all youth admitted to the center are classified
to provide the highest level of safety and security. Seven youth case management records were
reviewed for classification. Each of the seven youth case management records contained an
Admission Wizard which included a review of each youth’s history and status, sex, height,
weight, age, and level of aggressiveness. The classification form included considerations for
mental illness, intellectual disabilities, physical disabilities, history of violent behavior, gang
affiliation, criminal behavior, any history of sexual offenses including sexual battery charges
which were reduced to a lesser offense, Vulnerability to Victimization and Sexually Aggressive
Behavior (VSAB), medical, identified or suspected suicide risks, escape, and security risks. Six
of the seven youth reviewed were assigned to rooms based on classification procedures. One of
the seven youth’s history of violent behavior was not considered. None of the seven youth
reviewed records contained a reclassification related to observed behavior and status; however,
one of the seven youth case management records revealed a history of being placed in
confinement for fighting but there was no documentation for reclassification considering a
change in behavior. One of seven youth case management records reviewed had a history of
committing sexual offenses or the youth was the victim of a sexual offense and was placed in a
room alone. The center completes a VSAB at intake screening to identify youth vulnerability to
victimization as well as sexually aggressive behavior. Each of the classifications considered
VSAB, medical, identified or suspected suicide risk, escape, and security. All rooms assigned
are documented and youth with a history of committing sexual offenses or is a victim of a sexual
offense is placed in a room alone. The superintendent remains informed of how to identify and
address local youth gangs. The superintendent is informed when the center identifies a youth
suspected of gang affiliation or involvement through staff, special alerts, logbooks, youth case
management records, law enforcement, and weekly detention reviews. The superintendent
interview results were reviewed, and revealed when graffiti, gang signs, and writings are found,
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Office of Accountability and Program Support Page 19 of 57 (Revised July 2023)
a referral is submitted to the circuit gang representative and law enforcement, then a special
alert is entered and documented in the logbooks. Seven of the youth case management records
were reviewed and none were applicable for youth identified as gang affiliated. The
superintendent interview also revealed how factors such as mental health status, physical
health status, cognitive performance, age, and prior victimization determine whether a youth
needs to be placed on vulnerable status if not already on this status. This ensures the youth are
placed on single room only to prevent any issues and protect the youth from being victimized.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has a policy and procedures for youth who are newly admitted into the center to
determine if the youth is a gang member or gang affiliate. None of the seven reviewed youth
were identified as a gang member or having suspected gang affiliation in the Department’s
Juvenile Justice Information System (JJIS), which was reflected on the intake paperwork. The
center identified three youth suspected of gang involvement admitted during the annual
compliance review period. A referral was submitted and shared by email with the circuit gang
representative, indicating suspicions of gang activity such as youth flashing gang signs, gang
tattoos, gang-related drawings, or related activity in each of the three youth case management
records reviewed. The gang representative is currently the center’s assistant superintendent.
When the center identifies a youth with suspected gang affiliation or involvement, the captain
identifies the juvenile probation officer (JPO) designated as the circuit gang representative to
communicate suspected gang activity. The captain then submits a referral providing information
to the circuit gang representative by email. The email will include pictures, copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing”
when applicable. The staff/designee then enters the "other suspected gang affiliation" alert into
JJIS along with detailed information within the alert note. In each of the three records reviewed,
alerts were entered into JJIS along with detailed information within the alert note.
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 a policy and procedures to ensure a youth's personal property is maintained
securely. Seven youth case management records were reviewed, and each of the seven
reviewed records contained a Property Receipt form signed by the youth and juvenile justice
detention officer (JJDO). If the youth refused to sign the Property Receipt form, the booking
officer shall notify a supervisor and the supervisor shall document the youth’s refusal on the
form. None of the youth reviewed refused to sign the Property Receipt form. All seven reviewed
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Office of Accountability and Program Support Page 20 of 57 (Revised July 2023)
youth records contained a letter of acknowledgment regarding unclaimed property, signed by
each youth. All money and other personal items of value shall be verified and secured in a clear
tamper-proof property bag. The tamper-proof bags shall include the date, youth’s name,
Department identification number (DJJID), and a listing of the items in the bag. The tamper-
proof bag will be placed in a drop safe, which is under camera surveillance. The drop safe
bound logbook includes the date, time, youth’s name, DJJID, printed name of the officer who
secured the property, and the officer’s initials. The Personal Property Receipt form and Valuable
Property Receipt form are placed in the youth’s active record, if applicable. The personal
property is placed in an assigned bag as documented on the Property Receipt form, which was
found in all seven youth records reviewed. One of seven youth records reviewed had money
and other personal items of value which were verified and secured in a clear tamper-proof
property bag. The tamperproof bag included the date, youth’s name, DJJID, and a listing of the
items in the bag. The tamper-proof bag was placed in a drop safe, which is under camera
surveillance. The Valuable Property Receipt form was placed in the youth’s active record. An
observation of two additional youth was conducted in order to observe the storage and security
of the valuable and personal property of a minimum of three of youth. A review of admission
documents and observations of the storage of youth personal property revealed each youth’s
personal property was stored in a secured property room and the Property Receipt form was
placed in each youth’s active record which is accessible by designated staff only. There were no
incidents reported to the Department’s Central Communications Center (CCC) related to youth
property during the annual compliance review period. Seven youth were interviewed, and six of
the seven acknowledged staff checked their personal property and signed an acknowledgement
form. One of the seven youth acknowledged to not having any property. The superintendent
interview results revealed once the admission process is completed, the youth's clothing is
secured in the property room. Any valuables are secured in a tamper resistant bag, sealed, filled
out with the youth's name, DJJID, youth's signature, date, and the signature of the intake staff.
A disposal letter is sent to the youth for unclaimed property and disposed once it passes the
date of pending disposal. Money is turned into a money order and sent to headquarters. Cellular
telephones and accessories are turned over to a women's shelter to be refurbished. Other items
are disposed of to be used in shelters.
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Office of Accountability and Program Support Page 21 of 57 (Revised July 2023)
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 a policy and procedures verifying all releases to prevent the negligent release of
youth. Six of the seven youth case management records were not applicable; therefore, an two
additional closed records were reviewed for release documentation to conduct a review of a
minimum of three records. In each of the three closed records reviewed, the duty officer
reviewed all paperwork related to release prior to youth’s release. The juvenile justice detention
officer (JJDO) supervisor reviewed the release paperwork received from the court in each
record. Each youth’s identification was verified prior to release. In one of the three records
reviewed the identification of parent/guardian or responsible adult was verified prior to release,
with an identification card (ID) which is photocopied and placed in the youth’s record. In two of
the three records reviewed, a photocopy of the ID of the responsible adult to whom the youth
were released for transportation to a residential facility was verified and placed in the youth’s
record. In the three records reviewed, none of the youth had an endangered person alert in the
Department’s Juvenile Justice Information System (JJIS). Each of the youth, parent/guardian,
and/or responsible adult were reminded of future court dates and provided documentation,
which was documented in the youth’s case management record. All required parties signed all
applicable release forms in each youth’s release. In each of the three records, the date of
admission and date of release documented in the case file correlated with JJIS. An observation
of a youth release was conducted and verified all applicable steps were conducted.
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 a policy and procedures to ensure all releases from the center occur promptly
and accurately. Six of the seven youth case management records were not applicable;
therefore, two additional closed records were reviewed for release documentation to conduct a
review of a minimum of three records. In each of the three records reviewed, the youth and the
parent/guardian signed the receipt of property form upon release. In each of the three records
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reviewed documentation verified the youth was released to an appropriate person with a copy of
their identification. Two of the three reviewed records contained a receipt of medications signed
by the person receiving the youth, the remaining youth was not applicable. In each of the three
records reviewed the youth and the person to whom the youth was being released to were
reminded of any health or welfare issues including medical, mental health, and/or substance
abuse needs, and any pending appointments. The center provided three examples of property
held more than thirty days during the annual compliance review period which confirmed they
followed their disposal process. An observation of the release process was conducted to
confirm procedures are followed. The authorization was verified prior to release, the
parent/guardian identity was verified, and an identification (ID) card was photocopied prior to
release. None of the youth were listed as an endangered person. The youth and the
parent/guardian were advised of next court date. Youth and the parent/guardian signatures
were obtained on the property release form. The youth and the parent/guardian were reminded
of any health or welfare issues including medical, mental health, and/or substance abuse needs.
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 a policy and procedures ensuring detention reviews are conducted weekly for
youth securely detained to ensure proper management of youth and the sharing of information.
An observation of the weekly detention review for youth in secure detention was conducted. The
detention review addressed every youth reflected on the Department’s Juvenile Justice
Information System (JJIS) census for secure detention. The nurse, mental health, probation,
and other relevant staff participated in person or by virtually. Medical alerts, medications,
release dates, court dates, transfers, comprehensive evaluations to be conducted, residential
placements, new charges, and precautionary observations were discussed. Detention reviews
occur weekly with participants from all applicable areas required to attend. Documentation of
each weekly detention review is maintained, including a list of participants, notes on what was
discussed, and tasks assigned for follow-up and who is responsible for providing the
information. A review of documentation maintained during the annual compliance review period
confirmed all required participants (center medical and mental health, education, probation, and
residential staff, if applicable) attended the meeting, either in person, virtual conferencing, or by
telephone. If the participant was unavailable, an alternative participant was designated in their
place. An interview with the superintendent confirmed the detention review specialist conducts
detention reviews weekly along with probation, medical, education, mental health, and any other
parties needed to attend. An administrator is also present. Facility staff meet in person, other
parties attend virtually.
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Office of Accountability and Program Support Page 23 of 57 (Revised July 2023)
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has a policy and procedures to address the daily activity schedule. The daily activity
schedule is posted in each living area and outlines the days and times for each youth activity.
The schedule includes times for wake up, personal hygiene, meals, visitation, education,
recreation and physical activities, indoor activities, shift change, bedtimes, groups, and open
program time. There was an observation of a daily activity conducted in which the youth
participated in the constructive activity of step aerobics. The activity was arranged and approved
by the superintendent. The activity was supervised by center staff, and no issues were noted. A
review of logbooks and observations during the annual compliance review week indicated the
center follows the daily activity schedule. Interviews with seven youth were reviewed. Five of the
seven youth reported having a daily activity schedule. Two of the seven interviewed youth
reported no daily activity schedule. One youth reported they do not know whether the daily
schedule is followed or not. Two youth reported the schedule is sometimes not followed. Three
youth reported the daily activity scheduled is followed for school; however, they do not go
outside as much as schedule states due to being short staffed. Interviews with seven staff were
reviewed. Each of the interviewed staff reported the center’s daily activity schedule is followed.
The staff revealed that the daily activity scheduled is posted in each living area and outlines the
days and times of each youth activity. Activities include one hour of exercise, audiovisual
programming, bedtimes, movies, and video games which are rewarded for youth who maintain
their scores on the behavior management levels.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has a policy and procedures to provide educational access. The center provides
education services through the Alachua County School District and the 250-day calendar, which
is distributed over twelve months, including ten days used for teacher training and planning, was
reviewed. A review of the daily school schedule revealed the center provides four seventy five-
minute class periods daily, fulfilling the weekly requirement of twenty-five hours of instructional
time. A review of four random dates in the logbook for June 21, July 12, July 13, and August 3
showed the daily class schedule was being followed. Further review of logbook entries and
video footage for February 2, February 9, February 12, and February 26 verified the youth were
attending school as scheduled. Seven youth were interviewed and all seven reported they
attend school Monday through Friday. Two of the seven youth reported the school was
preparing them either very well or well regarding preparation towards their high school
equivalency diploma (GED), high school, vocational, employment, and/or college, while five
youth stated not well in their preparation. Seven staff were interviewed, and all seven felt there
was minimal interference in educational services. The interview with the superintendent also
reported there is minimal interference with educational services.
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Office of Accountability and Program Support Page 24 of 57 (Revised July 2023)
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has a policy and procedures to provide career education. A discussion with the lead
teacher confirmed the center offers Type 1 career education development which includes career
learning strategies such as résumé writing and interviewing skills. Naviance (college and career
software) is also used to assist with career planning.
Seven youth were interviewed, and all seven reported they were taking core classes such as
math, science, history, reading, and social studies.
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Office of Accountability and Program Support Page 25 of 57 (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 single licensed mental health professional who has been designated as the
designated mental health clinician authority (DMHCA). The DMHCA is on-site forty hours each
week and ensures the appropriate coordination and implementation of mental health and
substance abuse services taking place. The Department maintains a contract with VitalCore
Health Strategies, LLC to provide mental health and substance abuse services to all applicable
youth in the center. The DMHCA is a licensed mental health counselor with a clear and active
license in the State of Florida expiring March 31, 2025. One other DMHCA was used during the
annual compliance review period, and the DMHCA had a clear and active license in the State of
Florida at the time of their employment at the center. The center has a back-up DMHCA with a
clear and active license in the State of Florida expiring March 31, 2025, who provides coverage
in the DMHCA’s absence. Copies of the DMHCA’s agreement and position description were
reviewed and confirmed the weekly hours of coverage are provided, as required.
An interview with the DMHCA confirmed the center provides mental health and substance
abuse services and each youth who enters the facility is screened and evaluated by a mental
health counselor within twenty-four hours to determine if mental health/substance abuse
services are warranted. All youth are informed of how to access mental health services while in
secure detention during the intake process. Youth who are prescribed psychotropic medication
are scheduled for an initial evaluation with the psychiatrist within fourteen days of arrival and
every thirty days thereafter until released. Youth who are not prescribed psychotropic
medication are seen by mental health staff by their fourteenth day for mental health orientation.
Youth receiving mental health services are seen by mental health staff once a week, at a
minimum. Any youth in secure detention by their thirty-first day receives a Substance Abuse and
Mental Health Assessment to determine if services are needed. The DMHCA went on to explain
communication between the DMHCA and clinical staff takes place on an as-needed basis with
communication taking place daily, at a minimum.
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 clinical supervisor ensures the licensed clinical staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience.
The licensed mental health professional is licensed under the appropriate Florida Statute
chapter and copies of the licenses are available on-site. The center has two licensed mental
health counselors. Both licenses of both mental health professionals and licensed qualified
professionals were reviewed and were clear and active in the State of Florida.
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Office of Accountability and Program Support Page 26 of 57 (Revised July 2023)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. There is one non-
licensed mental health staff providing services at the center. The clinical supervisor ensures the
non-licensed clinical staff working under their supervision are performing services they are
qualified to provide based on education, training, and experience. A review of documentation
reflected the non-licensed mental health clinical staff working under the direct supervision of a
licensed mental health professional received a minimum of one hour a week of on-site, face-to-
face direct supervision by a licensed mental health professional for the purpose of overseeing
and directing the mental health services provided in the program during the annual compliance
review period. Direct supervision was recorded on the Department’s Licensed Mental Health
Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
form. The center does not have a Chapter 397 license, as such, all substance abuse services
are being provided by licensed mental health professionals only. The contract with the
Department confirms the center is not required to have any non-licensed clinical staff. The non-
licensed staff holds a master’s-level degree from an accredited university or college in the field
of counseling, social work, psychology, or other related human services field and completed
twenty hours of training and supervised experience in assessing suicide risk, mental health
crisis intervention, and emergency mental health services prior to conducting Assessments of
Suicide Risk.
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.
Seven youth mental health records were reviewed. All seven youth had a Suicide Risk
Screening Instrument (SRSI) and Massachusetts Youth Screening Instrument, Second Version
(MAYSI-2) completed in the Department’s Juvenile Justice Information (JJIS). The nurse and/or
mental health staff completed the required sections in each of the seven SRSIs and the
completed entries included an accurate referral selection in the “Screening Results” sections, as
required. Youth who had any positive responses on the SRSI were placed on suicide
precautions and a mental health referral was completed which documented the youth's need for
an Assessment of Suicide Risk (ASR). All seven SRSIs included a “yes” response when the
youth had any open or closed suicide risk alerts in JJIS, as prompted within the JJIS SRSI
navigation screen in red font. All seven MAYSI-2s and SRSIs were completed by trained staff.
The results of the SRSI and MAYSI-2 indicated a need for further assessment in all seven
records. One of the MAYSI-2s was determined to be “invalid” due to all negative responses, the
screening was marked as “invalid”, and the youth was referred for a comprehensive assessment
on the MAYSI-2 referral section, as required. Six of seven youth required further assessment, a
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referral was made, and the superintendent/designee was notified in all six records. Three of the
youth’s MAYSI-2s indicated elevated suicide risk subscales and the youth were placed on
suicide precautions and referred for an Assessment of Suicide Risk in all three records. The
results of four of the MAYSI-2s indicated the need for comprehensive assessment, and the
screener referred all four youth for a comprehensive assessment within the detention center.
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.
Seven youth records were reviewed for mental health and substance abuse evaluations. Four
youth were applicable for a new evaluation and two were applicable for an updated evaluation
made by the detention provider. Three of the evaluations were applicable for being completed
during the annual compliance review week. The remaining four evaluations were not due for
completion at the time of the annual compliance review. All three applicable mental health and
substance abuse evaluations were completed by the center’s mental health provider on-site by
the youth’s thirty-first day. Treatment recommendations were made which corresponded to all
diagnosed mental health or substance abuse disorders in all three records. None of the youth
were applicable for receiving a new comprehensive assessment from a community provider.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
Seven records were reviewed for treatment and discharge planning. Five of the youth were
applicable for having an initial treatment plan. One youth had not been in the facility long
enough for an initial treatment plan to be completed and the other was not on medications which
would require a plan. For all five applicable records, the initial treatment plan was in place within
seven days of the onset of treatment and developed on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form. All five initial treatment plans included the
reason for referral for treatment, initial Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) diagnosis/symptoms, initial treatment methods including counseling and
frequency, initial treatment goals, psychiatric services including psychotropic medications and
frequency of monitoring when applicable, the medication the youth was admitted with, and the
signatures of the mental health professional and youth. All five youth were assigned a mini-
treatment team. The members of the treatment team were involved in the development of the
initial treatment plan in all five records.
Four youth were applicable for receiving an individualized treatment plan which was developed
for youth receiving mental health and/or substance abuse treatment in the center by the thirty-
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first day of the youth’s admission. The remaining three youth have not been in the center long
enough for an individualized treatment plan to be completed. All four individualized treatment
plans included the youth’s DSM-5 diagnosis, symptoms which are treatment focused, treatment
goals which include mental health services if the youth has a mental illness, substance abuse
services if the youth has a substance-related diagnosis, strengths and needs, and psychiatric
services including psychotropic medication and frequency of monitoring. Four youth were
applicable for coming in on psychotropic medications or being prescribed psychotropic
meditations. The psychotropic medications listed in the initial treatment plan matched the
psychotropic medications the youth was prescribed at the time the treatment plan was
developed in all four applicable records. A review of documentation reflected the individualized
treatment plans were signed and dated by the youth, mental health/substance abuse
professionals, treatment team members, and parent/guardian, or the center attempted to get the
signature of the parent/guardian, in all four applicable records. Two of the individualized
treatment plans included thirty-day periods requiring individual treatment plan reviews. Four
thirty-day individual treatment plan reviews were completed and documented on the
Individualized Mental Health/Substance Abuse Plan Review form. Both plans were reviewed
every thirty days by the treatment team, as required. Modifications were documented on the
review form and clearly identified as such. A review of the documentation reflected the
individualized treatment plan reviews were signed and dated by the clinical staff, youth, licensed
mental health professional, treatment team members, and parent/guardian. The treatment plans
included treatment and services provided by a licensed psychiatrist, in both applicable records.
Neither of the youth were an alleged victim of a Prison Rape Elimination Act (PREA) event.
None of the records reviewed were applicable for mental health/substance abuse treatment
discharge. As such, the center provided three additional records for review. The discharge plan
was documented on the Department’s Mental Health/Substance Abuse (MH/SA) Treatment
Discharge Summary form and completed upon the youth’s transition/discharge in all three
records reviewed. A copy of the MH/SA Treatment Discharge Summary was provided to the
youth, parent/guardian (as allowed), and juvenile probation officer (JPO) in all three records. A
mini treatment team was not able to be observed as one did not take place during the annual
compliance review week.
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 records were reviewed for mental health and substance abuse treatment. All seven
youth required treatment. All seven youth were assigned to a mini treatment team which
consisted of mental health clinical staff, one staff from a different service area, the youth, and
the parent/guardian when possible. All seven youth required mental health treatment and
received individual, group, or family counseling provided according to the frequency required by
the plan. The plan included individual, group, and/or family therapy prescribed at least weekly.
The proper consent for treatment was obtained in all seven records. Two youth required
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substance abuse treatment and received individual, group, or family counseling provided
according to the frequency required by the plan. For both youth who required substance abuse
treatment, the proper consent for substance abuse treatment was obtained through the signed
Department form, and the proper consent for release of substance abuse treatment records was
obtained through a signed Department form. Treatment notes were documented on the
Department’s Counseling/Therapy Progress Notes form in all seven records.
Video of groups was reviewed for three random days and times. The video was compared to
logbooks and sign-in sheets. The facilitator was verified, and groups were conducted for the
required group time and length, as required. Mental health staff have adequate access to youth
and confidential space to provide treatment services. A review of records confirmed group
therapy was limited to ten or fewer youth with mental health diagnoses for mental health
treatment groups and fifteen or fewer youth with substance abuse diagnoses for substance
abuse treatment groups.
Seven youth were interviewed, two youth stated the mental health and substance abuse
services were “very good,” three stated they were “good,” one stated they were “fair,” and one
stated they were “poor.” The superintendent and designated mental health clinician authority
(DMHCA) were notified of the youth responses. The DMHCA stated mental health does not
provide long term trauma intensive therapies due to time and privacy constraints, as such, they
cannot provide the intensive therapies the youth want and need during their time at the center.
The DMHCA confirmed the initial treatment plan is developed within seven days from the date
the youth was evaluated by the psychiatrist. The individual treatment plan is developed based
on the initial assessment by the thirty-first day the youth has been in secure detention. The
clinical staff review individualized treatment plans, individualized substance abuse treatment
plans, or integrated mental health/substance abuse treatment plans every thirty days while the
youth is in secure detention.
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.
Psychiatric services are provided by a physician licensed pursuant to Chapter 458, Florida
Statutes who is board certified in child and adolescent psychiatry with a clear and active license
in the State of Florida expiring January 31, 2026. Services are not provided by an advanced
practice registered nurse. If the psychiatrist is not available, the center will use a back-up
psychiatrist with equal education to the psychiatrist, contracted through VitalCore Health
Strategies, LLC. The back-up psychiatrist is also licensed under Chapter 458. The center offers
tele-psychiatry as outlined in the contract. An interview with the designated mental health
clinician authority (DMHCA) determined the DMHCA meets with the psychiatrist at a minimum
of once a week.
Seven youth records were reviewed for psychiatric services. Six of the seven youth entered the
center on psychotropic medication or were referred for a psychiatric interview and received an
initial diagnostic interview within fourteen days of the youth’s admission to the center. All six
initial psychiatric interviews included the reason for referral, youth’s history, Mental Status
Examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, treatment recommendations specific to mental health and/or substance abuse
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diagnosis, and prescribed medication. All six initial psychiatric interviews documented the
medication name, explanation of the need for psychotropic medication, and frequency of
monitoring. An in-depth psychiatric evaluation was conducted on all seven referred youth within
thirty days of referral/admission which stated the reasons and factors leading to the referrals.
The evaluations included all the required elements of an in-depth psychiatric evaluation and
page three of the Clinical Psychotropic Progress Note (CPPN) when medication was prescribed,
or changes were made to the existing prescription and the CPPN was clearly identified as a
Psychiatric Evaluation in all four records.
Whenever psychotropic medication was prescribed/dispensed/administered the identifying date,
diagnosis, target symptoms of each medication, evaluation, and description of effect of
medication on target symptoms was recorded for all four youth. Prescribed psychotropic
medication included the name, dosage and quantity of the medication, normal dosage range,
ordered dosage, frequency and route of administration, and reasons for changes in medication
and/or dosage for all four records reviewed. Side effects, youth’s adherence to the medication
regime, height, weight, blood pressure, most recent drug serum levels, as appropriate,
telephone contact with the parent/guardian, signature of the psychiatrist, and date of the
signature were also documented in all four records. The psychiatrist and nursing staff
documented monitoring for Tardive Dyskinesia on a monthly basis, as indicated on the CPPN in
all four records reviewed. The consent for psychotropic medication included the Authority for
Evaluation and Treatment for four records and verbal consent from the parent/guardian for new
or discontinued medication for one record where a youth was prescribed medication. None of
the youth were in foster care or eighteen years of age during the annual compliance review
period. Tele-psychiatry services offer the same standard of care as services rendered in-person.
Tele-psychiatry services are only utilized for youth who agreed to participate in the sessions and
when the parent/guardian provided consent.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written suicide prevention plan detailing suicide prevention procedures which
is reviewed and signed by the designated mental health clinician authority (DMHCA) and
superintendent annually. The plan includes the identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referrals, 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
(requiring hospitalization or medical attention) and a mortality review for a completed suicide
which includes the circumstances surrounding the event, procedures relevant to the incident,
training received by the staff involved, pertinent medical and mental health services involving
the victim, possible precipitating factors, and recommendations for changes in policy, training,
physical plant, medical or mental health services, and/or operational procedures, if any.
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3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Seven youth records were reviewed for suicide prevention services. All seven youth were
determined to be a suicide risk during their admission screening. An alert in the Department’s
Juvenile Justice Information System (JJIS) was initiated for all seven youth when placed on
precautionary observation (PO), and a suicide risk assessment referral was made on the
required form. All seven youth had a qualified mental health professional involved when placed
on constant supervision and the suicide precaution observation logs were completed in their
entirety, to include documented “safe housing” areas and required signatures. None of the youth
were released prior to receiving an Assessment of Suicide Risk (ASR). Staff documented a
consultation with the designated mental health clinician authority (DMHCA) or licensed mental
health professional on the mental health/substance abuse referral summary and the
superintendent or designee was notified immediately of suicide risk for all seven records. The
ASR or Follow-Up ASR was completed prior to the removal of youth from PO, and there was
documentation of a conference held by the superintendent and licensed mental health
professional to reduce the level of supervision in all seven records. The discontinuation of close
supervision was documented in accordance with the center’s suicide prevention plan. All seven
suicide risk assessments were completed by a licensed mental health professional and results
of the assessments included recommendations for supervision follow-up. A review of JJIS
determined alerts were appropriately entered and removed following youth removal from PO. A
review of logbooks determined the beginning and ending times for PO were documented for
youth in all seven youth records.
None of the reviewed youth records were applicable for secure observation. As such, the center
provided three additional records for review. For the three applicable youth, placement in secure
observation was authorized by the superintendent and DMHCA and the secure room was
designated in writing. The Health Status Checklist was completed prior to placement in secure
detention and the Suicide Precaution Observation Logs were completed in their entirety for all
three youth. Within eight hours of placement, a Follow-Up ASR was completed for all three
youth. The youth’s parent/guardian and juvenile probation officer (JPO) were notified of the
youth’s potential suicide risk as indicated by the ASR. Mental health staff provided supportive
counseling services during secure observation and the observation log documented supervision
for the three youth. The youths’ level of supervision was reduced after a conference with the
superintendent and licensed mental health professional for all three records. The
discontinuation of secure observation and step-down to close supervision was documented in
the center’s logbook and in each of the three youth mental health records by mental health
clinical staff.
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Seven youth were interviewed, and five youth denied ever being on PO. The two youth who
confirmed they were on PO, confirmed staff watched them at all times. Seven interviewed staff
stated they would notify the mental health authority if a youth expresses suicidal thoughts, five
stated they would document supervision and inform the supervisor, and four stated they would
provide constant sight and sound supervision. The superintendent confirmed a youth is placed
on secure observation on an as-needed basis, only under the directive of mental health if the
youth is showing suicidal tendencies or behaviors. An interview with the DMHCA confirmed prior
to revising a youth’s supervision level, the licensed mental health professional meets with the
superintendent and the communication is documented on the ASR.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Seven youth records were reviewed for Suicide Precaution Observation Logs. The Suicide
Precaution Observation Logs were maintained for the duration the youth was on suicide
precaution in all seven records. The appropriate level of supervision and observations of the
youth’s behavior were documented in real time and not exceeding thirty-minute intervals in all
seven records reviewed. None of the youth records were applicable for warning signs. When
warning signs are observed, the center has policy outlining the expectation of notification of the
superintendent or designee and mental health clinical staff be documented on the Suicide
Precaution Observation Log. The logs were reviewed and signed by each shift supervisor and
signed by mental health clinical staff in all seven records. All seven logs documented safe
housing requirements. A review of video footage and corresponding documentation of youth on
precaution observation or secure observation confirmed the proper supervision was maintained
for youth placed on precautionary observation.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Seven pre-service and seven in-service staff training records were reviewed. Training includes
suicide drills no less than quarterly, on each shift. The center has twenty-one suicide response
kits which include a knife-for-life, wire cutters, and needle nose pliers which are located in the
vehicles, classrooms, sub-control, master control, the mods, mechanical room, assistant
superintendent’s office, kitchen, mental health, and intake. Suicide response kits are co-located
with first-aid kits. A review of direct care staff suicide prevention training showed nineteen staff
for the first six months and twenty staff for the second six months completed at least one drill.
All direct care staff participated in at least one drill which included the use of cardiopulmonary
resuscitation (CPR) annually. Members who were not present during a quarterly drill have the
opportunity to review each drill scenario and procedures in an effort to understand the process
and receive the necessary training to respond to an incident of a suicide attempt or incident of
serious self-inflicted injury in the center. Seven interviewed staff stated suicide response kits
were located in sub-control, three stated they were located in master control, four stated they
were in medical, and one stated they are located in the shift supervisor’s office. Staff also
mentioned kits are located in the electrical room, vans, administration office, and mental health.
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3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a combined written Crisis Intervention and Emergency Services Care Plan for
mental health services which includes a notification and alerts system, means of completing
referrals including self-referrals, communication, supervision, documentation, and reviews.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
A review of the center’s emergency care plan confirmed it included immediate staff response,
notification, communication, supervision, authorization to transport for emergency mental health
or substance abuse services, transport for emergency mental health evaluation and treatment
under Chapter 349 Florida Statutes, Florida’s Baker Act, transport for emergency substance
abuse assessment and treatment under Chapter 397 Florida Statutes Marchman Act,
documentation, training, and review. The plan was approved February 27, 2024. A copy of the
plan is located in the office of the designated mental health clinician authority, medical office,
master control, briefing room, break room, conference room, and the offices of both captains.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
Seven youth records were reviewed for Crisis Assessments. None of the reviewed youth were
applicable for having a Crisis Assessment during the annual compliance review period, as such,
the center provided three additional records for review. Each Crisis Assessment included the
reason for the Crisis Assessment, Mental Status Examination and interview, determination of
danger to self/others, initial clinical impressions, supervision recommendations,
recommendations for follow-up or further evaluation, and notification to the parent/guardian of
follow-up treatment for all three youth. A mental health alert was entered into the Department’s
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Juvenile Justice Information System (JJIS) when the youth was placed on precautions after
completion of a Crisis Assessment for all three records. In all three records, the youth was
identified by direct care staff or clinical staff as having acute emotional or behavioral problems,
or acute physiological distress. All three Crisis Assessments were conducted by a licensed
mental health professional immediately, or within two hours for emergencies, or within twenty-
four hours based on the needs of the youth. None of the youth were an alleged victim of a
Prison Rape Elimination Act (PREA) event.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has a licensed physician who holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida to serve as the
designated health authority (DHA). The DHA’s specialty is in pediatrics, and the license expires
on January 31, 2025. The DHA has an advanced practice registered nurse (APRN) who
provides clinical services on-site and has a collaborative practice protocol in place. The DHA
performs all administrative duties. A review of the sign-in logs for the annual compliance review
period indicated the DHA was on-site once a week two hours a week as contractually required.
If the DHA has scheduled absences the center has a backup DHA which can be utilized from a
licensed pool. There were no instances of a backup DHA utilized during the annual compliance
review period. There were no instances of tele-medicine utilized during the annual compliance
review period. The DHA interview confirmed availability by phone twenty-four hours a day,
seven days a week and being on-site for two hours a week.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the center. The designated health authority (DHA) and superintendent
reviewed all applicable facility operating procedures. The DHA revised/signed on February 21,
2024. The superintendent revised/signed September 25, 2023. The psychiatrist revised/signed
on February 27, 2024. The nursing staff reviewed, signed, and dated a cover page on which
medical FOPs, treatment protocols, and other procedures were listed on February 21, 2024.
There were no new policies or changes in policies made during the year which required
signature. An annual review of medical facility operating procedures (FOPs) and protocols was
signed on February 21, 2024. The center has FOPs for all health-related procedures and
treatment protocols utilized at the center. All newly employed healthcare personnel receive a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
given by a registered nurse. The approval of treatment protocols or standing procedures are
written and authorized by the DHA.
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.
Seven Individual Healthcare Records (IHCRs) were reviewed for an Authority for Evaluation and
Treatment (AET). All IHCRs included the original AET form with “Copy” stamped on the form. All
seven AETs were signed by a parent/guardian and a Department representative. An AET was
obtained prior to providing medical services in all seven records. All seven AET’s were valid.
None of the youth were in the custody of Department of Children and Families (DCF).
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4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Five of seven Individual Healthcare Records (IHCRs) reviewed were applicable for
parental/guardian notifications for over-the-counter medications beyond those covered by the
Authority for Evaluation and Treatment (AET). In all five applicable IHCRs written notifications
were sent utilizing the Department’s Parental Notification of Health-Related Care: General or
Parental Notification of Health-Related Care: Medication forms, all five had consent provided by
the parent/guardian. Four of the seven youth were on psychotropic medications and there were
no staff witnesses for telephone call attempts and conversations with the parent/guardian. The
nursing interview indicated all medical staff are being re-trained on all procedural requirements.
Two youth received new medications and documentation indicated the written parental/guardian
notices were sent regardless of telephone notifications. Two of seven youth had a new
psychotropic medication prescribed or discontinued, or the drug dosage was significantly
changed for which the parent/guardian verbal consent was documented on the Clinical
Psychotropic Progress Note (CPPN) page three and written notification was sent. None of the
youth were in the care of the Department of Children and Families (DCF). Seven IHCRs had
vaccines verified within thirty days of admission. An interview with the nurse confirmed
parental/guardian notifications are made to inform the parent/guardian of significant changes in
the youth’s condition and obtain consent when new medications are ordered, medications are
stopped, youth are sent off-site for treatment whether scheduled or emergency, and when
treatments are prescribed. These notifications are first done verbally and followed with a letter.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
In all seven Individual Healthcare Records (IHCRs) reviewed the Medical and Mental Health
Admission Screening form was completed on the day of admission by the juvenile justice
detention officer (JJDO). All seven were reviewed with the youth by a licensed medical staff
within twenty-four hours. In all seven IHCRs the notification to the designated health authority
was documented. Two additional records were reviewed for rescreening, due to a change in
custody. The center completed a Healthcare Admission Re-screening form each time the
change of custody occurred. The center only had two youth applicable for the annual
compliance review period. The nurse interview indicated supervisors or master control notify
medical of newly admitted youth. The admission screening is completed by a supervisor and the
nurse reviews it with the youth and signs the screening form.
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4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures which include access to medical care, sick call,
what constitutes an emergency and when to notify staff, medication process to include side
effect monitoring, the right to refuse care and how it is documented, what to do in the case of a
sexual assault or attempted sexual assault, the non-disciplinary role of the healthcare providers
and a review of the list of healthcare contacts to ensure accuracy. In all seven Individual
Healthcare Records (IHCRs), each youth received a general healthcare orientation, which was
documented on the Department Health Education Record form.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Four of seven Individual Healthcare Records (IHCRs) were applicable for known or suspected
chronic conditions. In all four records the designated health authority (DHA) notification was
documented in the progress notes. None of the four youth required emergency care upon
admission. Four of the youth were taking psychotropic medication upon admission and the
psychiatrist was notified in all four IHCRs. The nurse interview indicated the DHA is notified as
soon as the youth is seen in medical upon admission. It is documented on the intake log as well
as the admission form.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
In seven of seven Individual Healthcare Records (IHCRs) the Health-Related History (HRH)
form was completed within seven days of admission. The HRH form was completed prior to the
Comprehensive Physical Assessment (CPA) as evidenced by signature and date. The HRH
was completed by a licensed nurse or practitioner in all seven IHCRs. All seven HRH forms
were reviewed by the designated health authority or advanced practice registered nurse as
indicated by a checkbox on the CPA. The nurse interview indicated the HRH is the responsibility
of the nursing staff and it is completed within seven days of admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Seven Individual Healthcare Records (IHCRs) were reviewed for a Comprehensive Physical
Assessment (CPA) and Tuberculin Skin Test (TST). The youth’s physical assessment was
completed on the Department’s CPA form. Four youth had a new CPA completed on admission,
by the designated health authority (DHA) within seven days of admission in each record. The
Medical Grade was noted on each CPA. All sections of the CPAs were completed in full. Three
youth had a current CPA on file at admission. In the three applicable IHCRs, a current CPA with
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no changes in the youth’s medical condition was utilized. The current CPA was reviewed as the
youth was examined and signed off a reviewed by the DHA in the three IHCRs, which included
a focused evaluation. All seven youth records had documentation of youth refusing part of the
exam, which was documented on the CPA and on a Youth Refusal of Care form. The
Department’s Problem List in each record was updated. A TST was documented on the CPA
and the Infectious and Communicable Disease (ICD) form in all seven records reviewed. All
seven youth records had documentation the Tier 1 Tuberculosis (TB) screening was completed
within seventy-two hours. None of the youth required further evaluation as a result of the TST.
The nurse interview confirmed a CPA is completed within seven days of admission. A new CPA
is needed every two years if youth grade is a one. If the youth grade changes a new CPA is
created. TB screening is completed within seventy-two hours of admission if one is not
documented in the youth’s IHCR within the past year.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
In seven Individual Healthcare Records (IHCRs), each youth was clinically screened and
evaluated for sexually transmitted infections (STIs) within twenty-four hours of admission. In five
of seven, further evaluation was required and a referral was made to the designated health
authority (DHA), which was documented on the Department’s STI form. In the five applicable
IHCRs, testing was ordered and conducted. The testing results were documented on the
Infectious Communicable Disease (ICD) form and maintained in each IHCR. None of the youth
consented to a gynecological exam or were out of the Department’s physical custody. In the five
applicable IHCRs each youth was offered counseling and testing for human immunodeficiency
virus (HIV) which two declined and three agreed to be tested. All three youth had documented
consent for testing in their IHCR. Three youth had HIV test results filed confidentiality in a
sealed envelope marked “confidential”. Three records had proof of review by a practitioner
documented, and documentation of pre-test/post-test counseling documented on the Individual
Health Education Record. All seven youth interviews indicated they can ask for an HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
Seven Individual Healthcare Records (IHCRs) were reviewed for sick call. Three of the youth
had documentation of sick call on the sick call referral log. None of the youth presented with
similar sick call complaints three or more times within a two-week period. All three youth
completed a sick call request form. The nurse completed the sick call request form in all three
applicable youth IHCRs. All the sick call request forms were filed in the youth’s IHCR in reverse
chronological order. The sick call forms and progress notes were documented in accordance
with Florida Administrative Code. The youth’s sick calls were documented on the sick call index
and all dates corresponded to the appropriate sick call form. Sick call is conducted two hours a
day seven days a week in the medical clinic. Sick call hours are posted outside of medical and
on the mods. Nursing staff provide sick call care and there are approved treatment protocols for
both registered nurse (RN) and license practical nurse (LPN) level staff. When there is not a
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licensed nurse on-site, there are procedures in place for the shift supervisor to review all sick
call requests no longer than four hours after a request is submitted. There were no sick call
requests submitted during the annual compliance review week; therefore, observations of the
sick call process were not conducted. The nurse interview confirmed youth notify center staff of
a medical complaint and staff enter the sick call. The nurse pulls the sick call list twice a day and
nursing staff have twenty-four hours to see the youth. Seven youth were interviewed, and one
youth advised being seen immediately for sick call, five within one day, and one never
requested sick call. Seven staff were interviewed and advised the nurse conducts sick call, one
staff advised the supervisor will review if a nurse is not on duty.
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.
Four of seven Individual Healthcare Records (IHCRs) were applicable for episodic care. In the
four applicable IHCRs there was indication each youth required episodic care, which was
conducted by a licensed healthcare staff on-site and documented in problem-oriented charting.
In all four the nature of the event, the findings of the person rendering care, the treatment
provided, instructions to the youth, and plans for follow-up care were included. None of the
youth required off-site care, and none needed placement on the alert list or parental/guardian
notification. All events were documented on the Episodic Care Log and none of the youth
needed a follow-up evaluation. The first-aid kits are located in master control, classroom A,
classroom B, classroom C, B1, B2, B3, G1, intake, supervisor’s office, mental health, electrical
room, and five are used for transport. A review of three first-aid kits indicated the kits were
missing items or had expired items. Prior to the end of the annual compliance review week, the
center pulled all of the first-aid kits and contents were checked and stocked with designated
health authority (DHA) approved contents. The center’s process for ensuring contents are
maintained and stored in accordance with guidelines to prevent expiration or deterioration
includes monthly monitoring by nursing staff and documentation in the inspection log. A review
of monthly first-aid kit checks for the last full year indicated all were conducted as required. The
center has two automated external defibrillators (AEDs) containing the operating procedures,
located in the B1 hallway and main hallway across from medical and both were in working order
during the annual compliance review week. The nursing staff conducted checks monthly, as
indicated by a review of the AED checks for the last year. The AED batteries expire in
September 2027. The batteries had been changed in September 2022. The pads expire
December 28, 2025. Emergency medical drills and mental health drills with medical components
completed since the last annual compliance review were reviewed. Drill documentation showed
at least one medical drill was conducted on each shift monthly with the exception of B-Shift,
which had one quarterly drill missing. The current superintendent has put a corrective action in
place since September 2023 to ensure drill compliance. No drills were missed since then.
Cardiopulmonary resuscitation (CPR)/AED was demonstrated at least annually on each shift, in
accordance with facility operating procedures. A list of emergency telephone numbers is
maintained by master control and in the medical clinic. The telephone numbers are inaccessible
to youth. All licensed healthcare staff maintain current CPR and AED certifications. Fourteen
staff records were reviewed, and staff training requirements were met regarding episodic, first-
aid, and emergency care. For the emergency treatment of a known or suspected opioid
overdose emergency with signs of breathing problems and severe sleepiness or not being able
to respond, Naloxone Nasal Spray is a provided prescription strength medicine. The program
will maintain at least one prescribed stock Nasal Spray Kit for emergency purposes of
accidental overdose for use for youth in care. A Naloxone Nasal Spray kit must be maintained in
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a designated area, in the center’s medication cart. The medication cart must be locked at all
times, but still accessible to both nurses and supervisory staff trained to assist in the delivery of
medications when the emergency arises. Nursing staff and supervisors have access to the
medical cart and have been trained on when and how to use Naloxone Nasal Spray. The
medication is inventoried along with all other medication. An interview with the nurse advised
episodic care by licensed staff will be contained in an episodic care progress note and will cover
the elements required. Episodic care provided by non-licensed staff must have a follow up
evaluation by medical when the youth returns to center. Seven staff were interviewed, all seven
advised being able to call 9-1-1 if needed. Seven youth were interviewed, three youth rated
medical care as good, two stated it was fair, one stated it was poor, and one never received
medical care.
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.
Seven Individual Healthcare Records (IHCRs) were reviewed, and three were applicable for off-
site care. All three applicable youth records had documentation the Summary of Off-Site Care
form was utilized for the off-site care. Each of the off-site care events were documented on the
episodic care log. Parental/guardian notification efforts were documented in all three IHCRs. All
three youth were applicable and had discharge documents filed in the IHCR. The designated
health authority (DHA) was notified of the off-site care for each youth. The DHA or the advanced
practice registered nurse (APRN) initialed off-site findings, instructions, and information. None of
the youth required follow-up appointments or referrals. An interview with the nurse advised
youth are tracked utilizing the off-site care log which is documented on a board within the clinic
and email communication is utilized to share appointment follow up with staff.
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.
In four of seven Individual Healthcare Records (IHCRs) reviewed each youth was identified on
the Facility Entry Physical Health Screening form to have a current chronic health condition. In
the four applicable records all youth had a current chronic condition, none of the youth were
taking prescribed medication on an on-going basis, four were classified with a Medical Grade
between two and four, and all four were placed on a chronic conditions list. None of the youth
were pregnant, taking tuberculosis medication, received an off-site evaluation, or indicated any
lapses in care or periodic evaluation. Only one of the four had been at the center long enough to
be applicable for periodic evaluations. The one youth had documented progress notes for each
periodic evaluation in the IHCR. The nursing interview indicated youth with chronic conditions
have alerts entered into the Department’s Juvenile Justice Information System (JJIS) and the
designated health authority (DHA) is notified. The youth are tracked in a log in medical and the
DHA reviews the log and the youth. The DHA interview indicated the log is updated and
reviewed weekly to ensure it is current.
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4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
Seven Individual Healthcare Records (IHCRs) were reviewed for medication management. Four
youth were admitted with medication and had documentation of medication verification included
in the IHCR chronological progress notes. The designated health authority (DHA) and/or
psychiatrist was contacted to resume the specified medications for each youth.
All medications had a current, valid order, were administered pursuant to current prescription,
and all had an order on the practitioner order form. The standard Department Medication
Administration Record (MAR) is used to document all medication and treatment and is
completed for each youth monthly. Each MAR contained the youth’s name, Department
identification number, date of birth, youth allergies, precautions, Medical Grade, medical alerts,
and a current picture of the youth. At a minimum, the nursing staff documented side effects
weekly on the MARs. The MAR is usually completed electronically. If the electronic MAR is not
working, the MAR is printed, the medication administration is documented by hand, and the
printed MAR is uploaded into the Electronic Medical Record. Each MAR clearly indicated
medication start and stop dates. Nursing staff and youth initialed each administered medication
entry. Trained non-healthcare staff may assist in the delivery of medications only when licensed
staff are not on-site, though there were no examples of this in the records reviewed. None of the
youth required parenteral medication. None of the youth had refusals. Four of the reviewed
youth were on prescribed psychotropic medication upon admission. The psychiatrist was
notified upon admission. Each youth had an initial diagnostic psychiatric interview within
fourteen days of admission. There are no standing orders, pro re nata (PRN) orders, or
emergency treatment orders for psychotropic medications. Medication administration was
observed for one youth with their consent. Medication administration was the sole responsibility
of the nurse during the administration. The youth were escorted to the medical clinic one at a
time by direct care staff, who maintained supervision of the youth during the medication
administration. Youth approached the nurse individually and the Six Rights of Medication
Administration were verified. The nursing staff asked each youth how they were feeling. Nursing
staff observed youth to confirm the medication was swallowed. There was no pre-pouring of
medications. The nurse interview confirmed, if a youth arrives with the medication a medication
receipt is filled out and the nurse reviews the medication to ensure it is from a from a licensed
pharmacy with a current, patient specific label intact on the original medication container in
order to accept. Medications shall have a current, valid order and are given as ordered on
current prescription or practitioner order. The designated health authority (DHA) or psychiatrist
shall be contacted to obtain the order to resume the specified medications youth is prescribed
prior to admission. Seven staff were interviewed and all seven advised the nurse provides the
medication. Seven youth were interviewed and six advised the nurse provides the medication
and one advised not taking medication.
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4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The medical equipment classified as sharps were secured and inventoried utilizing a routine
perpetual inventory, descending count as each sharp was utilized and disposed for the annual
compliance review period. All medications were identified and secured in the locked area
designated for storage of medications. The medication cart was clean and organized with stock
items separate from youth-specific medications, and all controlled substances have a perpetual
inventory and are stored separately from other medications. All medications are stored in a
separate, secured area, inaccessible to youth. Narcotics and other controlled medications are
stored behind two locks. Medications which require refrigeration are stored in a secured
refrigerator, which is used for medication only. The center maintains a shift-to-shift inventory
count of all controlled substances documented on the youth’s individualized controlled
medication inventory record. Supervisory-level, non-healthcare staff trained in the delivery and
oversight of medication self-administration, and training was delivered by the registered nurse
(RN). Three controlled medications, three over-the-counter (OTC) medications, and three
sharps were reviewed, and inventory on-hand matched the perpetual inventory. Discrepancies
in inventory are investigated, and if it not resolved, the medical staff are to notify the designated
health authority (DHA), regional director, superintendent, and call the Department’s Central
Communications Center (CCC). A registered nurse shall be responsible for the disposal of
medications in conjunction with the pharmacy consultant. Controlled and non-controlled
medications for disposal shall be inventoried prior to disposal and disposed in the presence of
the pharmacy consultant. Controlled and non-controlled medications must be disposed of by
utilizing the Drug Enforcement Administration (DEA) approved Drug Buster disposal system and
in accordance with state board of pharmacy and DEA disposal plan. Documentation of the
disposal of all medication shall be maintained. An interview with the nurse confirmed the
process for destruction of medications, and storage of medications.
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.
Seven Individual Healthcare Records (IHCR) were reviewed for infection control education. All
seven youth records had documentation the youth received infection control training within
seven days of admission. Training topics included hand-washing techniques, universal
precautions, prevention/transmission of communicable diseases, vaccinations, and Center for
Disease Control and Prevention (CDC) guidelines for infection control. The exposure control
plan is written in accordance with Occupational Safety and Health Administration (OSHA). The
plan includes a risk assessment and methods of compliance. The infection control procedures in
place include prevention, containment, treatment, and reporting requirements related to
infectious diseases, according to OSHA and CDC guidelines. The infection control procedures
include common diseases of childhood, self-limiting episodic contagious illnesses, viral or
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bacterial infectious disease, tuberculosis, hepatitis, bloodborne pathogens, outbreaks or
epidemics, lice or scabies, methicillin-resistant staphylococcus aureus (MRSA), foodborne
illnesses, bioterrorist agents, and chemical exposures in the workplace. A review of the facility
operating procedures indicated the center’s process for needle stick post-exposure evaluation is
to notify the manager. The manager is responsible for notifying the regional manager and follow
up with testing and prophylaxis treatment is conducted. Hepatitis B immunizations are available
for staff upon hire. Staff have access to biohazardous kits for protective equipment. There were
no incidents of a facility occupational exposure. The nurse interview advised the registered
nurse (RN) conducts the infection control training for staff.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has nursing protocols and treatment plans addressing pregnant youth. All seven
Individual Healthcare Records (IHCRs) reviewed were not applicable for pregnant youth. The
center did not have any examples for the annual compliance review period. Seven pre-service
and seven in-service training records confirmed all staff received training on pregnant females
and related topics, which was conducted by a nurse. The nursing interview advised once a
youth is confirmed pregnant, obstetric care is scheduled, youth are started on a pregnancy diet,
youth receive education, receive monthly monitoring, and prenatal vitamins. Seven youth were
interviewed, and all seven youth advised the services were not needed.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
The center has facility operating procedures to ensure youth are actively supervised by staff.
During the annual compliance review week, staff were observed maintaining continuous sight
supervision of all youth in their assigned area, during education, meals, transportation, and line
movements. All movements are authorized by master control prior to the youth being moved
throughout the facility. A review of the facility logbooks maintained during the annual compliance
review period confirmed all movements were logged and counts were conducted consistently.
Facility staff were adhering to the daily activity schedule. Facility staff were interacting
appropriately with youth. Each day of the annual compliance review week, the facility had
adequate staffing to meet the required staff-to-youth ratio. Observations of shift change
confirmed the juvenile justice detention officers (JJDOs) received their assignments and youth
alerts during shift briefing. Seven staff were interviewed, and two stated there were enough staff
to provide adequate supervision, five stated there was not enough staff at this time and the
center must hold staff over from previous shifts to cover when the shift does not have enough
staff coverage.
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5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations.
Each center shall implement and maintain a behavior management system to meet the needs
of the youth and the center. The system shall include rewards for positive behavior and
consequences for inappropriate behavior.
The behavioral norms and expectations for youth shall be posted in all living areas and shall
clearly specify appropriate and inappropriate behaviors.
The system restricts certain types of penalties on youth who demonstrate negative behaviors.
Group punishment shall not be used. However, corrective action taken with a group of youth
is appropriate when the behavior of a group jeopardizes safety or security, and this should
not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
The use of drugs to control the behavior of youth is prohibited. This does not preclude the
proper administration of medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) detailing the behavior management system
(BMS) to ensure the safety and security of youth and staff. During a walkthrough of the center,
BMS posters were observed throughout the building where youth may be able to review. These
posters clearly specified rules, norms, and expectations. The center provides a BMS which
includes incentives for positive behavior and consequences for inappropriate behavior. The
BMS includes the use of a three-tiered level system where youth are given the opportunity to
earn points by meeting required expectations. All youth entering the center come in on a level
2.1. A review of completed point cards and logbook entries during the annual compliance review
period supported the center utilized the BMS in compliance with the components outlined in the
center’s FOPs. Seven staff were interviewed, and each confirmed the BMS includes a point
level system, the BMS is posted throughout the facility, and is included in the orientation
process. In addition, each staff confirmed the youth receive several incentives and believe the
center’s BMS is effective. All seven staff stated each youth who earns their level receives
incentives for positive behavior which include canteen, later bedtimes if staffing allows, and
special visitation with their family once they reach a level of 3.14. At the special visitation the
family is allowed to bring in food to youth food. All seven staff stated they speak with youth to
discuss the consequences being imposed. All seven staff stated youth are given an opportunity
to explain their behavior and discuss alternative acceptable behaviors. None of the staff
reported they have seen a staff encourage a youth to beat up another youth or had a youth’s
basic rights taken away. An interview with seven youth was conducted. Five out of the seven
stated they were briefed on the BMS system during the intake process. All seven youth were
able to explain the difference between each level and how to move from one level to next. Three
out of the seven interviewed youth stated all staff use rewards the same, staff are fair, and give
all youth the same rewards. Seven interviewed youth stated they are not allowed to punish other
youth. All interviewed youth stated they did not witness handcuffs or leg irons being used on
out-of-control youth to prevent them from hurting themselves or others. The superintendent was
interviewed and stated a standardized BMS is used which follows FOPs. All youth entering the
center will be placed on level 2.1 and after three consecutive days of positive behavior, youth
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will be placed on level three. Youth can move up or down the level system depending on their
behavior. The superintendent also confirmed all youth are provided basic rights no matter their
levels.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains a facility operating procedure requiring ten-minute checks to be conducted
when youth are in their rooms. The center has a total of 82 surveillance cameras, two were
out during the week of the annual compliance review. The surveillance cameras have a thirty-
day recording capacity. An electronic wand system is used in the center to document and collect
data of the ten-minute checks. Staff tap an electronic wand on the check point sensors on the
outside of each youth’s assigned sleeping room door and the data is downloaded as wand
reports. A review of video in comparison with wand checks was completed for nine random days
and times. This observation revealed staff were conducting each ten-minute check as required.
Staff were observed looking into the windows of each sleeping room before tapping the wand to
the check point sensor. Facility administration provides management oversight by conducting
weekly reviews of ten-minute checks to ensure fidelity. Seven staff were interviewed, and all
seven indicated room checks are conducted every ten minutes when a non-suicidal youth is
placed in their room. The superintendent interview confirmed when a youth is secured in a
room, an officer will conduct visual observation checks every ten minutes. They will approach
the door, stop, and look in the room to ensure the youth is safe, log the check, and then move to
the next door until completion of each room.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains a facility operating procedure to address census, counts, and tracking
which requires staff to always know the exact number and location of all youth under their
supervision. Living module counts are recorded in their assigned module logbooks. Logbook
reviews since the last annual compliance review indicated counts were conducted at the
beginning of each shift, prior to and following routine group movement, anytime a population
change occurred, randomly, at least once on each shift, for regular head counts, during youth
movements, and at the end of shifts. Three out of the seven interviewed staff indicated a
minimum of three counts are completed throughout each shift. Staff indicated if a count is
incorrect, the center stops all movement and secures the area to complete a recount. Seven
staff were interviewed, and each stated emergency counts were conducted if a youth is believed
to be missing, when visibility is hindered such as an electrical outage, after drills, and following
codes or any major disruptions.
5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has a facility operating procedure regarding logbooks. The facility has separate
logbooks for master control and each living module, visitors, and vehicles. A review of ten
logbooks indicated they were bound with numbered pages. All entries in the logbooks were
legible and written in ink with no erasures or whiteout areas. A review of logbooks for three full
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days each month during the annual compliance review period indicated counts were conducted
and documented at the beginning and end of each shift, prior to and following any movement of
youth, at least once randomly during the shift, any time the population changed, and following
routine group movement. Observations during the annual compliance review week showed
there was no youth movement until master control confirmed the count. Entries in each logbook
included the date and time of the event, name of the staff and youth involved, a brief description
of the event, and initials of the person making the entry. Documentation of the entries such as
special needs, mental health alerts, the opening and closing populations, emergency situations
including drills, were all noted in the logbooks. Admissions and releases, line movements, and
the presence of law enforcement were documented. Names of youth placed in confinement
were documented, including the time confinement began and ended. There was no
documentation noted where there is interference with the daily activity schedule of educational
instruction. Calls to the Florida Abuse Hotline and the Department’s Central Communications
Center (CCC) were documented in the master control logbooks. Seven staff were interviewed,
all of whom indicated youth counts are conducted at the beginning and end of each shift.
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has a facility operating procedure regarding logbook requirements. The master
control and living module logbooks for the months since the last annual compliance review were
reviewed. The juvenile justice detention officer supervisor (JJDOS) reviews the logbooks each
shift, including the master control logbook, when accepting the shift, to document they are
aware of current relevant situations in the center. The juvenile justice detention officers (JJDOs)
assigned to each living module review the module logbook upon accepting the shift. The
superintendent was interviewed and stated the superintendent or designee review all logbooks
and document each review weekly at a minimum ; however, when the logbooks were reviewed
it was determined the superintendent and/or designee were not consistent with their logbook
reviews. There were no reviews in any of the logbooks until the new superintendent was hired
and then reviews were inconsistently completed.
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5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys.
All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of
keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch.
The key(s) on these rings shall provide egress through facility exterior doors providing access
to evacuation areas.
A key inventory shall be maintained by the Superintendent or designee at all times.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center has a facility operating procedure describing the center’s key control process,
issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys,
and reporting and replacement of damaged keys. When detention staff enter the center, their
personal keys are to be secured in lockers on the non-secure side of the center or given to
master control prior to being issued a key set by the master control operator or during shift
briefing. Visitors and contracted staff secure personal keys in a locker outside of master control.
An observation during the week of annual compliance review and an informal interview with the
center’s master control staff revealed the facility keys are stored on a tamper-resistant key ring
which prohibits the removal of keys and is color coded specific to the position to which the keys
are assigned. These keys are stored in master control which is secured. An observation of the
collection of keys by master control confirmed the issuance and return of keys through
confirming the key ring numbers. Issued key sets are also documented on the daily shift reports
in SharePoint. Keys are consistently checked and maintained by supervisors and
administration. Staff were observed always carrying the facility keys on their person during the
week of the annual compliance review and youth did not have access to facility keys. In
addition, an informal interview of the master control operator and two other juvenile justice
detention officer II (JJDO II) staff was conducted. All three staff were knowledgeable of the keys
on their ring and their functions. Staff indicated youth have no access to facility keys. The
interview with the superintendent indicated administration staff, food service director, and
maintenance are the only staff with permanent keys. If a key is missing the juvenile justice
detention officer supervisor (JJDOS) must be notified immediately; a Department’s Central
Communications Center (CCC) report is generated if any key is not found or located. During the
annual compliance review period, there were no keys reported missing or broken Three staff
were interviewed and identified the restricted keys are for medical or mental health records,
case management records, youth property, kitchen, and egresses. Each staff reported they
knew the key control process and were able to explain the process for missing and/or broken
keys. The superintendent stated a key inventory must be always maintained. The inventory
must account for all keys by the ring number; the number of keys on each ring; the capability of
each key; and to whom (or where) each permanent key ring is issued.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 57 (Revised July 2023)
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains a facility operating procedure for transportation, operation, and
maintenance of each vehicle which is used to transport youth. The facility’s maintenance
mechanics and transportation coordinator are responsible for the weekly and monthly vehicle
inspections. The maintenance mechanics, transportation coordinator, or staff using vans for
transport complete the vehicle checks daily to ensure all vehicles are equipped and readily
available to drive. The facility has a total of seven vehicles, five vans were at the facility, and two
vans out on a transport at the time of the annual compliance review. Each vehicle had an
annual safety inspection conducted by a certified automobile mechanic. Observations of five
vehicles were conducted, which confirmed all were secured at the time of inspection. Four out of
the five vehicles had the appropriate number of seatbelts, a seatbelt cutter, a window punch,
and up-to-date fire extinguishers. During the annual compliance review week one of the vehicles
was missing the hazard kit. Once it was discovered as not being in the vehicle, the hazard kit
was later added to the vehicle by the maintenance mechanic. A first-aid kit with approved items
by the designated health authority (DHA) is checked out for each transport from master control.
A binder is maintained for each vehicle which contains the vehicle mileage log, vehicle
inspection log, vehicle oil change log, automobile accident reporting form, driving directions and
maps, AmeriSys information, gas card, vehicle registration, and relevant vehicle policies.
Weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventive maintenance check sheets. Staff are to conduct contraband
inspections prior to and after each trip. The contraband inspection is to be logged in the vehicle
log and master control is to be notified. An observation of a pre-trip inspection was conducted
during the annual compliance review week. An observation was conducted of one youth being
transported to court, which was conducted by two officers during the annual compliance review
week and the transporting staff were observed following required transportation procedures
prior to transport. Staff are given a mobile telephone to take with them on the transport. The
assigned mobile telephones are kept in master control. The vehicle logbooks did not indicate
whether the vehicle was searched for contraband prior to use and again upon return. The
vehicle logbooks did not indicate which staff was riding in the back of the vehicle with the youth
if there were two or more youth being transported. This was addressed in the contraband
indicator. The number of youth transported, and the destination including the date and time
were documented for each trip. Seven youth were interviewed, all seven indicated they feel
staff drive safely during transports and none of the youth ever observed anyone place
contraband in a transport vehicle. The superintendent provided a training roster during the
annual compliance review week to show corrective action being conducted to remind staff of the
transport logbook requirements.
5.09 Tool Inventory and Management Failed Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center maintains a facility operating procedure detailing the requirements for tool inventory
and management. A perpetual tool inventory list is to be maintained by the center. All tools are
stored in a locked area when not in use. During the annual compliance review week, a visual
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 57 (Revised July 2023)
observation was conducted of the tools. Tools were maintained on a shadow board and were
identified with a number. Observations indicated there were four missing tools from the shadow
board. All tools are to be checked out on a tracking form prior to use and checked in after they
are returned. There were four screwdrivers missing from the shadow board, which were found in
a tool bag laying on a desk in the tool shed. The center did not have a perpetual log created for
signing tools in and out. An interview with the maintenance mechanics indicated there were no
instances of missing or broken tools since the last annual compliance review. An itemized
inventory of kitchen equipment and tools is maintained. All kitchen items, including seven
knives, are inventoried twice daily and then again in SharePoint on a weekly basis. The kitchen
knives and other hazardous kitchen sharps are stored in a locked cabinet. No service vendors
were observed during the week of the annual compliance review. An informal interview with the
maintenance mechanics indicated all service vendors are identified prior to entering the secure
area of the facility and are always accompanied. Youth are removed from the area being
serviced and are not allowed to re-enter the area until it has been searched and cleared by
facility staff. The vendor checks for all their tools to ensure they leave with the tools they entered
the facility with. Seven interviewedstaff were able to explain the process when there are missing
or damaged tools by reporting, removing a damaged item, and securing it until repaired. During
an interview with the superintendent, it was confirmed only maintenance staff, and
administration have access to facility tools. Inspections and inventories are required to be
uploaded into SharePoint and reviewed by the superintendent or designee.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center maintains a facility operating procedure prohibiting youth from having access to any
tools, including kitchen and/or medical equipment. Youth are allowed to use cleaning items such
as mops, brooms, and other common household items under staff supervision when these items
are in use. Seven interviewed youth indicated they only use mops and brooms under the
supervision of staff. Seven interviewed youth stated they do use cleaning agents, but they are
not allowed to handle the cleaning agents. The staff handle the cleaning agents such as
spraying a table and then the youth can wipe it down. Seven interviewed staff stated youth are
allowed to use mops, and brooms.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 57 (Revised July 2023)
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous
Failed Compliance
Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center maintains a facility operating procedure to ensure the proper inventory of flammable,
toxic, caustic, and poisonous items. All items are inventoried and securely stored. All items
observed had a Safety Data Sheet (SDS) on record for each chemical. Five chemical items
were reviewed on-site during the week of annual compliance review for which the facility
maintained a corresponding SDS; however, inventory on hand was unable to be verified as
there were no inventories for the items. Flammable, toxic, caustic, and poisonous items were
observed to be stored securely in areas inaccessible to youth. The facility did not have a
perpetual running log created to show when flammable, toxic, caustic chemicals and poisonous
items are being signed in and out.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center maintains a facility operating procedure to ensure limited access to flammable, toxic,
caustic, and poisonous items. These Items can only be used by authorized staff. Youth are not
permitted to use or handle hazardous chemicals. No toxic materials were observed at the center
in any place accessible to youth during the week of annual compliance review. Seven youth
were interviewed, each stated they do not have access to flammable, toxic, caustic, and/or
poisonous items. An interview with seven staff indicated each stated youth are not allowed to
clean with substances which are toxic, flammable, or poisonous.
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Office of Accountability and Program Support Page 53 of 57 (Revised July 2023)
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) addressing proper use, storage, and
disposal of flammable, toxic, caustic, and poisonous items. The maintenance mechanics
reported in the event a chemical is to be disposed of, it is done so in accordance with the Safety
Data Sheet (SDS) requirements. The facility’s maintenance mechanics also reported the center
does not utilize grease for cooking and all kitchen liquid waste is disposed in the kitchen grease
trap. Medical sharps and waste are disposed of through a contracted medical waste disposal
company. No disposal of chemicals could be observed during the annual compliance review
week. The superintendent and the maintenance staff reported the center has not experienced
any chemical spills or leaks during the annual compliance review period.
5.14 Confinement Under Twenty-Four Hours Failed 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 facility has facility operating procedures (FOPs) ensuring confinements under twenty-four
hours are used as an immediate, short-term response to incidents which affect physical safety
of youth or others. Seven confinements reports were reviewed. The remaining visual
observation reports (VORs) were unable to be reviewed due to these records being placed in
surplus according to the center superintendent. Confinement reports for each confinement
confirmed all rooms were searched prior to youth being placed in confinement, all non-fixed
items were removed from the room, and each documented approval by a juvenile justice
detention officer supervisor (JJDOS). The assistant superintendent reported each youth had
access to mental health and education, as needed, and each youth showered and was given
clean clothes if in confinement. The confinement checks did not have notation on the
observation sheets to validate education was offered, meals were given, medications were
given (if needed), or if showers were conducted. All youth were notified they could grieve the
situation of being placed in confinement. All seven confinement reports were completed before
the end of the staff’s shift. Two out of the seven confinement checks were not being conducted
according to policy as multiple checks were missing on the two reports. Each reviewed report
indicated a JJDOS conducted an initial confinement review with the youth within two hours from
the incident. A JJDOS evaluated each youth every three hours and documented the need for
confinement. Each report indicated the youth were released from confinement within twenty-four
hours. Each of the seven confinement reports indicated the superintendent or designee
reviewed the confinement report within forty-eight hours. There were no pregnant youth
confined during the annual compliance review period. None of the reviewed youth confinement
records had any notation of physical injury, youth complaint of injury or illness, a known chronic
health condition, or an injury which would have required a healthcare professional to be
immediately notified for timely assessment and treatment. Seven staff were interviewed. One
staff stated the confinement process is explained, and the youth has a right to the grievance
process. Six stated checks are completed, the JJDOS must approve the confinement, and the
room is searched. The superintendent interview confirmed confinements are tracked for
appropriateness by the center’s administration within the Department’s Juvenile Justice
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 57 (Revised July 2023)
Information System (JJIS). A supervisor will approve the confinement and conduct a review in
the first two hours and then every three hours after. Checks will be conducted on the behavior
every five minutes for the first hour and every ten minutes thereafter. The behavior is what
determines when the youth is released from confinement. Once released, an administrator will
review the confinement within forty-eight hours.
5.15 Confinement Over Twenty-Four Hours and Confinement
Failed Compliance
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 maintains a facility operating procedure addressing confinement over twenty–four
hours. The center had twelve instances of confinements over twenty-four hours during the
annual compliance review period. A review of five confinements over twenty-four hours was
conducted. The visual observation reports (VORs) were unable to be reviewed due to these
records being placed in surplus according to the superintendent. One of the reviewed
confinement reports indicated there was no supervisory review conducted for twelve hours.
Three out of the five youth did not receive a supervisory review or counseling to consider the
removal of the youth from confinement throughout the youth’s confinement. None of the
reviewed youth confinement records had any notation of physical injury, youth complaint of
injury or illness, a known chronic health condition, or experienced an injury which would have
required a healthcare professional to be immediately notified for timely assessment and
treatment. None of the five youth reviewed for confinements over twenty-four hours reflected a
confinement review was held to extend the time the youth were in confinement, as indicated by
the superintendent on each of the confinement reports. The superintendent was interviewed and
confirmed the confinement process and reported all confinements are reviewed daily.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains a facility operating procedure to manage various emergencies and
disaster events. Documentation confirmed the center conducted hurricane drills twice during the
annual compliance review period. Written scenarios, drill forms, training rosters, copies of
logbook pages, Delegation of Authority, Cooperative Agreements, Continuity of Operations Plan
(COOP) checklists, and electronic emails were used for documentation. Seven staff were
interviewed, and each staff indicated they have participated in COOP, bomb threat, escape, fire,
mental health, and medical drills. The superintendent interview reported the center has a COOP
in place along with a Memorandum of Understanding (MOU) with other centers to continue
operations in an emergency and COOP drills are conducted twice a year.
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Office of Accountability and Program Support Page 55 of 57 (Revised July 2023)
5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains a facility operating procedure to address escape drills and escape
prevention. The policy requires the center to conduct escape drills at least quarterly. The
documentation of the drills included scenarios, as well as the dates and times of the drills. The
drill documentation form included the signatures of the supervisory staff and the staff
coordinating the drill. Recommendations and critiques of the drills were included in each report.
A review of logbooks revealed escape drills were documented in the logbook, as required. All
documentation was also uploaded into SharePoint and signed off by the superintendent or
designee. A review of staff training records in the Department’s Learning Management System
(SkillPro) validated each staff completed escape prevention training. Five of the seven
interviewed staff indicated they had participated in an escape drill in the past twelve months.
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The facility has a disaster plan, fire prevention plan, and evacuation plan addressing fire
prevention and safety in the center. The center has evacuation egress plans posted throughout
the facility. Each egress plan defined the primary and secondary exit route and the locations of
emergency equipment such as fire extinguishers and first-aid kits. The facility’s disaster plan,
fire prevention plan, and evacuation plan were reviewed and approved by the local fire marshal.
Reviewed documentation also revealed the center’s fire extinguishers are inspected annually.
Documentation verified the center conducts fire drills each month, on each shift, during different
times. Drills are also reviewed during shift briefings. All documentation is uploaded into
SharePoint and signed off by the superintendent or designee. Seven youth were interviewed,
and all seven youth stated they have been instructed on what to do in case of a fire. Seven staff
were interviewed, all seven stated fire drills take place at least monthly.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 57 (Revised July 2023)
5.19 Search and Contraband Procedures Failed 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 for search and contraband procedures. Full body
visual searches shall be conducted during admission, if there is a reasonable suspicion a youth
is harboring contraband, and when deemed appropriate by the shift supervisor. All searches are
to be documented in the logbook. Staff are required to wear gloves during all searches.
Electronic searches are conducted on all staff and visitors entering the facility. All shoes, bags,
cases, jacket pockets, and other items are searched. All personal keys, personal cell phones,
and other contraband items were prohibited from entering the secure area. Prior to admission,
all youth are searched for contraband by electric wand and full-body visual search. One
admission was observed during the annual compliance review week. The youth was
electronically searched, and frisk searched which was conducted by an officer of the same
gender. The youth was also full-body visual searched by two officers present of the same
gender. One frisk search was observed during the annual compliance review week prior to a
transport. The staff completing the searches were of the same gender and wearing gloves. The
superintendent stated room searches are to be conducted upon a youth’s release, prior to new
youth being placed in a room, and searched for contraband on each awake shift. A sampling of
one day from each month during the annual compliance review period indicated room searches
were not being completed during each awake shift. In addition, none of the contraband
searches of vehicles were documented throughout the annual compliance review period.
Searches of staff and visitors were observed prior to entering the secure area every day of the
annual compliance review week.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 57 (Revised July 2023)

source: DJJ

report_type: QI Detention

rule: Indicator 5.09

rating: Failed Compliance

rule: Indicator 5.11

rule: Indicator 5.14

excerpt: Confinement Under Twenty-Four Hours

rule: Indicator 5.19

excerpt: Search and Contraband Procedures