facility_name: Leon Regional Juvenile Detention Center

summary: QI Detention - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Leon Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
2303 Ronellis Drive
Tallahassee, Florida 32310
Review Date(s): October 10-13, 2023
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Stephanie Solano, Office of Accountability and Program Support, Lead Reviewer (Standard1)
Janise Best, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Patrick Brock, Office of Education, North Central Region Education Coordinator, (Standard 2)
Lea Herring, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Interviews)
Christi Stua, North Region Detention Services, Senior Management Analyst (Standard 5)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Program Name: Leon Regional Juvenile Detention Center MQI Program Code: 32
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Leon County / Circuit 2 Number of Beds: 50
Review Date(s): October 10-13, 2023 Lead Reviewer Code: 209
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 56 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) 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 56 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 56 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 56 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 56 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 56 (Revised July 2023)
Program Overview
The Leon Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Tallahassee, Florida. The center serves youth in Leon, Gadsden,
Wakulla, and Franklin counties in Circuit 2. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-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 Leon County School Board. The
center’s management team includes a superintendent, two assistant superintendents, one
administrative assistant, eight juvenile justice detention officer (JJDO) supervisors, and thirty-
nine JJDOs. Mental health and healthcare services are provided through the contracted
provider VitalCore. Mental Health services are provided by a designated full-time mental health
clinician authority (DMHCA) who is responsible for all coordination and oversight of mental
health and substance abuse services at the center, and two non-licensed clinical staff. In the
event the DMHCA is unavailable, there is another full-time licensed clinical social worker
(LCSW) who can serve as the back-up DMHCA. 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 a designated health authority (DHA), an advanced practice
registered nurse (APRN), four registered nurses (RNs), and one licensed practical nurse (LPN).
The medical clinic maintains nursing coverage seven days a week, for eight hours a day. Food
services are provided by Department staff and include menus, meal planning, meal schedules,
special diets, nutritional analysis, daily allowance, food preparation, health certifications, food
product standards, sanitation, and cleaning. Staff are responsible for the custody and control of
youth in their care, providing youth supervision twenty-four hours a day, seven days a week.
The center has three living modules which are divided by male and female. There are sixty-four
security cameras at the center, of which fifty-eight were operational. At the time of the annual
compliance review, the center had five vacancies, which included the superintendent and four
JJDOs. At the time of the annual compliance review, the regional program operations chief was
serving as the acting superintendent.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 56 (Revised July 2023)
Strengths and Innovative Approaches
• Monday through Saturday the center has Level 3 Incentive Days. Each day has food,
video games, board games, cards, positive male and female interaction, treasure chest
day, and music provided by the center’s very own in-house disc jockey.
• This year the center held a field day, and other fun days with the youth. The center had a
youth and staff tournament followed by a big easter egg hunt on the recreation yard. The
center had baskets and eggs filled with candy for the youth and a guest speaker to
motivate youth and staff.
• The youth got to decorate their faces and other body parts with scary designs and the
staff got to dress up in a kid friendly costume. The center set up stations around the
facility and escorted the youth around the different departments and let them go trick or
treating ending with a spooky themed party.
• The center had a door decorating contest judged by all staff. The center decorated
cookies and had a staff versus youth trivia game followed by traditional and untraditional
holiday food the staff, youth, and the volunteers got to enjoy.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 56 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
Eight newly hired staff were applicable and reviewed for initial background screening. All
reviewed staff had a background screening completed prior to their hire date. A criminal history
report was reviewed for all eight staff and none required an exemption. All eight staff were
reviewed in the Department’s Staff Verification System (SVS), and none had a break in service;
therefore, a new background screening was not required. The center utilizes Ergometrics for
pre-employment testing for direct care applicants. All eight staff were applicable and completed
a pre-employment assessment tool with a passing score. None of the staff were contracted by a
provider; therefore, none were added to the Clearinghouse employee roster. The center had six
volunteers, mentors, or interns who assisted or interacted with youth on an intermittent basis for
less than ten hours a month who did not need to be background screened and were within the
line of sight at all times with a staff who had been background screened. The center’s and the
school board’s Annual Affidavit of Compliance with Level 2 Screening Standards were
completed January 17, 2023 and January 27, 2023 respectively.
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.
Two staff were applicable and reviewed for five-year rescreening. Both staff had the five-year
rescreening completed every five years, calculated from the center’s hire date. The center did
not have any contracted provider staff who required a rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 56 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
Six staff records were reviewed for staff code of conduct. All six of the staff had signed codes of
conduct in their personnel records. Three of the staff were applicable for receiving disciplinary
actions for violations of the code of conduct during the annual compliance review period.
Management took immediate action to investigate or address all allegations or violations of the
code of conduct and each of the three staff separated voluntarily from the Department. The
remaining three staff were applicable for receiving employee of the month for September 2023.
Seven youth were interviewed. Two youth reported they have never been stopped from
reporting abuse to the Florida Abuse Hotline since they have been at the center. The remaining
five stated they had never had to report abuse. All seven youth stated staff are respectful when
talking to youth. Five youth stated they have never heard staff use profanity toward youth. The
remaining two youth stated once and often respectively. All seven youth stated they have never
heard staff threaten a youth. All seven youth reported feeling safe at the center. All youth
reported never exchanging emails, telephone numbers, or social media contact with staff.
Seven staff were interviewed. All staff were able to explain the process for allowing staff and
youth to call the Florida Abuse Hotline or the Department's Central Communications Center
(CCC) to report suspected abuse. Five staff reported never observing another staff use profanity
when speaking to youth. The remaining two stated once and occasionally respectively. All
seven staff reported never hearing another staff using threats, intimidation, or humiliation when
interacting with youth. Four staff reported the center's working conditions were fair, two reported
good, and the remaining staff stated very good. The acting superintendent reported the center's
code of conduct is to remain professional at all times and follow the rules. If staff use physical
abuse, threats, or profanity towards a youth then staff are questioned. If appropriate, the Florida
Abuse Hotline and law enforcement are contacted, and mental health and medical assistance is
requested.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 56 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center had a total of fifty calls to the Department’s Central Communications Center (CCC)
during the annual compliance review period. Five incidents were reviewed. Four of the five were
reported to the CCC within the two-hour required time frame. The remaining call was seven
hours and eight minutes late. A review of logbooks revealed one incident was documented
appropriately. The remaining four were not located in the logbook and the center indicated they
missed documenting them. There were no additional incidents which were not reported to the
CCC. The acting superintendent stated all staff report to the supervisor if any inappropriate
actions are noticed and the CCC and/or Florida Abuse Hotline is contacted. Any person can
contact the CCC or Florida Abuse Hotline.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
During the annual compliance review period the center had a total of eighty-six Protective Action
Response Right Interactions model (PAR/RI) incidents involving physical intervention
techniques. The center’s most recent PAR/RI rate was 11.80, which is below the statewide
detention PAR/RI rate of 17.52. Nine PAR/RI incidents were reviewed for the annual compliance
review period. Eight PAR/RI Reports were completed by the end of the staff’s workday and
included statements from all staff involved. The remaining PAR/RI had one statement
completed ten days late. None of the reviewed PAR/RI incidents resulted in serious injury of the
youth or staff. None of the youth involved in the PAR/RI incidents requested to contact the
Florida Abuse Hotline. All nine PAR/RI Reports were reviewed by a supervisor, and a post-
PAR/RI interview was conducted with the youth by the administrator, or designee, within thirty
minutes. All were reviewed and comments were made by the superintendent or designee after
all other reviews and within seventy-two hours. Three PAR/RI Reports indicated a PAR/RI
medical review was conducted and it was documented in each youth’s Individual Healthcare
Record (IHCR). The remaining six PAR/RI Reports did not indicate a PAR/RI medical review
was necessary or the youth refused a medical review. No mechanical restraints were utilized,
and no youth were sent off-site for an evaluation. Seven staff were interviewed. All staff stated
they try to talk to youth prior to using physical restraints or mechanical restraints. The acting
superintendent reported the restraints are tracked and reviewed by the supervisors on a
quarterly basis by the supervisor. Restraints are used for transportation, court, and medical
transports. PAR/RI incidents and use of force incidents are reviewed and if it is deemed
excessive force was used, the staff is placed on no youth contact, and the incident is
investigated.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 56 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
Seven staff were reviewed for pre-service and certification requirements being completed within
180-days of hire. Each of the seven staff completed a new staff orientation within thirty days of
hire. One staff completed Phase One and Phase Two training within 180 days of hire. The
remaining staff were still within 180-days of hire. Three were in Phase One training and the
remaining three were in Phase Two training. None of the staff were returning staff with less than
one year of separation. All required 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.
Seven staff training records were reviewed for in-service training requirements. Four of the
seven reviewed staff were juvenile justice detention officers (JJDOs), and the remaining three
staff were JJDO supervisors. In-service training for 2022 was previously reviewed during the
last annual compliance review; therefore, the training for this annual compliance review period
was still in progress and the center has the remainder of the year to complete the required
training. Documentation was provided which verified the licensed nursing staff provided in-
service education on girls’ healthcare annually to all non-healthcare staff involved in the
supervision and treatment of girls. The center’s in-service training plan was approved by the
Department’s regional director on November 29, 2022 which include course names,
descriptions, objectives, and training hours as required. The center maintains an annual in-
service training calendar which is updated as changes occur. The acting superintendent stated
they received training in the Department’s Office of Systems Innovation (OSI), leadership
development and training, hiring, retraining, and individuals with disabilities. The JJDOs are
required to complete Protective Action Response Right Interactions model update,
cardiopulmonary resuscitation, facility operating procedures, suicide prevention, and mental
health training.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 56 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a facility operating procedure (FOP) which ensures each youth has the right to
grieve, is treated fairly, respectfully, without discrimination, and their rights are protected.
Grievance forms were available for the youth in each youth living module. The center
had seven grievances completed since the last annual compliance review. A review of all seven
grievances indicated they were all documented in the Facility Management System (FMS) as
required. They were each signed and resolved in accordance with the center’s FOP as required.
Seven youth were interviewed. All youth were able to explain the center’s grievance process. All
youth stated they have never had to file a grievance. Seven staff were interviewed. All staff were
able to explain the center’s grievance process. The acting superintendent reported the youth are
given the grievance form and upon completion, the form is given to a staff and is entered in
FMS. Once each level has reviewed and discussed the grievance with the youth it is signed off
in FMS. If the youth is not in agreement with level one, it is moved to level two, and finally level
three. Grievance forms are kept in a binder in the superintendent’s office and in FMS.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 56 (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.
Seven youth records were reviewed for entering alerts in the Department’s Juvenile Justice
Information System (JJIS). A total of sixteen alerts were applicable and reviewed for the seven
youth records. All alerts were documented in the logbook and shift report. All alerts were
entered into JJIS and the internal alert system within the required timeframe. The JJIS alerts
reports were reviewed daily by supervisors and administrators. The information regarding youth
alerts is shared with staff during shift briefings. The center’s shift briefing minutes are reviewed
for identification of youth with alerts. During the annual compliance review week the staff were
working in twelve hour shifts; therefore, a shift briefing could not be observed. When the center
becomes aware of new information the administration team is responsible for updating alerts.
There were no other alerts noted which should have been entered into the alert system. Seven
staff were interviewed. All staff stated they received information of alerts specific to youth in shift
briefings. Six staff stated in JJIS and one staff stated on alert forms. Seven staff stated
management informs staff about issues within the center through shift briefings. Three stated in
meetings, one stated in the logbook, one stated in email, and one stated in alerts. Two staff
stated communication for receiving information is fair, two stated good, and the remaining three
stated very good. The acting superintendent reported upon admission into the center, the youth
is seen by medical within twenty-four hours. During the intake process the center staff will place
an alert for the youth in the system. The alerts are discussed during shift briefing with each staff
and a copy is provided.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 56 (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 chief was informally interviewed regarding the center’s data trend analysis. The center’s
practice is to obtain confinement and Protective Action Response Right Interactions mode
(PAR/RI) data from the region during supervisor and department head meetings. The
information is shared with administration monthly and staff quarterly. The center uses the data
to enhance discussions on PARs/RIs and confinements with staff if the numbers are increasing
or decreasing. It allows the administration team to show the staff how fluctuations occur from
time to time. The chief provided graphs, meeting minutes, and meeting sign in sheets for review.
It is the Department’s Office of Systems Innovation’s (OSI) goal to decrease the use of both
confinement and PAR/RI. The data is used to demonstrate how there are fluctuations in both
areas and areas in need of improvement. The center is utilizing the collected data to improve
their processes by having open communication and discussions with administration and staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 56 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures in accordance with Florida Administrative Code
ensuring proper screening, evaluation, and documentation is provided for each youth admitted
into secure detention. Seven youth case management records reviewed had a Department’s
Juvenile Justice Information System (JJIS) Admission Wizard which contained all the required
admission elements. Six of seven youth case management records had an arrest affidavit and
Detention Risk Assessment Instrument, and the remaining one youth was a transfer from
another center. A Suicide Risk Screening Instrument (SRSI) was contained in each record.
Documentation confirmed all seven youth were full-body searched and/or electronic searched
by an officer of the same gender. Seven reviewed youth records documented youth telephone
calls to their parent/guardian and receipt of a meal. Each reviewed youth record documented
the youth received medical, mental health, and substance abuse screenings upon admission.
During the annual compliance review week no admission occurred; therefore, no observation of
a youth admission process was completed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 56 (Revised July 2023)
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures ensuring each youth admitted into the center
receives an orientation within twenty-four hours of admission. During orientation the center’s
rules and regulations, grievance procedures, visitation, telephone calls, available medical,
mental health, and substance abuse services and how to access them, how to access the
Florida Abuse Hotline or the Department’s Central Communication Center (CCC) for youth
eighteen years of age or older, possible new law violations for destruction of property, youth
rights, expectations for behavior, and related consequences for failing to meet behavior
expectations are reviewed. Seven reviewed youth records documented an orientation was
conducted within twenty-four hours of admission and each youth signed an orientation
acknowledgement brochure. Each reviewed youth record documented the orientation was
explained to the youth verbally and in writing by a juvenile justice detention officer (JJDO). The
brochure covered information related to rules and regulations, grievance procedures, visitation,
telephone calls, access to medical, mental health, and substance abuse services, access to the
Florida Abuse Hotline and CCC, behavior expectations and related consequences, possible
new law violations for destruction of property, youth rights, and Prison Rape Elimination Act
(PREA) related information. Six interviewed youth stated they were told about the rules and
regulations, daily schedule, education services, visitation, abuse reporting, and behavior
management system during orientation, and one youth stated they were not. During the annual
compliance review week no admission occurred; therefore, an observation of an orientation was
not conducted.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 19 of 56 (Revised July 2023)
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center maintains facility operating procedures ensuring all youth admitted to the center are
classified by the officer conducting an admission to provide the highest level of safety and
security. A review of seven youth records confirmed information concerning the youth’s history
and status including all other required documentation was included in the classification process.
Prior to placing a youth into a room the center considers several factors inclusive of gender,
height, weight, age, level of aggression, mental illness, intellectual disabilities, physical
disabilities, history of violent behavior, gang affiliation, criminal history, history of sexual
offenses including sexual battery charges, Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) screening results, medical, identified or suspected suicide risk,
escape, and security risks. A review of seven youth records documented youth are assigned to
a room based on their classification. None of the reviewed youth required reclassification for
changes in behavior or status. Youth with a history of committing sexual offenses or youth
identified as a victim of a sexual offense are not to be placed in a room with any other youth.
The superintendent remains informed of how to identify and address local gangs through
communication with the juvenile probation officer gang liaison during detention reviews and
emails. An interview with the acting superintendent confirmed the center’s classification
process.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 20 of 56 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures for all youth admitted into the center to be
evaluated to determine if the youth is a documented gang member, suspected gang member, or
associated with a gang member. Seven youth records were reviewed and none of the youth
reviewed were suspected or documented as being a gang member. The superintendent stated
the center has not identified any youth as gang members or affiliates during the annual
compliance review period. The superintendent also stated the center does not have a
designated gang representative. If a youth is identified as a gang member or associate, an
email is sent to the youth’s juvenile probation officer (JPO).
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center maintains facility operating procedures related to ensuring safe handling and
security of each youth’s personal property to include valuables, which are collected and secured
at the time of admission. Seven reviewed youth records confirmed each youth had a property
form which detailed personal property, valuable property, and youth and staff signatures. Five of
seven youth records contained letter of acknowledgment forms regarding unclaimed property
which were signed by each youth and the remaining two youth did not have any property at the
time of admission. Each applicable youth’s personal property was placed in an assigned
locker/bag and documented on the Property Receipt form. One of seven youth had valuable
property which was documented in the safe logbook and placed in a clear tamper-proof bag
which included the youth’s name, Department identification number (DJJID), date, staff name,
and signatures of youth and staff. Youth property is stored in the property room with limited staff
access. Valuable property is placed in a drop safe which is under surveillance twenty-four hours
a day. The center maintains a drop safe logbook which documents the time, youth’s name,
DJJID, and listing of items in the bag. The center had no admissions during the annual
compliance review week; therefore, no observation of accepting youth property was completed.
A review of the Department’s Central Communications Center reports since the last annual
compliance review found no incidents regarding youth property. Seven youth were interviewed,
and five of seven youth stated staff checked their personal property and then had them sign a
form stating the personal property was correct. Two youth stated they did not have property at
time of admission. An interview with the acting superintendent regarding personal property
revealed property items are behind two locked sources. Youth property is stored in a locked
safe in master control, and youth items which remain in the center and are not claimed are
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 21 of 56 (Revised July 2023)
processed and donated. Applicable funds are documented and sent to Department
headquarters by money order.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center maintains facility operating procedures addressing youth releases from the center. A
review of three applicable closed youth records revealed each record contained the appropriate
documentation signed by each youth’s parent/guardian or person taking custody of the youth
and a copy of the identification card of the person taking custody of the youth. Each record
confirmed the on-duty supervisor reviewed all paperwork related to the youth’s release, the
release paperwork received from the court, and verified the identity of the youth prior to the
youth’s release. Two of three reviewed records included documentation confirming each youth
and person to whom the youth was being released to were reminded of future court dates, the
remaining one youth did not have a future court date. None of the youth were applicable for an
endangered person alert. All applicable release forms were signed. Each youth’s admission and
release dates correlated with the information in the Department’s Juvenile Justice Information
System. An observation of a youth being released from the center was conducted, which
confirmed the center’s practice.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures ensuring, upon the youth’s release from detention
and retrieval of personal property, the releasing officer, the youth, and the youth’s
parent/guardian review and sign the Property Receipt form and account for all the youth’s
personal property. The center ensures there are provisions in place to ensure prescribed
medications, along with medical instructions, accompany detained youth upon release. Two of
three youth records documented each youth and parent/guardian signed the Receipt of Property
form upon release. The remaining youth was eighteen and did not required parent/guardian
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 22 of 56 (Revised July 2023)
signature.Each youth record documented the youth was released to an appropriate person with
a copy of their identification. There were no youth applicable for the release of medication. Each
youth record documented 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 had no property held for
more than thirty days during the annual compliance review period. An observation of the
center’s release process confirmed the center’s practice.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures ensuring the center conducts detention
reviews on a weekly basis to ensure proper management of youth placed in secure detention
and the appropriate sharing of information. The superintendent and juvenile justice detention
officer supervisor coordinate detention reviews. Observations of the detention review process
and Secure Detention Log review were conducted during the week of the annual compliance
review. There were no discrepancies found during the review. Detention reviews are conducted
on a weekly basis, every Wednesday, to address the status of each youth. Reviewed
documentation for detention review meetings since the last annual compliance review confirmed
all required participants attended the meeting, either in person, through virtual conferencing, or
by telephone. An interview with the superintendent regarding weekly detention reviews for
secure detention indicated all of the youth in secure detention are discussed. All court hearings,
evaluations, appointments, release dates, and commitment status for youth are reviewed.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center maintains facility operating procedures ensuring youth participate in constructive
activities by maintaining a daily schedule which is posted in all living areas, including weekdays,
weekends, and holidays, and incorporates both structured and free time. The schedule
indicated the time frames of activities provided to youth on a regular basis, including wake-up,
personal hygiene, mealtime, visitation at a minimum of twice a week, recreation, physical
activities including at least one hour of daily large muscle exercise outdoors, indoor activities
which promote education, problem solving and life skills, shift change, bedtimes, groups, and
open program time. Throughout the annual compliance review week, observations confirmed
the center followed the posted activity schedule and the schedule was posted in all living areas.
An interview was conducted with seven youth, and each reported the center has a daily activity
schedule which is followed. An interview was conducted with seven staff, and each reported the
center’s daily schedule is followed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 23 of 56 (Revised July 2023)
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. The center provides
education services through the Leon County School District and the 250-day calendar, which is
distributed over twelve months, was reviewed. The schedule accounted for eight teacher
training and planning days. A review of the daily school schedule revealed the center provides
three 101 minute class blocks daily with a sixty-minute lunch, fulfilling the weekly requirement of
twenty-five hours of instruction time. On July 26, 2023, a minor deficiency was assigned for
educational access, which was verified and closed on September 21, 2023. Center logbooks
and video were reviewed for three days following closure of the deficiency and verified the
school schedule was being properly followed, with no indications of education being cancelled.
Seven youth were interviewed, and all reported they attend school Monday through Friday. All
felt the school was preparing them either very well or well towards a high school equivalency
diploma (GED), high school, vocational, employment, and/or college. Seven staff were
interviewed, and all seven felt there was minimal interference in educational services, with one
staff stating they do not like to remove any youth from the classroom unless it is necessary. The
interview with the acting superintendent indicated there is minimal interference with educational
services except for attending court or other required appointments.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to provide career education. A discussion with the
lead teacher confirmed the facility offers Type 1 career education development which includes
career learning strategies such as interviewing skills, résumé writing, and exploring various
career paths. The career education programming includes communication, interpersonal, and
decision making skill development. Seven youth were interviewed, and all reported they were
taking core classes such as math, science, history, reading, and social studies. They also
reported they were taking life skills and career choices.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 24 of 56 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor (LMHC), with a clear and active license in the State of Florida, with an
expiration date of March 31, 2025. A contract between the Department and VitalCore Health
Strategies, LLC outlines the role of the full-time DMHCA as responsible for all coordination and
oversight of mental health and substance abuse services at the center. The DMHCA works full
time at the center with at least forty hours a week, as required. In the event the DMHCA is
unavailable, there is another full-time licensed clinical social worker (LCSW) who can serve as
the back-up DMHCA. An interview was conducted with the DMHCA confirmed they oversee all
mental health and substance abuse services at the center, including making sure each youth
entering the center is evaluated within twenty-four hours, offering voluntary mental health and
substance abuse services to youth during the orientation process, and making sure any youth
prescribed psychotropic medications is evaluated by the psychiatrist within the required time
frame. When a youth is determined to need treatment, the youth is provided weekly individual
and group therapy. The DMHCA reported they communicate daily with full-time clinicians on the
youth’s status, treatment planning, meetings, and policy changes. The DMHCA meets weekly
with the registered mental health intern and frequently communicates with the part-time
clinicians either in-person, by telephone, or email.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has one full-time licensed clinician and four part-time mental health licensed
clinicians providing mental health and substance abuse services to youth at the center, in
addition to the designated mental health clinician authority (DMHCA). One of the clinicians is a
licensed clinical social worker (LCSW) and the four part-time licensed clinicians are all licensed
mental health counselors (LMHCs) with clear and active licenses in the State of Florida which all
expire March 31, 2025. The DMHCA is responsible for ensuring all licensed clinicians provide
services they are qualified to provide. Staffing of licensed clinicians was maintained in
accordance with the provider’s contract with the Department.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 25 of 56 (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 center has one non-licensed clinician providing mental health services to youth at the
center. The clinician is a registered mental health clinical intern (RMHCI) with a master’s-level
degree in counseling, meeting requirements outlined in the provider’s contract with the
Department. The center does not have a Chapter 397 license for substance abuse services;
therefore, only licensed staff provide substance abuse services to youth at the center. The
designated mental health clinician authority (DMHCA) is responsible for ensuring the non-
licensed staff provide services they are qualified to perform. A review of weekly supervision logs
found the DMHCA conducted at least one hour of face-to-face supervision with the non-licensed
staff each week using the Department form. The DMHCA or one of the licensed mental health
staff reviewed and approved all assessments completed by the non-licensed staff, as required.
The non-licensed staff had documentation of training in the administration of Assessment of
Suicide Risk (ASR).
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has a facility operating procedure (FOP) regarding mental health and substance
abuse admission screenings utilizing the Massachusetts Youth Screening Instrument, Second
Version (MAYSI-2) and Suicide Risk Screening Instrument (SRSI). Seven youth records were
reviewed, and each youth was screened using the SRSI which was completed in the
Department’s Juvenile Justice Information System (JJIS) and reviewed by detention staff with
the nurse and mental health staff completing the required sections. Six of the seven records
included a MAYSI-2 which was completed in JJIS by a trained staff. One record did not have a
MAYSI-2 because the youth was transported in from another center and did not require another
Juvenile Assessment Center (JAC) screening. Four youth had at least one positive response on
the SRSI indicating an increased suicide risk and were placed on precautionary observation
(PO), an alert was entered, and referral made for an Assessment of Suicide Risk (ASR). One
youth refused to answer any questions for the MAYSI-2 and SRSI, which requires the youth be
placed on PO and an ASR referral. One youth did not have any positive responses on the SRSI
or an elevated suicide risk subscale on the MAYSI-2, but was placed on PO and referred for an
ASR due to previous suicide risk alert. Three other youth had previous suicide risk alerts in
JJIS. Each of the seven records contained a referral for further assessment. Three of the
MAYSI-2s were marked as invalid and all three generated an override for referral for services.
One youth refused to answer and was referred for the ASR and a comprehensive assessment.
One youth received positive responses on the SRSI and an ASR was referred. One youth
requested mental health and substance abuse services. Each of the seven youth were referred
for a comprehensive assessment as required, and the superintendent/designee notified. Two
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 26 of 56 (Revised July 2023)
youth’s MAYSI-2 results indicated elevated risk subscales and one youth had a completed
referral. The second youth had an incomplete referral within their record.
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 comprehensive
assessments, with six records referred for a comprehensive assessment. One of the six youth
scheduled to receive a comprehensive evaluation did not contain the referral form; however, did
have the Substance Abuse and Mental Health (SAMH) assessment completed within thirty days
of being identified for treatment. One youth record did not have a completed referral indicating
what was referred; however, received an Assessment of Suicide Risk (ASR) and was released
from the center within thirty days of receiving the comprehensive assessment. The
comprehensive assessment is referred by the center’s clinical staff to the community provider
for a new assessment to be completed. If an assessment is not completed for the youth within
the required time frame the center’s clinical staff will complete the assessment on the
Department’s Substance Abuse Mental Health (SAMH) form in its entirety ensuring the
treatment recommendations correspond with the youth’s diagnoses.
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 youth records were reviewed, with two records applicable for mental health and/or
substance abuse treatment while at the center, requiring a treatment plan. One additional record
was provided to review youth treatment planning. All three applicable youth had an Initial
Treatment Plan completed within seven days of the onset of treatment. Each plan was
documented on the Department form and included all required elements. Each plan was signed
by the licensed clinician who completed the plan, each youth, members of each youth’s mini-
treatment team, and documented notation of the plan sent to the parent/guardian. Two of the
three youth were at the center long enough to require an Individualized Treatment Plan. The two
Individualized Treatment Plans were documented on the Department’s form and included all
required elements. Each plan was signed by the licensed clinician who completed the plan and
included signatures of each youth, members of each youth’s mini-treatment team, and
documented notation of the plan being sent to the parent/guardian. Both records were
applicable and contained one treatment plan review conducted within thirty days of the
individual treatment plan. Both treatment plan reviews contained all the required elements and
were signed by the clinical staff, youth, licensed clinician, treatment team members, and
documented notation of the plan being sent to the parent/guardian. One youth was applicable
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 27 of 56 (Revised July 2023)
for psychiatric services and their individualized treatment plan contained pharmacological
interventions, progress notes validating the youth was receiving treatment services as stipulated
on their treatment plan, and listed medications. The one applicable youth record included
treatment services which were provided by the psychiatrist, and any modifications were
documented on the review form. None of the three youth were an alleged victim of a Prison
Rape Elimination Act event. Three closed youth records were reviewed and found each youth
had a discharge plan documented on the required Department form. A copy of the plan was
emailed to the juvenile probation officer (JPO) who is responsible for sharing the plan with each
youth and parent/guardian. A mini treatment team was observed at the time of the annual
compliance review. The youth’s treatment status and any psychotropic medication changes
were discussed during the treatment team meeting.
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 with two applicable for mental health and/or substance
abuse treatment while at the center. One additional youth record was provided. All three youth
were assigned to a mini treatment team. Each youth’s mini treatment team included all required
parties. A review of treatment notes and treatment plans confirmed each of the three youth
received individual, group, and/or family counseling in accordance with their treatment plan and
at least weekly. All three youth received substance abuse services and signed the Department
consent forms for substance abuse treatment and substance abuse treatment records release.
All treatment notes were documented on the required Department form. Each of the three youth
records included a valid Authority for Evaluation and Treatment. Video review indicated one
group was conducted in the last thirty days. The mental health group had less than ten youth in
the group and each youth signed the group sign-in sheet confirming their participation. The
center reported they did not provide additional groups during the last thirty days due to the youth
refusing group therapy. The center utilizes several areas which provide a large confidential
space for groups to occur. Seven youth were interviewed and one youth reported the mental
health services at the center were good. Six youth stated they were not receiving mental health
and substance abuse services. The designated mental health clinician authority was interviewed
and reported the clinical services the center provides are cognitive and dialectical behavior
therapy, substance abuse treatment, and individual and group therapy.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 28 of 56 (Revised July 2023)
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has a psychiatrist who has a clear and active license under Chapter 458 as a
medical doctor, which expires January 31, 2024. Documentation was provided to support the
psychiatrist completed a training program in psychiatry, as required. The center utilizes a back-
up psychiatrist who is licensed as a medical doctor with additional training in psychiatry, which
expires January 31, 2024. The provider’s contract with the Department outlines the center is
approved for tele-psychiatry; however, has not been utilizing tele-psychiatry. Seven youth
records were reviewed and none were applicable for psychiatric services. Three additional
records were provided for the review of psychiatric services. All three applicable youth entered
the center on psychotropic medications, were seen by the psychiatrist within the required time
frame, and had their medications continued. Each youth had an Initial Diagnostic Psychiatric
Interview within fourteen days of admission which included all required elements. Each youth
had a psychiatric evaluation completed within the required time frame containing all required
elements. One of the two youth was at the center long enough and received one thirty-day
medication monitoring review. Each youth’s medication was continued, and all required
information was documented on page three of the Department’s Clinical Psychotropic Progress
Note (CPPN). Parent/guardian verbal consent was obtained any time psychotropic medication
was prescribed, discontinued, or the dosage was significantly changed. The psychiatrist signed
and dated each CPPN. All three youth had a valid Authority for Evaluation and Treatment
(AET). The DMHCA was interviewed and reported meeting with the psychiatrist once a week for
initial and follow-up evaluations, and speaking with the psychiatrist two to three times each
week to discuss treatment and any upcoming youth evaluations.
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 which includes all required elements, and is
reviewed and approved by the superintendent and designated mental health clinician authority
(DMHCA) annually. The center’s plan includes an established review process detailing all
required elements for every serious suicide attempt or self-inflicted injury.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 29 of 56 (Revised July 2023)
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Seven youth records were reviewed, and six youth were identified at admission to be a suicide
risk and placed on precautionary observation (PO). Each of the six applicable youth were
placed on PO upon arrival and referred for an Assessment of Suicide Risk (ASR). Each youth’s
Suicide Precaution Observation Logs were completed in their entirety with a qualified mental
health professional involved. All six youth had an alert placed and closed in the Department’s
Juvenile Justice Information System (JJIS), as required. Each youth received an ASR within the
required time frame, which was documented on the Department’s form and included all required
elements, including recommendations for supervision and follow-up. Each form was completed
by a licensed clinician. The superintendent or designee was notified of each youth’s status and
involved in a consultation with a licensed clinician prior to stepping each youth down to standard
supervision which was documented on the ASR. None of the youth were discharged while on
PO. One of the youth required a Follow-Up ASR which was completed on the Department’s
form and documentation of a conference held by the superintendent and licensed mental health
professional prior to transitioning the youth to close supervision was maintained. The date and
time of the discontinuation of PO was documented in accordance with the center’s suicide
prevention plan. Five of the six applicable youth placed on PO had required documentation in
the center’s logbook. The one remaining youth placed on PO was removed from PO at intake
and was not required to be logged in the center’s logbook. None of the youth were applicable for
placement in secure observation. The acting superintendent was interviewed and reported the
center can use secure observation if needed. The acting superintendent explained it would be
utilized if a youth posed a threat to themselves or others while on PO. Seven staff were
interviewed, and each reported in the event youth express suicidal thoughts staff are required to
notify the mental health authority. Six staff reported to document supervision and place the
youth on constant sight and sound supervision. Two staff also reported to notify the supervisor.
Two of the seven interviewed youth reported they were placed on PO while at the center and
staff watched the them at all times, the remaining five youth stated they were not placed on PO.
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.
Six of seven youth records reviewed were applicable for youth on precautionary observation
(PO). The applicable six records reflected each youth’s PO supervision was documented on the
Department’s form, which was completed in its entirety. Each youth was maintained on the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 30 of 56 (Revised July 2023)
proper level of supervision for the duration of PO and observations were documented at
intervals not to exceed thirty minutes. None of the youth were applicable for warning signs while
on PO. Each log was signed by the shift supervisors and a mental health clinician and
documented safe housing requirements. Video observation of two youth on PO verified each
was being supervised as required. No additional youth were on PO within the last thirty days to
review.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has a Suicide Prevention Plan which includes requirements for staff training in
suicide prevention. Seven pre-service and seven in-service training records were reviewed for
this calendar year. In-service training for 2022 was previously reviewed during the last annual
compliance review; therefore, the training for this annual compliance review period was still in
progress and the center has the remainder of the year to complete the required training. All
seven pre-service staff had the suicide prevention training completed in the Department’s
Learning Management System only. A review of mock suicide drills found the center conducted
drills at least quarterly on each shift for the duration of the annual compliance review period.
Thirty-five staff were applicable for a mock suicide drill for the first six months and were
documented on a sign-in sheet as completing a drill. Thirty-five staff were applicable for a mock
suicide drill in the second six months and thirty-three staff were documented on a sign-in sheet
as completing a drill. Each of the staff who completed a drill completed at least one drill which
included the practice of cardiopulmonary resuscitation (CPR). Staff who were not present for a
drill had the opportunity to review the drill at the next all-staff meeting. The center has seven
suicide response kits, co-located with first-aid kits, one on each of the three youth modules, one
in master control, one in the nurse office, and two for transports, each of which included the
knife-for-life, needle nose pliers, and wire cutters. Seven staff were interviewed regarding the
location of the suicide kits. All seven staff reported suicide kits are located on the modules, two
staff added they were in the vans, two staff reported medical, and one staff reported in master
control.
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 Emergency Services Plan which documents all required information
for crisis intervention.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 31 of 56 (Revised July 2023)
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has a Combined Emergency Services Plan which includes all required elements.
The plan was last reviewed and approved by the superintendent and designated mental health
clinician authority (DMHCA) on August 9, 2023. The plan is maintained on the boy’s module and
can be found on SharePoint, accessible to all staff.
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, and none were applicable for a Crisis Assessment. The
center had only one youth who required and received a Crisis Assessment during the annual
compliance review period. The assessment was conducted immediately upon identification of
the youth’s crisis by a licensed clinician and was documented on the Department form, which
included all the required elements. Notification was made to the parent/guardian for follow-up
treatment. Based on the result of the Crisis Assessment the youth was placed on precautionary
observation and referred for an Assessment of Suicide Risk (ASR). An alert was placed in the
Department’s Juvenile Justice Information System (JJIS) as required. The youth was not
applicable for an assessment based on a Prison Rape Elimination Act (PREA) incident. A
review of reports to the Department’s Central Communications Center (CCC) found the center
did not have any PREA incidents during the annual compliance review period requiring a Crisis
Assessment.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth were reviewed, and none were applicable for a Baker or Marchman Act. The
center had one youth applicable for three admissions for Baker Act and returned to the center
during the annual compliance review period. Upon return from the Baker Act the youth was
placed on precautionary observation (PO) and a referral made for an Assessment of Suicide
Risk (ASR), including a Mental Status Examination (MSE), on all three occasions. The ASR and
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 32 of 56 (Revised July 2023)
MSE were completed by a licensed clinician, the youth was maintained on PO until a Follow-Up
ASR was completed and it was determined the youth could be safely transitioned to a lower
level of supervision. The youth’s supervision was not lowered until a consultation was
conducted between the licensed clinician and the center superintendent. The youth had an alert
appropriately entered and closed in the Department’s Juvenile Justice Information System
(JJIS), as required.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 33 of 56 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The Department contracts with VitalCore Health Strategies, LLC, for medical services at
detention centers statewide. The contract went into effect on March 17, 2022. VitalCore Health
Strategies, LLC subcontracts with a medical doctor (MD) to serve as the designated health
authority (DHA) at the center. The DHA holds an unrestricted license and meets all
requirements for independent and unsupervised practice in Florida. The DHA’s license expires
January 31, 2024. The DHA has completed training and has a specialty certification in internal
medicine. The center also has an advanced practice registered nurse (APRN), who holds an
unrestricted license to practice in Florida with a specialty certification as a family nurse
practitioner. The APRN’s license expires April 30, 2024. Due to the APRN not being licensed as
autonomous, a Collaborative Practice Protocol is in place at the center. The protocol was
originally enacted on May 20, 2020 and is reviewed annually, most recently on September 25,
2023 by the DHA and October 7, 2023 by the APRN. A review of the sign-in logs for medical
staff and forms to document DHA visits found the DHA was on-site each week for at least two
hours during the annual compliance review period. If the DHA is on vacation or scheduled
absence, a DHA from another center is utilized. All applicable facility operating procedures
(FOPs) were reviewed by the DHA. The contract outlines the DHA’s responsibilities, to include
but not limited to oversite of medical services at the center, assisting in the development of and
approval of all medical policies, procedures, and protocols, on-site healthcare, and consultation
for acute medical concerns, emergency care, coordination of off-site services, and other
responsibilities as needed. The DHA interview confirmed the responsibilities outlined in the
contract. For instances in which tele-medicine was utilized, the facility had a tele-medicine log
documenting youth seen for care. A review of the provider’s tele-medicine FOPs documented
the process for sign-in and sign-out of the practitioner.
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
treatment protocols. The medical FOPs were developed and signed/approved by the designated
health authority (DHA) and superintendent at the time of the new contract with VitalCore Health
Strategies, LLC on March 28, 2022, and reviewed signed this annual compliance period on
August 9, 2023. Nursing staff reviewed, signed, and dated a cover page to document their
review of all medical FOPs, treatment protocols, and other procedures on various dates
throughout the months of September and October during the most recent annual compliance
review period. Approval of medical treatment protocols or standing procedures are written and
authorized by the DHA and are not delegated to any other staff. All newly hired staff received a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
given by a registered nurse or designated, licensed healthcare professional.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 34 of 56 (Revised July 2023)
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Seven Individual Healthcare Records (IHCRs) were reviewed for completion of an Authority for
Evaluation and Treatment (AET) form. Six of seven records had a current AET. Six of the seven
youth records had the AET signed by the youth’s parent/guardian as required. The remaining
AET was a limited AET signed by the superintendent, the on-site nurse reached out to
parent/guardian to obtain signed AET. . . All seven AETs were signed by a Department
representative, obtained prior to any medical service delivery, and six AETs were valid. One of
the remaining two AETs belonged to a youth who had turned eighteen years of age within the
past month of the annual compliance review week; therefore, nullifying the originally signed
AET. Youth eighteen years of age or older are able to give consent verbally at the time of
service delivery. The eighteen year old youth did not have a release of information documented
on record; however, the center had contact with the youth’s parent/guardian after the youth
turned eighteen. None of the reviewed youth were in the care of the Department of Children and
Families (DCF).
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Seven Individual Healthcare Records were reviewed for parental notification and consent. Five
youth were applicable for parent/guardian notification for over-the-counter (OTC) medication
beyond those covered by the Authority for Evaluation and Treatment (AET). Consent was
provided in four instances by the parent/guardian. Written parental notifications were completed
on the correct form in all seven records. None of the selected youth were taking psychotropic
medications. None of the seven youth were applicable for vaccinations/immunizations. Four
youth were applicable for new medication had included documentation of attempted contact with
the parent/guardian in the progress notes. Parental notices were sent regardless of telephone
notifications. None of the youth were applicable for new psychotropic medication. None of the
selected youth were in the care of the Department of Children and Families (DCF). Each youth
record contained a vaccination record from Florida Shots, which had been reviewed by medical
staff within thirty days of admission or during a youth’s prior admission to the center, with the
exception of two youth. One youth was vaccinated out of state and the center was in the
process of obtaining the records, and the other youth had a religious exemption. Each of the six
youth’s immunizations were current and the youth with the religious exemption’s record
contained the Religious Exemption from Immunization form provided by the county health
department. The center has not had any youth requiring vaccinations during the annual
compliance review period. The nurse interview confirmed and outlined in what circumstances
the AET is required, when parental notification is required, and in what circumstances
vaccinations are given at the Department of Health.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 35 of 56 (Revised July 2023)
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Seven Individual Healthcare Records (IHCRs) were reviewed for an initial healthcare admission
screening. Six youth records had a Department Medical and Mental Health Admission
Screening form completed on the date of admission; one youth record contained an admission
screening completed two days late. All seven forms were completed by the juvenile justice
detention officer (JJDO) or juvenile justice detention officer supervisor (JJDOS) conducting
intake and reviewed with each youth by a licensed medical staff within twenty-four hours. Six of
seven records were applicable and documented notification of admission to the designated
health authority (DHA). The center completes a new healthcare admission screening on all
youth entering or reentering the center. The center had no youth applicable for rescreening
during the annual compliance review period. None of the records reviewed were for female
youth; therefore, were not applicable for documentation of a qualitative urine pregnancy
screening test at the time of admission following consent. The nurse interview also confirmed
this process.
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.
Seven Individual Healthcare Records (IHCRs) were reviewed for youth orientation to healthcare
services. All seven youth records had documentation each youth received general healthcare
orientation, which was documented on the Department’s Health Education form. The healthcare
topics included access to medical care, sick call, what constitutes an emergency, medication
process, right to refuse care, what to do in case of sexual assault, the non-disciplinary role of
healthcare providers, and a review of all healthcare contacts to ensure accuracy. All health
education topics were documented on the Department form.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Seven Individual Healthcare Records (IHCR) were reviewed for designated health authority
(DHA) admission notification. Four of the youth were admitted with a known or suspected
chronic condition and had a referral to the DHA documented in each youth’s Chronological
Progress Notes. None of the youth were identified as in need of emergency care upon
admission. Notification of the DHA was completed within twelve hours of admission and
documented in each youth’s IHCR in all four records. None of the youth were admitted with
psychotropic medications. The nurse interview confirmed procedures for DHA notification, to
include an emergency response, if needed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 36 of 56 (Revised July 2023)
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
Seven Individual Healthcare Records (IHCRs) were reviewed for completion of a Department
Health-Related History (HRH) form. All seven records had a HRH completed within seven days
of admission by a licensed nurse. Each HRH was reviewed by the designated health authority
(DHA) or advanced practice registered nurse (APRN) before or at the time of the
Comprehensive Physical Assessment (CPA), as evidenced by signature and date. The nurse
interview confirmed the HRH is completed within seven days of admission and prior to youth
being exposed to any extreme outdoor weather conditions.
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 (IHCR) 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. In two of the seven records, a current CPA was on
file at admission and utilized. The remaining five youth had a new CPA completed by the
designated health authority (DHA) or advanced practice registered nurse within seven days of
admission. The applicable two youth’s CPAs were reviewed and signed off by the DHA or
APRN as they examined the youth. A focused evaluation was completed with each readmission
for the two youth who had a current CPA on file. The Medical Grade was noted on each CPA.
All sections of the CPAs were completed in full and marked as required. All seven youth records
had documentation of youth refusing part of the exam, which was documented on each CPA
and on a Youth Refusal of Care form. The Department’s Problem List in each record was
updated. A TST completed within the last year was documented on each CPA and Department
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 on the
Department’s Medical and Mental Health Admission Screening form. One of the seven youth
required further evaluation as a result of the TST. The DHA ordered the youth to be transported
to the nearest hospital or health department for further evaluation, which was conducted prior to
the youth entering general population, and the youth was provided a mask and isolated until the
transport occurred. The nurse interview fully described the processes and time frames for the
completion of the CPA and TST, and confirmed the facility operating procedures provided by the
center.
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.
Seven youth Individual Healthcare Records (IHCR) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. An additional
record was reviewed to capture the minimum requirement of three. Eight reviewed IHCRs
documented each youth was sexually active and were subsequently referred and screened for
STIs. Further evaluation was required for all eight youth and the referrals were documented on
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 56 (Revised July 2023)
the STI form. Five of the eight youth did not receive testing within seven days of admission due
to refusing the test. For the remaining three youth, testing, screening results, clinical
evaluations, and diagnoses were documented on the Department’s Infectious and
Communicable Disease form. Documentation of the refusal was available in each IHCR. None
of the eight youth received a gynecological exam. None of the eight youth were ever out of the
Department’s physical custody. All eight youth were offered counseling and testing for HIV.
Three youth received testing for HIV and a documented consent was obtained. The HIV test
results were filed in a sealed envelope marked “Confidential”. The designated health authority
(DHA) did not sign the envelope; however, did comment in the youth’s chronological progress
notes of being contacted by a licensed nurse regarding the results. Documentation of pre-test
and post-test counseling was documented on each Individual Health Education Record and in
the progress notes. All three-youth’s status of the HIV results were protected by not including
the results on the center’s internal alert system. The nursing staff interview confirmed all
applicable youth are screened for STIs and described the procedures as well as how the results
are stored. All seven interviewed youth stated they can request an HIV test if they desire to be
tested.
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 youth Individual Healthcare Records (IHCR) were reviewed for sick call process
requirements. Three out of seven youth received sick call services. All three youth’s sick calls
were documented on the sick call referral log. None of the three youth presented with a similar
sick call complaint three or more times within a two-week period; therefore, no referral was
needed to the designated health authority (DHA). One youth had a complaint of severe pain, the
nurse immediately made a referral to the DHA, and the youth was seen within seven days from
the sick call complaint. All three applicable youth completed a Sick Call Request form. Only
nursing staff completed the sick call request form. All three sick calls were conducted by a
registered nurse (RN) the same day of each request. All sick calls for each youth were filed in
each IHCR in reverse chronological order. None of the seven reviewed youth were in restricted
housing during sick call hours. All three sick call forms were documented in accordance with
Florida Administrative Code. All three youth sick call forms included a youth signature at the
bottom of each form. All three youth sick calls were documented on the Sick Call Index inside
each IHCR with the dates listed on the sick call forms matching the dates on the Sick Call Index.
The sick call process and dates/times are posted in visible areas for the youth and staff. A RN
was interviewed and noted sick calls hours are Monday through Friday from 9:00 a.m. until
10:30 a.m. and 3:30 p.m. until 4:30 p.m. During the weekend, sick call is conducted from 10:00
a.m. until 11:00 a.m. Sick call hours are posted on the medical door facing the hallway, on the
medication window at medication pass, and in the youth living areas. The center has approved
treatment protocols for both RN and licensed practical nurse (LPN) level staff to utilize. Only
licensed nurses complete sick calls. When there is not a licensed nurse on-site, the center has
procedures whereby the shift supervisor reviews all sick call requests as soon as possible,
within four hours after the request is submitted, and notifies the on-call medical staff. If on-call
medical staff are unavailable, the shift supervisor contacts the DHA. The center has facility
operating procedures (FOPs) for room restrictions/confinements. The FOP states youth in
restricted housing shall be afforded access to healthcare at equal or greater intervals of youth
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 38 of 56 (Revised July 2023)
who are in regular housing. A sick call was not observed during the annual compliance review
week; however, an informal interview with the RN described the process of the sick call. The RN
expressed after receiving verbal consent from the youth, the nurse identifies themselves, and
the youth would state why they were being seen. The nurse stated the office door would be
closed to the hallway for privacy while the juvenile justice detention officer is stood off to the
side to keep the youth in constant sight. The nurse conducts an examination on the exam table.
Seven youth were interviewed. Five youth stated they have never submitted a sick call request.
The remaining two youth stated they were seen immediately and the nurses conduct sick call.
Seven staff were interviewed. Six staff stated the nurse reviews and conducts sick calls, and
one staff stated medical staff conduct sick calls. Three staff also stated supervisors review sick
calls.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for episodic/first-
aid/emergency care requirements. Four youth required on-site first-aid or episodic care
conducted a licensed healthcare staff which was documented in a subjective, objective,
assessment, and plan (SOAP) format. All four youth complaints were documented with findings
by the staff rendering care. Each of the four youth received treatment. Off-site care was not
required for any youth. Education and instructions were documented for all four youth, as well
as a plan for follow-up care. Two youth were required to be placed on the alert list and were
found on the alert roster. Parental notification was made and documented for all four youth and
each event was documented on the Episodic Care Log. Only two of the four youth required and
received a follow-up evaluation from a licensed healthcare staff.
The center has a total of twenty first-aid kits located throughout center areas which are
accessible to staff in the event of an emergency. A first-aid kit is available for each of the six
transport vehicles. The first-aid kits included a DHA approved list of items documented on each
kit. Three kits were opened and examined. All three had the required contents within their date
of expiration. First-aid kits are inventoried monthly by the medical staff. Documentation indicated
inventories were conducted and documented on the monthly first-aid kit and automated external
defibrillator (AED) logs. The center has a total of two AED units, with one located in master
control and the other in the medical office co-located with the AED procedures. Both are
inspected monthly by medical staff and a log is kept documenting any findings or discrepancies,
as well as dates when pads or batteries were changed. The batteries and pads of the device
were observed within their date of expiration. A licensed medical staff was observed performing
an inspection of the AED during the annual compliance review week. The device was operating
as required.
In August 2023 the facility transitioned to two twelve-hour shifts (7 a.m. to 7 p.m. and 7 p.m. to 7
a.m.). Emergency drills have been conducted every month on the first shift throughout the
annual compliance review period and in five months on the second shift. The drills were
unannounced in which a simulated episodic care event took place. Five drills were conducted in
which cardiopulmonary resuscitation (CPR) was rendered and the use of the AED was
conducted to show proper techniques. Three of the drills were conducted on the first shift and
two on the second shift. Any staff not present for a man-down drill were afforded the opportunity
to review each drill scenario. Documentation of all drills were kept in the medical office. A list of
emergency numbers was found accessible to licensed and unlicensed staff, which included the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 39 of 56 (Revised July 2023)
number to the Poison Information Center. The numbers were not accessible to any youth. All
authorized direct care staff were appropriately trained by a registered nurse on the
administration of an epinephrine auto-injector. Seven staff in-service training records were
reviewed which showed training requirements were met regarding episodic care, first-aid, and
emergency care.
The center stores NARCAN® in a locked cabinet in the medical office at room temperature
which is accessible to the nurses, superintendent, and captain. Each staff with access to
NARCAN® has been trained on when and how to use it and it is inventoried by a licensed nurse
weekly. One of the seven interviewed youth rated the medical care at the center fair, two youth
rated it very good, and four youth stated they have not received any medical services. Seven
interviewed staff stated they can call 9-1-1 if they feel it was necessary. The nursing staff
interview confirmed the number and location of the first-aid kits and AEDs, the documentation
requirements for episodic, first-aid, or emergency care, drill requirements, and the location of
the emergency numbers.
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 youth Individual Healthcare Records (IHCRs) were reviewed for completion requirements
concerning off-site care/referrals. Four youth were applicable for requiring off-site care. All four
records contained the Department’s Summary of Off-Site Care Consultation Report form, which
was filed in each IHCR, and each event was also documented on the Episodic Care Log.
Parental notifications were made for each youth and documented in the IHCRs. Discharge
documents were filed in each IHCR and the designated health authority (DHA) reviewed the
discharge instructions, findings, and care rendered within seven days of the incidents evidenced
by signature and date. Documentation the DHA was notified was found in all three youth IHCRs
in the chronological progress notes section, with the date and time the DHA was notified of the
event. None of the youth required follow-up care or appointments. The nursing staff interview
confirmed the tracking of youth who require off-site care, ensuring hospital orders are followed,
and ensuring the DHA reviews all findings, instructions, and information.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for chronic
conditions/periodic evaluation requirements. Four youth were applicable as being identified on
the Facility Entry Physical Health Screening (FEPHS) form for having a chronic condition. None
of the youth reviewed had a communicable disease. Two of the youth were prescribed
medication on an ongoing basis. All four youth were undergoing treatment for physical health
conditions. Four of the youth were diagnosed with treatment for physical health conditions.
Three youth were classified with a Medical Grade of two to four. All four youth were placed on
the chronic conditions list. None of the youth were female; therefore, they were not identified as
pregnant. None of the youth were applicable for receiving a periodic evaluation every ninety-
days, and the center had no additional applicable youth. None of the youth were identified as
taking anti-tuberculosis medication. The Department’s Problem List was updated in accordance
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 40 of 56 (Revised July 2023)
with the Health Services Rule for each applicable youth. The designated health authority was
interviewed and stated all youth with chronic conditions are seen for evaluations for chronic
conditions every ninety days or sooner, if needed. The nursing staff interview confirmed inside
the medical office, the center’s chronic care board is maintained by the registered nurse to
determine when the youth is due for periodic evaluations.
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 youth Individual Healthcare Records (IHCRs) were reviewed for medication management
requirements. Five of the seven youth were taking medication at admission and the medication
was verified prior to being admitted into the center. Prescription verification for all five youth
were completed utilizing the Department’s Prescription Medication Verification Checklist form.
For all five youth, the designated health authority (DHA) was contacted within twelve hours of
admission to obtain the order to continue the current prescribed medication and it was
documented on a practitioner order form. All five youth medications were verified on the
Department’s Medication Receipt Transfer Disposition form maintained inside each youth IHCR.
None of the youth reviewed were in restricted housing during medication administration hours.
Five out of the seven reviewed youth were given over-the-counter (OTC) medications which
were not listed on the Authority for Evaluation and Treatment (AET) form; however, were given
in accordance with approved protocols or doctor’s orders with the permission of the
parent/guardian. One youth turned eighteen years old at the time of the order and consented for
OTC medications himself. All six youth records contained a standard Department Medication
Administration Record (MAR) in the Electronic Medical Record (EMR). Each reviewed MAR
clearly indicated medication start and stop dates. All medications had a current, valid order and
were administered pursuant to a current prescription. The DHA placed an order on the
Practitioner Order form for any continued, discontinued, changed, or new medications. There
were no undocumented explanations for lapses or errors in medication administration. Nursing
staff documented side effect monitoring for all six youth weekly. One youth was applicable for
refusal of medication. Each time the youth refused medication, it was documented on the MAR
with the youth’s initials indicating refusal, and the youth signed the Refusal of Treatment form.
All six applicable IHCRs contained MARs with all required elements to include the youth’s
name, Department identification number, date of birth, youth allergies, Medical Grade, medical
alerts, precautions, and current picture of the youth. All six records contained MARs with
nursing staff initials and youth initials for each medication given. None of the seven reviewed
youth required parenteral medication. None of the reviewed youth entered the facility on
psychotropic medications. The medical department reported there are no standing orders,
emergency treatment orders, or pro re nata orders for psychotropic medications. A medication
pass was observed during the annual compliance review week. Medication administration was
completed by the licensed medical staff. The youth was escorted to medical by the juvenile
justice detention officer. The youth approached the nurse station individually. The medical
provider identified themselves and prepared the medications for the youth as prescribed. The
allergy and alert status were verified on the MAR. The youth initialed for their medication after
receipt and the licensed staff indicated the medication was provided. The six rights of
medication administration were completed. Prescription medications were not pre-poured from
their original packaging and placed in another container for administration. No non-healthcare
staff provided medications to youth during the annual compliance review period, however, staff
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 56 (Revised July 2023)
are designated by name and title and trained to do so by a registered nurse. The center
disposes of medications by holding them until they are verified by medical staff, recorded on the
disposal log, and destroyed.
Seven staff were interviewed regarding medication delivery to youth. One staff indicated they
give medications and six staff stated they do not give medications. Seven youth were
interviewed regarding who gives medications. One youth stated the nurse administers
medications. Six youth reported not having to take medications. The nursing staff interview
confirmed the process for youth medication administration, medication pass times, and staff
training for medication administration.
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 office was found to be neat, clean, organized, and inaccessible to youth in the area
where sharps and medications were maintained. Medical equipment classified as sharps were
found secured and inventoried utilizing a routine perpetual inventory with descending count as
each sharp was utilized or disposed of in the medical clinic. Three sharps were reviewed and
counts of the items matched the ending inventory numbers. All medications were identified and
secured in the locked area designated for storage of medications inside the medical office. The
medication cart was found to be clean and organized with stock items separate from youth-
specific medications. All medications were stored in a separate, secured, and locked area,
inaccessible to youth. Narcotics and other controlled medications were stored behind two locks.
No oral medications were stored with topical medications. Medications requiring refrigeration
were found inside a secured refrigerator labeled “Medication Only”. For youth on controlled
medications, a perpetual shift-to-shift inventory count was conducted and documented on the
Individualized Controlled Medication Inventory Record.
Non-health care staff were trained in the delivery and oversight of medication self-administration
when nursing staff are not on-site. This training was delivered by a registered nurse (RN). Three
controlled medications were reviewed with no discrepancies and counts matching ending
counts. Three over-the-counter (OTC) medication samples were reviewed with one discrepancy.
One count was off and the RN was immediately able to rectify the error and the counts matching
ending counts. Perpetual weekly inventories of all sharps and OTC medications were observed.
Observations of inventories confirmed the center’s medical staff conduct inventories of
medications and sharps as required.
The procedure for reporting inventory discrepancies states any medication inventory
discrepancy shall require notification to the Department’s Central Communications Center
(CCC), completion of an internal investigation, and a root cause analysis utilizing a medication
error report shall be maintained. The center has facility operating procedures regarding the
disposal process for medications. The disposal process indicates a RN shall be responsible for
the disposal of medications in conjunction with the pharmacy consultant. Non-Controlled
medications are disposed using the approved Drug Buster disposal system. The nursing staff
interview confirmed the process for disposing medications, securing medications, and working
with the contracted psychiatrist.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 42 of 56 (Revised July 2023)
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 youth Individual Healthcare Records (IHCRs) were reviewed for infection control,
exposure control, and education requirements. All seven of the youth records documented
infection control training was completed within seven days of admission to include hand-
washing techniques, universal/standard precautions, prevention/transmission of communicable
disease, vaccinations, and the Centers for Disease Control and Prevention (CDC) guidelines for
infection control. The Exposure Control Plan was written in accordance with Occupational
Safety and Health Administration (OSHA) guidelines and included a risk assessment listing job
classifications in which staff have the potential for occupational exposure, including tasks and
procedures which would cause staff in specific job classifications to have an occupational
exposure. A method of compliance outlining infection control practices, engineering, and work
practice controls was also found in the plan. The center’s infection control procedures included
prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to OSHA and the CDC guidelines. Infection control procedures also outlined all
required elements such as, common infectious diseases of childhood, the common cold, viral or
bacterial infections, Hepatitis A, B, C, human immunodeficiency virus (HIV), other outbreaks or
epidemics caused by any other infectious agent, pediculosis, food-borne illnesses, chemical
exposure, bio-terrorist agents, and Methicillin-Resistant Staphylococcus Aureus (MRSA).
Tuberculosis (TB) was not specified in the plan itself; however, was included in the center’s
facility operating procedures for the admission process, as well as screening for TB and
exposure control. The infection control plan includes processes for needle stick post-exposure
evaluation. Hepatitis B immunizations are made available for staff. All staff have access to
protective equipment. The registered nurse stated there have been no instances in which
infectious diseases and sexually transmitted infections needed to be reported to the local health
department or the Department’s Central Communications Center (CCC). There were also no
hospitalizations or quarantining of at least ten percent of the total population for youth or staff.
The superintendent was interviewed and stated they maintain a separate file containing all
documents for youth and staff who have experienced facility/occupational exposure for ten-
years, as required. All staff received pre-service or in-service training on the center’s specific
Exposure Control Plan. The nursing staff interview confirmed the location of the plan, the
training requirements, and the services the local county health department is used for.
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.
Seven youth Individual Healthcare Records (IHCR) were reviewed for prenatal care and
education, none were applicable. One female record was applicable and reviewed for prenatal
care. Prenatal care began immediately upon determination the youth was pregnant and
continued until discharge/transfer and was provided at recommended intervals. The youth was
placed on the internal alert system for vital nutrition, health awareness, and sleeping
arrangements. The youth was not in the center long enough to have medical evaluations every
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 43 of 56 (Revised July 2023)
thirty days. The youth complained of issues related to pregnancy and the staff notified the
designated health authority /advanced practice registered nurse immediately. The youth was
monitored daily for danger signs of pregnancy complications. There was documentation the
youth was provided information describing post birth psychological and physical care.
Additionally, there was documentation located in the IHCR the youth was educated on the
dangers of alcohol use, drug use, sexually transmitted diseases, and smoking while pregnant.
All education was documented in the IHCR in the Health Education Record. The youth was
educated on the importance of good nutrition, contraception, prenatal care, the birthing process,
postpartum care, basic baby care, child development, and parenting skills. The youth received
nutritious food in quantities appropriate for a pregnant youth. The licensed healthcare staff
provided routine monitoring of the pregnant youth nutritional and weight status while in the
center. A review of the training provided by a licensed nurse confirmed it included observation
and monitoring of emergency care needs/symptoms for possible miscarriage. The center has
nursing protocols and treatment plans in place for pregnant youth. All staff in pre-service were
trained in the supervision and treatment of a pregnant youth. All seven interviewed youth were
males indicating they did not need these services. The nursing staff interview confirmed the
procedures and training for prenatal care and education.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 44 of 56 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
Observations were completed daily during the annual compliance review week to ensure staff
were actively supervise youth at all times. Youth movement was observed to ensure at least
one staff was present at all times and all movement was authorized by master control. Census
counts are conducted throughout each shift at both specified and random times, and
documented in logbooks. Observations found staff provide active supervision and interactions
with youth were positive. Seven staff were interviewed with six stating there is adequate staffing
to provide a safe and secure environment. Three staff indicated there are staffing challenges
although they do not compromise the safety of the youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 45 of 56 (Revised July 2023)
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations.
Each center shall implement and maintain a behavior management system to meet the needs
of the youth and the center. The system shall include rewards for positive behavior and
consequences for inappropriate behavior.
The behavioral norms and expectations for youth shall be posted in all living areas and shall
clearly specify appropriate and inappropriate behaviors.
The system restricts certain types of penalties on youth who demonstrate negative behaviors.
Group punishment shall not be used. However, corrective action taken with a group of youth
is appropriate when the behavior of a group jeopardizes safety or security, and this should
not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
The use of drugs to control the behavior of youth is prohibited. This does not preclude the
proper administration of medication as prescribed by a licensed physician.
A tour of the center found behavior management system (BMS) postings present in each living
module. The BMS postings included guidelines for appropriate/inappropriate behavior,
consequences for negative behavior, and monthly reward calendars. The center utilizes point
cards for daily documentation of the BMS. Cards are reviewed daily by staff and weekly by
administration to ensure staff are following facility operating procedures (FOP) for the BMS.
Documentation was found in both module and master control logbooks to indicate when
rewards were distributed. No group punishment was noted in logbooks. A review of the center’s
FOPs confirmed compliance with the BMS components outlined in the center’s policies and
procedures. Seven youth were interviewed and provided positive feedback on the BMS. There
were no youth grievances found in the Facility Management System pertaining to the BMS.
Seven staff were interviewed and were found to be knowledgeable of the BMS and felt it is
effective. The acting superintendent interview supported use of the BMS and adherence to the
FOPs in place.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 46 of 56 (Revised July 2023)
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 facility operating procedures (FOPs) requiring ten-minute checks to be
conducted when youth are in their rooms. The center has sixty-four surveillance cameras, and
fifty-eight were operational during the week of the annual compliance review. The center has the
capacity to store video recordings for up to thirty days. An electronic wand system is used in the
center to document and collect data of the ten-minute visual checks. Staff tap an electronic
wand on the check point sensors outside of each youth’s assigned sleeping room door and the
data is downloaded as wand reports. A review of six samples of video over three different days
and their corresponding wand reports, including samples from each living module, revealed staff
conducted ten-minute checks as required. Only one check was missed on one night at 12:22
a.m. A review of the logs matched the ten-minute checks reviewed. No additional logs were
reviewed due to the deficiency verification date being October 6, 2023. Staff were observed
looking into the windows of each sleeping room before tapping the wand to the check point
sensor. The center documented a weekly review of management oversight. Seven staff were
interviewed. All staff stated checks are conducted at ten-minute intervals when a youth (non-
suicidal) is placed in their room for sleeping or non-punishment reasons. The acting
superintendent stated ten-minute checks begin when youth go behind closed doors and an
electronic wand is utilized.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 47 of 56 (Revised July 2023)
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
Census counts are completed by master control at the beginning, end, and at random intervals
during each shift. The counts are documented in the master control and module logbooks. In
addition, counts are conducted following admissions/releases and any emergency or unusual
activities such as power outage, drills, and codes. If a count is not cleared in a timely manner,
all movement is stopped, and a physical head count is completed. Observations were
conducted and logbook entries reviewed, no issues were noted. Seven staff were interviewed
and confirmed counts are completed at the beginning and end of the shift as well as throughout
the day and after events.
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 maintains a logbook in master control and each living module. Three days each
month of the annual compliance reviewed period were reviewed in the master control and living
unit module logbooks. Logbooks were bound with numbered pages. Dates were documented at
the top of each page. Entries were made in blue or black ink and included the time of activity,
name(s) of those involved, a brief description of the activity and the initials of the staff making
the entry. Significant occurrences such as safety and security events, medical and/or mental
health information, and special alerts were highlighted. All errors were struck through with a
single line and “void” was written after the error followed by the staff’s initials, however, the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 48 of 56 (Revised July 2023)
supervisor did not record any comments regarding the corrected errors, as required. A review of
logbooks by the superintendent or designee was documented and highlighted in each logbook.
A review by the shift supervisor was documented daily and highlighted. Each logbook review
designated the name and position of the reviewer and the date and time the review was
completed. A review of master control and module logbooks since the last annual compliance
review confirmed the staff documented entries for emergency situations, incidents, all drills,
medical and mental health alerts (including start and end time of precautionary/secure
observation), formal and informal headcounts, changes to population count, population counts
at the beginning, end, and throughout each shift, counts following emergency situations, group
movement, admissions and releases, movement to and from education,, and youth in any type
of confinement.
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 master control and living unit module logbooks were reviewed for three days each month
during the annual compliance review period. The facility superintendent or designee reviews
logbooks on a weekly basis. The entries include the name and title of the person completing the
review and are highlighted. The superintendent or designee tours youth living areas and
documents their visit in each area’s logbook as required. Shift supervisors review logbooks daily
in master control and on the living modules. Documentation for the master control logbook
review was found in nineteen of the twenty-four examples reviewed there were no entries
regarding accepting responsibility of the shift. Reviewed documentation indicated officers are
required to review the module logbook for the area they are assigned to. The acting
superintendent reiterated administration is expected to review logbooks weekly and supervisors
daily.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 56 (Revised July 2023)
5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys.
All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of
keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch.
The key(s) on these rings shall provide egress through facility exterior doors providing access
to evacuation areas.
A key inventory shall be maintained by the Superintendent or designee at all times.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center has facility operating procedures (FOPs) regarding key control, which include all
required elements. A review of the center’s key control process was completed during the
annual compliance review week. Keys are maintained on tamper proof rings and secured in
master control when not in use in a key box which is not easily accessible while locked. The key
inventory was reviewed and matched the actual keys in use as well as the emergency key rings.
The master key inventory includes a ring number, number of keys on each ring, capability of
each key, and the assignment of the keys. All key rings are numbered and color coded. Upon
reporting for duty, staff receive their assigned keys from the shift supervisor. Personal keys are
secured in master control. Reviewed documentation included the date and time of the issuance
of keys, name of staff issuing and receiving the key ring, and the time the key ring was returned.
During the annual compliance review week staff were observed carrying keys on their person,
youth were not permitted to handle center keys. Keys are returned at the end of each shift prior
to staff exiting the facility. Staff are not permitted to remove keys from the facility grounds,
however, if they do, they must contact the shift supervisor immediately and return the key within
two hours of notification. Shift reports and key inventories documented when keys were
distributed and returned. Keys are counted at the beginning and end of each shift by master
control. The emergency keys are kept in master control with only master control, shift
supervisors, and administration having access to the keys. The center has a procedure for
addressing missing, lost, and damaged keys as well as provisions for restricted keys. Five key
rings were compared to the inventory and key log, and all were documented as required. A
sample of three staff key rings was observed and compared to the inventory and key log, no
issues were found including the staff knowing the function of each key. Seven staff were
interviewed, all were able to explain the key control process. An interview with the acting
superintendent found only administration and maintenance have permanently issued keys.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 56 (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 had six vans on-site during the annual compliance review week; one was out for
repair. Vehicle logs and invoices for routine services/inspections were reviewed. All vehicle
inspections are documented as required in SharePoint. The vehicles inspected had required
equipment to include appropriate number of seatbelts and fire extinguishers. Each vehicle has a
“go-bag” which includes a logbook, seatbelt cutter/window punch, and first-aid kit which is
maintained in master control or the transportation office. It is checked out at the time of
transport. Transportation procedures were maintained in each vehicle along with the vehicle and
mechanical restraint keys, gas credit card, and vehicle registration. The vehicle logbook
documented the inspection. A transport to and from the center was observed during the annual
compliance review week. The staff conducting the transport checked out the “go-bag” and
cellular telephone from master control, inspected the van for contraband, ensured there was a
sufficient amount of fuel for the trip, checked the seatbelts and cage, searched youth prior to
placement in the van, ensured youth were wearing seatbelts, and ensured youth and the vehicle
were searched upon return to facility. Staff were also observed wearing their seatbelts and
ensured the vehicle was locked upon their return to the center. Logbook entries in the vehicle
logbooks were inconsistent for what information staff documented. Logbooks consistently
documented the vehicle was checked, however, were inconsistent with documentation of the
destination, number of youth and staff names, name of the officer riding in the back of the van,
and the transport beginning and ending times. Seven youth were interviewed, and all advised
they felt safe on transports, and had not seen any contraband in the vans. All center vehicles
and six random personal vehicles were checked and all were locked when not in use.
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center maintains a policy and procedures for tool inventory and management. Maintenance
personnel have a shadow board of all tools and a master inventory which reflects what is on the
shadow board. Kitchen knives and sharps are stored in a locked cabinet and inventoried daily. A
review of the tool inventory was conducted with regional maintenance staff and all tools were
accounted for. Tools are stored in a secured maintenance office which has restricted access.
Kitchen sharps are secured and maintained in kitchen. Youth do not have access to tools. Tool
inventories are completed and documented as required on SharePoint. Tools are marked or
etched to identify them as Department property. Any damaged or missing tools are reported to
center administration. At the time of the annual compliance review there were no instances of
missing or damaged tools. The kitchen has an itemized list of all utensils which is maintained by
the food service director and on SharePoint. Inventories of kitchen tools are documented
weekly; knife inventories are conducted daily. The acting superintendent reported the
maintenance mechanic maintains an area away from the secure floor for tools and supplies. A
shadow board is used to house tools and an inventory is conducted monthly. All vendors are
accompanied by maintenance or a center staff when in a secure area. Seven staff were
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 56 (Revised July 2023)
interviewed, all reported lost or damaged tools must be reported to a supervisor and/or
maintenance.
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.
Youth do not have access to tools, kitchen items or medical equipment while at the center.
Youth are only permitted use of mops and brooms under the direct supervision of staff. Seven
youth were interviewed, all reported they are able to use mops and brooms. Seven staff were
interviewed, all reported youth are permitted to use mops and brooms; two reported youth can
use dust pans. Youth using tools were unable to be observed during the annual compliance
review week as no youth used any while the annual compliance review team was on-site.
5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center has a facility operating procedure (FOP) which acts as their safety plan for
addressing the proper use, storage, and disposal of chemicals, including flammable, toxic,
caustic, and poisonous items. Chemicals are kept in a secured supply shed which is not
accessible to youth. The center maintains an inventory including flammable, toxic, caustic, and
poisonous items. Observations of the supply area indicated the inventory was accurate and was
documented properly for the annual compliance review period. A binder with Safety Data
Sheets (SDS) is maintained for all chemicals used in the facility. A small amount of cleaning
materials are housed inside the facility and are securely maintained. SDS binders and accurate
inventories were present in the area with the cleaning materials. A review of five random
chemicals confirmed the SDS for the chemical was present for the item and no discrepancies
were noted between the inventory list and actual count of the observed items.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 56 (Revised July 2023)
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
Only authorized personnel are permitted access to flammable, toxic caustic, and poisonous
items. These items are stored in a secure location, inaccessible to youth. Youth do not have
access to these items and are not permitted to use them. Seven youth were interviewed and
reported they do not have access to flammable, toxic, caustic, and poisonous items. Seven staff
were interviewed, all stated youth are not allowed to use flammable, toxic, caustic, and
poisonous items.
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures for the disposal of flammable, toxic, caustic, and
poisonous materials. There were no reported chemical spills or disposals of flammable, toxic,
caustic, or poisonous items since the last annual compliance review. The kitchen has a grease
trap and a vendor is used for disposal services. An interview with maintenance indicated there
were no chemical spills during the annual compliance review period. The center contracts with a
company for the disposal of chemicals.
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures for use of confinement under twenty-four hours.
Twenty confinement reports were reviewed. Youth are offered and/or given three meals a day,
snacks, access to mental health and medical services, daily shower, clean clothing, their right to
grieve a confinement, bedding, and educational materials when applicable. If a youth refused
their educational materials, it was noted on the Visual Observation Report (VOR). Confinements
are approved by the shift supervisor and only one youth may be assigned in each room. Rooms
are searched for contraband and findings are documented on the Facility Management System
(FMS) Confinement Report. Cameras and windows are free from obstructions. Youth were
supervised at five-minute intervals for the first hour, and ten-minute intervals thereafter, until
release from confinement. Youth were supervised as required with the exception of one
instance where no documentation of the youth checks could be located. Staff completed the full
confinement report before the end of their shift and explained to the youth the reason why the
confinement was necessary. Supervisors conduct an initial review and additional reviews until
the youth is released from confinement which were conducted as required with two exceptions.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 56 (Revised July 2023)
Two reports documented one late initial supervisory review each; two hours, and twelve minutes
late respectively, and three documented late additional supervisory reviews by ten minutes,
nineteen minutes, and eleven and one-half hours. One youth was counseled by the supervisor
eleven and one-half hours late in order to consider removal from confinement. The
superintendent or designee reviews reports within forty-eight hours of confinement. Two of the
twenty reports had an administrative review completed fifteen days late. One confinement
interfered with visitation, and the center documented attempts to inform the parent/guardian of
the youth’s confinement. Seven staff were interviewed, and all were able to explain the center’s
confinement procedures. All seven indicated youth in confinement are provided with educational
materials. The acting superintendent advised there is monthly regional oversight of the use of
confinement.
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has a Continuity of Operations Plan (COOP) as well as a facility operating procedure
to address their emergency plan. Two COOP drills have been completed since the last annual
compliance review; one of them was conducted prior to the start of hurricane season.
Documentation of the drills was reviewed and information included type of drill, date and time,
participants, scenario, response, and recommendations, if appropriate. Seven staff were
interviewed, all reported participating in drills. The acting superintendent was interviewed and
reported the facility has a COOP plan in place..
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.
A review of the center’s Escape Prevention Plan verified the inclusion of the Department’s
policies and procedures regarding escapes. The center conducted escape drills on a quarterly
basis throughout the annual compliance review period as required. Seven in-service staff
records were reviewed and indicated all received escape prevention annually. The drills were
documented in the center’s logbooks, and the completed drills were uploaded in SharePoint.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 56 (Revised July 2023)
Seven staff were interviewed and three indicated they had participated in escape drills. The
remaining four have the rest of the year to complete them.
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a Continuity of Operations Plan (COOP) and facility operating procedures
(FOPs) which include a fire and fire protection plan. Fire drills are completed monthly on each
shift. Drills are documented and reviewed by administration. Drill information is entered on
SharePoint and documented in master control logbooks. Each drill, with the exception of two,
was documented in the master control logbook. The fire extinguishers in the facility and secure
vehicles are inspected annually and documentation is entered on SharePoint. Seven youth were
interviewed and reported they have been instructed what to do in case of a fire. Seven staff
were interviewed and reported fire drills are conducted monthly. Six reported they have
participated in a fire drill.
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) in place for searches and to ensure
contraband is prevented from entering the secure area of the center. The policy includes
procedures for electronic, frisk, strip, room, and staff/visitor searches. An admission was not
able to be observed during the annual compliance review week. Youth returning from a
transport were observed. Staff inspected the secure vehicle, and a frisk and electronic search of
the youth was completed prior to the youth returning to their modules. Searches of staff and
visitors prior to entering the secure area were observed. All observed people entering the facility
were electronically searched, all bag, cases, jacket pockets, and other items were searched,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 56 (Revised July 2023)
and all prohibited items were secured prior to the person entering the facility. Staff were
observed wearing gloves for all searches. Documentation of room searches was found in
module and master control logbooks. A sample of shift reports since the last annual compliance
review was reviewed and it was determined room searches are completed daily on each shift.
There were three instances of contraband being found at the center during the annual
compliance review period, all were reported to the Department’s Central Communications
Center (CCC) within the required time frame. For each instance, the center documented all
required information and responded in accordance with the center’s FOP. The acting
superintendent reported youth are searched when they leave the facility, upon arrival to the
module from school, during large movements, and in dining hall. Depending on the contraband
found, law enforcement is contacted and the youth are confined and charged. Youth may also
be searched when deemed appropriate by the supervisor and when there is reasonable
suspicion the youth has contraband. Youth rooms are searched after the youth’s release and
prior to placing a new youth in the room.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 56 (Revised July 2023)

report_type: QI Detention

file_name: LRJDC-FINAL-FY2324 (1).pdf

program_name_raw: Leon Regional Juvenile Detention Center