state: FL

facility_name: Orange Youth Academy

summary: QI Detention - FY23-24 - 2 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Orange Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
2800 S Bumby Avenue
Orlando, Florida 32806
Review Date(s): September 19, 2023 - September 22, 2023
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Jennifer Tummino, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Teresa Andersen, Office of Accountability and Program Support, Deputy Regional Supervisor
(Interviews)
Melissa Johnson, Office of Accountability and Program Support, Regional Supervisor (Standard
2)
Cindy Jones, Office of Education, Deputy Education Director (Standard 2)
Jesin Miah, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Tyler Mocere, Brevard Regional Juvenile Detention Center, Assistant Superintendent (Standard
5)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Orange Regional Juvenile Detention Center MQI Program Code: 247
Provider Name: State Operated Contract Number: NA
Location: Orange County / Circuit 9 Number of Beds: 95
Review Date(s): September 19 – September 22, 2023 Lead Reviewer Code: 201
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
2.10 Educational Access*
3.12 Suicide Prevention Training *
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 58 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 58 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 58 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Limited
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 58 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 58 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58 (Revised July 2023)
Program Overview
The Orange Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Orlando, Florida. The center serves youth in Orange and Osceola
counties in Circuit 9. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the ninety-five bed center.
Youth are provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Orange County School Board. The center’s
management team includes the superintendent, two assistant superintendents, one
administrative assistant, eleven juvenile justice detention officer supervisors (JJDOSs), and
seventy-four juvenile justice detention officers (JJDOs). Mental health and healthcare services
are provided through the contracted provider, VitalCore Health Strategies, LLC. Mental health
services are provided by one psychiatrist, one designated mental health clinician authority, six
licensed mental health professionals, one non-licensed mental health professional, and one
regional clinical mental health director. Clinical services provided by the center include mental
health and substance abuse evaluations, mental health treatment planning, individual, group
and family therapy, mental health crisis intervention services, on-site psychiatric services, and
availability for substance abuse services for youth with co-occurring disorders. Medical services
are provided by one registered nurse (RN) manager, three RNs, one licensed practical nurse, a
designated health authority, and an advanced practice registered nurse. The medical clinic
maintains nursing coverage twelve hours a day, seven days a week. Food services are provided
by Department staff and include menus, meal planning, meal schedules, special diets,
nutritional analysis, daily allowance, food preparation, health certifications, food product
standards, sanitation, and cleaning. Staff are responsible for the custody and control of youth in
their care, providing youth supervision twenty-four hours a day, seven days a week. The center
has four living modules which are divided by male and female. There are 154 security cameras
at the center, of which 144 were operational at the time of the annual compliance review. The
superintendent reported work orders were in effect for the cameras not currently working. At the
time of the annual compliance review, the center had fifteen vacancies, which included twelve
JJDO Is, one JJDO II, one assistant superintendent, and one administrative assistant.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 58 (Revised July 2023)
Strengths and Innovative Approaches
• The center holds youth field days for exercise, sports, and leisure to include, but not
limited to basketball, corn hole, and running.
• Male and female youth are educated by a local agency for an hour each week about
sexually transmitted diseases (STDs), abstinence, and the responsibilities of young
parents.
• Youth are involved in the center gardening project where they grow produce to be used
to prepare some of their meals.
• Youth are allowed to utilize chalkboard paint on the walls and behind the doors in their
rooms to prevent graffiti on the walls. This gives youth the chance to journal and express
themselves in a positive manner and/or pass time.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 58 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures addressing the initial background screenings for all
staff and volunteers. An informal interview with the superintendent confirmed the center had
three new volunteers who assisted or interacted with youth on an intermittent basis for less than
then hours a month and did not need to be background screened. The center’s policy requires a
staff, who is background screened, to always be present within the line of sight of the volunteers
who are not background screened. A review of the center’s staff, volunteer, and contractor
rosters found eighteen staff, including three contracted staff, were applicable for an initial
background screening during the annual compliance review period. No volunteers were
applicable for an initial background screening during the annual compliance review period. Each
of the eighteen applicable staff had a completed and eligible background screening, as required,
prior to hire, access to youth, and confidential youth records. Reviewed documentation validated
a criminal history report was reviewed for each staff and two of eighteen staff required an
exemption, which was obtained prior to hire. A pre-employment assessment tool was
administered for each direct care staff and a pre-employment assessment passing score was
documented in each reviewed direct care staff’s record. Each of the three contracted staff were
added to the center’s roster in the Agency for Healthcare Administration’s Clearinghouse
system, as required. A background screening was completed when two Department staff were
hired by a contracted provider, the remaining contracted staff was never employed by the
Department. An Annual Affidavit of Compliance with Level 2 Screening Standards was
completed and submitted to the Department’s Background Screening Unit on January 23, 2023,
meeting the annual requirement. The center has teachers who are paid by the local school
board, and they received an Annual Affidavit of Compliance with Level 2 Screening Standards
on September 15, 2023.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures addressing five-year background rescreening for
staff. The center had seven staff and one contracted staff applicable for a five-year rescreening
during the annual compliance review period. Seven of the eight applicable staff received a five-
year rescreening within the required time frame and a rescreening was submitted to the
Department’s Background Screening Unit (BSU) at least ten business days prior to the five-year
anniversary date, as required. The five-year rescreening/renewal for the remaining staff was
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58 (Revised July 2023)
submitted on January 5, 2023; however, at the time of the annual compliance review, the BSU
did not reflect the five-year background screening as completed. The center followed up in
January, February, and during the week of the annual compliance review they reached out to
the BSU with comments concerning the pending status of the five-year background screening.
On September 21, 2023, the BSU requested the staff fingerprints be resubmitted by the Florida
Department of Law Enforcement (FDLE); additionally, the center took the staff’s fingerprints
again and resubmitted them to the BSU on September 22, 2023. There were no volunteers
applicable for a five-year background rescreening during the annual compliance review period.
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures which outline the code of conduct for staff to
ensure an environment free from any form of abuse. Three staff personnel records were
reviewed, and each record contained a signed code of conduct form. All three personnel
records contained disciplinary actions for violations of the code of conduct and all three staff
received written reprimands. All three staff personnel records included commendations during
the annual compliance review period. Reviewed documentation revealed each of the three
applicable staff received awards for services to the center. All three staff were recognized as
employee of the month. Seven youth were interviewed, and each indicated they have never
been stopped from reporting abuse to the Florida Abuse Hotline and have never heard staff
threaten any youth. Each youth stated staff are respectful when talking with them and other
youth. Four of the seven youth have never heard a staff use curse words when speaking with
youth, while one youth answered once, one youth indicated occasionally, and the remaining
youth responded often. One youth additionally commented when staff curse, it just slips out and
is not directed at the youth, and another youth indicated sometimes it is directed at youth and
sometimes it is just in a sentence. All seven interviewed youth indicated they feel safe at the
program, and indicated they have never exchanged emails, telephone numbers, or social media
contact information with staff. Seven staff were interviewed, and each staff was able to explain
the process for allowing youth to call the Florida Abuse Hotline or the Department’s Central
Communications Center (CCC) to report suspected abuse. Five of the seven interviewed staff
reported never hearing staff use profanity when speaking to youth, one staff indicated once, and
the remaining staff revealed they have occasionally observed staff using profanity when
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 58 (Revised July 2023)
speaking to youth. All seven of the interviewed staff reported never hearing staff using threats,
intimidation, or humiliation when interacting with youth. Four of the seven interviewed staff
described the working conditions as good at the center and the remaining three described the
working conditions as fair. The superintendent was interviewed and indicated the purpose of the
center’s code of conduct is to ensure staff communicate and interact with youth in a manner to
provide a role model of socially accepted behavior, and staff behavior shall be respectful of
others and reflect desired behaviors for youth. If there is an allegation of abuse from a youth,
the staff is immediately removed from contact with the youth. The youth will be afforded the
opportunity to call the Florida Abuse Hotline. Additionally, law enforcement will be notified, if
necessary, as well as the Department’s Central Communications Center (CCC).
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures addressing the process for contacting the
Department’s Central Communications Center (CCC). The center reported eighty-seven
incidents to the CCC during the annual compliance review period. A review of nine reportable
CCC incidents during the annual compliance review period revealed eight of nine incidents were
reported to the CCC within the required time frame, and each incident was documented in the
center’s logbook. The center indicated the remaining incident was called in by the juvenile
probation officer when they were notified by the residential program. This incident was reported
one hour and fifty-seven minutes late and was not applicable for documentation in the center’s
logbook. There were no additional internal incidents or grievances during the annual compliance
review period which should have been reported to the CCC and were not. An interview with the
superintendent confirmed any reportable incident must be reported to the CCC within the
required time frame and any allegations of abuse will also be reported to the Florida Abuse
Hotline.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center had 169 Protective Action Response Right Interactions model (PAR/RI) reports
during the annual compliance review period, nine of which were reviewed. Each of the nine
reviewed PAR/RI Reports were completed by the end of the staff’s workday. Eight of the nine
PAR/RI Reports included statements from all involved staff and one PAR/RI Report was lacking
a statement from one involved staff. None of the incidents resulted in serious injury to the youth
or staff, required the use of mechanical restraints, or needed to be reported to the Florida Abuse
Hotline. All nine PAR/RI Reports were reviewed by a supervisor or a PAR/RI instructor. Eight of
the nine reports documented a post-PAR/RI interview which was conducted with the youth
within thirty minutes of the incident. The remaining report documented the post-PAR/RI
interview was conducted with the youth eleven minutes late. None of the nine reviewed PAR/RI
Reports required post-PAR/RI medical reviews based on the post-PAR/RI interviews. The
reviewed records reflected all nine of the PAR/RI Reports were reviewed by the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 58 (Revised July 2023)
superintendent/designee within seventy-two hours, as required. The center's PAR/RI rate during
the annual compliance review period was 8.90, which is below the statewide Detention PAR/RI
rate of 17.73. Seven staff were interviewed, and each confirmed staff try to talk to youth prior to
using physical PAR/RI maneuvers or mechanical restraints with the youth. The superintendent
was interviewed and indicated when a PAR/RI is conducted by a staff, an incident report as well
as a PAR/RI Report are entered into the Department’s Juvenile Justice Information System
(JJIS). The superintendent or designee is then required to conduct a post-PAR/RI review within
a thirty-minute time frame of the use of a PAR/RI. Video is reviewed within twenty-four hours, by
the superintendent or designee, to ensure the PAR/RI was in compliance. The superintendent
or designee will have seventy-two hours to review the PAR/RI Report. Mechanical restraints
may only be used in exigent circumstances, when necessary, to prevent harm to youth or staff.
The use of mechanical restraints requires the regional director or designee to be notified. Staff
will complete the Mechanical Restraint Log and ensure ten-minute circulation checks are
completed. The staff supervising the youth should have a mechanical restraint key readily
available. The mechanical restraints should be removed as soon as it is safe to do so.
Mechanical restraints shall never be used as a means of discipline and staff should not carry
mechanical restraints on their person.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures outlining the training and certification requirements
for all new staff. Seven staff training records were reviewed for pre-service/certification
requirements. All seven staff completed all required pre-service trainings and were certified
within the required 180 days from their date of hire. A new staff orientation was completed within
thirty days of hire for all seven staff. All seven reviewed staff completed both the Phase One and
Phase Two trainings. All trainings were documented in the Department’s Learning Management
System (SkillPro), as required.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures outlining the in-service training requirements for
staff. Seven staff training records were reviewed for in-service trainings including four direct
care staff and three supervisory staff. All four direct care staff completed all required in-service
trainings. Each of the three supervisory staff training records included all required in-service
trainings and exceeded the required eight hours of supervisor trainings. All trainings were
entered into the Department’s Learning Management System (SkillPro). The center maintains
an annual in-service training calendar which is updated as changes occur. An interview with the
superintendent confirmed staff are required to complete twenty-four hours of annual in-service
trainings and supervisory staff are also required to complete an additional eight hours of
supervisory trainings. The superintendent indicated he has completed numerous management
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 58 (Revised July 2023)
training classes in SkillPro such as trauma informed care, sexual harassment, delivering
constructive criticism, as well as a college management training, and is currently attending the
Certified Public Manager (CPM) program. He is also a master Protective Action Response Right
Interactions model instructor.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures addressing grievances which consists of three
phases, including informal, formal, and the appeal phase. The center keeps blank grievance
forms on the living modules which are available for youth, upon request. Staff document all
grievances in the Department’s Facility Management System (FMS) on behalf of youth. A
review of FMS found the center did not have any grievances during the annual compliance
review period. The superintendent was interviewed and confirmed the center has had no
grievances during the annual compliance review period. The superintendent indicated the
purpose of the grievance process is to ensure each youth has the right to grieve, ensure all
youth are treated fairly, respectfully, and without discrimination, and to protect youth rights. The
interview with the superintendent also revealed the center’s grievance process includes the
informal phase, wherein the juvenile justice detention officer (JJDO) attempts to resolve the
complaint or condition with the youth using effective communication skills. The formal phase,
wherein youth submit a written grievance which results in a response from a JJDO supervisor
by the end of the shift if possible or within twenty-four hours. The appeal phase, wherein the
youth can appeal the outcome of the formal phase to the superintendent or designee. The
superintendent indicated youth shall be given a grievance form and pencil to complete the
grievance. If the youth is exhibiting violent behavior, filing the grievance will be delayed until the
youth is under control. The denial and the reason shall be documented in the logbook. The
supervising staff shall enter the grievance into FMS on behalf of the youth. The completed
grievance form shall be submitted to the JJDO supervisor within two hours. The supervisor shall
document their findings on the grievance form and shall advise the youth of what actions, if any,
may be taken. The supervisor shall forward the grievance form to the superintendent or
designee upon completion. The superintendent or designee then reviews the completed
grievance form within seventy-two hours of receipt excluding weekends and holidays and shall
take corrective action as deemed necessary. The superintendent’s decision is final. The youth
shall sign a hard copy of the grievance form which shall be maintained in a separate grievance
file uploaded into FMS. Seven youth were interviewed, all indicated they have never had to file a
grievance, and six youth were able to describe the grievance process. The remaining youth said
they were not sure of the grievance process, but has heard of it, and it was explained after.
Seven staff were interviewed, and all were able to articulate the different phases of the
grievance process including requesting a grievance, staff providing the youth with a grievance
form and pencil, and then submitting the grievance into FMS once the form is completed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 58 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures addressing the process of entering and sharing
alerts. Seven youth records were reviewed for alerts, six youth were applicable. The six
applicable youth had alerts entered and updated in the Department’s Juvenile Justice
Information System (JJIS) by the appropriate staff, as required, and all applicable alerts were
documented in the shift report. The center utilizes JJIS as their internal alert system. Reviewed
shift briefing documents and an interview with the superintendent revealed JJIS alert reports are
reviewed daily by the administrative and supervisory staff. A printed copy of the alert report is
provided to the supervisory staff, on each shift daily, and alerts are reviewed with all staff during
each shift briefing. The superintendent indicated medical alerts are entered and updated in JJIS
by the medical staff and all staff review those alerts during the shift briefing. A shift briefing was
observed during the week of annual compliance review and alert information for each applicable
youth was reviewed and discussed during the shift briefing. Seven staff were interviewed, and
all seven staff confirmed the alert information is shared through alert forms, during the shift
briefings, and in JJIS. Three of the seven interviewed staff described the process for
communicating information as very good, two staff described the process as good, one staff
described the process as fair, and the remaining staff described the process as poor.
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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 superintendent indicated the center’s practice regarding data trend analysis is to review
incident reports, confinements, Protective Action Response Right Interactions model (PAR/RI)
Reports, the Department’s Central Communications Center (CCC) reports, and vacancies.
Information is shared with staff and administration during central region leadership meetings by
digital video calls or face-to-face. At the facility level, data trends are reviewed with supervisors
during monthly supervisor meetings and then the supervisors review them with staff during
briefings on all shifts. The minutes for the August 7, 2023, central region superintendent's
meeting, the July 25, 2023, Supervisor Meeting Agenda, the fiscal year (FY) 2022/2023
Worker's Compensation Injury/Illness Notices Cause Report, the FY 2022/2023 Department of
Juvenile Justice (DJJ) Orange Workers' Compensation Claim Cause Chart, and the July 26,
2023, Regional Overtime Report by facility were reviewed which confirmed information sharing.
Additionally, the December 29, 2022, Statewide Recap (Data Communication) included
statewide data collected for detention (education levels of staff, Baker Acts for youth (broken
down quarterly), incident reports broken down by youth on youth and youth on staff, as well as
operational activity). All of the reviewed documentation supported the practice of information
sharing. Additionally, the superintendent indicated the center shares information with providers
and stakeholders, during circuit advisory board (CAB) meetings. The Juvenile Justice CAB
agenda was reviewed from the September 20, 2023, meeting, which took place during the
annual compliance review. The committees are inclusive of the membership committee, the
community outreach committee, civil citation committee, and the grants and legislative
committee. Presentations were given by the Circuit 9 chief probation officer, the circuit nine
probation and community intervention operations coordinator, the systems improvement coach,
and the delinquency prevention specialist. The CAB meetings alternate between Orange and
Osceola counties, on a monthly basis. The superintendent indicated the center implements the
collected data to improve their processes by incorporating the data into policy changes,
additional training, programming, scheduling, and for recruiting/hiring.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
Seven youth intake records were reviewed to support the youth were admitted to the center as
required. All seven records contained a completed Admission Wizard documenting the review of
the youth’s arrest affidavit/custody order, Detention Risk Assessment Instrument (DRAI), and
Suicide Risk Screening Instrument (SRSI). The Admission Wizard document for each youth
confirmed a youth full-body search was completed. Searches are conducted by an officer of the
same gender as evidenced by documentation in the intake logbook. An informal interview with
the superintendent indicated there is always a male and female staff scheduled to complete the
transportation from the Juvenile Assessment Center (JAC) and those are the staff who conduct
the youth search. Five of the seven Admission Wizard documents support the youth received a
telephone call or refused the intake telephone call. Two of the documents indicated the youth
did not receive a telephone call. Logbook documentation supported both youth received their
telephone calls later in the day. The Admission Wizard document for each of the seven youth
documented each youth received a meal during the admission process. Documentation for all
seven youth supported medical, mental health, and substance abuse screenings were
completed for each youth during the admission process. One Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) screening was not signed by the supervisor and one
SRSI did not document the parent/guardian was called.
Observations of three youth admissions were completed during the annual compliance review
week. During the first observation conducted, two youth were being admitted at the same time.
One admission process was completed as required. The other admission process was
conducted differently, as in, the officer did not interview the youth to complete the VSAB, and
instead asked the youth to review the information on the completed VSAB, and indicate if the
information was correct. During the admission telephone call, the same officer allowed the youth
to dial the telephone number and talk to people on the other end of the telephone. The officer
did not dial the telephone number and verify the identity of the person being called as required
by the facility operating procedure. These observations were shared with the center’s
administration and they informed the annual compliance review team they were aware of and
working with the individual who did not conduct the admission as required. Observations of the
other two admissions confirmed the officers completed all processes as required. All three youth
were provided a meal to eat.
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2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
Seven youth intake records were reviewed to support the youth received an orientation process
within twenty-four hours of being admitted to the center. All seven records contained an
orientation packet addressing rules and regulations, grievance procedures, visitation and
telephone calls, access to medical, mental health, and substance abuse services, access to the
Florida Abuse Hotline and/or the Department’s Central Communications Center, behavior
expectations and related consequences, possible new law violations for destruction of property,
youth rights, and Prison Rape Elimination Act (PREA) related information. All documentation
was signed by each youth and dated the date they were admitted into the center. Three
admissions were observed during the annual compliance review week. All three youth were
observed reviewing and signing all documentation while the detention staff completed
admission documentation. The required orientation video tape was playing while the admission
process was conducted. During two of the three admissions, detention staff asked the youth if
they had any questions about the information contained in the orientation packet. Seven youth
were asked if when they arrived at the center if someone told them about the rules and
regulations, daily schedule, education services, visitation, abuse reporting, and behavior
management system. Six youth indicated yes, and one youth indicated no.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has a facility operating procedure addressing the classification process. During the
admission process, detention staff review the youth’s face sheet, Detention Risk Assessment
Instrument (DRAI), booking classification form, gang form, the screening for Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB), the Suicide Risk Screening Instrument
(SRSI), the medical screening, and alerts in the Department’s Juvenile Justice Information
System (JJIS) while completing the Admission Wizard document. In the seven intake records
reviewed, there was no specific form containing documentation to verify how all related
information is used to classify youth for room placement. The center does not use a specific
classification form, instead the detention staff use the information they reviewed from the
various intake documents to assist in room and mod assignment. There is a section on the
booking classification form to document the module the youth is assigned to; however, the
section of the form was left blank on six of the seven forms. The admission process was
observed during the annual compliance review week. During the admission process,
observations confirmed the youth completed the booking classification form. The printed
property receipt in six of the seven intake records documented each youth’s assigned module
but left the room number assignment blank on the form. Informal interviews with three intake
staff supported all information is gathered when completing the admission process and taken
into consideration when placing a youth in a particular module. Staff indicated all youth are
placed in a single room. Staff were able to identify youth who were required to be housed in a
single room based on the history of the youth’s charges. During the admission process,
observations confirmed the youth completed the gang form. Three of the seven youth in the
sample size had gang alerts in JJIS. All three youth completed the gang form during the
admission process; however, none of the documents reflected information corresponding with
the JJIS gang alert. The forms were signed by detention staff; however, only one of the three
forms were updated by the detention staff to indicate the gang information. There was no
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indication of any gang involvement on the other two forms. An interview with the superintendent
indicated he is informed of how to identify and address local youth gangs by the center’s gang
liaison. The superintendent indicated factors such as mental health status, physical health
status, cognitive performance, age, and prior victimization are considered by reviewing the
DRAI, SRSI, VSAB, Community Assessment Tool (CAT), and past and current charges of the
youth to assist with classification of module/room assignment during the initial intake process.
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.”
Three of the seven youth in the review sample were previously identified as a suspected gang
member or gang member and the alert was entered in the Department’s Juvenile Justice
Information System (JJIS). The center’s gang representative indicated the center has not had
any youth newly identified as having suspected gang involvement which would require
notification to the circuit gang representative during the annual compliance review period. The
center’s gang representative also indicated he did not have any examples of suspicious gang
activity identified during the review period. The gang representative indicated he attends
monthly gang meetings with the local law enforcement. He also communicates regularly with the
JPO designated as the circuit gang representative.
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.
Seven youth intake records were reviewed to support the center took possession of each
youth’s personal property. Six of the seven intake records contained an itemized personal
Property Receipt Form. One youth did not have any personal property upon admission. The
Property Receipt Form for each youth contained the youth’s signature and staff signatures. All
six intake records also contained the letter of acknowledgement regarding unclaimed property
signed by the youth. One of the seven youth was admitted to the center with valuable property.
A copy of the clear tamper proof property bag was maintained in the record. The information on
the property bag included the date, youth's name, the youth’s Department identification number
(DJJID), and a listing of items in the bag. A review of the drop safe logbook supported the
youth’s property was placed in the drop safe. A review of the drop safe logbook found
documented information included the date, time, youth’s name, DJJID, printed name of the
officer who secured the property, and the officers initials. Valuables removed from the drop safe
are maintained in a locked file cabinet until the youth is released from the center. The
information in the drop safe logbook was compared to the valuables located in the locked file
cabinet. Two of the four youth randomly picked from the drop safe logbook had been released;
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however, the drop safe logbook did not have the documentation to support the valuable property
was returned to the youth. The superintendent was able to produce the Property Receipt Form
for each of the youth supporting the valuable property was returned to the youth upon release.
The other two youth’s valuable property was located within the file cabinet. There were no
examples where a youth refused to sign the Property Receipt Form. Observations of the
personal property storage room confirmed each youth’s property was stored in an individual bag
with the number of the bag documented on their Property Receipt Form. Observations of the
individual property bags supported a copy of the Property Receipt Form was located with the
individual bag. Observations of the admission process during the annual compliance review
week supported each youth’s property was maintained in accordance with the facility operating
procedure (FOP). The FOP indicates all persons with access to the valuable property shall be
designated in writing by the superintendent. The drop safe and the door to the property room
are under video surveillance. A review of the Department’s Central Communications Center
(CCC) reports during the annual compliance review period confirmed there were no incidents
regarding youth property. All seven interviewed youth reported staff checked their personal
property and had the youth sign a form stating the personal property was correct when they
arrived at the center. During the formal interview with the superintendent, he indicated personal
property is stored and locked in a room which has a camera placed in the room. Valuable
property is stored, in a safe, located in the intake office under video surveillance. Only
supervisors and administration have access to the valuable property. Clothes and non-valuable
property are stored, in a locker, under video surveillance in which all juvenile justice detention
officers (JJDOs), juvenile justice detention officer supervisors (JJDOSs), and administration
have access to. The process for disposal of property after thirty days of a youth not retrieving
their property includes sending out a certified letter to the parent/guardian indicating they have
thirty days to retrieve the property. If the parent/guardian does not retrieve the property an
inventory is done with the unclaimed property and donated. The money from the donated items
is added up and a money order is made and sent to the regional office.
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.
Three closed records were reviewed for release procedures. Documentation in all three closed
records supported the on-duty supervisor reviewed all the paperwork prior to each youth’s
release, and the juvenile justice detention officer supervisors (JJDOSs) reviewed the release
paperwork received from the court prior to each youth’s release. The youth’s identification was
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verified prior to release for all three youth. There was a photocopy of the parent/guardian’s
identification maintained in each of the three closed records reviewed. Documentation
supported the identification of the parent/guardian responsible for picking up the youth was
verified prior to each youth’s release. Documentation also supported the youth and
parent/guardian were reminded of future court dates for each youth. All applicable release forms
were signed by each youth’s parent/guardian. None of the youth had an endangered person
alert. For two of the three released youth, the date of admission and date of release
documented in the intake record correlated with the dates on each youth’s Department’s
Juvenile Justice Information System (JJIS) face sheet. One youth had the release date of
September 11, 2023, on the release documentation and a release date of September 15, 2023,
in JJIS. The superintendent explained the release documentation was created on the date the
youth was supposed to be released; however, staff from the Department of Children’s and
Families (DCF) did not come to the center and pick up the youth until September 15. The
youth’s Property Receipt form was signed by the youth and the DCF staff on September 15,
2023. An observation of a release during the annual compliance review could not be completed
as there were no releases conducted while the annual compliance review team was on-site.
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.
Three closed records were reviewed for release of personal property. Documentation in all three
closed records supported the parent/guardian signed the Receipt of Property Form upon each
youth’s release. There was a photocopy of the parent/guardian’s identification maintained in
each of the three closed records reviewed. Documentation supported the identification of the
parent/guardian responsible for picking up the youth was verified prior to each youth’s release.
None of the three youth were taking medications at the time of release. Documentation
supported the youth and parent/guardian were reminded of any applicable medical, mental
health, or substance abuse needs, and any pending appointments for each youth. An
observation of a release during the annual compliance review week could not be conducted as
there were no releases conducted while the annual compliance review team was on-site.
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.
Detention review meeting minutes were reviewed to ensure appropriate sharing of information.
Forty-nine of fifty-four weeks of detention review meeting minutes were observed to be
uploaded in the Department’s SharePoint site. The center was unable to locate five weeks of
meeting minutes. A random review of meeting minutes from one week each month from
September 2022 through September 2023 supported all required attendees attended the
meetings consistently. The detention review meeting was observed during the annual
compliance review week. Observations confirmed all required attendees participated in the
meeting. The superintendent indicated detention reviews are conducted in the center’s
conference room every Thursday morning. Items discussed include court hearings, placements,
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youth behaviors and wellbeing, and youth detention status. Staff in attendance include
probation, residential, education, medical, mental health, and staff from the public defender’s
office.
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 had a daily activity schedule posted in all living areas. A random sample of the
master control and individual module logbooks was reviewed to ensure the daily activity
schedule was being followed throughout the annual compliance review period. Due to lack of
detail documented in the module logbooks, a crosswalk of both the module logbook and master
control logbook was completed to substantiate the daily activity schedule was being followed.
Documentation in the logbooks confirmed youth were regularly receiving personal hygiene,
meals, visitation, recreation and physical activity, education, and groups. The master control
logbook documented reasons for the deviation of the schedule. There was one exception where
the schedule deviated, and the reason was not documented in the master control logbook. All
seven interviewed youth stated the daily schedule is followed. All seven interviewed staff
reported the daily schedule is followed.
2.10 Educational Access (Critical) Limited Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures addressing educational access. The year-long
district calendar was reviewed and provided the required 250 days of instruction, with ten days
allowed for professional development. Educational services are provided by Orange County
Public Schools, who also approves the calendar. The center’s daily bell schedule allows for six
fifty-three minute classes four days a week, and six forty-five minute classes on Wednesday,
which meets the required twenty-five hours of instruction weekly. The center’s activity schedule
is slightly different than the district’s daily education schedule, but the beginning and ending
times were the same. Randomly selected logbook entries from January, June, and July showed
the daily school schedule was not being followed, and required educational time was not being
met. The main deviations identified were up to twenty minutes late returning to class after the
scheduled lunch time and being released up to thirty minutes early at the end of the school day.
Video footage and logbook entries were reviewed for three days in September. The outcome of
those reviews indicated there were deviations in the movement of youth to and from the
classrooms according to the school schedule. Those reviews showed a deficiency of fifty-one to
eighty-four minutes of instructional time, which confirms the youth are not receiving the
mandated school time of twenty-five hours for the week. The main deviations were after the
scheduled lunch time and releasing youth from class early at the end of the school day. All
youth have an opportunity to earn course credit upon completion. Seven youth were
interviewed, and each youth stated they attend classes Monday through Friday, with little
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interruption during the scheduled school day. Six youth reported they were being well or very
well prepared to return to school, post-secondary school, or employment, and the teachers were
all providing instruction. One youth felt like he was not being well prepared, and shared he only
watches videos, does word searches, or packets in class. Seven interviewed staff indicated
there is minimal interference of educational instruction. An interview with the superintendent
was inconclusive, as he responded with a not applicable on the question referring to minimal
interference of educational instruction.
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 offers a career education competency development program provided by Orange
County Public Schools for all youth in secure detention. The career education programming is
based on each youth’s age, assessed educational abilities, the goals of each youth, the typical
length of stay, and fulfills the requirements for a Type 1 career program. The career education
programming includes communication, interpersonal skills, and decision-making skills.
According to the lead educator, the center is providing ServSafe (food handler certificates),
typing, career interest inventories, hospitality-themed activities, business-themed courses, and
other job-related hands-on activities which align with career preparations, such as, résumés, job
applications, and more. Seven interviewed youth responded they are taking math, science,
social studies, and history. Six of the seven youth indicated they are taking life skills and
English, while two of the seven youth are also taking career choices.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center contracts with VitalCore Health Strategies, LLC to provide mental health and
substance abuse services, and has a single licensed mental health professional designated as
the designated mental health clinician authority (DMHCA). The center’s DMHCA has a clear and
active Florida mental health counselor license, which expires March 31, 2025. The center has
one back-up DMHCA, who is a licensed clinical social worker, with a clear and active Florida
license, which expires March 31, 2025. The back-up DMHCA was utilized during the annual
compliance review period, as evidenced by the DMHCA sign-in log. A review of the DMHCA
sign-in and sign-out logs verified the DMHCA was on-site, forty hours a week, as contractually
required. The DMHCA agreement/position description was available and was reviewed, with no
issues noted. The DMHCA was interviewed and indicated the center’s mental health department
provides suicide risk screenings, crisis assessments, individual and group therapy, along with
treatment and discharge planning. The DMHCA is available to communicate with clinical staff at
any time. All clinical staff have offices in the same section of the center, allowing for face-to-face
communication. The DMHCA, or designee, is also available by telephone and email. These
methods of communication are regularly utilized for communication between the DMHCA and
clinical staff.
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 contracts with VitalCore Health Strategies, LLC to provide mental health and
substance abuse services to youth and has six licensed clinical staff, exceeding the minimum of
four required by contract, on-site throughout the week. Each clinical staff has a clear and active
Florida license, and each expires March 31, 2023. Each staff has the proper credentials
(education, training, and experience); and a copy of each license and credentials were on-site
for review and were verified. The contracted provider has a clinician supervisor/director, who
comes on-site; the director has a clear and active Florida license, which expires March 31,
2023, and credentials were verified.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center contracts with VitalCore Health Strategies, LLC to provide mental health and
substance abuse services to youth and had one non-licensed clinical staff for part of the annual
compliance review period. The contract does not specify the center must have non-licensed
staff; however, does specify minimum qualifications and supervision for any non-licensed
clinical staff employed. The center utilizes all licensed clinical staff to fulfill contractual
requirements. Documentation of the staff’s one-hour weekly direct supervision logs, on the
required form, was reviewed, and no discrepancies were located, which confirmed the licensed
clinical staff assured the non-licensed clinical staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience.
The center does not have a Chapter 397 license. The non-licensed staff appeared on the Office
of Health Services (OHS) list of detention mental health/substance abuse provider qualifications
tracking log, dated July 12, 2023; confirming OHS approved the staff’s qualifications. The non-
licensed staff did conduct Assessments of Suicide Risk (ASRs) for the center, and
documentation of the required twenty hours of training was provided. The center did not have
any clinical mental health/substance abuse vacancies at the time of the annual compliance
review.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures to ensure each youth receives a comprehensive
screening, and proper referrals for services are made based on the results. Seven individual
youth mental health records were reviewed. Six of seven reviewed individual youth mental
health records contained a completed and accurate Suicide Risk Screening Instrument (SRSI)
and a Massachusetts Youth Screening Instrument, Second Version (MASYI-2); the remaining
record had a completed SRSI, but a MASYI-2 was not located for the referral reviewed. Each
reviewed document was completed by the Juvenile Assessment Center, and then reviewed by
detention staff as a part of each youth’s intake process. The detention staff, medical, and/or
mental health staff completed each applicable required section. The forms were in the
Department’s Juvenile Justice Information System (JJIS). Five of seven reviewed individual
youth mental health records contained at least one positive response on the SRSI; each of the
five records had documentation of a completed mental health referral. The remaining two
records were not applicable, with all negative responses on the SRSI. Four of five individual
youth mental health records with positive responses were applicable for prior open or closed
suicide risk alerts in JJIS; the remaining one record was not applicable. All seven individual
youth mental health records had screenings completed by trained staff, according to the
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Department’s Learning Management System (SkillPro). Each of the seven individual youth
mental health records indicated the need for further assessment based on the screening results.
All seven youth had a referral made, and the superintendent/designee was notified. Two of
seven individual youth mental health records contained an invalid MAYSI-2, resulting from all
negative responses, and each youth was referred for a comprehensive assessment. The
remaining five records were not applicable, as they contained valid MAYSI-2 screenings. Three
of seven individual youth mental health records contained a MAYSI-2 with elevated suicide risk,
and each youth was placed on suicide precautions and referred for an Assessment of Suicide
Risk (ASR). The remaining four records were not applicable. Six of seven individual youth
mental health records contained an elevated score on at least one domain on the MAYSI-2, or
had an invalid MAYSI-2, and each was referred for a comprehensive assessment. The
remaining record was not applicable.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures to ensure each youth is screened for mental
health/substance abuse (MH/SA) issues or problems, and qualifying youth receive an in-depth
assessment. Two of seven individual youth mental health records contained an updated
Comprehensive Mental Health Evaluation completed by the center’s on-site mental health
provider within thirty-one days, as required. Each evaluation was completed on an approved
Department instrument and was in the Department’s Office of Health Services (OHS) Electronic
Medical Record. All treatment recommendations made correspond to all diagnosed MH/SA
disorders. The remaining five records were within the first thirty-one days during the annual
compliance review week, and each record documented a referral was made; however, the
update had not yet been completed. None of the reviewed records had a community provider
complete the evaluation.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures to ensure each youth needing treatment services
has an Initial and/or Individual Treatment Plan created and has a discharge summary completed
when youth leave the center. One of seven individual youth mental health records was
applicable, and required a treatment plan; therefore, two additional individual youth mental
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Office of Accountability and Program Support Page 28 of 58 (Revised July 2023)
health records with required treatment plans were reviewed. Each of the three records reviewed
had an Individualized Treatment Plan created within thirty-days of admission by mental health
staff in detention. Each treatment plan identified the youth’s individual mental health/substance
abuse (MH/SA) diagnoses, treatment-focused symptoms, treatment goals, and strengths/needs.
The three reviewed plans did not require psychiatric services or psychotropic medication
information to be included. Each individual youth mental health record contained progress notes
to validate the services included in the treatment plan were being received. All the treatment
plans were signed and dated by the youth, MH/SA clinical staff, and treatment team members;
each had a note regarding the parent/guardian’s presence over the telephone, and each was
dated. Two of three individual youth mental health records contained thirty-day individualized
treatment plan reviews; the remaining treatment plan was not past the first thirty-day period.
Both of the applicable individual youth mental health records contained a thirty-day review
completed as required; and one record had modifications documented clearly on the review.
Both treatment plan reviews were signed and dated by the youth, MH/SA clinical staff, and
treatment team members; each had a note regarding the parent’s presence over the telephone
and each was dated. Treatment plan reviews did not require psychiatric services or
psychotropic medication information to be included; nor were any of the youth identified as
involved in, or assessed as a result of, a Prison Rape Elimination Act event. Three closed
individual youth mental health records were reviewed for MH/SA treatment discharge
summaries. Each MH/SA treatment discharge summary was completed on the required
Department form, and each record indicated a copy of the summary was provided to the youth,
juvenile probation officer, and parent/guardian, if applicable. The center holds treatment team
meetings on Monday, each week; therefore, a treatment team meeting was not observed during
the annual compliance review week.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center’s mental health and substance abuse treatment planning ensures mental
health/substance abuse (MH/SA) interventions are provided to applicable youth to reduce or
alleviate symptoms of MH/SA issues. One of seven individual youth mental health records were
applicable; therefore, two additional individual youth mental health records were also reviewed.
Each of the three applicable individual youth mental health records required the youth to receive
treatment. Each youth was assigned a mini-treatment team consisting of all required and
applicable parties. Each record contained documentation of the youth receiving mental health
treatment in the form of individual, group, and/or family counseling as outlined in the treatment
plan, at least a minimum of once a week. None of the three youth required substance abuse
treatment. Each individual youth mental health record contained the proper Authority for
Evaluation and Treatment (AET) consent form, and each contained treatment notes
documented on the required Department form with all required elements.
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Office of Accountability and Program Support Page 29 of 58 (Revised July 2023)
Three full days of video were observed for mental health groups and compared to the group
sign-in sheets. Two groups were completed on two days and one group on one day. Each group
had the appropriate number of youth in the group, not exceeding the required maximum. Each
group was thirty-five minutes, with the exception of one group, which was thirty-two minutes.
The times noted on the sign-in sheets matched the video review. An Informal interview with the
center's designated mental health clinician authority (DMHCA) was completed. The DMHCA
stated the center conducts groups on Wednesday's each week. The center does not conduct
substance abuse (SA) or delinquency intervention groups. When a youth's treatment plan
incorporates delinquency or SA services, these services are conducted with the youth
individually. All youth who have a treatment plan will have an individual session or group
session each week. If group is not completed one week, the youth participate in individual
sessions.
Five of seven interviewed youth were receiving services; one rated the services fair and four
rated the services very good. One youth additionally stated they were receiving both individual
and group services. The remaining two youth stated they were not receiving services.
The DMHCA stated the center provides suicide risk screenings, crisis assessments, individual
therapy, group therapy, treatment planning, and discharge planning, as needed.
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 facility operating procedures to address psychiatric services. The center has a
board-certified psychiatrist, and a specified back-up psychiatrist, with clear and active Florida
licenses, which expire March 31, 2025. The contract with the provider does not include tele-
medicine/tele-psychiatry. Clinical staff and the psychiatrist meet to discuss applicable youth on a
weekly basis. The designated mental health clinician authority (DMHCA) noted the psychiatrist
is always available by telephone if clinician staff have a question regarding a youth. Three
additional individual youth mental health records were reviewed for psychiatric services; two of
the seven youth in the sample had been at the center less than fourteen days and the remaining
five were not applicable. Each of the three individual youth mental health records contained
documentation of a psychiatric referral and interview completed within fourteen days of
admission. Each psychiatric interview contained all required elements and all three pages of the
Clinical Psychotropic Progress Note (CPPN) form in their entirety; not applicable was recorded
for any non-applicable element for each youth.
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Office of Accountability and Program Support Page 30 of 58 (Revised July 2023)
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a detailed written plan outlining suicide prevention procedures, which is
reviewed and signed each year by the superintendent and designated mental health clinician
authority (DMHCA). The written plan contained all required elements. The center also has an
established review process for each serious suicide attempt or serious self-harming injury. This
review process included all required elements.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures to address supervising, observing, monitoring, and
housing youth identified through screenings, documentation, and observation as being at risk for
suicide. Five of seven individual youth mental health records were reviewed for suicide
prevention services; the remaining two individual youth mental health records were not
applicable. Each applicable youth was determined to be at risk during the admission screening,
and each had a precautionary observation (PO) log started once they were completed with the
admission procedures and placed in the dormitory. Each youth’s PO status was documented in
the logbook. Each applicable individual youth mental health record contained a completed
mental health (MH) referral, PO log, Assessment of Suicide Risk (ASR), and the Department’s
Juvenile Justice Information System (JJIS) alert. Each ASR was completed within the required
time frame, and none of the reviewed records required a follow-up ASR. All reviewed forms
were completed by a licensed clinician staff and contained all required elements. Each
applicable JJIS suicide alert was observed to be open and closed appropriately. Each youth
was removed from PO after being evaluated by the licensed clinician staff and notification was
made to the superintendent. The superintendent’s interview indicated the center does not utilize
secure observation for potentially suicidal youth. One of seven interviewed youth indicated they
had been on suicide watch and the staff watched them the entire time; the remaining six youth
stated they had not been on suicide watch. All seven interviewed staff stated they notify the
designated mental health clinician authority, and the youth is placed on constant sight and
sound supervision when a youth expresses suicidal thoughts. Three of seven added the staff
must search the youth and youth’s room for sharp objects; two staff added the staff must
document the constant supervision; and one staff indicated, if needed, staff are to use the knife-
for-life.
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Office of Accountability and Program Support Page 31 of 58 (Revised July 2023)
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures to address precautionary observation (PO) and
documentation. Five of seven individual youth mental health records reviewed had
documentation of suicide precaution observations; the remaining two individual youth mental
health records were not applicable. Each of the five applicable individual youth mental health
records contained Suicide Precaution Observation Logs completed, on the required Department
form, and for the duration of the youth’s PO incident. The appropriate level of supervision was
maintained, and checks were documented in real time, at a minimum every thirty-minutes as
required, for each youth. Each PO log reviewed was completed in its entirety and contained all
required elements. A review of three youth, who were placed on PO, was completed through
completed PO logs and video observation. The review confirmed proper supervision was
maintained for all three youth.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Limited Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures to address staff training and drills. Seven pre-
service and seven in-service staff training records were reviewed, and all fourteen staff had the
required six hours, two hours online and four in-person, instructional hours of suicide training.
The center conducts suicide drills monthly on each shift, exceeding the minimum requirement of
quarterly on each shift. The center has seven suicide response kits, four in the east building, in
master control and each of the three sub-control rooms, and three in the west building, located
in each sub-control. Each of the seven suicide response kits contained the knife-for-life, wire
cutters, needle nose pilers, one-way cardiopulmonary resuscitation (CPR) mask, micro-shield or
face shield, non-latex gloves, and a first-aid kit. The required first-aid supplies were located
within each suicide response kit; therefore, the center did not need to have additional first-aid
kits co-located with the suicide response kits.
The center’s suicide drills from September 2022 until September 2023 were reviewed. Each
month, each of the three shifts had a suicide drill conducted, an additional drill was completed
the week of the annual compliance review totaling thirty-seven suicide drills. Nineteen of the
thirty-seven reviewed suicide drills were missing key components to the drill; the remaining
eighteen suicide drills were completed and documented, to include review by mental health,
medical, and the superintendent/designee, in their entirety. The missing key components were
either key personnel contacts, and/or key life saving measures documented in the drill, or the
drill review recommendations. The center’s response indicated their policy and procedures
include a directive which states the responding medical personnel/nurse is to respond with the
first-aid kit; therefore, when medical personnel response was documented in the drills, they did
not indicate separate documentation of the first-aid kit being present.
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Office of Accountability and Program Support Page 32 of 58 (Revised July 2023)
Fifty-two staff were reviewed for the first six months of the annual compliance review period;
forty-four staff participated in at least one suicide drill, and the remaining eight staff did not have
documented participation in at least one suicide drill. Sixty-five staff were reviewed for the
second six months of the annual compliance review period; sixty-two staff participated in at least
one suicide drill, and the remaining three staff did not have documented participation in at least
one suicide drill. Each direct care staff who participated in suicide drills, had at least one suicide
drill documenting the use of CPR. There was no documentation reviewed indicating staff who
were not present for the suicide drill, had the opportunity to review the drill scenario.
Seven staff were interviewed and all indicated the knife-for-life, wire cutters, and needle nose
pliers were located in each sub-control; and three of seven staff also indicated these items were
located 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 to address mental health crisis
intervention and emergency services. This plan included notification, and alert systems, means
of referrals, communication, supervision, and documentation and review.
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 an Emergency Care Plan located in the superintendent’s office and is accessible
to all staff. The plan was last updated and approved on August 15, 2023. The plan contained
immediate staff response, notifications, communication, supervision, authorization to transport
for mental health/substance abuse (MH/SA) services, transport for emergency MH/SA
treatment, documentation, training, and review.
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Office of Accountability and Program Support Page 33 of 58 (Revised July 2023)
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures to address Crisis Assessment and response. The
center had one applicable individual youth mental health record during the annual compliance
review period. The record contained documentation of a Crisis Assessment being completed, by
a licensed mental health clinical staff, within two hours of the youth being determined to be in
crisis, and the Crisis Assessment contained all the required elements.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures to address Baker and Marchman Acts. The center
had two applicable individual youth mental health records during the annual compliance review
period. Each record contained documentation of placement on suicide precautions upon re-
admission to the center, and an Assessment of Suicide Risk (ASR) was completed by a
licensed clinical staff for both. The ASR for each record was reviewed and found to be
completed with the required elements including mental health referral, Mental Status
Examination, maintenance of constant supervision, and the Department’s Juvenile Justice
Information System (JJIS) alert. The ASR in both records determined when the alerts and
precautions were to be discontinued.
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Office of Accountability and Program Support Page 34 of 58 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has a board-certified physician who holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida serving as the
designated health authority (DHA), and the license expires on January 31, 2025. The DHA’s
specialty is internal medicine. The DHA has an advanced practice registered nurse (APRN) to
provide clinical services on-site who has a Collaborative Practice Protocol in place with the DHA
performing all administrative duties. A review of the DHA sign-in logs during the annual
compliance review period indicated the DHA was on-site at least once a week, as contractually
required. The center has a back-up DHA who is a licensed physician, holds an unrestricted
license, and meets all requirements for independent and unsupervised practice in the State of
Florida. The back-up DHA’s license expires on January 31, 2025. The back-up DHA was not
utilized during the annual compliance review period. The center has facility operating
procedures in place regarding tele-medicine. The center utilized tele-health appointments during
the annual compliance review period and utilized tele-health logs to document the name of the
youth, date and time of service, and the type of service provided as required. The DHA was
interviewed and indicated the DHA's duties include completing Comprehensive Physical
Assessments, focused medical reviews, periodic evaluations, reviewing chronic medical logs
and alerts, and medical facility operating procedures and policies review. The DHA also
indicated the DHA is available on-site weekly to provide on-site medical services and available
by cellular telephone twenty-four hours a day, seven days a week for both medical and non-
medical staff.
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 medical and health-related protocols.
The designated health authority (DHA) conducted an annual review and signed all respective
treatment FOPs on June 26, 2023, the superintendent reviewed and signed on March 15, 2023,
and the psychiatrist reviewed all FOPs related to psychiatric services and psychotropic
medication on July 14. 2023. The DHA authorized and approved all treatment protocols and
standing procedures. The nursing staff reviewed, signed, and dated a cover page on which all
FOPs, treatment protocols, and other procedures were listed, as required. The center had one
newly hired healthcare staff during the annual compliance review period and the new staff
received a comprehensive clinical orientation to the Department’s healthcare policies and
procedures, as required.
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Office of Accountability and Program Support Page 35 of 58 (Revised July 2023)
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center has facility operating procedures regarding the Authority for Evaluation and
Treatment (AET). A review of seven youth Individual Healthcare Records (IHCRs) revealed six
youth had a valid AET maintained in their IHCR, all of which were obtained prior to providing
medical services. Each of the six IHCRs had either the original AET or one which had the word
“copy” stamped on the form, and all were signed by the parent/guardian and a Department
representative. The remaining youth was under the custody of the Department of Children and
Families and a court order was obtained for all treatment procedures and maintained in the
IHCR, as required. None of the seven reviewed youth were eighteen years of age or older;
therefore, none of the seven reviewed youth required release of information.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and five IHCRs were
applicable for parental notification/consent. The written notifications were sent in each of the five
applicable records utilizing the required Department form. None of the IHCRs were applicable
for parental notification regarding over-the-counter medications, which were not covered by the
Authority for Evaluation and Treatment or vaccinations/immunizations. One youth was
applicable for psychotropic medication and the IHCR documented a staff witness for all
telephone call attempts and conversations for psychotropic medications. Two youth received
new medications. Contact with the parent/guardian for both applicable youth was documented in
the progress notes, and written parent/guardian notifications were documented in both
applicable IHCRs, as required. One youth was under the custody of the Department of Children
and Families and a court order was obtained for all treatment procedures and maintained in the
IHCR, as required. None of the youth were applicable for new psychotropic medications and
written parent/guardian notification for new psychotropic medications or significant change of
drug dosage. Immunization records were verified in six of seven reviewed IHCRs within thirty
days of each youth admission, as required. The remaining youth was released from the center
prior to thirty days. None of the seven youth required immunizations/vaccinations after
admission to the center. The nursing staff were interviewed and indicated parent/guardian
notifications are made to inform the parent/guardian of significant changes in youth condition, to
obtain consent when new medications are ordered, medications are stopped, youth are sent off-
site for treatment, and when treatments are prescribed. These notifications are first done
verbally and followed with written letter.
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Office of Accountability and Program Support Page 36 of 58 (Revised July 2023)
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed. Each IHCR included the
Medical and Mental Health Admission Screening form completed, on the date of admission, by
a juvenile justice detention officer (JJDO) or juvenile justice detention officer supervisor
(JJDOS). All admission screenings were reviewed by the medical staff within twenty-four hours
of the screening, as required. Two youth were applicable for notification to the designated health
authority (DHA) due to chronic conditions and notifications to the DHA were documented in both
applicable IHCRs. None of the seven reviewed IHCRs were applicable for healthcare admission
rescreening; therefore, three additional applicable records were requested and reviewed for
healthcare admission rescreening. Reviewed documentation validated the center completed a
rescreening in all three applicable IHCRs each time a change of custody occurred. Each
rescreening was completed by a JJDO or JJDOS and reviewed by the medical staff within
twenty-four hours of screening. None of the youth required a qualitative urine pregnancy
screening test. The nursing staff were interviewed and indicated youth are first seen by the
center’s nursing staff on the day of admission. The youth are seen the following morning by the
nursing staff if youth arrive at the center after the nursing staff are gone for the day. The
JJDO/JJDOS complete the Medical and Mental Health Admission Screening form and the
nursing staff review and sign the form.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures for all required health education topics including
access to medical care, sick call, what constitutes an emergency and when to notify staff,
medication process with side effect monitoring, the right to refuse care and how it is
documented, what to do in case of sexual assault or attempted sexual assault, the non-
disciplinary role of healthcare providers, and review of the list of healthcare contacts to ensure
accuracy. A review of seven Individual Healthcare Records indicated each youth received a
general healthcare orientation which was documented on the required 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 youth Individual Healthcare Records (IHCRs) were reviewed, and two records were
applicable for designated health authority (DHA) notification for known or suspected chronic
conditions; therefore, an additional record was requested and reviewed. The DHA was notified
within the required time frame for each of the three applicable records and the DHA referrals
were documented in each IHCR, as required. None of the youth required emergency care upon
admission. One of the three applicable youth was taking psychotropic medication and the
psychiatrist notification was documented in the IHCR. The nursing staff were interviewed and
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Office of Accountability and Program Support Page 37 of 58 (Revised July 2023)
indicated the nursing staff are responsible for DHA notification and to contact the DHA by
telephone for youth with chronic conditions or serious issues.
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 youth Individual Healthcare Records (IHCRs) were reviewed for health-related history.
The Health-Related History (HRH) form was completed by a licensed nurse or practitioner prior
to the Comprehensive Physical Assessment and within seven calendar days of admission, as
required, for six of the seven reviewed records. The HRH was completed three days late for the
remaining record. Each of the seven HRH forms for each youth’s most current admission were
reviewed by the designated health authority or advanced practice registered nurse as required.
The nursing staff were interviewed and indicated the center’s nursing staff are responsible for
completing the HRH form within seven days of admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and each IHCR included
the Department’s Comprehensive Physical Assessment (CPA) form. The Department’s Problem
List was updated for each IHCR. Five of the seven IHCRs had a current CPA maintained from a
prior admission with no changes in medical condition, the current CPAs were reviewed by the
designated health authority (DHA) or advanced practice registered nurse (APRN), and the
focused medical evaluations were completed. The remaining two IHCRs had a new CPA
completed within seven calendar days of admission, as required. Each of the seven reviewed
IHCRs documented the youth’s Medical Grade, the CPAs were completed by the DHA or
designee, and all sections of each CPA were marked with “O” or an “X,” as required. One youth
refused part of the exam, the clinician wrote “Youth Refused”, and the youth signed a refusal
form. Each of the seven reviewed IHCRs maintained a verified Tuberculosis Skin Test (TST), as
required, and a tuberculosis (TB) screening was conducted within the required time frame. The
results of the TST documented on the CPA and Infectious and Communicable Disease (ICD)
form matched for each youth. None of the youth required further evaluation, isolation, or
hospitalization. The center has facility operating procedures (FOPs) documenting when any part
of the CPA is refused by the youth, the clinician will write “youth refused”, or a similar term. The
FOPs also include a TB screening and rescreening process. The nursing staff were interviewed
and indicated the CPA is completed within seven calendar days of admission. A new CPA is
needed every two years if youth have Medical Grade one. A new CPA is created if a youth’s
Medical Grade changes from one.
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Office of Accountability and Program Support Page 38 of 58 (Revised July 2023)
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) screening. Six youth were applicable for STI screenings for being sexually active
and each of the six applicable youth were clinically screened and evaluated for STIs. All six
applicable youth were offered counseling and human immunodeficiency virus (HIV) testing. All
six youth required further evaluation, the designated health authority (DHA)/designee reviewed
the STI screening tool, the referrals were documented on the Department’s STI form, and
testing was ordered for all six applicable youth. One youth refused testing and the testing and
screening results were documented in the remaining five applicable IHCRs on the Infectious
Communicable Disease (ICD) form and filed in the laboratory section. Five youth received HIV
testing with documented consent, and the remaining youth refused HIV testing. The HIV test
results for all five applicable youth were filed confidentially in a sealed envelope, as required,
with a proof of a DHA review on the sealed envelope. The pre-test/post-test counseling was
documented in the IHCR for all five youth and the confidentiality for each youth was protected
by not including the HIV status on the internal alert system. None of the youth were applicable
for gynecological exams or were out of the Department’s physical custody. Seven youth were
interviewed, and all indicated they can ask for a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
Seven youth Individual Healthcare Records (IHCRs) were reviewed and three youth IHCRs
were applicable for sick call. Each of the three applicable youth sick calls were documented on
the Sick Call Referral Log. None of the three applicable youth were presented with similar sick
call complaints three or more times within a two-week period or with complaints of severe pain
with which medical staff were unfamiliar. The center utilized an electronic Sick Call Request
form for all three applicable youth and the registered nurse (RN) completed the Sick Call
Request form for each youth. Each Sick Call Request form was filed in the IHCR in reverse
chronological order in accordance with Florida Administrative Code. One of the three applicable
youth was also in restricted housing and the IHCR for the youth documented daily visits by
nursing staff for any health complaints. All sick call events were documented on the Sick Call
Index and corresponded with the Sick Call Request forms. A review of the sick call hours posted
on the clinical door and an informal interview with the nursing staff revealed the sick call is
conducted daily, as required, and as needed. Sick calls are conducted by nursing staff and the
center has treatment protocols addressing different levels of nursing staff. The center also has
procedures in place for shift supervisors to review all sick call requests as soon as possible and
within four hours if there is not a licensed nursing staff on-site. The shift supervisor will discuss
with youth about medical issues for youth in confinement. For non-emergency issues, the shift
supervisor will input the sick call request for the youth to be seen at the next scheduled sick call
time. Nursing staff are required to make daily visits for youth in confinement. All youth in
confinement will receive all prescribed medication. The nursing staff will evaluate youth every
two hours if a youth in confinement has an active medical condition. A sick call was observed
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during the week of the annual compliance review. The youth was escorted to the sick call and
the youth’s verbal consent was obtained. The nursing staff identified themselves and stated why
the youth was there. The youth was seen in a private area with no other youth present and the
youth’s privacy was maintained. An exam table was used to perform the sick call and the youth
was examined by the nursing staff. The nursing staff complete all sick calls. The RN reviews the
sick call within twenty-four hours if the sick call is conducted by the licensed practical nurse.
Seven youth were interviewed, four youth indicated the nursing staff conduct sick call, and the
remaining three youth indicated they have not had any sick calls. Seven staff were interviewed,
and each staff indicated the nursing staff conduct sick call.
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 and six IHCRs indicated the
youth had an on-site first-aid or episodic care event conducted by a licensed healthcare staff in
problem-oriented charting including the nature of the complaint, findings, treatment rendered,
education/instruction provided, and follow-up/future care. None of the episodic care events were
handled by non-healthcare staff or required placement on the center’s internal alert list. One
episodic event was applicable for off-site care and parental notifications, and the off-site care
and parental notifications were documented as required. The episodic care events were
documented in the Episodic Care Log for each of the six applicable IHCRs.
The center has a total of twenty first-aid kits, seven of which are used for transportation. The
center’s first-aid kits are strategically located in the east annex clinic, the west annex clinic,
master control, kitchen, training room, and module. Observations of three first-aid kits during the
week of the annual compliance review revealed each was fully stocked with designated health
authority approved contents. The center has a process to ensure all first-aid kit contents are
maintained and stored in accordance with guidelines to prevent expiration. All first-aid kits are
inventoried and restocked monthly, and when necessary, by the nursing staff. If a first-aid kit
seal is broken, nursing staff restock and seal it. A review of first-aid kit checks during the annual
compliance review period validated the checks were conducted monthly, as required.
The center has three automated external defibrillators (AEDs) located in master control, the east
annex clinic, and the west annex clinic. The AED procedures are located with each AED. The
nursing staff conduct monthly checks for all AEDs. Reviewed AED check documentation during
the annual compliance review period validated the nursing staff conducted monthly AED
checks, as required. A review of all three AEDs indicated all batteries expire on May 20, 2026,
and pads expire on October 28, 2024. The AED batteries and pads were last changed on July
13, 2022. A self-test was conducted for each AED and each AED was operational with no issue.
Emergency drills, for the last year, were reviewed during the annual compliance review week.
The use of cardiopulmonary resuscitation (CPR)/AEDs for emergency drills was confirmed to
have taken place during two different drills for each shift; therefore, meeting the annual
requirement. The center maintains all completed emergency drills in a drill binder. A review of all
the emergency medical drills, for the last year, confirmed a drill was completed on each shift,
each month, with the exception of two. The drills for the months of October and December
2022, for A shift were not completed. The center’s facility operating procedures require the
center to complete an emergency medical drill each month for each shift. Thirty-four emergency
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medical drills were reviewed. Nine of the drills did not document a response to the scenario
demonstrating an immediate response of first-aid and/or administration of CPR techniques, nor
the initiation of the emergency procedures to follow when a life-threatening emergency
occurred. In addition, in the nine drills, the reviewer did not document the Recommendations for
Improved Emergency Response section. The superintendent confirmed all staff with direct
contact on a day-to-day basis with youth have the opportunity to participate in at least one
emergency “man-down” drill annually. Announced and unannounced emergency medical drills
were conducted at least quarterly on each shift. A list of emergency numbers, including the
Poison Information Center, was posted and accessible for non-licensed and licensed staff and
inaccessible to youth. A review of training documentation revealed supervisory level staff were
trained on the administration of the epinephrine auto-injector by a registered nurse (RN). A
review of seven pre-service and seven in-service staff training records indicated each staff
completed the required training in episodic, first-aid, and emergency care. The center has
facility operating procedures (FOPs) detailing the use, access, and inventory of Naloxone
(NARCAN). The FOP indicates the center will maintain at least one prescribed stock nasal
spray kit for emergency purpose of accidental overdose for use for youth. NARCAN should not
be ordered for each individual youth. The center maintains NARCAN in the medical office and
the nursing and supervisory staff have access to NARCAN. A review of training documentation
revealed each staff with access to NARCAN received training on the use of NARCAN. The
nursing staff conducts a weekly count of NARCAN, and reviewed documentation validated the
nursing staff conducted a weekly count of NARCAN during the annual compliance review
period.
The nursing staff was interviewed and indicated the center's AEDs are located in the center's
clinics and master control. The AED procedures are located with the AED. The list of
emergency numbers is available in the medical office. Seven youth were interviewed, two youth
said the medical services at the center are good, two youth said very good, and the remaining
three youth said they are not currently receiving medical services. Seven staff were interviewed,
and each staff said they can call 9-1-1 if needed.
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 and two IHCRs were
applicable for off-site care; therefore, one additional youth record was requested and reviewed.
Reviewed documentation indicated each of the three applicable youth required off-site care and
the off-site care events for each youth were documented on the off-site referral tracking
log/Episodic Care Log. Parental notifications, discharge, and other applicable documents were
filed in the IHCR for each of the three applicable youth. The designated health authority (DHA)
notification, DHA or designee review and signature of off-site care findings, and the
Department’s Summary of Off-Site Care Consultation Report form were filed in two of the three
applicable IHCRs. The DHA notification, DHA or designee review and signature of off-site care
findings, and the Department’s Summary of Off-Site Care Consultation Report form were
missing in the remaining applicable record. The nursing staff indicated there was a court order
for the off-site appointment, nursing staff received an email and the court order the day prior to
the appointment, and nursing staff were not aware of this in advance; therefore, the DHA
notification and the Department’s Summary of Off-Site Care Consultation Report form were an
oversight for this one remaining record. Two of the three IHCRs were applicable for follow-up
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appointments. The follow-up appointments and referrals were documented on the off-site
referral tracking log for both youth and both youth received appropriate and timely follow-up
care as needed. The nursing staff were interviewed and indicated off-site care is tracked on the
off-site care log. The nursing staff review the hospital orders with the DHA. The DHA reviews
off-site care findings when on-site.
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 (IHCR) were reviewed and two IHCRs were
applicable for chronic conditions; therefore, one additional youth record was requested and
reviewed. Each of the three applicable youth were identified on the Department’s Facility Entry
Physical Health Screening form with a current chronic condition, had a documented Medical
Grade, and were taking prescribed medication on an on-going basis. Each of the three
applicable youth were placed on a chronic conditions list, as required. None of the three
applicable youth stayed at the center for at least ninety days for periodic evaluations, were
taking tuberculosis medication, had a communicable disease, were pregnant, needed
evaluation prior to renewing an expired medication, or required off-site evaluation. The
Department’s Problem List was updated, as required, for each of the three applicable youth and
there was no indication of lapses in care for any youth. The nursing staff were interviewed and
indicated the designated health authority (DHA) is notified and sees youth with chronic
conditions, and chronic conditions are listed in the chronic condition binder. The DHA was
interviewed and indicated chronic medical conditions are seen for periodic evaluations a
minimum of every ninety days. Frequency of evaluation may be more often based on plan of
care at the time of the Comprehensive Physical Assessment or focused medical evaluation.
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 and five IHCRs were
applicable for medication. Three youth were taking medication at the time of admission which
were verified prior to being admitted to the center. The prescription verification and the
designated health authority (DHA) and psychiatrist notification to obtain an order to resume the
medications were documented in the chronological progress note, as required, for each of the
three youth. The remaining two youth had medications ordered after admission. All medications
had a current, valid order, were administered pursuant to a current prescription, and the
DHA/designee placed an order on the Practitioner Order form for all five applicable youth with
medications. The prescription verification for each youth was documented in the chronological
progress note in the IHCR. Two of the five applicable youth were in restricted housing and
received all prescribed medications as ordered, and the nursing staff completed daily visits for
both youth. None of the youth required over-the-counter medications not listed on the Authority
for Evaluation and Treatment (AET). The Electronic Medical Record Medication Administration
Record (MAR) was utilized for all five applicable IHCRs to document all medication and
treatment including start and stop dates. Each MAR contained all required elements. The
nursing staff documented weekly side effect monitoring on each MAR, and each youth and
nursing staff initialed each provided medication entry. There were no lapses or errors noted for
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any medication. None of the medications were administered by non-healthcare staff. None of
the youth required parenteral medications. One youth was applicable for refusal and the refusal
was clearly documented on the MAR with youth signature. One youth was prescribed
psychotropic medication prior to admission and the DHA and psychiatrist were notified of the
youth’s admission. The youth was released from the center prior to fourteen days; therefore, no
psychiatric interview was conducted. The youth did not remain at the center for thirty days to
receive a thirty-day medication review.
The center has a facility operating procedure (FOP) for medication disposal which indicates a
registered nurse shall be responsible for the disposal of medications in conjunction with the
pharmacy consultant. Controlled and non-controlled medications must be disposed of by
utilizing the Drug Enforcement Agency (DEA) approved Drug Buster disposal system in
accordance with state board of pharmacy and DEA disposal plan. The center did not have any
standing orders, emergency treatment orders, or pro-re-nata orders for psychotropic
medications.
One medication pass was observed during the annual compliance review week. The youth was
escorted to the medical clinic and the youth’s verbal consent was obtained. The youth
approached the nursing staff individually and the nursing staff indicated why the youth was
there. The nursing staff verified the youth’s allergy and alert status, prepared and administered
the medication, did not pre-pour the medication from original packaging, and observed the youth
to ensure the medication was swallowed. Both youth and nursing staff signed the MAR, and the
medication administration was documented as required.
The nursing staff were interviewed and indicated if a youth arrives with medication, the nursing
staff review the medication to ensure the medication is from a licensed pharmacy with a current,
patient specific label intact on the original medication container to accept the medication.
Medications shall have a current, valid order, and are given as ordered on current prescription
or the Practitioner Order form. The DHA or psychiatrist shall be contacted to obtain the order to
resume the specified medications prescribed prior to admission. Seven youth were interviewed.
Six youth said they do not currently take medication and the remaining youth said the nurses
provide the medication to youth. Seven staff were interviewed and four said they do not provide
medication to youth. The remaining three staff said they are supervisory staff and are authorized
to provide medication to youth.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has facility operating procedures regarding medical equipment classified as sharps.
An observation of the center’s medical area was completed during the week of the annual
compliance review. The center maintains all sharps in a locked cabinet in medical. Sharps are
inventoried utilizing a perpetual inventory, which descends as sharps are utilized and disposed.
All medications are maintained in medical, and all are locked in designated storage areas. The
medication cart is clean and organized with stock items separate from youth-specific
medications. All injectable, topical, and liquid medications are securely maintained, separated,
and inaccessible to youth. The oral medications were stored separate from injectable and
topical medications. The center did not have any controlled medications during the week of the
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annual compliance review. The nurse indicated the center’s practice is to store all narcotics and
controlled medications behind two locks in the medication cart. An observation of the medication
cart confirmed the separate box inside the cart with an additional lock. The center maintains two
small refrigerators in medical, which are utilized for medication only. An observation confirmed
only medication was in the refrigerators. A review of the medical binders for sharps and over-
the-counter (OTC) medications confirmed a perpetual inventory is maintained for OTC
medications. On August 17, 2023, supervisory floor staff were trained by the center’s registered
nurse (RN) on the delivery and oversight of medication administration. An observation of counts
of three different sharps and OTC medications was completed during the week of the annual
compliance review. Both the sharps and OTC medication counts matched the center’s inventory
counts. An informal interview was conducted with the RN regarding reporting criteria and
procedures regarding inventory discrepancies and the disposal and destruction of expired
and/or discontinued medications. The RN stated it would be confirmed if the missing medication
was used and not documented and a review of youth information would be completed. Medical
staff would be asked to determine if the medication was administered and they forgot to be
document it. If unable to determine the location of the missing medication, a report would be
submitted to the medical supervisor and a report would be submitted to the Department’s
Central Communications Center notating the medication error. The RN stated the medical staff
utilize destroyer solution to dissolve medications. If a controlled substance is being destroyed,
the controlled substance is dissolved when the pharmacist is on-site. The destruction of a
controlled substance is documented in the pharmacy book. The center’s RN was interviewed
and confirmed all controlled medications are disposed of by nursing staff and the pharmacy
consultant. Other medications are disposed of by nurses. The RN stated all controlled
substances such as narcotics are kept in a locked compartment in the medication cart which is
also locked. The RN stated the center has a current agreement with a consultant pharmacist,
who is on-site monthly. The pharmacy consultant reviews the center’s medication cart,
medication cabinets, medication refrigerator, destroys medications, ensures all items are
labeled appropriately, reviews Medication Administration Records (MARs) and sharps; as well
as ensures licenses are up to date. The RN confirmed the center maintains a copy of the
pharmacy consultant’s license on-site and it is a Consultant Pharmacy License, not a
Registered Pharmacy Consultant License.
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, and each youth received
infection control training within seven days of admission, including hand-washing techniques,
vaccinations, universal precautions, prevention/transmission of communicable diseases, and
the Centers for Disease Control and Prevention (CDC) guidelines on infection control. A review
of the center’s Exposure Control Plan revealed the plan was written in accordance with
Occupational Safety and Health Administration (OSHA) standards and included all required
elements of risk assessment and methods of compliance. A review of the center’s infection
control procedures revealed they included prevention, containment, treatment, and reporting
requirements related to infectious diseases, according to the OSHA and CDC guidelines, and
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included all required elements. The center has facility operating procedures addressing needle
stick post-exposure evaluation, and for staff to have access to personal protective equipment
and Hepatitis B immunizations. The procedures for needle stick post-exposure evaluation
include identification and status of the source of the individual, testing of the blood of the
individual, documenting route of exposure and circumstances related to incident, referring the
individual for medical attention, offering post-exposure prophylaxis and counseling, informing
the individual on potential illnesses to be alert for, and assuring the process is effectively carried
out. An informal interview with the nursing staff revealed the center did not have any infectious
diseases or sexually transmitted infections during the annual compliance review period which
had to be reported to the local health department, the CDC, and the Department’s Central
Communications Center (CCC). The center's process is to quarantine youth in their living
module each time there is any positive COVID-19 case; however, COVID-19 cases are no
longer required to be reported to the CCC. The superintendent indicated the center has not had
any instances of occupational exposure. A review of seven pre-service and seven in-service
staff training records revealed each staff received training on the center’s Exposure Control
Plan. The nursing staff were interviewed and indicated Infection and Exposure Control Plans are
available to staff and the registered nurse manager conducts exposure control training for staff.
Youth receive training during admission.
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 (IHCRs) were reviewed, and none were applicable
for prenatal care/education. The center only had two pregnant youth during the annual
compliance review period and the two applicable records were reviewed. Reviewed IHCRs for
the applicable youth revealed each youth received prenatal care immediately upon
determination of pregnancy and continued until discharge. Neither of the two youth were at the
center long enough to receive routine, focused medical evaluations every thirty days, but both
youth received prenatal care in recommended intervals. Both youth were placed on the center’s
internal alert system for vital nutrition, health awareness, and sleeping arrangements. None of
the youth complained of issues related to pregnancy during their stay at the center. The nursing
staff provided routine monitoring of nutritional and weight status and signs for pregnancy
complications for both youth. Each youth received nutritious food in quantities appropriate for a
pregnant youth and they each had a documented plan for post-birth psychological and physical
care. Reviewed IHCRs revealed each youth received education related to pregnancy including
all required topics which were documented on the Health Education Record. Reviewed training
documents validated the center’s licensed nursing staff provided education on prenatal
healthcare annually to all non-healthcare staff involved in the supervision of pregnant youth. A
review of seven pre-service and seven in-service staff training records revealed each staff
received training in youth healthcare including observation and monitoring of emergency care
needs and symptoms of possible miscarriage. The center has standing orders for pregnant
youth. The nursing staff were interviewed and indicated pregnant youth receive scheduled
gynecology appointments, pregnancy diet, vitamins, and are educated on pregnancy. Female
youth are tested for pregnancy upon admission and as ordered by the designated health
authority. Seven youth were interviewed, and none needed prenatal care.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
The center has facility operating procedures to ensure youth are actively supervised by staff.
During the annual compliance review week, observations confirmed youth were actively and
appropriately supervised during daily activities such as school, outside recreation, and meals.
All movement was requested to master control prior to the movement occurring and was cleared
by master control. A review of the center’s master control logbooks verified all movements were
logged into the master control logbook and headcounts were routinely conducted to track the
daily census. Seven staff were interviewed with six indicating there are enough staff to provide
for the safety and security of the youth and staff. The remaining staff responded no and
indicated staff have to improvise to make things safe for both staff and youth.
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5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations.
Each center shall implement and maintain a behavior management system to meet the needs
of the youth and the center. The system shall include rewards for positive behavior and
consequences for inappropriate behavior.
The behavioral norms and expectations for youth shall be posted in all living areas and shall
clearly specify appropriate and inappropriate behaviors.
The system restricts certain types of penalties on youth who demonstrate negative behaviors.
Group punishment shall not be used. However, corrective action taken with a group of youth
is appropriate when the behavior of a group jeopardizes safety or security, and this should
not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
The use of drugs to control the behavior of youth is prohibited. This does not preclude the
proper administration of medication as prescribed by a licensed physician.
The center has facility operating procedures addressing a behavior management system (BMS).
The center provides a system of rewards, privileges, and consequences to encourage youth to
meet the center’s expectations utilizing the BMS. The policy outlines restrictions and
punishments which are prohibited. A copy of the center’s BMS was provided and was verified as
the statewide BMS which was approved by the Department. During a facility tour, the BMS
information was observed throughout the center, including postings in the living areas clearly
specifying appropriate and inappropriate behaviors, rules, norms, and expectations. The BMS is
a three-tiered level system. Each youth enters at level two when admitted, and their level moves
up or down depending on their behavior in the center. The BMS includes rewards for positive
behavior and consequences for negative behaviors. A review of the center’s policy in
comparison with BMS documentation found the center is complying with all requirements of the
BMS and assignment of positive and negative consequences. A review of youth level cards
showed staff are properly filling out the point cards and documenting positive and negative
behaviors of youth in the center. A review of documentation did not find any instances of
inappropriate or group punishment being conducted. Seven staff were interviewed and all seven
were able to accurately describe the BMS level system, to include the types of rewards provided
by the center, and each staff indicated levels are the only things taken away from youth as a
consequence. All seven staff also reported the center’s BMS to be effective, indicated they
speak with youth to discuss the consequences being imposed and alternative acceptable
behaviors, and each youth is given the opportunity to explain their behavior. All seven staff
explained supervisors provide feedback to staff verbally regarding the implementation of the
BMS, and five staff indicated the feedback is received daily while two staff stated weekly. None
of the seven staff have ever seen a coworker take meals, snacks, clothing, education, or
medical care from youth because they were acting out, nor have they ever observed any staff
encouraging youth to beat up another youth. Seven youth were interviewed, and five youth
reported the BMS to be fair and two youth reported the BMS to be very good. Four of seven
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youth were able to explain how the BMS works and how they move from level to level. Two of
the remaining three youth were not sure about the levels as they were newly admitted and the
remaining youth didn’t know the details but knew the level he was on. Six of seven youth
provided examples of how youth are rewarded in the center, and the remaining youth was just
admitted and was not sure. Five of seven interviewed youth felt staff use rewards in a consistent
manner and the remaining two youth were not sure, due to being newly admitted and had not
received any rewards yet. All seven youth reported youth are never allowed to punish other
youth. Three of seven youth indicated they have been sent to their rooms for punishment, each
specified they were in their rooms for confinement, with the door shut and locked and the
remaining four youth said no. When asked if the youth ever received consequences, only three
youth were applicable. Each of the three youth stated the consequences they received were fair
and they had only points, or levels taken away. The remaining four youth had never received
consequences. None of the seven youth have ever witnessed the use of handcuffs or leg irons
on out-of-control youth to prevent them from hurting themselves or others.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures which require visual checks on youth at least every
ten-minutes when they are in their sleeping rooms, or at other times such as during an illness or
room restriction. The center has 154 cameras, of which 144 were operational during the annual
compliance review week. The center had a work order submitted for each of the remaining ten
cameras. The center’s surveillance cameras have a thirty-day capacity for video storage. The
center utilizes an electronic wand system which generates a report of conducted checks. The
staff, when conducting checks, taps the wand on the check point sensor located on the door. A
review of three samples of video, including samples from each shift and each living module,
revealed staff conducted ten-minute checks as required, with the exception of two video checks,
one three minutes late, and one thirteen minutes late. A review of eleven days of wand check
reports, including samples from each shift and each living module, revealed staff conducted ten-
minute checks as required, with the exception of one three minutes late. Weekly reviews of
management oversight was completed for ten-minute checks during the annual compliance
review period. Seven staff were interviewed, and each staff reported checks are conducted at
least every ten-minutes. The superintendent interview confirmed staff conduct checks every ten-
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Office of Accountability and Program Support Page 48 of 58 (Revised July 2023)
minutes while youth are in their rooms for sleeping or non-punishment reasons and paper
checks require the completion of a paper Visual Observation Report (VOR).
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures to ensure the census, counts, and tracking of all
youth are always maintained. A review of logbooks for three days each month during the annual
compliance review period found counts were conducted and documented at the beginning and
end of each shift, following any emergency, including a power outage, prior to and following
routine group movement, any time a population change occurred, and randomly once a shift.
Observations conducted during the annual compliance review week confirmed master control
conducted a random headcount and documented in the logbook as required. Seven interviewed
staff reported headcounts are conducted at the beginning and end of each shift, and before and
after meals and school. Interviewed staff stated, if a headcount is off, all movement is stopped,
and the headcount is repeated until it is accurate. Additionally, staff indicated emergency head
counts are conducted if a youth is believed to be missing, after a major disturbance, after a code
is called, or if visibility is hindered in any way, such as an electrical outage.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 58 (Revised July 2023)
5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has a policy and procedures outlining the use of logbooks to maintain a
chronological record of events, incidents, and activities. The center has separate logbooks for
master control and each living module. A review of each logbook found they were bound with
numbered pages. A review of logbooks since the last annual compliance review for each living
module and master control verified all entries were legible and written in ink with no erasures or
whiteouts. All entries included the date and time of the event, name of the staff and youth
involved, a brief description of the event, initials of the person making the entry, and the date
and time of the entry. There were no obliterated or removed pages. All entries which impacted
the safety and security of youth were highlighted. Any errors were struck through with a single
line and initialed by the staff correcting the error. None of the errors required supervisor
intervention. Supervisors reviewed the master control logbook when accepting responsibility of
the center and each logbook review designated the name and position of the reviewer and the
date and time the review was completed. A review of the master control logbook confirmed the
inclusion of all required elements. After a review of the logbook, it was determined youth were
arriving late to school and leaving early compared to the daily schedule.
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Office of Accountability and Program Support Page 50 of 58 (Revised July 2023)
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has facility operating procedures addressing logbook reviews. Logbooks for three full
days each month during the annual compliance review period were reviewed, which confirmed
the superintendent reviewed the logbooks on a weekly basis, juvenile justice detention officer
supervisors reviewed the logbook prior to accepting the living unit for shift, and supervisory
reviews were conducted in each living area logbook daily. An interview was conducted with the
superintendent who confirmed reviews of each logbook are conducted weekly by management.
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 describing the center’s key control, issuance of
keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys, and reporting
and replacement of damaged keys. Missing or lost keys must be documented, and the
supervisor must be notified immediately; a Department’s Central Communications Center (CCC)
report is generated if any key is not found or located. An incident report is completed if any key
is damaged, and the key is replaced by the superintendent. An inventory of keys was conducted
and all keys on the inventory matched the actual key rings in use. Keys are stored in master
control and the supervisor office. An observation of staff, during shift change, displayed staff
turning in their personal keys to receive facility keys. All keys were maintained on a tamper-
resistant ring. Emergency keys which provide egress through exterior doors are stored in
master control and the module sub-control rooms which staff can access. The master key
inventory included the ring number, number of keys on each ring, the capability of each key, and
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Office of Accountability and Program Support Page 51 of 58 (Revised July 2023)
to whom the key ring was issued. All key rings were numbered and indicated on the ring. The
facility keys were placed on color coordinated hubs and all colors matched the correct keys as
required. Each time a key was issued to staff it was documented on the shift report. Based on
observation, staff carried keys on their person at all times, and did not allow youth to handle
facility keys at any time. The key boxes in master control and in the supervisor’s office were not
easily accessible while locked. There were no incidents reported to the CCC relating to key
control concerns. A review of five key rings was conducted, and all key rings had the
appropriate number of keys on the ring as reflected in the inventory. Three staff were informally
interviewed and they were able to accurately describe each function of the keys they
possessed. An informal interview was conducted with master control and the operator was able
to explain the process for restricting key usage. Seven staff were interviewed, and all seven
staff were able to accurately explain the key control process and which of the center’s keys are
restricted. The superintendent was interviewed and stated permanent keys are issued to
administration and the center has signed documentation of who each key is assigned to.
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures addressing transportation procedures and the
maintenance and operation of Department vehicles. Observations during the annual compliance
review week confirmed each of the six center vehicles had the appropriate number of seatbelts,
a seatbelt cutter, a window punch, a fire extinguisher, and a first-aid kit, with items approved by
the designated health authority (DHA). Each vehicle underwent an annual vehicle inspection.
Maintenance staff had documentation to support monthly visual checks of the water coolant,
lights, oil, emergency equipment, brakes, horn, interior/exterior, and cleanliness. Monthly
checks of the tires, windshield, wipers, windows, and mirrors were conducted by the
maintenance technician. Each inspection was documented on the mandatory inspection form
and maintained by the maintenance technician. A review of logbook documentation determined
staff are acknowledging the vehicle was checked, the destination, the number of youth and staff
including names, the name of the officer riding in the back of the van, the time the transport
began, and the time the transport ended. During the annual compliance review week, a
transportation was observed. Prior to the transport staff inspected the vehicle for contraband
and made sure the cage area of the vehicle was checked, ensured the vehicle had sufficient
gasoline for the transport, verified seatbelts were secure, ensured the vehicle binder contained
the vehicle log, and documented the inspection in the vehicle logbook. Staff searched youth
prior to placing them into the vehicle and ensured each youth and staff wore their seatbelts.
After the transport, the vehicle was searched by staff for contraband, staff ensured the vehicle
was locked, and ensured youth were searched upon return to the center. All six vehicles were
checked to ensure they were locked and all six were locked. Seven youth were interviewed, and
all seven youth stated they felt staff are driving safely when transporting youth. Seven youth
also reported they have never seen anyone place contraband in a transport vehicle.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 58 (Revised July 2023)
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center has facility operating procedures addressing tool inventory and management. The
center’s policy indicates maintenance tools shall be on a shadow board with a master inventory
to reflect the shadow board. The kitchen knives and other hazardous sharps shall be stored in a
locked cabinet located in the kitchen. During the annual compliance review week, observations
confirmed all tools were secured and locked in the maintenance workshop, and the
maintenance and kitchen tools were inaccessible to youth. During the annual compliance review
week, a small kitchen knife was missing from the sharps box. Proper procedures were followed
by the kitchen staff and administration. The facility was searched, and the Department’s Central
Communications Center (CCC) was contacted in a timely manner by the superintendent. Upon
reporting for duty, kitchen staff completed the itemized inventory of all equipment on a daily
basis. An informal interview with the maintenance staff indicated all service vendors are
accompanied by designated center staff or a designee at all times. A review of the tool inventory
confirmed the center has an accurate count of all tools and a log indicating which tool has been
signed out and returned. A review of monthly inventory sheets since the last annual compliance
review confirmed there were no missing maintenance tools. A review of five tools in the
maintenance shed was completed. Observations confirmed each tool was secured, was marked
for easy identification, the inventory accurately reflected the number of tools, and the inventory
was signed by the superintendent/designee. Seven staff were interviewed and were able to
explain the process of reporting a damaged or missing tool. The superintendent was interviewed
and indicated only the maintenance staff has access to the facility tools.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center has facility operating procedures ensuring youth do not use or have access to
kitchen and medical equipment. The center does not allow youth to use tools or kitchen and
medical equipment. Youth are allowed to use cleaning items such as mops, brooms, and
common household items under the direct care and supervision of staff. Seven staff were
interviewed, and each staff indicated youth are allowed to use a mop and broom. Seven youth
were interviewed and five stated they use mops and brooms. The remaining two youth reported
they have not used any tools while in the center. Five youth reported using a cleaning agent
while the remaining two reported they do not use any cleaning agents.
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Office of Accountability and Program Support Page 53 of 58 (Revised July 2023)
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 to ensure proper inventory of all flammable, toxic,
caustic, and poisonous items. These items can only be used by authorized staff. During the
annual compliance review week, a review indicated the center has an accurate count of all
chemicals on-site. A Safety Data Sheet (SDS) was maintained in a binder near the stored
chemicals and was available to staff. A review of five SDSs and corresponding items was
completed, and all five chemicals were properly accounted for and stored in a secure place.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center has a facility operating procedure which states flammable, toxic, caustic, and
poisonous items, 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. Observations were conducted during the
annual compliance review week and found only authorized staff are permitted access to these
items. Seven youth were interviewed and stated they do not have access to toxic, caustic, and
poisonous chemicals. Seven staff were interviewed and six stated no youth are allowed to clean
with flammable, toxic, caustic, and poisonous items. One staff reported youth are allowed to use
flammable, toxic, caustic, and poisonous items while cleaning. An informal interview with the
superintendent confirmed youth do not clean with any flammable, toxic, caustic, or poisonous
items.
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Office of Accountability and Program Support Page 54 of 58 (Revised July 2023)
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures addressing the proper use, storage, and disposal of
all flammable, toxic, caustic, and poisonous items. Since the last annual compliance review,
there have been no instances of chemical spills. The maintenance staff stated all chemicals are
either used or picked up by the center’s vendor to be removed for proper disposal. The kitchen
has a container outside of the kitchen, which stores the grease, and is disposed of monthly by
the center’s vendor. An interview with the maintenance staff and superintendent confirmed
chemicals are being disposed of appropriately.
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 which outline the process of placing youth in
confinement under twenty-four hours. Since the last annual compliance review, the center had
497 instances of confinement. Twenty confinement reports were reviewed in the Facility
Management System (FMS). Prior to placing each youth in confinement, the youth room was
searched, and the youth was notified of the right to file a grievance. All twenty of the
confinements were approved by a supervisor within the required time frame and the initial
confinement review stated the reason for confinement. Each confinement log reflected
confinement checks were conducted every five minutes for the first hour and ten minutes after
the first hour which is in accordance with the facility policy. All twenty of the reviewed reports
documented youth received their meals as scheduled, had access to mental health and medical
care, daily shower, clean clothing, mattress and bedding, and education materials during the
required hours. None of the youth were injured or pregnant while in confinement. The reports on
all twenty confinements reviewed had the full report completed before the end of the involved
staff’s shift. Supervisors conducted additional reviews at a minimum of every three hours and
documented the reviews in FMS. The superintendent or designee reviewed all twenty reports
within forty-eight hours and determined if the confinement was appropriate or inappropriate.
Windows of the youth rooms were free of obstruction and scratches. The superintendent was
interviewed, and confirmed data driven decision making is used to track the appropriateness of
confinements. Seven staff were interviewed with all seven staff stating they must complete the
confinement report and conduct/document ten-minute checks, while youth are in confinement.
Four out of seven staff reported they search the confinement room before placing a youth in the
room. Each staff reported they have to conduct checks every five minutes for the first hour of
confinement on all youth placed into confinement and youth in confinement are provided
educational materials.
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Office of Accountability and Program Support Page 55 of 58 (Revised July 2023)
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 facility operating procedures in place which include the center’s Disaster
Preparedness Plan and the Continuity of Operations Plan (COOP). The plan specifies COOP
drills shall be conducted and documented, at a minimum, twice a year, with one drill being
completed prior to hurricane season. The center completed two COOP drills since the last
annual compliance review. A review of both drills confirmed the center conducted a COOP drill
before hurricane season. Both drills had documentation containing the type of drill, time and
date, participants, a brief scenario, and findings and recommendations. Seven staff were
interviewed and all seven reported participation in escape and fire drills since the last annual
compliance review. Additionally, six staff reported they participated in a weather drill and two
staff reported participation major disturbance, bomb threat, hostage situations, chemical spills,
flooding, and terrorism drills. The superintendent was interviewed, and confirmed the COOP is
the center’s comprehensive safety/emergency program.
5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures regarding escape drills and an Escape Prevention
Plan. The centers policy requires escape drills to be completed on a quarterly basis. A review of
drills for the past twelve months was conducted during the week of the annual compliance
review, which confirmed the center conducted escape drills quarterly. A review of seven staff
training records confirmed staff were trained in escape prevention annually. The logbooks
contained documentation of escape drills being conducted. Seven staff were interviewed, and
all seven staff reported they have participated in escape drills.
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Office of Accountability and Program Support Page 56 of 58 (Revised July 2023)
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has facility operating procedures and a Fire Prevention Plan addressing fire drills.
Fire drill documentation was reviewed and found the center conducted fire drills monthly, on
each shift, during the annual compliance review period. The master control logbook included
documentation of each drill. All drill forms were reviewed and signed by facility administration.
Fire extinguishers were inspected annually, and the maintenance staff checked the
extinguishers on a monthly basis. Seven staff were interviewed, and all seven staff reported
they have participated in monthly fire drills. Seven youth were interviewed, and six youth
reported they knew what to do in the case of a fire, while the remaining youth stated they did not
know what to do in the case of a fire. The superintendent indicated the youth was not in the
facility long enough to participate in a fire related 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 addressing illegal contraband and prohibited items.
Upon admission to the detention center, youth are searched by detention staff. During the
annual compliance review week, a search was observed, and the staff thoroughly searched the
youth with gloves on and reported the search to master control. Since the last annual
compliance review, there were no strip searches conducted by the center outside of the initial
strip search at admission. Electronic searches were conducted on all persons entering the
center. All bags, cases, jacket pockets, and other items were searched. All personal keys were
collected by master control before entering the secure floor. Personal cellular telephones and
other contraband items were prohibited. Room searches are completed upon releasing a youth
and prior to placing a new youth in a room. Room searches were also conducted on each
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Office of Accountability and Program Support Page 57 of 58 (Revised July 2023)
awake shift. A review of room searches was conducted for one day each month during the
annual compliance review period and confirmed both awake shifts completed and documented
room searches. Since the last annual compliance review there were sixteen instances which
compromised the safety or security of the center. A review confirmed all instances were
reported to the on-duty supervisor and to the Department’s Central Communications Center
(CCC) in a timely manner. A review of the master control logbook confirmed the center was
documenting confiscation of contraband. A review of incident reports confirmed staff were
completing incident reports when contraband was discovered in the center. Law enforcement
was notified when necessary. Confiscated items were secured by either the on-duty supervisor
or administration, and then turned over to law enforcement. Chain of custody was documented
on incident reports by the shift supervisor. The CCC was notified for all incidents involving
contraband in the center. The regional director or designee was notified regarding contraband in
the center. The superintendent was interviewed and confirmed all youth re searched upon entry
into the building. The superintendent also informed youth are frisk searched after all movements
which take place internally at the facility, and new intakes are searched and then strip searched
during the youth initial intake shower. The superintendent additionally stated an internal
investigation will be initiated, and law enforcement will be notified to come and take possession
of contraband, if it is found at the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 58 (Revised July 2023)

source: DJJ

report_type: QI Detention

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 3.12