state: FL

summary: QI Detention - FY24-25 - 2 findings

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Marion Regional Detention Center
Department of Juvenile Justice
(State-Operated )
3040 NW 10th Street
Ocala, Florida 34475
Review Date(s): August 26-30th, 2024
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Renette Crosby, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Cio’nna Allen, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Lori Bright, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Jeff Campbell, Office of Education, Education Specialist (Standard 2)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 1,
Interviews)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Brittany Thomas, Rite of Passage, National Director of Nursing (Standard 4)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Devon Whitten, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Program Name: Marion Regional Juvenile Detention Center MQI Program Code: 094
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Marion County / Circuit 5 Number of Beds: 60
Review Date(s): August 27-30, 2024 Lead Reviewer Code: 186
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
5.03 Ten-Minute Checks*
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 53 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) 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 53 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 53 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Baker and Marchman Acts * Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 53 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 53 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Limited
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 53 (Revised July 2023)
Program Overview
The Marion Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Ocala, Florida. The center serves youth in Marion, Citrus, Hernando,
Lake, and Sumter counties in Circuit 5. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
sixty-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 Marion County School Board.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant, eight juvenile justice detention officer (JJDO) supervisors, and
forty-three JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore. Mental health services are provided by one designated mental health
clinician authority (DMHCA), four licensed clinical staff, one non-licensed staff, and one
psychiatrist. Clinical services provided by the center include mental health and substance abuse
evaluations, mental health treatment planning, individual, group, and family therapy, mental
health crisis intervention services, on-site psychiatric services, and availability for substance
abuse services for youth with co-occurring disorders. Medical services are provided by one
designated health authority (DHA), two advanced practice registered nurses (APRNs), five
registered nurses (RNs) including the supervisory RN, and one licensed practical nurse (LPN).
The medical clinic maintains nursing coverage Monday through Friday, from 7:00 a.m. to 7:30
p.m. and on weekends from 7:00 a.m. to 5:30 p.m. Food services are provided by Department
staff and include menus, meal planning, meal schedules, special diets, nutritional analysis, daily
allowance, food preparation, health certifications, food product standards, sanitation, and
cleaning. Staff are responsible for the custody and control of youth in their care, providing youth
supervision twenty-four hours a day, seven days a week. The center has four living modules
which are divided by male and female. There are eighty-eight security cameras at the center, of
which eighty-eight were operational. The center has maintenance work orders in place for
bathroom fixtures and repairs for damaged areas. At the time of the annual compliance review,
the center had eight vacancies, which included seven JJDOs and one kitchen staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 53 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has a policy and procedures for volunteers, mentors, and interns who work with
youth less than ten hours a month requiring sight and sound supervision. The Annual Affidavit of
Compliance with Level 2 Screening Standards was submitted to the Department on January 8,
2024, meeting the annual requirement. The teachers who are paid by the school board, or have
funding provided by the school board or Department of Education, received an Annual Affidavit
of Compliance with Level 2 Screening Standards which was completed on January 8, 2024. The
center had nine direct care staff, two volunteers, and five contracted staff, for a total of sixteen
applicable records, who required background screenings since the last annual compliance
review. A background screening was completed on each staff, volunteer, and contracted
provider prior to contact with youth or confidential youth records. Both volunteers interacted with
the youth intermittently less than ten hours a month; however, each was background screened
prior to youth contact. The criminal history report was reviewed for all sixteen records reviewed.
None of the records were applicable for requiring an exemption. A pre-employment assessment
tool was administered to all nine direct care staff. Each of the nine staff had a pre-employment
assessment passing score documented in the staff’s personnel record. The center added the
five contracted staff to the Clearinghouse employee roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
Three staff were applicable for requiring a background rescreening. The five-year
rescreenings/renewals for the three Department staff were completed every five years,
calculated from the agency hire date, and were not completed more than twelve months and no
later than ten days prior to the staff’s five-year anniversary date in all three records. None of the
contracted staff were applicable for requiring a five-year rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 53 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
Nine staff personnel records were reviewed for staff code of conduct and each record contained
a code of conduct signed prior to their date of hire. None of the nine staff reviewed had
disciplinary actions for violations of the code of conduct or for commendations; therefore, no
records were applicable for review. Nine youth were interviewed. Four youth stated they have
never been stopped from reporting abuse to the Florida Abuse Hotline since being admitted to
the center. Five youth stated they never had to report abuse. Nine youth stated staff are
respectful when talking to them and other youth. Five youth stated they had never heard staff
use profanity when talking to youth and four stated hearing staff use profanity occasionally. The
superintendent advised the code of conduct would be reviewed with all staff. Nine youth stated
they had never heard staff threaten youth. Eight youth stated feeling safe at the center and one
youth advised not feeling safe. The superintendent advised the center was aware of the
situation and the issue has been addressed. All nine youth denied ever having contact with staff
on social media.
Nine staff were interviewed. All nine staff could articulate the appropriate response to a youth
requesting to call the Florida Abuse Hotline. Eight staff stated never hearing a co-worker use
profanity when speaking to a youth and one staff stated hearing a co-worker use profanity
occasionally when speaking to a youth. The superintendent advised code of conduct would be
reviewed with all staff. All nine staff denied hearing other staff use threats or intimidation when
interacting with a youth. Five stated working conditions at the center have been fair and four
stated they were very good. The superintendent was interviewed and advised all staff are to
maintain professionalism when interacting with the youth. Staff are to maintain confidentiality
and not release any information to the public or news media about youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 53 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
There were 108 incidents reported to the Department’s Central Communications Center (CCC)
within the annual compliance review period. Ten incidents were reviewed, and all were reported
to the CCC within two hours of the center becoming aware of the incident. A review of the
logbooks revealed nine of ten incidents were documented, one did not require logbook
documentation. A review of nine youth records and logbooks did not indicate additional
incidents which needed to be reported to the CCC. The superintendent explained the center’s
incident reporting process to the CCC/Florida Abuse Hotline. Any reportable incidents shall be
reported to the CCC within two hours of the reporting staff becoming aware of the incident.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center had forty-two Right Interaction (RI) incidents reported since the last annual
compliance review. Nine RI incident reports were reviewed and showed the report was
completed by the end of the staff’s workday in all nine reports. All nine reports included
statements from all staff involved. Only one report resulted in injury to a staff and the
Department’s Central Communications Center (CCC) was contacted within two hours of the
incident. The staff went for medical treatment outside of work hours. None of the youth alleged
abuse. The RI Report was reviewed by a supervisor in all nine incident reports. A post-RI
interview was conducted with the youth by the administrator, or designee, as soon as possible,
but no longer than thirty minutes after the incident in all nine reports reviewed. None of the
incidents were applicable for a medical review. The superintendent or designee reviewed the
report, after all other reviews and comments were made, if appropriate, within seventy-two
hours in all nine reports reviewed. There were no additional RI incidents noted in internal
incidents, grievances, or logbooks which were not documented by a RI Report. Nine staff were
interviewed, and all confirmed staff try to talk to youth prior to using physical restraints or
mechanical restraints. An interview with the superintendent confirmed RI is only used when
reasonable and necessary to prevent harm to staff or youth. Staff must use verbal de-escalation
before any physical RI techniques are applied. The superintendent also stated restraints are
stored in a secured and designated area and numbered. Restraints are inventoried quarterly by
the superintendent or designee and any damaged restraints are replaced as needed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 53 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
Nine staff training records were reviewed for pre-service training. Five staff were certified
within 180 days of hire, four staff were in the academy at the time of the annual compliance
review. Each of the nine staff completed a new staff orientation within thirty-days of hire. Five
staff completed the pre-service training and four staff were in the academy. None of the nine
staff reviewed were returning direct care staff. All staff completed the required trainings prior to
contact with youth. Five of nine staff had all trainings documented in the Department’s Learning
Management System (SkillPro), the four staff in the academy were not required to have the
training added, since they were still within their first 180 days of hire.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
Training is required for all staff to include annual training and a review of and training on facility
operating procedures. Nine staff training records were reviewed for in-service training. Training
hours ranged from thirty-four to seventy-four hours. All nine staff completed the mandatory
training topics required each year by detention staff. Three supervisory staff were reviewed. All
three supervisory staff completed the required eight hours additional annual training. All
trainings were documented in the Department’s Learning Management System (SkillPro). A
licensed nurse provides in-service education of girls’ healthcare annually to all non-healthcare
staff involved in the supervision or treatment of girls. The center maintains an annual in-service
training calendar, which is updated as changes occur. The superintendent indicated supervisory
training is completed in certified public manager (CPM), leadership development, hiring, de-
escalating emotions, equal employment opportunity, and labor law management.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 53 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center provides youth grievance forms in the living modules which are available to youth at
all times. The superintendent explained the center’s grievance process includes three phases.
During the informal phase, the juvenile justice detention officer (JJDO) will attempt to resolve
the complaint by using verbal skills. If the grievance cannot be resolved in the informal phase, it
will move to the formal phase and youth will be given a grievance form and pencil to submit a
written complaint/grievance. The juvenile justice detention officer supervisor (JJDOS) will
respond to grievances in the formal phase. The JJDOS will enter the grievance into the
Department’s Facility Management System (FMS). The completed grievance form must be
submitted within two hours. The JJDOS will give a response by the end of the shift, if possible,
otherwise within twenty-four hours. The supervisor will document findings on the grievance form
and advise youth of the outcome. The youth have a right to appeal the supervisor’s findings. If
the youth makes an appeal, the superintendent or designee will review the completed grievance
within seventy-two hours and take corrective action when necessary. The superintendent’s
decision is final. Youth will sign a hard copy of grievance form and it will be maintained in a
separate file in FMS. Nine youth were interviewed regarding the center’s grievance process.
Four youth stated they did not know how to write a grievance. The remaining five youth were
able to explain the center’s grievance process. The superintendent was informed of the youth
responses. The superintendent stated staff go over the orientation brochure with all youth during
the admission process. The grievance process is one of the items covered in the orientation
brochure. The youth sign the brochure and a copy is placed in youth’s record. Nine staff were
interviewed, and all were able to articulate the center’s grievance process, including the
difference phases of the process. The center did not have any grievances during the annual
compliance review period, as such, no grievances were able to be reviewed.
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
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 53 (Revised July 2023)
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.
Nine youth records were reviewed for alerts in the Department’s Juvenile Justice Information
System (JJIS). A total of twenty alerts were reviewed for nine youth. All alerts were appropriately
entered into JJIS on the date each was identified. All twenty applicable alerts included the name
and title of the staff entering, removing, or updating the alert. All alerts were documented in the
logbooks or shift report, as required. All the dates were entered on the same date the alert was
identified and matched the internal alert system. The JJIS alerts are reviewed daily by the
supervisors and administration. Information is shared through email, logbooks, and shift
debriefings. The center’s shift briefing minutes were reviewed for identification of youth with
alerts. An interview with the superintendent confirmed the process, which upon completion of
admission, the juvenile justice detention intake officers and medical staff ensure all critical and
special alerts are entered in JJIS after being confirmed with the youth and parent/guardian.
Master control staff update alerts for new intakes. Medical staff will update alerts as needed. If a
youth needs a new or updated alert during their stay, the staff who initiated the alert either
enters or updates it in JJIS and on the alert log. Nine staff were interviewed, and all advised
alert information is shared through logbooks, shift debriefing, meetings, and internal alerts. Nine
staff explained management inform staff about issues at the center though shift briefing and
email. Four staff stated this process for communication is very good, while three staff stated it
was good, and two staff stated it was fair.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has facility operating procedures and practices for utilizing data in decision-making
practices, including the review and analysis of data. The administration utilizes data from
Tableau and SharePoint to share with staff during supervisor meetings, management meetings,
and shift briefings on a monthly basis, at a minimum, which was supported by a review of
meeting minutes. The data is shared with center administrators who disseminate the information
to stakeholders at least quarterly, which was supported by a review of meeting minutes. The
center uses the information to make policy, practice, and programming changes.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 53 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has a facility operating procedure in place to ensure proper screening, evaluation,
and documentation of each youth, ensuring all youth are admitted into the center in accordance
with Florida Administrative Code. A review of nine Admission Wizard forms from the
Department’s Juvenile Justice Information System (JJIS) found documentation of a Detention
Risk Assessment Instrument (DRAI), Suicide Risk Screening Instrument (SRSI), and an arrest
affidavit or order to retain the youth in custody for each youth. Reviewed documentation
confirmed all nine youth had a full body visual search and/or electronic search by a staff of the
same sex. Each youth received a telephone call and were evaluated for medical, mental health,
and substance abuse needs upon admission. All youth were offered a meal, due to admission
being completed two or more hours prior to next scheduled meal. An observation of the youth
admission process was completed during the annual compliance review week, which followed
all required procedures, including offering the youth a telephone call to their parent/guardian.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 53 (Revised July 2023)
The center has a facility operating procedure to ensure each youth admitted into the center is
informed of the center rules and regulations, grievance procedures, visitation, telephone calls,
available medical, mental health, and substance abuse services and how to access them, how
to access the Florida Abuse Hotline or the Department’s Central Communications Center (CCC)
for youth eighteen years of age or older, expectations for behavior, related consequences for
failing to meet behavior expectations, youth rights, and Prison Rape Elimination Act (PREA)-
related information within twenty-four hours of admission. Nine youth case management records
were reviewed, and each included an orientation packet which was completed within twenty-four
hours of admission. Each orientation packet included the required information. Each of the nine
reviewed case management records had an orientation acknowledgement form signed by the
youth. Nine youth were interviewed regarding the orientation process, and all indicated they had
been provided information regarding the center’s rules and regulations, daily schedule,
education services, visitation, abuse reporting, and behavior management system.
Documentation confirmed all interviewed youth signed an acknowledgement form when their
orientation was completed, and the information was relayed during admission. One admission
and orientation was observed during the week of the annual compliance review. The
observation confirmed orientation is conducted as required. The required orientation videotape
detailing PREA guidelines was included in the orientation process.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has a facility operating procedure ensuring all youth admitted into the center are
classified to ensure the highest level of safety and security. The center’s policy listed all the
required considerations, including human trafficking information. All youth are given a room
assignment based on their classification and may be reclassified if there are any changes in the
status or behavior. The center reviews several factors prior to placing the youth into a room
inclusive of height, weight, age, gender, level of aggression, mental illness, intellectual
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disabilities, history of behavior, gang affiliation, criminal history, and history of sexual, security,
and escape risks. Youth classification documents included all required considerations, and each
youth was assigned to a room based on their classification. All room assignments are
documented in the Department’s Juvenile Justice Information System (JJIS). Nine youth case
management records were reviewed for classification. Each reviewed record contained a copy
of the JJIS Admission Wizard, which included the classification results and the screening for
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB). Nine reviewed youth
records contained a classification form which identified the module or room where the youth was
placed. One of the nine youth records notated the youth had a history of committing sexual
offenses or vulnerability to victimization and the youth was assigned a single room, as required.
The superintendent remains informed of how to identify and address local youth gangs by
communicating with gang liaison for the center. An interview with the superintendent confirmed
youth are assigned a room based on their classification and will be reclassified if
behaviors/status changes. Upon identification, the intake staff will inform the superintendent of a
youth’s gang status, which instigates the notification 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.”
The center has a facility operating procedure in place to ensure all information regarding
suspected youth gang affiliation is shared with the circuit gang representative. The center has
designated one juvenile justice detention officer supervisor (JDOS) to serve as the gang
representative for the center. This JDOS communicates with the center’s superintendent who
then corresponds with the chief probation officer (CPO) regarding all suspected gang activity.
The center is required to enter the suspected gang affiliation alert into the Department’s
Juvenile Justice Information System (JJIS) if there is a youth suspected to have gang affiliation.
Staff are notified of all updates and alerts during shift briefings and on a daily alert sheet. An
informal interview with the superintendent confirmed the center’s practice. None of the nine
youth case management records were applicable for gang affiliation. The informal interview with
the center’s gang liaison revealed there had been no suspected gang activity, or newly identified
gang affiliated youth at the center during the annual compliance review period to warrant
communication with the circuit gang representative.
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Office of Accountability and Program Support Page 18 of 53 (Revised July 2023)
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has a facility operating procedure in place ensuring the proper safe handling and
security of personal property, including valuables, which are collected and secured at the time of
a youth’s admission. In the presence of each youth, staff inventory all personal property in the
youth’s possession and record 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. An itemized personal Property Receipt form, containing the youth’s signature
and the staff receiving the property signature, was maintained in all nine reviewed youth
records. A letter of acknowledgment regarding unclaimed property signed by the youth and
included in each of the nine youth records. Personal items, such as clothing and shoes, are
placed in a mesh bag with the itemized inventory and secured in the center’s youth property
room. Valuable items are inventoried and placed in a clear tamper-proof property bag, identified
with the date, the youth’s name, and Department identification number (DJJID). The valuable is
then secured in the locked property cabinet located in the administrative office which is under
video surveillance. The center maintains a secured valuables logbook to document the time,
youth’s name, name of the juvenile justice detention officer (JJDO) securing the property, and
the JJDOs initials. Nine youth case management records were reviewed, and each contained
documentation of a letter of acknowledgement of unclaimed property signed by the youth and
staff. Each record contained a property receipt form documenting the assigned locker for
personal items. An observation of all nine youth personal property bags was conducted and
each contained an inventory form. Three reviewed records contained a Property Receipt form
for valuable items. One admission was observed during the annual compliance review week
and property was inventoried and stored as required. The secured valuables logbook contained
all required elements for the applicable reviewed records. All three applicable youth with
valuable items had their items stored in a clear tamper-proof bag and securely stored in the
administration office. A copy of the actual clear tamper-proof bag with its contents visible is
maintained in the youth’s record. None of the nine reviewed youth refused to sign the Property
Receipt form. A review of the Department’s Central Communications Center (CCC) reports
since the last annual compliance review did not find any incidents regarding the reported loss of
youth property. Nine interviewed youth reported staff checked their inventoried property and
each youth signed the inventory was correct. The superintendent interview confirmed the
center’s property storage practice and verified only JJDO supervisors (JJDOSs) and
administrators have access to the youth property room. The superintendent explained when
property is unclaimed after thirty days, notification of impending Disposal of Property is sent to
the last known address for the youth. If no contact is made, a money order is obtained and sent
to the regional fiscal manager who will forward the money order to Headquarters. Other property
is disposed of, and a record is kept of the disposition of each.
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2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has a facility operating procedure in place to ensure all releases from the center
occur promptly and accurately. Three closed youth case management records were reviewed.
The on-duty juvenile justice detention officer supervisor (JJDOS) verified each youth’s release
by reviewing all related release paperwork, the court order, and youth identification. The JJDOS
completes the verification by signing the secure detention release form. Each of the closed
youth records had the appropriate documentation including a copy of the photo identification of
the person taking custody, youth and parent/guardian notifications to any future court dates, and
all parties signed all required release forms. None of the released youth had an alert reflecting
an endangered person. The release date in the Department’s Juvenile Justice Information
System (JJIS) corresponded with the youth’s correct release date in each reviewed record. Two
youth releases were observed during the annual compliance review week and all required
procedures were followed.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has a facility operating procedure in place to ensure all youth personal property is
released to the youth or the youth’s parent/guardian. The parent/guardian, youth, and staff must
sign a receipt acknowledging all property was returned upon the youth’s release. A review of
three closed youth case management records revealed each youth record contained the
required information with all required signatures of receipt of the youth’s personal property.
Each record contained identification documentation verifying the youth was released to an
appropriate person. One closed youth case management record was applicable for the release
of medications and the record contained the Department’s Medication Receipt form signed by
the youth and person whom the youth was being released to. The one youth record contained
documentation indicating both the youth and person the youth was being released to were
reminded of any health or welfare issues, including medical, mental health, or substance abuse
needs, and any pending appointments. The center keeps and inventory of unclaimed property
held for more than thirty days. An interview with the superintendent confirmed when there is
unclaimed inventory, a notice of impending disposal of property is inventoried, and a record is
kept of any disposed property or unclaimed money, which is given to the regional fiscal
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manager by money order. An observation of a youth release was conducted, and it was
observed the youth received their personal property back and all documentation completed as
required.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains a facility operating procedure ensuring detention reviews are conducted
weekly of youth securely detained, placed on home detention, or placed on electronic
monitoring to ensure proper management of youth and the sharing of information. Detention
reviews are conducted on a weekly basis to address the status of each youth. The center has a
designated staff, who is the detention review specialist, appointed to coordinate the weekly
detention reviews. The detention review specialist reported updates are provided regarding the
youth’s next court date, behavior while in detention, residential placement status, and release
status. Documentation reflects the reviews conducted with the center’s staff included medical,
education, mental health, commitment, and representatives from probation. Each of the staff
attending in-person signed the sign-in sheet. Attendees from outside the center participated
virtually utilizing video conferencing. An interview with the superintendent confirmed detention
reviews are conducted each Thursday where they discuss each youth’s status updates, and
reviews are attended by all required participants. An observation of the detention review was
conducted and confirmed the center’s documented process was followed.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has a facility operating procedure addressing the daily activity schedule. The
center’s daily activity schedule includes daily expectations in accordance with the behavior
management system (BMS), wake up, personal hygiene, education, mealtimes, visitations,
indoor and outdoor recreation, shift changes, bedtimes, groups, and open program time. The
center provides and maintains weekday, weekend, and holiday schedules. Observations during
the annual compliance review week revealed daily schedules were posted throughout the center
along with a monthly activity calendar. Visitations are held twice a week for youth. The youth
participate in education Monday through Friday. Reviewed documentation reflected activities
included behavior management incentives and a variety of recreational activities. A review of
the center’s logbook and annual compliance review team observations confirmed the center
adheres to the daily activity schedule with some variation due to staffing shortages. Nine youth
were interviewed, and each indicated the center has a daily schedule which is followed. Nine
staff were interviewed, and all reported with daily schedule is followed.
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Office of Accountability and Program Support Page 21 of 53 (Revised July 2023)
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has a facility operating procedure to provide educational access. The center
provides education services through the Marion County School Board. The 250-day calendar,
distributed over twelve months, including ten days used for teacher training and planning, was
reviewed. A review of the daily school schedule revealed the center provides eight class periods
daily, four class periods of forty-two minutes and four class periods for thirty-seven minutes,
fulfilling more than the weekly requirement of twenty-five hours of instructional time. A review of
the center’s activity schedule and the educational bell schedule showed a discrepancy at
lunchtime. The center activity schedule has a lunch period from 11:30 a.m. to 12:30 p.m., and
the bell schedule has a lunch period from 12:00 p.m. to 1:00 p.m. A review of the logbook for
each month since the last annual compliance review indicated all classes started on time;
however, it showed classes ended early in September, October, and November 2023, and
March, April, and May 2024. The times ranged from seven to fifteen minutes. The daily bell
schedule has additional time built into the schedule to cover the missed education time. Nine
youth were interviewed and eight reported attending school Monday through Friday. One youth
has a high school equivalency diploma (GED). Nine interviewed staff reported there is minimal
interference with education. The superintendent also noted there was minimal interference. Nine
youth were interviewed and eight reported the program was preparing them very well or well
regarding high school, GED, vocational school, employment, and/or college. One youth reported
the education was not helpful because only one class provides instruction and in the other
classes they watch videos. Observations of the program video for three days indicated classes
started and ended on time as scheduled.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has a facility operating procedure to provide career education. The center offers
Type 1 career education development, which includes career learning strategies such as
interviewing skills and techniques, career interest, and completing employment applications.
The lead teacher was interviewed and indicated every youth in the center is enrolled in a
credited course of careers and personal development. Nine youth were interviewed and
reported taking core classes such as math, science, history, and social studies.
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Office of Accountability and Program Support Page 22 of 53 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a designated mental health clinician authority (DMHCA) who is a licensed
mental health counselor (LMHC) with a clear and active license in the State of Florida with an
expiration date of March 31, 2025. The contract between the Department and the mental health
and substance abuse provider outlines the role of the DMHCA, including the provision for the
DMHCA to be on-site forty hours a week. A review of sign-in sheets confirmed the DMHCA is
on-site at least forty hours a week. The contract requires the DMHCA to ensure the
implementation of mental health and substance abuse services at the center. The back-up
DMHCA is also a LMHC with a clear and active license in the State of Florida with an expiration
date of March 31, 2025. An interview with the DMHCA confirmed their role at the center
includes completing chart reviews and providing supervision and training to licensed and non-
licensed staff. The mental health staff provide intake, suicide screening and prevention, crisis
intervention, and supportive services as needed. Youth enrolled in mental health services are
provided individual and group counseling, treatment planning, substance abuse and mental
health evaluations, and treatment plan reviews as required. The DMHCA and clinical staff
complete weekly treatment team meetings and supervision. All mental health staff meet with the
DMHCA as needed for additional treatment or supervision as needed.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has four licensed mental health and substance abuse staff providing services to the
youth in the center in addition to the designated mental health clinician authority (DMHCA).
Each of the four licensed staff are licensed mental health counselors (LMHCs) with clear and
active licenses in the State of Florida with expiration dates of March 31, 2025. The DMHCA
ensures each licensed therapist is qualified to provide services based on their education,
training, and experience. A review of the mental health and substance abuse provider’s contract
with the Department revealed the center has the required staff in place as outlined in the
contract.
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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 has one non-licensed mental health and substance abuse clinical staff providing
services to youth in the center. The non-licensed staff possess a master’s-level degree in
psychology. The provider’s contract with the Department outlines the provider should only utilize
master’s-level non-licensed clinicians unless approved by the Department’s Office of Health
Services (OHS). The center does not have a Chapter 397 license for the provision of substance
abuse services; therefore, all substance abuse services are provided by the licensed clinical
staff. The non-licensed staff had documentation of training in the facilitation of Assessments of
Suicide Risk (ASRs) in addition to supervised practice to provide ASRs to youth. A review of the
center’s direct supervision log found the non-licensed staff completed direct supervision with the
designated mental health clinician authority (DMHCA) on the weeks the non-licensed therapist
worked due to the position being an as needed position. All supervision was documented on the
required Department form which included all required elements. A review of the non-licensed
staff’s degree, experience, and training verified the DMHCA ensures the non-licensed staff
under their supervision is providing services they are qualified to perform. A review of the
mental health and substance abuse provider’s contract with the Department revealed the center
has the required staff in place as outlined in the contract.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has a facility operating procedure (FOP) which requires all youth to receive a mental
health and substance abuse screening upon admission through completion of a Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2) and Suicide Risk Screening Instrument
(SRSI). Nine youth mental health and substance records were reviewed for an admission
screening and six included documentation a MAYSI-2 and SRSI were completed at intake in the
Department’s Juvenile Justice Information System (JJIS), by trained staff, and reviewed by
detention staff. Three records did not have the SRSI and the MAYSI-2 completed in JJIS due to
Department-wide system outages. The MAYSI-2 and SRSI for each youth included all required
elements. The MAYSI-2 for all nine youth indicated the youth required a referral for a
comprehensive assessment, including two MAYSI-2 screenings marked as invalid. A referral for
a comprehensive assessment with the reason for the referral was found in each youth’s record.
Three of the youth were indicated as a suicide risk on the MAYSI-2 and seven youth were
indicated as a suicide risk on the SRSI. Seven applicable youth were referred for an
Assessment for Suicide Risk (ASR) and placed on precautionary observation. Each of the
referrals documented the superintendent or designee was notified as required.
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Office of Accountability and Program Support Page 24 of 53 (Revised July 2023)
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.
Nine youth mental health and substance abuse records were reviewed for completion of a
mental health and substance abuse comprehensive assessment. Eight youth were at the center
long enough to have a new or updated assessment completed. Two of the eight applicable
youth had community provider comprehensive assessments completed within thirty days of
being detained and the center received and utilized those evaluations. The remaining seven
youth had new or updated assessments completed by the detention provider within the youth’s
first thirty days in detention. In the seven applicable records, treatment recommendations were
made corresponding with all diagnosed mental health and/or substance abuse disorders. In the
two records having an evaluation completed by a community provider, the center was able to
obtain the comprehensive evaluation which contained all required elements including the
signature of the licensed mental health professional.
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.
Nine youth mental health and substance abuse records were reviewed and seven were
applicable for requiring an initial treatment plan while in the center. Two youth did not agree to
services until the completion of the individual treatment plan prior to the youth’s thirtieth day in
detention and one was released prior to beginning treatment. The remaining four had an initial
treatment plan completed and documented on the correct Department form with all required
elements within seven days of the onset of treatment. Each initial treatment plan included the
signature of the youth and mini-treatment team indicating each was involved in the development
of the plan. Six of seven youth were applicable for completion of an individualized treatment
plan. One youth who completed an initial treatment plan was released prior to completion of any
further treatment. The six applicable youth’s individualized treatment plans were documented on
the required Department form with all required elements within thirty days of admission and
completed by the designated mental health clinician authority (DMHCA). The plan was signed
by all required parties apart from the parent/guardian; however, there was documentation center
staff attempted to contact the parent/guardian to develop the plan. Three youth were applicable
for treatment plan reviews and all youth had the required number of reviews completed every
thirty days while in the center. Any modifications documented on the review form were clearly
documented as such and were signed and dated by all required parties except for the
parents/guardians; however, documentation showed the center attempted to include the
parent/guardian to review the plan. Five of the six youth were receiving psychiatric services and
the treatment plan included treatment and services provided by the psychiatrist. A review of
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progress notes indicated each youth received all services as stipulated on their treatment plan.
Three closed youth mental health and substance abuse records were reviewed, and each
included a completed mental health and substance abuse treatment discharge plan. Each plan
was completed on the required Department form with all required elements. There was
documentation each of the three plans were sent to the youth’s juvenile probation officer (JPO).
All documentation practices adhered to facility operating procedures, including completion on
the day of service, signed by the licensed mental health professional (LMHP), and any
additional documentation was uploaded within fourteen days. A mini treatment team was able to
be observed. Any issues identified within charts were addressed with the staff responsible for
providing services to youth. Individual treatment plans are reviewed with any youth within thirty-
days of completion of the previous individualized treatment plan or treatment plan review. Goals
and objectives outlined in the plan are reviewed with the youth and changes are made based on
youth's identified goals and youth progress in treatment.
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.
Nine youth mental health and substance abuse records were reviewed and six were applicable
for requiring mental health and/or substance abuse treatment while at the center. Each youth
was assigned to a mini-treatment team on the day of the development of the initial treatment
plan. Each mini-treatment team was comprised of all required parties apart from the
parent/guardian; however, there was documentation the center attempted to contact each
youth’s parent/guardian. A review of progress notes for each youth confirmed services were
provided as stipulated on the plan and included at least weekly individual, group, or family
therapy. All progress notes were documented on the required Department form. All six
applicable youth required mental health treatment and substance abuse treatment. Each youth
record included a properly executed Authority for Evaluation and Treatment (AET) and a
consent for substance abuse treatment and records release. Each release was documented on
the required Department form. A review of video and sign-in sheets verified groups were being
conducted as scheduled. Mental health staff had adequate access to youth and confidential
space to provide treatment services. A review of records confirmed group therapy was limited to
ten or fewer youth with a mental health diagnosis for mental health treatment groups. There was
no documentation indicating substance abuse groups were occurring. Nine youth were
interviewed and reported the mental health and substance abuse services were good or very
good. The youth believe the services assist them with coping skills and whenever a youth needs
services the mental health staff come to do a session with them. The designated mental health
clinician authority (DMHCA) reported in an interview all youth who are admitted into the facility
with a Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) referral are seen
for completion of the substance abuse and mental health evaluation and individualized
treatment plan on or before each youth's thirtieth day in the center’s custody. Any youth enrolled
into mental health services prior to the thirtieth day are seen for completion of the substance
abuse and mental health evaluation and individualized treatment plan on or before their thirtieth
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day as well. Goals and objectives are identified with the youth and the youth participates in
completion of the treatment plan. Substance abuse services are offered to all youth on or before
their thirtieth day in custody. Youth accepting substance abuse services will review substance
abuse related goals with the counselor. Goals and objectives are identified with the youth and
the youth participates in the completion of the treatment plan.
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 utilizes a psychiatrist through a contract with the mental health and substance abuse
service provider who is a licensed physician and has completed a training program in
psychiatry. The psychiatrist’s license is clear and active in the State of Florida and expires on
January 31, 2026. The center has one back-up psychiatrist whose license expires on March 31,
2026. The center does not utilize a psychiatric advanced practice registered nurse (APRN).
Nine youth mental health and substance abuse records were reviewed and five were applicable
for receiving psychiatric services while in the center. The six applicable youth either entered the
center on psychotropic medications or were identified as needing a referral to see the
psychiatrist and were referred at admission. Each of the six applicable youth received an Initial
Diagnostic Psychiatric Interview within fourteen days of referral which included all required
elements and was documented on the Department’s form. All six youth received an in-depth
psychiatric evaluation which included all required elements. Each youth was applicable for
psychotropic medications and each youth’s medications were documented with all required
information on the Department’s form. All applicable youth records included an Authority for
Evaluation and Treatment (AET) for psychotropic medication. The center’s contract with the
provider was reviewed for tele-psychiatry and the center is permitted to use tele-psychiatry;
however, there was no indication tele-psychiatry was provided to the applicable youth during the
annual compliance review period. According to the designated mental health clinician authority
(DMHCA), mental health services provided at the center include individual or group sessions,
completion of initial treatment plans, individualized treatment plans, treatment plan reviews,
substance abuse and mental health updates, and discharge summaries. All youth requesting
services through a mental health referral are required to be seen within twenty-four hours and
any youth enrolled into mental health services are seen for a minimum of once weekly
counseling sessions in either group or individual format. Youth are also seen for completion of
suicide risk assessments and Crisis Assessments as required.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written plan detailing suicide prevention procedures which includes all required
elements. The center has an established review process for every serious suicide attempt or
self-inflicted injury and a mortality review for a completed suicide. The multidisciplinary review
includes all required elements.
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3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has a Suicide Prevention Plan which includes an established review process for
incidents of serious suicide attempts or self-inflicted injuries. Nine youth mental health and
substance abuse records were reviewed for suicide prevention services and seven youth were
identified upon admission as a suicide risk and placed on precautionary observation (PO). Four
of the seven records had an alert entered into the Department’s Juvenile Justice Information
System (JJIS) timely. Three youth did not have the JJIS alert initiated due to Department-wide
system outages Each youth was placed on PO and supervised as required which was
documented on the Department form with all required elements completed. Reviewed referrals
documented the licensed mental health counselor (LMHC) and the superintendent/designee
were notified of the youth’s suicide risk immediately. An Assessment for Suicide Risk (ASR) was
completed for all seven youth within twenty-four hours of the referral and documented on the
required Department form. Five ASRs were completed by a LMHC and two were completed by
non-licensed staff. All seven were provided supportive services while the youth were on PO. A
conference with the LMHC and superintendent/designee was documented on the ASR prior to
changing the youth’s supervision level. Two youth required a Follow-Up ASR, and one was
completed for each prior to the removal of the youth from PO. The five remaining youth were
stepped down to standard supervision and did not require a Follow-Up ASR or transition to
close supervision which was in accordance with the center’s Suicide Prevention Plan. The
center’s logbooks and the ASRs had supporting evidence administration provided instructions
related to the suicide risk assessment findings and precaution findings for all youth. One
interviewed youth was on suicide watch and stated they were not watched all the time and were
placed in a room for fifteen minutes when staff had to do something else. Administration was
made aware of this. Due to the youth not disclosing when this occurred it was unable to be
investigated further; however, administration reported when a youth is behind closed doors, they
are checked on every ten minutes. Nine staff interviews indicated when a youth is a suicide risk,
they are to notify the designated mental health clinician authority (DMCHA), search the youth
and their room for sharp objects, document supervision, and place the youth on constant sight
and sound supervision. Four of the seven staff indicated they are to place the youth in a locked
room. According to the superintendent, secure observation is only utilized when a youth exhibits
harmful acts towards others or themselves.
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Office of Accountability and Program Support Page 28 of 53 (Revised July 2023)
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
Nine youth mental health and substance abuse records were reviewed for secure observation
incidents. Two of the nine records were applicable and one additional record was provided for a
sample of three youth placed in secure observation. In all three records, each youth’s placement
in secure observation was authorized by the superintendent and designated mental health
clinician authority (DMHCA) and documented in writing. The Health Status Checklist was
completed for all three youth and the Suicide Precaution Observation Log was also completed
in its entirety to include supervision documentation. All three youth were given an Assessment
of Suicide Risk (ASR) within eight hours of their placement and notification of risk of suicide was
provided to the parent/guardian and the juvenile probation officer (JPO). In all three records, a
mental health professional provided supportive counseling services during each youth’s secure
observation status. Each youth’s level of observation was reduced only after a conference with
the superintendent and/or a licensed mental health professional. Discontinuation or step down
from secure observation was documented in the center’s logbook as well as in all three youth’s
mental health records by mental health staff.
3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has a suicide prevention plan which indicates a youth placed on suicide precautions
must be maintained on one-to-one or constant supervision. The staff member 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. Nine youth records were
reviewed and seven were applicable. The Suicide Precaution Observation Logs were
maintained the entire time the youth were on suicide precaution and observations of the youth’s
behavior were documented in real time and did not exceed thirty minutes. Two of the seven
youth had appropriate warning signs documented when warning signs were observed. The logs
were reviewed and signed by the supervisor and mental health clinical staff. The logs
documented safe housing requirements.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has a suicide prevention plan which outlines required staff training and mock drills.
Nine pre-service and nine in-service staff training records were reviewed for suicide prevention
training. Each pre-service and in-service training record reflected the staff completed training in
suicide prevention, as required. The center has nine suicide response kits containing all
required tools maintained throughout the facility in master control, the sub-controls, and each
transport vehicle. Nine staff interviews confirmed the locations of the suicide response kits,
including in the medical office, kitchen, and intake room. The center conducted mock suicide
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Office of Accountability and Program Support Page 29 of 53 (Revised July 2023)
drills on each shift at least quarterly for the annual compliance review period. All mock mental
health drills were in response to a simulated suicide attempt and/or an incident of self-injury.
The center did not utilize any youth in the drill simulations. The program provided semi-annual
training on emergency response procedures including the mock training in emergency response
to a suicide attempt or incident of serious self-inflicted injury. Any staff not present during a
quarterly drill are also afforded the opportunity to review each drill scenario and procedures to
understand the process and receive the necessary training to respond to an incident of a suicide
attempt or serious self-inflicted injury while in the center.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a crisis intervention plan which includes a notification and alert system, means
of referral/self-referral, communication, and supervision. The crisis intervention plan included
documentation and review procedures.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has a combined Emergency Services Plan which includes all required elements and
was last updated on August 18, 2023. The plan was approved and signed by the superintendent
on August 18, 2023, and on September 6, 2023, by the designated mental health clinician
authority (DMHCA). The plan is in the superintendent’s office, break room, and conference
room, and is available to all staff.
3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
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Office of Accountability and Program Support Page 30 of 53 (Revised July 2023)
There was one youth in the center who had a Crisis Assessment during the annual compliance
review period. The youth was determined to be in crisis on July 31, 2024, and the Crisis
Assessment was completed the same day. The reason for the assessment and the Mental
Status Examination and interview were documented along with the determination of danger to
self/others and the initial clinical impressions. The assessment included recommendations for
treatment and follow-up for further evaluations. The alert was not placed in the Department’s
Juvenile Justice Information System (JJIS) due to Department-wide system outages. The youth
was identified by direct care staff as having acute psychological distress and the assessment
was completed by the designated mental health clinician authority (DMHCA).
3.17 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 31 of 53 (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’s designated health authority (DHA) is a board-certified physician who is a licensed
medical doctor (MD) who specializes in family medicine. The DHA’s license is unrestricted,
meets all requirements for practice in the State of Florida, and expires on January 31, 2025. The
center utilizes an advanced practice registered nurse (APRN) who has a collaborative practice
protocol in place which is signed by the DHA and APRN. The APRN license expires April 30,
2026. During the annual compliance review, it was found the DHA has been on-site at least
once a week with no time lapse more than nine days between visits, which is in contractual
compliance. The center does not utilize a physician assistant (PA) or have a backup DHA in
place. No tele-medicine was used during the annual compliance review period. The DHA was
interviewed and stated their role was performing Comprehensive Physical Assessments,
conducting periodic evaluations, sick call, and policy and procedure development. The DHA
stated they communicate with the program staff regarding youth medical needs by telephone or
when they are on-site. If off-site, they are on call twenty-four hours a day, seven days a week
and staff call them with any needs or concerns. Any off-site care findings, instructions, or
information is reviewed by the DHA on a weekly basis.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center utilizes a facility operating procedure (FOP) for all health-related procedures and
protocols. During the annual compliance review period, it was found the designated health
authority (DHA) signed the FOPs August 21, 2024, the superintendent signed on August 26,
2024, and the psychiatrist signed on August 26, 2024 for all respective treatment FOPs. No new
policies or changes had been made during the annual compliance review period. FOPs and
nursing protocols were reviewed annually as required and signed on August 21, 2024. New
employed healthcare personnel received a comprehensive clinical orientation to the
Department’s healthcare policies and procedures, which was conducted by a registered nurse
(RN). Nursing staff reviewed, signed, and dated a cover page on August 21, 2024 and August
26, 2024 for all medical FOPs, treatment protocols, and other procedures.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for Authority of Evaluation
and Treatment (AET) requirements. Eight of nine IHCRs included an AET obtained prior to
providing medical services. Each of the eight applicable youth’s AETs were originals and filed in
the youth’s IHCR. Each applicable AET was signed by a Department representative. The center
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Office of Accountability and Program Support Page 32 of 53 (Revised July 2023)
had no youth applicable for being eighteen years of age or older. One of the nine records
included a court order authorizing treatment as the youth was in the custody of the Department
of Children and Families (DCF) at the time of the annual compliance review.
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.
Nine youth Individual Healthcare Records (IHCR) were reviewed for parental/guardian
notification/consent requirements. Five out of nine youth were found to have parental/guardian
notification for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). Verbal consent was obtained from the parent/guardian for all
medications outside what was covered by the AET and documented with a second witness in
the IHCR. Written notifications were sent utilizing the Department’s Parental Notifications of
Health Related Care: General Parental Notification or Medication forms. Four of the nine youth
were taking psychotropic medications on admission. All four youth had medications which were
prescribed, discontinued, or had a significant change in the dosage. Written notification was
sent on all four youth regardless of the telephone notifications, with two witnesses documented
on the Clinical Psychotropic Progress Note (CPPN) page three. One youth was in the
Department of Children and Families (DCF) care with a pending court order for a new
medication prescribed during the annual compliance review. All nine youth’s vaccines were
verified within thirty days of each youth’s admission with no additional vaccines needed. None of
the nine youth required a “Religious Exemption from Immunization” as all nine youth AETs gave
consent for any necessary vaccinations. The nurse was interviewed and reported the nursing
staff obtain immunization records through the Florida Shots website.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for healthcare admission
screening requirements. All youth received a medical and mental health admission screening
completed on the Department’s Facility Entry Physical Health Screening (FEPHS) form on the
date of admission by the juvenile justice detention officer (JJDO) with the screening reviewed
with the youth by a licensed nurse within twenty-four hours. Notification was made to the
designated health authority (DHA) for all nine youth and documented in the youth’s IHCR. One
out of nine had a change in physical custody and the youth was rescreened for healthcare at
time of readmission by the JJDO and the screening was reviewed by a licensed practical nurse
(LPN) within twenty-four hours. Three out of nine youth were applicable for and received a
qualitative urine pregnancy screening test and written consent was obtained by each youth prior
to testing. Results were found in each youth’s IHCR. The nurse was interviewed and reported
detention will do another intake packet and nursing will do a full admission if the youth is new. If
the youth is on a stop-hold, detention does the intake and medical sees the youth within twenty-
four hours. If the youth transfer back to the center, detention staff will see the youth first and
medical will complete a note on the youth.
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Office of Accountability and Program Support Page 33 of 53 (Revised July 2023)
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for youth orientation to
healthcare services and health education. The center’s has a facility operating procedure which
included access to medical care, sick call access, what constitutes an “emergency” and when to
notify staff, medication process to include side effect monitoring, the right to refuse care and
how it is documented, what to do in the case of a sexual assault or attempted sexual assault,
the non-disciplinary role of the healthcare provider, and the review of the list of healthcare
contacts to ensure accuracy. All nine youth received a general healthcare orientation within
twenty-four hours of admission and was documented on the Health Education 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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for notification requirements
to the designated health authority (DHA). Five of the nine youth were admitted with known or
suspected chronic conditions and a referral was made to the DHA within twelve hours. No youth
were identified as in-need of emergency care upon admission. The notifications to the DHA of
all five youth were documented in each youth’s IHCR in the chronological progress notes. Four
of the nine youth were taking psychotropic medications upon admission. The psychiatrist was
also notified within twelve hours of admission for each youth and the notification was
documented in the chronological progress notes section in each youth’s IHCR. The nursing staff
interview stated the DHA is notified within twenty-four hours of admission, as well as the
psychiatrist, if the youth are admitted on any psychotropic medications.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for Health-Related History
(HRH) forms. All nine youth’s HRH forms were updated or completed within seven calendar
days of admission. The HRH form was completed prior to the Comprehensive Physical
Assessment (CPA) or focused evaluation by evidence of a signature and date by a licensed
nurse. The designated health authority (DHA) or advanced practice registered nurse (APRN)
reviewed each HRH for all nine youth by documenting their review on the HRH with a date and
signature. Nursing interviews were conducted, and the licensed nurse stated the HRH is
completed or reviewed by the nursing staff with the youth no later than seven days from
admission.
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Office of Accountability and Program Support Page 34 of 53 (Revised July 2023)
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for the Comprehensive
Physical Assessment (CPA) and Tuberculosis (TB) screening requirements. Each of the nine
youth’s CPAs were completed on the Department form. Five out of the nine youth had a current
CPA on file at the time of admission. Four out of nine youth did not have a CPA on file at the
time of admission. A CPA was completed for the four youth within seven calendar days of
admission. Two of the nine youth CPAs were conducted by the designated health authority
(DHA). Seven of the nine youth CPAs were conducted by the advanced practice registered
nurse (APRN). The correct Medical Grade was listed on seven of the nine CPAs with no missing
or incomplete elements noted. One CPA was listed as a Medical Grade one and it should have
been a Medical Grade two due to the youth having a chronic condition listed on their CPA. The
other incorrect CPA should have been a Medical Grade four due to pregnancy. Each of the nine
reviewed CPAs were current with no changes in the youth’s medical condition. The current CPA
was reviewed by the DHA or APRN and signed off on within seven days of admission. Eight of
nine sections of the CPA were marked with either an “O” or an “X” with any “X” documenting in
further detail in the comment section to elaborate on the abnormality. One of the nine had slash
marks instead of “X”s or “O”s. All nine youth refused a portion of the exam; however, the refusal
was written as “deferred” instead of “youth refused”. The Department’s Office of Health Services
noted this on their recent review and the issue has been corrected on new admissions. Each of
nine refusals were documented in the chronological progress notes which was signed by the
youth, a licensed nurse, and the DHA or APRN. Six applicable youth’s problem lists were
updated to reflect any current issues and dated as resolved if appropriate. All nine CPAs had a
current Tuberculosis Skin Test (TST) documented in the IHCR which were administered within
the last year. The results of all nine youth were found documented on the Infectious and
Communicable Disease forms which matched their results documented on the CPA. None of
the nine youth required further evaluation or transportation for hospitalization. Nursing staff
were interviewed and reported Tuberculosis must be tested for every year.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Nine youth Individual Healthcare Records (IHCR) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. All nine
records stated the youth were sexually active and were screened for STIs. Further evaluation
was required for three youth and the referral was documented on the STI form. Two of the three
youth requested to be tested and testing was ordered and conducted within seven days of
admission. The results were documented on the Infectious Communicable Diseases (ICD) form
and filed in the lab section of the IHCR. None of the nine youth received a gynecological exam
and one youth was out of the Department’s physical custody and received a rescreen. All nine
youth were offered counseling and testing for HIV. Three out of nine youth were tested for HIV
and documented consent was obtained for those youth. The HIV test results were filed in a
sealed envelope marked “Confidential” consistent with Administrative Rule. The designated
health authority (DHA) did not sign the envelope but did comment in the youth’s chronological
progress notes they had been telephoned by a licensed nurse with the results. Documentation
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Office of Accountability and Program Support Page 35 of 53 (Revised July 2023)
of pre-test and post-test counseling was documented on the IHCR for all three youth in the
progress notes. The youth’s status of the HIV results were protected by not including the results
on the program’s internal alert system. Eight out of the nine interviewed youth stated they are
able to request an HIV test if they have the desire. One youth stated in the interview they
requested to be HIV tested and were not. A review of this youth’s record showed the youth had
been tested and the results were filed in the youth’s chart as required.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for sick call process
requirements. Three out of nine youth received sick call services. All three youth’s sick calls
were documented on the Sick Call Referral Log. None of the three youth presented with a
similar sick call complaint three or more times within a two-week period; therefore, no referral
was needed to the designated health authority (DHA). All three youth completed a sick call on
the Sick Call Request form and only nursing staff completed the Sick Call Request form. One
out of the three youth’s sick calls were conducted by a licensed practical nurse (LPN) and was
reviewed by a registered nurse (RN) the same day of each sick call. All three youth’s sick calls
were filed in the youth’s IHCR in reverse chronological order. None of the reviewed youth were
in restricted housing during sick call hours. All three sick call forms were documented in
accordance with Florida Administrative Code. All three of the youth’s sick calls were
documented on the Sick Call Index and kept in each IHCR with the dates listed on the sick call
forms matching the dates of the Sick Call Index. Sick call processes and dates/times are posted
visible for the youth and staff. The RN was interviewed and noted sick calls hours are seven
days a week from 10:00 a.m. until 11:00 a.m. and 3:00 p.m. until 4:00 p.m. These hours are
posted in medical at the medication window and also on the youth modules. There are approved
treatment protocols for both RNs and LPNs to utilize. Only licensed nurses complete sick calls.
When there is not a licensed nurse on-site the center has procedures whereby the shift
supervisor reviews all the sick call requests as soon as possible and within four hours after the
request is submitted and notifies the DHA. The center has a policy for room
restrictions/confinements in which youth in restricted housing shall be afforded access to
healthcare at equal or greater intervals of youth who are in regular housing. No observations of
a sick call were conducted due to no youth placing a sick call in during the annual compliance
review week. The nurse reported sick call is conducted twice daily. The sick calls are completed
by a RN or LPN. If the LPN completes the sick call it is reviewed by a RN. If a youth complains
of the same issue three times, the youth must be referred to the provider. Six out of nine
interviewed youth stated they are seen immediately when they request a sick call and three out
of nine stated they are seen within one day. Each of the nine youth stated the nurses conduct
sick call. Nine staff were interviewed and stated the nurse reviews and conducts the sick calls.
One staff stated medical/supervisors review sicks calls and conduct sick calls.
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Office of Accountability and Program Support Page 36 of 53 (Revised July 2023)
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for episodic/first
aid/emergency care requirements. Three out of nine youth required on-site first-aid or episodic
care. All three youth received episodic or first-aid care by a licensed healthcare staff which was
documented in subjective, objective, assessment, and plan (SOAP) format. None of the youth
received episodic or first-aid care by a non-healthcare staff. All three youth complaints were
documented with findings of the person rendering care included. One youth required a referral
to off-site care. Education/instructions were documented for all three youth. A plan for follow-up
care was found one of three youth’s progress notes with one youth requiring follow-up care by
the designated health authority (DHA) and was seen within seven days. One out of three youth
required to be placed on the alert list and was found on the alert roster. Parental/guardian
notification was made and documented for the one youth who received off-site care. All three
youth’s episodic/first-aid care was documented on the Episodic/First-Aid Care Log. Only one of
the three youth required plans for follow-up care. The center has a total of sixteen first-aid kits
located throughout program areas and accessible to staff in the event of an emergency. A first-
aid kit is available for each of the seven transport vehicles. The first-aid kits included an
approved list of items present which were documented on each kit. Three kits were opened and
examined. All three had contents within their date of expiration. First-aid kits are inventoried
monthly by the medical staff. Reviews the inventories were conducted and documented on the
monthly first-aid kit and automated external defibrillator (AED) logs. The center has a total of
two AED units with one located in the conference room and the other in sub-control. Both are
inspected monthly by medical staff and a log is kept documenting any findings or discrepancies
fixed with dates of pads changed and batteries changed. The batteries and pads of the device
were observed within their date of expiration. A licensed medical staff was observed performing
an inspection of the AED during the annual compliance review week. The device was operating
as required. Emergency drills have been conducted every month on each shift and were
unannounced in which a simulated episodic care event took place. Five out of the twelve
months a “man down” drill was conducted in which cardiopulmonary resuscitation (CPR) was
rendered and the use of the AED was conducted to show proper techniques were being used.
Documentation of all drills was kept in the medical office and reviewed. A list of emergency
numbers was found accessible to licensed and unlicensed staff which included the number to
the Poison Information Center. The numbers were not accessible to any youth. All authorized
direct care staff were appropriately trained by a registered nurse on the administration of an
epinephrine auto-injector. Nine staff records were reviewed which showed training requirements
were met regarding episodic care, first-aid, and emergency care. The policy on the use of
NARCAN states for the emergency treatment of a known or suspected opioid overdose
emergency with signs of breathing problems and severe sleepiness or not being able to
respond. There is a process in place for supervisors to access the stock Naloxone Nasal Spray
kit when there is no medical staff in the facility as is with the epinephrine auto-injector. The
center stores NARCAN in their medication cart, which is accessible to the registered nurse,
licensed practical nurse, superintendent, assistant superintendents, and sergeant. Each staff
with access to NARCAN has been trained on when and how to use it and it is inventoried by a
licensed nurse weekly. Four of the nine interviewed youth stated they would rate the medical
care at this center as good, with the other five youth rating it very good. Each of the nine
interviewed staff stated they are able to call 9-1-1 if they feel it was necessary. Nursing staff
indicated on-site episodic care is recorded in an episodic note. If a non-healthcare staff deals
with an episodic episode, the officers make note on the report of On-Site Healthcare by Non-
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Healthcare Staff form. Off-site logs and providers logs are completed when youth are sent off-
site for care. The DHA and nursing staff follow-up with the provider when the youth returns.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for completion requirements
concerning off-site care and referrals. One out of nine youth required off-site care in which the
Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR. The off-
site care was also documented on the Episodic Care Log. Parental/guardian notifications were
made for the youth and documented in the IHCR. Discharge documents were filed in the youth’s
IHCR, and the designated health authority (DHA) reviewed the discharge instructions, findings,
and care rendered within seven days from the incidents by evidence of signature and date.
Documentation the DHA was notified was found for the youth in their IHCR in the chronological
progress notes section with the date and time the DHA was notified of the event. The youth
required follow-up appointments and the referrals were entered on the center’s referral tracking
log. After review, it was found the youth received appropriate and timely follow-up care. Nursing
staff indicated a daily call and note are made on a youth if they are sent out for an emergency.
The note will be on an incidental progress note. All hospital orders will be relayed to the provider
by telephone if they are not on-site and copies will be given on the next scheduled day the
provider is on-site. The orders provided by the DHA are provided to medical staff and will be
followed. The youth also follows-up with the provider on the next scheduled day. The center has
logs for testing, electronic referrals, and appointments are kept on a calendar with a note in the
youth’s IHCR.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for chronic conditions/periodic
evaluation requirements. Five youth were identified on the Facility Entry Physical Health
Screening (FEPHS) forms for having a chronic condition. None of the nine reviewed youth had a
communicable disease. Five of the nine youth were taking prescribed medications on an on-
going basis. Five of the nine youth were classified with a Medical Grade of two to four. One
youth was identified as pregnant. The one pregnant youth was evaluated every two to four
weeks for the time during their stay. At the time of the annual compliance review, only one youth
was applicable for having a periodic evaluation which was documented and found in the
progress notes section with proof the review was conducted prior to renewing a prescription
medication. None of the youth were identified as taking anti-tuberculosis medication. One youth
required an evaluation by off-site care which was documented on the Summary of Off-Site Care
form and filed in the youth’s IHCR. The Department’s Problem List was updated in accordance
with Florida Administrative Code for each applicable youth. The designated health authority
(DHA) was interviewed and stated all youth with chronic conditions are seen for evaluations
every ninety days or sooner if needed. Inside the medical clinic, the center’s chronic care board
is maintained by the registered nurse to determine when the youth is due for periodic
evaluations.
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4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for medication management
requirements. Five of the nine youth were taking medication at admission and the medication
was verified prior to being admitted into the center. Prescription verifications for all five youth
were completed utilizing the Prescription Mediation Verification Checklist form. One youth’s
parent/guardian stated the youth was on medications but was not able to bring the medications
up to the facility. The physician and psychiatrist were notified and an order to continue the
medications was ordered. For the four youth who entered on psychotropic medications, the
psychiatrist was notified within twelve hours of admission and an order was obtained to continue
the current prescribed medication documented on a practitioner order form. All five youth’s
medications were verified on the Medication Receipt Transfer Disposition form inside each
reviewed IHCR. None of the nine reviewed youth were in restricted housing during medication
administration hours. None of the nine youth were given over-the-counter (OTC) medications
which were not listed on the Authority for Evaluation and Treatment (AET) form. Each of the
nine youth utilized a standard Department Medication Administration Record (MAR) in the
Electronic Medical Record (EMR). All nine of the youth’s MARs clearly indicated medication
start and stop dates. None of the nine youth received a medication by a trained non-healthcare
staff after hours when a licensed staff was not on-site. No lapses or errors in medication
administration was noted. Side effect monitoring and the six rights of medication administration
were followed. Nursing staff did document side effect monitoring for all nine reviewed youth
weekly. Two of the nine youth refused a medication which was documented by a “R” on the
MAR with the youth’s initials found under the “R” indicating refusal. Both refusal forms were
found in the youth’s IHCRs indicating the date of the refusal, medication refused, reason for
refusal, the youth’s signature, date, and staff signature with date. Each of the nine youth’s
MARs contained all required elements to include the youth’s name, the Department
identification number (DJJID, date of birth, youth allergies, precautions, Medical Grade, medical
alerts, and a current picture of the youth. All nine MARs documented the licensed staff assisted
in medication administration and each instance was found to have the staff initials and youth
initials for each medication given. None of the nine youth required parenteral medication. Four
of the nine youth entered on psychotropic medications and for each youth, the psychiatrist
conducted an initial diagnostic psychiatric interview with the youth within fourteen days of
admission. Each youth received medication monitoring by the psychiatrist every thirty days as
required. The center’s medical department reported there are no standing orders, pro re nata, or
emergency treatment orders for psychotropic medications. A medication pass was observed.
Medication administration was completed by the licensed medical staff. Youth were escorted to
medical by the juvenile justice detention officer (JJDO). The youth approached the nurses
station individually. The medical provider identified themselves and prepared the medications
for each youth as prescribed. The allergy and alert status were verified on the MAR. Each youth
initialed for their medication after receiving it and the licensed staff indicated they have given the
medication. The six rights of medication were done. The nursing staff indicated they verify
medication with the parents/guardians and pharmacy for the youth. Detention staff can accept
medications if the bottle has a fill date no longer than a month prior. The detention staff provide
the parents/guardians with a medication receipt and the medications are brought to medical.
The MARs used at the center are the Department’s form. Training is provided on use of the
MAR forms and officer protocols. Nine interviewed staff indicated they do not give medications
to youth. Two out of nine interviewed youth stated the nurse administers medications and seven
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stated they do not take medications. The disposal process indicates a registered nurse (RN)
shall be responsible for the disposal of medications in conjunction with the pharmacy consultant.
Controlled and non-controlled medications for disposal shall be inventoried prior to disposal and
disposed in the presence of the pharmacy consultant. Medications are disposed using the
approved Drug Buster disposal system.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The medical office was found to be neat, clean, organized, and inaccessible to youth in the area
where sharps and medications were maintained. Medical equipment classified as sharps were
found secured and inventoried utilizing a routine perpetual inventory descending count as each
sharp was utilized or disposed of in the medical clinic. A sample of three sharps was reviewed
and counts of the items matched the ending inventory numbers. All medications were identified
and secured in the locked area designated for storage of medications inside the medical office.
The medication cart was found to be clean and organized with stock items separate from youth-
specific medications. All medications were stored in a separate, secured area, inaccessible to
youth. Narcotics and other controlled medications were stored behind two locks. No oral
medications were stored with topical medications. Medications requiring refrigeration were
found inside a secured refrigerator labeled “Medication Only”. For youth on controlled
medications, a perpetual shift-to-shift inventory count was conducted and documented on the
youth’s individualized Controlled Medication Inventory Record. Non-healthcare staff were
trained in the delivery and oversight of medication self-administration for when nursing staff are
not on-site. This training was delivered by a registered nurse. Three controlled medications
were reviewed with no discrepancies and counts matched ending counts. Three over-the-
counter (OTC) medication samples were reviewed with no discrepancies and counts matched
ending counts. Perpetual weekly inventories of all sharps and OTC medications were observed.
Observations of inventories confirmed the center’s medical staff conduct inventories of
medications and sharps as required. The procedure for reporting inventory discrepancies states
any medication inventory discrepancy shall require notification to the Department’s Central
Communications Center (CCC), completion of an internal investigation, and root cause analysis
utilizing a medication error report shall be maintained. The center has a written policy and
procedures concerning the disposal process for medications. The disposal process indicates a
registered nurse (RN) shall be responsible for the disposal of medications in conjunction with
the pharmacy consultant. Controlled and non-controlled medications for disposal shall be
inventoried prior to disposal and disposed in the presence of the pharmacy consultant. Non-
controlled medications are disposed using the approved Drug Buster disposal system. The
nurse was interviewed about medication disposal and reported the procedure is for two nurses
to dispose of a medication with the pharmacist.
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4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for infection control, exposure
control, and education requirements. All nine of the reviewed youth received infection control
training on admission to include hand-washing techniques, universal/standard precautions,
prevention/transmission of communicable disease, vaccinations, and the Center for Disease
Control and Prevention (CDC) guidelines for infection control. The Exposure Control Plan was
written in accordance with Occupational Safety and Health Administration (OSHA) standards
and included a risk assessment listing job classifications in which staff have the potential for
occupational exposure, including tasks and procedures which would cause staff in specific job
classifications to have an occupational exposure. A method of compliance outlining infection
control practices and engineering and work practice controls was also found in the plan.
Infection control procedures in place included prevention, containment, treatment, and reporting
requirements related to infectious diseases, according to OSHA and the CDC guidelines.
Infection control procedures included all required elements such as common infectious diseases
of childhood, the common cold, viral or bacterial infections, Hepatitis A, B, and C, human
immunodeficiency virus (HIV), pediculosis, food-borne illnesses, chemical exposure, bio-terrorist
agents, and Methicillin-Resistant Staphylococcus Aureus (MRSA). Tuberculosis (TB) was not
specified in the plan itself; however, was included in the center’s facility operating procedures
(FOPs) for the admission process, to include screening for TB and exposure control. The
inflection control plan includes processes for needle stick post-exposure evaluation. No
Hepatitis B immunizations are made available for staff. All staff have access to protective
equipment. The registered nurse stated there have been no instances in which infectious
diseases and sexually transmitted infections needed to be reported to the local health
department as required or the Department’s Central Communications Center (CCC). There
were also no hospitalizations or quarantine of at least ten percent of the total population for
youth or staff. The superintendent was interviewed and reported the center maintains a
separate file containing all documents for youth and staff who have experienced
facility/occupational exposure for ten years as required. All staff received pre-service or in-
service training on the center’s specific Exposure Control Plan by the clinic manager as noted in
the nursing interview results and found in the staff’s training records.
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.
One out of nine reviewed youth was identified as pregnant at the center at the time of the
annual compliance review. The center had no other youth applicable during the annual
compliance review period. The youth received prenatal care immediately upon determination
the youth was pregnant at admission. The designated health authority (DHA) was notified upon
admission and a medical evaluation was completed within seven days of admission. Prenatal
care was provided at recommended intervals. The youth was placed on the internal alert system
for vital nutrition and health awareness for staff along with an alert in the Department’s Juvenile
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Justice Information System (JJIS) to include the youth’s sleeping arrangements for two
mattresses and pillows for support. The youth had no complaints or issues during their stay.
There was documentation daily monitoring was being conducted by a licensed staff for danger
signs of pregnancy and complications. Education to the youth was found in the youth’s
Individual Healthcare Record (IHCR) under the education tab which included a plan for post-
birth psychological and physical care, alcohol and drug use, smoking, nutrition, sexually
transmitted infections, contraception, prenatal care, birthing process, postpartum care, basic
baby care, child/infant development, and parenting skills which was conducted by a licensed
staff. The youth received nutritious food and appropriate servings as ordered by the DHA. A
review of in-service training was found to include observation and monitoring of emergency care
needs/symptoms for possible miscarriage and has nursing protocols and treatment in place for
pregnant youth. All required staff completed pre-service training in the supervision and
treatment of pregnant youth. The nurse confirmed center medical staff provide special diets,
outside obstetrics services, on-site provider services, education, and monitoring. Each female
youth is screened for pregnancy during intake. Pregnant youth have routine visits with a
provider and these increase during the length of the pregnancy. Urine screens and vitals are
obtained during the pregnancy. The clinic manager provides training for non-medical staff for
pregnant youth in the center. Education topics provided to pregnant youth include diet, sleeping,
vitamins, restrictions, and emergencies. One out of nine interviewed youth stated they had
received prenatal, obstetrical, or gynecological services at the center. Eight of the nine
interviewed youth stated they did not need these services.
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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.
Observations of youth supervision were completed during the annual compliance review week,
with no exceptions noted. Staff were aware of the location of all youth assigned to their
supervision, as reflected by their correct answers when asked by the monitors. Observations
also confirmed staff supervise youth during movements from one location to another in
accordance with Florida Administrative Code, and staff are properly positioned with youth in
their line of sight. Master control authorizes all movement of youth prior to the actual movement,
and no movement occurs until cleared by master control. This practice is documented in the
center logbook. All youth were accounted for and accompanied by staff at all times, and the
interactions between youth and staff demonstrated active supervision. Observations made
during the annual compliance review week included daily activities such as school/education,
recreation, meals, breaks, searches, census counts, and youth to staff interactions. Positive
interactions were consistently observed between youth and staff. Nine staff were interviewed
and six reported they believe the center has enough staff to provide for the safety and security
of the youth and staff. Three staff stated no, there are not enough staff. Five also reported the
center could use more staff, there are enough staff the majority of the time, however, it depends
on call-outs. Another staff reported some days there are enough staff and some days there
aren’t enough. Other staff reported the staffing could be better and the center has a lot of youth,
and more staff need to be hired.
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.
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The center has a facility operating procedure (FOP) in place to address the behavior
management system (BMS), a system of rewards, privileges, and consequences to encourage
youth to fulfill the program’s expectations. The center maintains a BMS implemented to meet
the needs of the youth and the center. The BMS is approved by the regional director and
includes rewards for positive behavior and consequences for inappropriate behavior. The
behavioral norms and expectations for youth are posted in all living units and clearly specify
appropriate and inappropriate behaviors. Daily activities were observed to determine
implementation of the BMS by staff. A review of supporting documentation confirmed positive
rewards are given to youth to match the BMS incentive calendar and are given in accordance
with the BMS. Reviewed documentation showed there were no instances of inappropriate use of
restrictions or group punishment. Nine staff were interviewed regarding the BMS. Seven of the
nine staff stated it is a level system, six stated it is a points system, and individual staff reported
the BMS is based on the youth's behavior. Staff reported it is firm, fair, and consistent. Nine
staff reported the center's BMS is effective, staff speak with youth to discuss consequences,
youth are given an opportunity to explain their behavior, and staff speak with youth about
alternative acceptable behaviors. The interviewed staff gave examples of rewards given to
youth at the center as canteen, movie nights, slushies, telephone calls, game room access, and
special visitation. Staff reported supervisors provide feedback regarding the implementation of
the BMS through briefings, coaching, and in real time as needed. Seven of nine staff stated
supervisors give feedback on the implementation of BMS as needed and two staff reported
supervisors provide feedback daily. Six staff reported the youth’s level can be dropped and
three staff said nothing can be taken from youth as a consequence. None of the nine
interviewed staff reported seeing a co-worker take meals, snacks, clothing, education, or
medical care from a youth because they were acting out and none have observed any staff
encouraging youth to beat up another youth.
Nine youth were interviewed. Two youth said the BMS is very good, six said good, and one
stated the BMS is fair. All nine youth were familiar with or had been explained the BMS. The
youth listed canteen, ice cream, movie nights, extra telephone calls, and special visitation as
rewards. Eight of nine youth reported all staff use the rewards the same, with one youth saying
they are new and did not know. One of nine youth stated they have been sent to their room for
punishment; however, they also reported they were in a fight. Two of the nine youth said the
consequences received at the center were fair, two said they were not fair, and five youth said
they have never received consequences. None of the youth reported consequences including a
removal of meals, snacks, points, level, sleep, clothing, bedding, medical care, or education.
Youth were asked if handcuffs or leg irons are used on out of control youth to prevent them from
hurting themselves or others, six youth stated the center does not do this, and three said they
have never witnessed it.
The superintendent reported the center’s level system is used to track youth behavior. There
are three levels and all youth enter the center on a two-point-one level. Their behavior
determines if the level moves up or down. The higher level the youth becomes, they can earn
incentives. Level one is a restrictive level. Youth on level one have exhibited major behavioral
problems and/or received confinement. Level one youth are ineligible for incentives, level two
can earn regular incentives, and level three are eligible for special incentives.
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5.03 Ten-Minute Checks (Critical) Limited 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 eighty-eight cameras, and all were operational during the annual compliance
review week. The center has the capacity to store video recordings for up to thirty days. A
sample of three days of security footage and corresponding electronic wand logs, and twelve
additional days of electronic wand logs were reviewed to verify ten-minute checks were
conducted. The review of video footage revealed thirteen of eighteen checks, from three
separate units, were not done within the required ten minutes. In one check, there was no
observation of half of the dorm for thirty-seven minutes. The remaining time gaps ranged from
one minute to seventeen minutes late. During the annual compliance review week,
documentation of progressive discipline for the staff was presented to the annual compliance
review team for the staff not completing checks correctly. Additionally, the assistant
superintendent showed the annual compliance review team previous discipline given as a result
of camera reviews done frequently by the center administration. Nine staff were interviewed,
eight of the nine staff said checks are required every ten minutes, and one staff said contraband
checks are completed every shift. The superintendent stated when youth are placed in their
rooms, ten minutes checks are conducted in real time, and electronic wands are used to
document room checks during shift change, bedtime, and showers.
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).
During the annual compliance review week, observations of counts being conducted were made
while youth were in the classrooms, medical clinic, to and from intake for youth transport, and
during regular scheduled movements. In all observations, counts were conducted according to
policy, including when a count could not be reconciled over the radio. The master control
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operators and assistant superintendent worked together to do an in-person count which verified
all youth were accounted for. A sample of logbooks for twelve months, including one full day
each month, was reviewed for the annual compliance review period, with no exceptions found.
The review revealed census counts were conducted, at a minimum, at the beginning and end of
each shift. In addition, census counts were conducted prior to and following routine movement,
following any emergency or drill, anytime a population change occurs, randomly during each
shift, and formal head counts.
Nine staff were interviewed, and each was familiar with the regularity of the center’s census
counts, to include the beginning, middle, and end of the shift. Each staff confirmed the
supervisor will complete a physical headcount if the census cannot be rectified over the radio.
Six staff reported emergency counts are conducted when a youth is believed to be missing, five
stated after drills, codes, and escapes, and three said after a major disturbance.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
A sample of logbooks for twelve months was reviewed for the annual compliance review period,
with no exceptions noted. The center maintains separate logbooks in master control, each living
area, visitors, and each vehicle. Logbooks were observed to be bound with numbered pages
and the date documented at the top of the page. Each observed entry included the time of
events in a.m. and p.m., with the name of the staff and youth involved. In addition, logbook
entries included a brief description of the events, along with the initials of the staff making the
entries. Logbook entries impacting the safety and security of the center, including medical,
special needs, and mental health alerts, were observed to be highlighted. Any errors were
struck through with a single line and “void” was written after the error, followed by the staff’s
initials. In addition, the juvenile justice detention officer supervisor (JJDOS) and/or lead officer
recorded comments regarding the corrected errors. The center does not utilize an electronic
logbook. The reviewed logbooks documented the JJDOS reviewed the master control logbook
when accepting responsibility for the center and reviewed the living area logbooks daily. In
addition, the juvenile justice detention officers (JJDOs) reviewed logbook entries from the
previous shift when accepting responsibility for the living area. Logbook reviews were observed
to designate the name and position of the reviewer along with the date and time the review was
completed. The review of the master control logbook revealed the center documented
emergency situations, drills, incidents including the use of Right Interactions, and reports to the
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Florida Abuse Hotline and the Department’s Central Communications Center. In addition,
documentation of receipt of medical/mental health alerts, population counts at the beginning and
end of each shift, population counts throughout shifts as counts change, and population counts
following emergency situations were included. Logbook documentation also included youth
group movement, admissions and releases, presence of law enforcement, names of youth
placed in confinement with the time of when confinement began and ended, and names of youth
placed on precautionary/secure observation along with the time initiated and time ended. A
sample of all types of logbooks for twelve months was reviewed during the annual compliance
review week. The center’s activity schedule and logbook document minimal interference with
educational instruction. A review of the logbook indicated education classes were conducted as
scheduled with youth arriving and departing school on time. The superintendent stated
management’s role in regard to logbooks is to review all logbooks, including master control and
living quarters, daily.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center’s facility operating procedure (FOP) covering key control was reviewed. The center’s
FOP addressed key assignment and usage, including restrictions on usage, inventory, daily
tracking, reconciliation of keys, and secure storage of keys not in use. In addition, the FOPs
addressed procedures for missing or lost keys and the reporting and replacement of damaged
keys. A review of shift reports during the annual compliance review period indicated issuance of
keys and key ring numbers were documented and included the date and time of issue, name of
staff issuing the key ring, name of staff who received the key ring, and time the key ring was
returned. Observations of the key storage area occurred during the annual compliance review
week, which determined emergency key rings were located in the supervisor’s office. Only the
superintendent, supervisors, and maintenance staff have access to emergency keys with all
other keys being located in master control. The key rings examined were on a tamper-resistant
ring, numbered, indicating the number of keys on the ring, as well as being color-coded, as
required. An observation of the collection of keys at shift change showed teachers and other
support staff turned in their personal keys to master control before obtaining facility keys.
Operations staff secured personal keys in assigned lockers located in the staff restrooms before
facility key issuance. The provisions for restricted keys were observed, with no exceptions
noted. Three staff were informally interviewed and were able to indicate the number and
function of each key on their key ring. Nine staff were interviewed, and all were able to identify
restricted keys with four identifying medical records keys, three identifying mental health records
keys, one identifying youth property keys, and six identifying administrative, supervisory, and
maintenance keys. The nine interviewed staff demonstrated an understanding of the key control
process with two indicating staff keys must be given to master control upon entry, six identifying
personal keys must be securely stored, one identifying visitor’s keys must be secured in main
control, three identifying a daily tracking system for keys and six identifying keys are assigned to
program staff. The superintendent stated a key inventory is maintained when keys are
permanently issued for staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 47 of 53 (Revised July 2023)
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has six vehicles used to transport youth. A review of documentation showed all six
vehicles underwent an annual vehicle inspection by a certified mechanic. Water coolant, lights,
oil, emergency equipment, brakes, horn, interior/exterior, and cleanliness inspections were
conducted monthly by staff for all six vehicles. Maintenance checks on tires, batteries,
windshield and wipers, windows, mirrors, and damage to include all scratches and/or dents was
conducted monthly by staff for all six vehicles. All inspections were documented on the
mandatory inspection form and copies of the forms were maintained by the maintenance staff
for all six vehicles. All vehicles were equipped with the appropriate number of seatbelts, a
seatbelt cutter, a window punch, a current fire extinguisher, and first-aid kits approved by the
designated health authority (DHA). For each transport, the logbook documented the
acknowledgement the vehicle was checked, the destination, the number of youth and staff
names, the name of the officer riding in the back, and the time the transport began and ended.
A return from transport was observed and staff searched youth upon return. Ten center vehicles
were checked at random, and all were locked when not in use. Nine youth were interviewed,
and each confirmed they feel staff drive safely when transporting them. All nine youth denied
ever seeing someone place contraband in the transport vehicles.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has a facility operating procedure addressing maintenance and kitchen tool
practices. Inspections of the maintenance room, kitchen tool and knife storage, and broom
closets found each area to be secured and inaccessible to youth. Maintenance tools are placed
on a shadow board and engraved with a Department identification code in the maintenance
room. A sample of ten items listed on the maintenance inventory was observed and each was
logged and accounted for. Documentation indicated kitchen staff conduct an itemized inventory
of all equipment, including a storage box for all knives, upon reporting for duty daily. All kitchen
items were accounted for, and logs were up to date at the time of the annual compliance review.
An informal interview with maintenance staff confirmed service vendors were accompanied by
designated center staff at all times when in a secure area of the center. Informal interviews with
the maintenance and kitchen staff revealed if there are any missing, lost, or damaged tools, it
would be reported to the supervisor and maintenance. The superintendent was interviewed and
reported the maintenance mechanic has access to the center’s tools.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 48 of 53 (Revised July 2023)
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has a safety plan included in their Continuity of Operations Plan (COOP)addressing
proper use, storage, and disposal of chemicals including flammable, toxic, caustic, and
poisonous items. All flammable, toxic, caustic, and poisonous items are inventoried and secured
when not in use. All Safety Data Sheets (SDSs) were located in a logbook posted near the
items and available to staff. Only authorized personnel are permitted access to flammable, toxic,
caustic, and poisonous items. No chemicals were observed to be accessible to youth. Five
SDSs and the items they correlate to were reviewed. The actual counts of all items matched the
ending count observed on the inventory form. Nine youth were interviewed. One indicated they
were allowed to use a scrub brush, a mop, and a broom, three indicated they could use mops
and brooms, and five indicated they don’t use any tools. Nine staff were interviewed on the
center’s practice for damaged or missing tools. Five staff indicated they would notify the
supervisor for damaged or missing tools with one of those five also indicating they would secure
the item if it were damaged and put in a work order to have it replaced. One staff said they did
not know what to do. One said to report it to the maintenance man. Two staff said they would
stop all movements and conduct a search for the missing item.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures requiring the inventory, storage, and disposal of
any flammable, toxic, caustic, and poisonous items. During the annual compliance review week,
there were no instances of chemical spills. The center disposed of flammable, toxic, caustic,
and poisonous items during the annual compliance review period. The maintenance man
provided a receipt for disposal from the Marion County Solid Waste Department as
documentation. The maintenance staff confirmed there is a container in the kitchen designated
for grease disposal.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 53 (Revised July 2023)
5.11 Confinement Under Twenty-Four Hours Limited 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 had a total of 405 confinements since the last annual compliance review. A sample
of fifteen confinement reports was reviewed. A review of fourteen applicable youth found
thirteen were provided a meal and one was not. A review of five applicable youth found all were
given a shower. A review of three applicable youth found two were given access to mental
health care as requested and one was not. A review of thirteen applicable youth found all were
given clean clothing. A review of twelve applicable youth found no youth were provided
education materials. All fifteen youth were notified of their right to grieve the confinement.
Documentation reflected the supervisor approved fourteen of the confinements and one was not
approved. All fifteen youth were placed into the confinement room alone and fourteen youth had
their rooms searched prior to confinement. All fifteen youth confinements were documented on
a completed Visual Observation Report (VOR). All fifteen VORs had documentation of five
minute checks for the first hour in confinement. In all fifteen records, the youth were notified of
the reason for confinement. In fourteen of the fifteen confinement records the supervisor
conducted an initial confinement review with the youth within one hour of the incident. One
review was completed the next morning. Fourteen of the fifteen confinement reports were
completed by end of shift, and one was completed the day after. Eleven of fifteen records
reflected an additional review with each youth was completed every three hours by the
supervisor. Two of the records were each three minutes late. One record was ten minutes late
and one record was completed the next morning. In fourteen of the fifteen confinements
supervisors/staff continually counseled the youth and considered removing the youth from
confinement as soon the youth was able to safely rejoin the population. One youth was not
continually counseled. In twelve of the fifteen confinement reports, the superintendent or
designee reviewed the confinement report within the required forty-eight hour time frame. One
report was not completed, one was done the next day, and one was eight hours late. No
pregnant youth were reportedly put in confinement during the annual compliance review period.
All windows and cameras were free of obstructions and scratches so the youth could be visually
observed. Nine staff were interviewed and six stated a confinement report is completed. Four
staff stated ten-minute checks needed to be documented and one stated the first hour is five
minute checks. Four staff stated the confinement room needed to be searched. Two staff stated
approval is needed from a supervisor for confinement. One staff stated video is reviewed of the
incident, and one said staff use verbal de-escalation and Right Interactions, then lock them into
the room. Of the nine staff, five stated youth placed in temporary confinement are provided
education materials and four stated youth were not provided materials. The superintendent was
interviewed and reported the use and appropriateness of confinement is tracked by having an
incident report generated in the Department’s Facility Management System (FMS). The
superintendent also stated regional detention management reviews the use of confinement,
lockdown, and restraints through monthly reports.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 53 (Revised July 2023)
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have any confinements over twenty-four-hours during the annual compliance
review period; therefore, this indicator is rated as non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center documented having completed two Continuity of Operations Plan (COOP) drills
during the annual compliance review period, with no exceptions noted. Two weather drills were
completed prior to hurricane season. Documentation of the center’s COOP drills included brief
scenarios, type of drill, date and time, and notable critiques or corrective action required. The
documentation did not include a staff participation roster; however, was supported by logbook
entries. Nine staff were interviewed. Five staff stated they participated in a weather drill, five
stated a major disturbances drill, eight stated an escape drill, and nine staff stated they
participated in fire drills over the annual compliance review period. The superintendent was
interviewed and stated the facility utilizes a COOP in case of an emergency and have a
coordinated plan with mental health facilities in the area.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has a written escape prevention plan which includes the Department’s policy and
procedures regarding escapes. The center conducted escape drills at a minimum of once a
quarter, with the exception of the quarter dated October 1, 2023, through December 31, 2023.
During this quarter no escape drills were conducted on either day or night shift. The assistant
superintendent presented disciplinary documentation for the responsible staff regarding the
failure to conduct the required drills. Documentation was found in the center’s logbooks for each
of the nine escape drills conducted. During the annual compliance review week, a review of nine
training records ensured staff were trained in escape prevention annually. Nine staff were
interviewed and eight stated they had participated in escape drills since the last annual
compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 53 (Revised July 2023)
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has implemented a Fire Prevention Plan. The center provided documentation of
thirty fire drills conducted during the annual compliance review period. The center has
completed monthly fire drills, as required with the exception of day shift in September of 2023
and night shift in October of 2023. A review of drill documentation reflected all documents were
completed and/or signed by the superintendent, as required, with the exception of one. A review
of the master control logbooks revealed all fire drills were documented as required and
highlighted with the exception of two. All fire extinguishers are inspected annually. Nine staff
were interviewed, and all reported fire drills are conducted monthly and eight stated they have
participated in a fire drill. Four of the nine interviewed youth stated they had been instructed on
what to do in case of a fire, and five said they have not been instructed.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
Documentation determined youth electronic and strip searches were conducted prior to each
admission. Youth frisk searches are conducted when deemed appropriate by the shift
supervisor when there was reasonable suspicion the youth was harboring contraband and
during facility-wide initiatives to reduce the introduction of contraband. All searches were
documented in the logbook and electronically. During the annual compliance review week,
observations of a youth and room search were conducted. Staff wore gloves during the
searches of seven male youth arriving from court transport. One of two staff were observed
wearing gloves while conducting room searches though the second had the gloves in hand.
Reviewed documentation confirmed an incident report was created for any strip search
conducted at any time other than admission, two staff of the same gender of the youth were
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 53 (Revised July 2023)
present when conducting the search, and all strip searches were conducted individually and not
in a group setting. Electronic searches were conducted on all persons entering the facility; staff
searched all bags, cases, jacket pockets, and other items, and all personal keys, personal cell
phones, and other contraband items were prohibited from entering the secure area. Room
searches occurred upon a youth’s release, prior to placing a new youth in the room, and for
contraband on each awake shift.
A reviewed sample of room searches for one day of each month of the annual compliance
review period for each awake shift found each room searched was documented and completed
as required, with no exceptions noted. Nine staff records were reviewed, and all included a
contraband attestation. The center documented the confiscation of contraband in the master
control logbook. Incident reports were completed to identify findings and disposition of
contraband. Law enforcement was contacted if any found item was considered illegal as defined
in Florida Statutes or if there was evidence of any type of unlawful activity. Confiscated items
were secured by the discovering officer and hand-delivered to the supervisor. The shift
supervisor documented the chain of custody of confiscated items, and the process was
documented in the incident report. The Department’s Central Communications Center (CCC)
and the regional director or designee were notified of the discovery and confiscation of
contraband. The superintendent was interviewed and stated any item discovered during a
search of youth or staff would be removed from the secure area. Law enforcement shall be
contacted if the contraband found is considered illegal, and the CCC will be notified.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 53 (Revised July 2023)

source: DJJ

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.11