state: FL

summary: QI Detention - FY25-26

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Escambia Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
1800 St. Mary Ave
Pensacola, Florida 32501
Review Date(s): September 9 – 12, 2025
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:
Rebecca Smith, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Ken Myers, Office of Education, Education Coordinator Circuit 1 (Standard 2)
Kayshala Patterson, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Andre Watson, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Arnica Wilson, Detention Services, Superintendent (Standard 5)
Program Name: Escambia Regional Juvenile Detention Center MQI Program Code: 2
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Escambia County / Circuit 1 Number of Beds: 50
Review Date(s): September 9-15, 2025 Lead Reviewer Code: N/A
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
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 57
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Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 57
1 .0 1
1 .0 2
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1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
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In d ic a t o r R a t in g s
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * S a tis fa c to
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a tis fa c to
S ta ff C o d e o f C o n d u c t S a tis fa c to
In c id e n t R e p o rtin g (C C C ) * S a tis fa c to
R ig h t In te ra c tio n s (R I) S a tis fa c to
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a tis fa c to
In -S e rv ic e T ra in in g S a tis fa c to
G rie v a n c e s S a tis fa c to
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n * S a tis fa c to
D a ta T re n d A n a ly s is S a tis fa c to
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a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 57
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 2 - Y o u th M a n a g e m e n t
A d m is s io n S a tis fa c
O rie n ta tio n S a tis fa c
C la s s ific a tio n S a tis fa c
N o tific a tio n o f J P O C irc u it G a n g R e p re s e n ta tiv e S a tis fa c
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty S a tis fa c
R e le a s e S a tis fa c
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s S a tis fa c
R e v ie w o f Y o u th in S e c u re D e te n tio n S a tis fa c
D a ily A c tiv ity S c h e d u le S a tis fa c
E d u c a tio n a l A c c e s s * S a tis fa c
C a re e r E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 57
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3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
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In d ic a t o r R a t in g s
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A ) S a
L ic e n s e d M H /S A C lin ic a l S ta ff * S a
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff S a
M H /S A A d m is s io n S c re e n in g S a
M H /S A E v a lu a tio n S a
T re a tm e n t a n d D is c h a rg e P la n n in g S a
M H /S A T re a tm e n t S a
S u ic id e P re v e n tio n P la n * S a
S u ic id e P re v e n tio n S e rv ic e s * S a
S e c u re O b s e rv a tio n * S a
S u ic id e P re c a u tio n O b s e rv a tio n L o g s * S a
S u ic id e P re v e n tio n T ra in in g * S a
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s * S a
E m e rg e n c y C a re P la n * S a
C ris is A s s e s s m e n ts * S a
B a k e r a n d M a rc h m a n A c ts * S a
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra
m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to d o
p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 57
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
4 .1 9
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
In d ic a t o r R a t in g s
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * S a tis fa
F a c ility O p e ra tin g P ro c e d u re s S a tis fa
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t S a tis fa
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm S a tis fa
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n S a tis fa
D H A /D e s ig n e e A d m is s io n N o tific a tio n S a tis fa
H e a lth -R e la te d H is to ry S a tis fa
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g S a tis fa
S e x u a lly T ra n s m itte d In fe c tio n & H IV S c re e n in g S a tis fa
S ic k C a ll P ro c e s s S a tis fa
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re S a tis fa
O ff-S ite C a re /R e fe rra ls S a tis fa
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s S a tis fa
M e d ic a tio n M a n a g e m e n t S a tis fa
P s y c h ia tric S e rv ic e s * S a tis fa
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s S a tis fa
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n S a tis fa
P re n a ta l C a re /E d u c a tio n S a tis fa
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth* Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance 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 57
Program Overview
The Escambia Regional Juvenile Detention Center is a state-owned detention facility, operated
by the Department, located in Pensacola, Florida. The center serves youth in Escambia and
Santa Rosa counties in Circuit 1 and is co-located with the Escambia Juvenile Assessment
Center. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the fifty-bed center. Youth are
provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Escambia County School Board. The center’s
management team includes the superintendent, two assistant superintendents, one
administrative assistant, seven juvenile justice detention officer supervisors (JJDOS), and forty-
four JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by one
designated mental health clinician authority (DMHCA), one psychiatrist, two licensed mental
health counselors (LMHCs), two licensed clinical social workers, and one non-licensed mental
health and substance abuse clinical staff. Clinical services provided by the center include
mental health and substance abuse evaluations, mental health treatment planning, individual,
group and family therapy, mental health crisis intervention services, on-site psychiatric services,
and availability for substance abuse services for youth with co-occurring disorders. Medical
services are provided by one designated health authority (DHA), one advanced practice
registered nurse (APRN), seven registered nurses (RNs), and one records clerk. The medical
clinic maintains nursing coverage seven days a week from 8:00 a.m. to 5:00 p.m., Monday
through Friday, and 8:00 a.m. to 4:30 p.m. Saturday and Sunday. Food services are provided by
Department staff and include menus, meal planning, meal schedules, special diets, nutritional
analysis, daily allowance, food preparation, health certifications, food product standards,
sanitation, and cleaning. Staff are responsible for the custody and control of youth in their care,
providing youth supervision twenty-four hours a day, seven days a week. The center has three
living modules which are divided by male and female. There are sixty-four security cameras at
the center, of which sixty-four were operational. At the time of the annual compliance review, the
center had eight vacancies, which included two JJDO II and six JJDO I positions.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 57
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures (FOPs) outlining the process of background
screening for all new staff, volunteers, and contracted staff. The program has a facility operation
procedures relating to volunteers, mentors, and interns who work with youth less than ten hours
a month requiring sight and sound, though all volunteers receive a background screening. An
Annual Affidavit of Compliance with Level 2 Screening Standards was submitted to the
Department’s Background Screening Unit (BSU) on January 7, 2025, meeting the annual
requirement. The center employs local school board teachers and their Annual Affidavit of
Compliance with Level 2 Screening Standards was completed on January 7, 2025, meeting the
annual requirement. Since the last annual compliance review, the center had ten newly hired
staff, fourteen volunteers, and five contracted staff. Each staff was found to have an eligible
background screening in the BSU which was completed prior to their hire date. Each contracted
staff and volunteer found to have an eligible background screening completed prior to hire date.
A review of each staff’s personnel record found the center reviewed each staff’s criminal history
report in all applicable staff records. Additionally, a pre-employment assessment, with a passing
score or exemption documentation was in all applicable staff records. Also, five contracted staff
were added to the Clearinghouse employee roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures addressing the process of five-year background
rescreening. Five staff were applicable and reviewed for five-year background rescreening.
Each staff had the five-year rescreening completed with the required five-year timeframe,
calculated from the hire date. The center did not have any applicable contracted provider staff
who required a background rescreening.
.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 57
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures (FOP) outlining the guidelines of staff code of
conduct. The FOPs state any form of abuse, profanity, threats, harassment, intimidation,
“horseplay,” or personal relationships with youth are prohibited for staff. If the code of conduct is
violated, there is a process in place for management to follow to address each violation. Six
staff records were reviewed for staff code of conduct. All six of the staff had signed codes of
conduct in their personnel records and were applicable to receive disciplinary actions for
violations of the code of conduct during the annual compliance review period. Management took
immediate action to investigate or address all allegations or violations of the code of conduct.
Two staff received a written reprimand, and one staff was placed on suspension. The remaining
three staff were applicable to receive an award. All three staff received an award on July 1,
2025. Seven youth were interviewed regarding reporting suspected abuse to the Florida Abuse
Hotline. Six of the youth reported they have never been stopped from calling the Florida Abuse
Hotline. One youth reported they were stopped from calling the Florida Abuse Hotline. Six of the
seven youth reported staff are respectful when talking with the youth while one youth reported
the staff do not speak respectfully. One youth went on to state the staff are respectful for the
most part, but if a youth is disrespectful, staff just put them in confinement. The youth also
reported the staff get a certain tone with the youth at times. Another youth reported all the staff
are disrespectful when speaking with the youth with the exception of the major. Four youth
reported the staff occasionally use curse words, one youth reported they have not heard the
staff use curse words, one reported they have heard it once, and one reported hearing it often.
None of the youth have ever heard the staff threaten the youth. All seven youth feel safe at the
center and none of them have ever exchanged contact information with staff.
Seven staff were interviewed and were able to summarize the process for allowing staff and
youth to call the Florida Abuse Hotline or the Department’s Central Communication Center to
report suspected abuse. Six staff reported never hearing staff use profanity with the youth and
one staff reported they have heard it occasionally used. None of the staff have ever observed a
co-worker using threats, intimidation, or humiliation when interacting with the youth. Four staff
reported the working conditions have been fair over the past year, two staff reported it has been
good, and one staff reported it has been very poor. One staff added the administration exhibits
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 57
favoritism, which makes it a poor working condition. The superintendent was interviewed
regarding employee code of conduct and what actions are taken. The superintendent stated
staff adhere to a code of conduct which does not allow any form of abuse, profanity, threats,
harassment, intimidation, or personal relationships with youth. Any allegation or suspicion of
physical abuse or neglect shall be reported to Department of Children and Families (DCF), Law
Enforcement and the CCC. Corrective action shall be given to any staff who violate the code of
conduct, up to and including termination.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures addressing the process of contacting the
Department’s Central Communications Center (CCC). Since the last annual compliance review,
the center had seventy CCC incidents. Seven reports were reviewed. Each incident was
reported to the CCC in the required timeframe. A review of logbooks found all seven incidents
were documented as required. There were no additional incidents/grievances which should
have been reported to the CCC during the annual compliance review period. The
superintendent was interviewed, stating whenever a reportable incident occurs, the CCC shall
be notified within two hours of the facility gaining knowledge of the incident or event. CCC shall
also be contacted by a youth eighteen years of age or older who is making an allegation of
abuse or neglect. Department of Children and Families (DCF) shall be contacted if any incident
of abuse or neglect is observed, reported, or if a youth requests to contact the agency.
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 has facility operating procedures outlining the staff’s use of physical intervention
techniques. During the annual compliance review period, the center had 158 Protective Action
Response (PAR)/Right Interactions (RI) incidents. Nine youth records were reviewed for PAR/RI
compliance by the facility. All nine PAR/RI reports were completed the same day as the RI
incident prior to the end of shift. None of the incidents resulted in serious injury to the youth.
None of the youth alleged abuse. All nine of the PAR/RI reports were reviewed by a supervisor
or instructor and a post-PAR/RI interview was conducted with the youth by the administrator, or
designee, as soon as possible, no longer than thirty minutes after the incident. None of the nine
youth were applicable for a PAR/RI medical review. All nine PAR/RI reports were reviewed by
the superintendent or designee within the required timeframe. The center’s PAR/RI rate during
the annual compliance review period was 9.10, which is below the statewide Detention PAR
rate of 12.59. Seven staff were interviewed, and all stated staff talk to youth before using PAR
techniques and/or mechanical restraints. The interviewed superintendent was able to relay the
procedures and timeframes of when staff need to utilize mechanical restraints, as well as the
process for monitoring PAR incidents and reports.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 57
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures addressing the training requirements for all newly
hired staff. Seven staff were reviewed for pre-service training. Three staff completed all pre-
service training and certification requirements, including completion of Academy Training, within
the required 180 days of hire. The remaining four staff were still within their 180 days of hire and
will be attending the academy; however, completed all other required training. Each reviewed
staff also completed orientation within thirty days of hire with all training entered in the
Department’s Learning Management System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures outlining the annual training requirements for staff.
The center has an annual in-service training calendar, which was approved by the assistant
secretary of the Department’s Office of Detention Services on December 2, 2024, the director of
the Department’s Office of Talent, Leadership and Culture (TLC) on December 5, 2024, and the
facility superintendent on December 12, 2024. The training calendar was observed posted on
the employee bathroom doors, break room, and staff office. The superintendent indicated during
an interview, they have received the following management training: conflict management,
emotional intelligence, fundamentals of coaching, interviewing dos and don’ts, real colors for
leaders, and supervising for success. Additionally, the following trainings are required for center
staff: pre-service training, 120 hours of certification training (computer-based and instructor-led),
and successful completion of the detention academy which will be conducted by TLC at an
approved training site. Seven staff were reviewed for in-service training. Six staff completed all
required in-service training. The remaining staff completed all training with the exception of
human trafficking intervention, Prison Rape Elimination Act (PREA), professionalism,
interpersonal communication, and ethics including standards of conduct, sexual harassment,
suicide awareness and prevention, and trauma responsive practices. Three supervisors were
reviewed and each completed at least eight hours of annual training in addition to the twenty-
four hours required for all staff. Also, a licensed nurse provided in-service education on girls’
healthcare annually to all non-healthcare staff involved in the supervision for treatment of girls.
The training also included monitoring, observation, and emergency care of the pregnant youth.
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1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a facility operating procedure which established each youth right to grieve and
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. A review of the Department’s Facility Management System (FMS) found the center
did not have any grievances submitted during the annual compliance review period. There are
grievance forms available for all youth in each youth living module. The interviewed
superintendent was able to summarize the grievance process, including the three phases Seven
youth were interviewed regarding the grievance process. Five of the youth were able to
summarize parts of the grievance process. One youth reported writing one but not turning it in.
Three of the youth have never filled out a grievance because they do not think anything will be
done with it. One youth did not feel the grievance process works but was able to explain the
process. Five of the youth reported they have never filed a grievance, one youth reported the
process is fair, and one youth reported it was poor. Seven staff were interviewed and were able
to explain the grievance process for the center.
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1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center maintains facility operating procedures (FOP) outlining the process of entering and
sharing alerts information. Seven youth were reviewed for alerts entered by the center. A total of
thirteen alerts were reviewed in the Department’s Juvenile Justice Information System (JJIS).
Eight out of the thirteen applicable alerts were entered timely into JJIS. Three of the alerts were
not applicable or required to be entered into the master control logbook. Two alerts were not
entered into the logbook as required. The JJIS alerts are reviewed daily by supervisors and
administrators, which is shared with all staff during daily debriefings and logbook reviews. The
center’s shift briefing minutes were provided for review with no discrepancies noted. A shift
briefing was observed during the annual compliance review week. Staff shared all alert
information during the briefing as required. Alerts are updated in the living module logbooks,
master control logbook, and during shift briefings. No additional alerts were found during the
annual compliance review week which should have been entered. The superintendent reported
medical alerts are entered into JJIS during the intake process. Medical staff shall review alerts
to ensure each alert is correctly tracked and managed. Seven staff were interviewed regarding
communication in the center. Staff reported they are informed of alerts through shift debriefings,
alert forms, and keep documentation on their person which was provided for review. Staff are
informed of any issues within the center through the logbook, staff debriefings, meetings, and
pass downs when on the modules. Four staff reported communication is good and three
reported it is very good.
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1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a facility operating procedure ensuring the review and analysis of data in
decision making practices and these data trends are shared among all staff and shareholders.
An informal interview was conducted with the superintendent regarding the center’s data trend
analysis. The superintendent stated information is gathered from various reports, reviewed, and
discussed during monthly meetings and advisory boards. Administration reviews the reports
with any noticeable trends being discussed in management meetings and relayed with staff
during monthly meetings, with the main topics revolving around Right Interaction and
confinement data trends. Staff members are afforded the opportunity to discuss any issues and
ask questions. The center also holds quarterly meetings with circuit stakeholders.
Documentation reviewed for the annual compliance review period found the meetings are being
conducted as required, with meeting agendas being uploaded in Detention Services SharePoint.
An observation of a monthly advisory board meeting was conducted, which solidified the
information gathered from the superintendent.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, 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.
A review of seven youth records found each had an arrest affidavit/custody order, Detention
Risk Assessment Instrument, and a Suicide Risk Screening Instrument reviewed and
subsequently documented on the admission wizard. The admission wizard also documented a
full-body search, youth meal, and if applicable, a medical, mental health and or substance
abuse screening. Two of the seven youth did not have documentation on the admission wizard
as having had a telephone call made. Further review found the two youth’s telephone log
indicated having had a call made. The remaining five youth had a telephone call documented on
the admission wizard. No observation of the center having a youth admission was made; the
center did not inform the reviewer of an admission, if one had occurred.
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
A review of seven youth records found the center provided orientation within twenty-four hours
of admission. In each admission, the youth signed an orientation acknowledgment. The youth
orientation form contained all required elements. No observation of the center having a youth
orientation was made; the center did not inform the reviewer of an orientation, if one had
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occurred. Seven youth were interviewed and reported the rules, regulations, daily schedule,
education services, visitation, abuse reporting, and behavior management system of the center
were explained to them when they first came to the center.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
A review of seven youth records found during the classification process, the youth’s history and
status as indicated on the admission wizard was reviewed. Each youth was considered and
placed accordingly prior to making any room assignment, based upon their respective
classification, and required topics. An informal interview with the center’s gang representative
revealed the superintendent is informed of how to identify and address local youth gangs. The
superintendent is informed of any issues by the center’s gang representative. The
superintendent was interviewed and reported youth shall be assigned to a room based on
classification and are reclassified if changes in behavior or status are observed. Youth with a
history of committing sexual offenses, a history of being a victim of a sexual offense and/or
abuse, or youth determined to be physically or sexually aggressive are not to be placed in a
room with any other youth. Youth with poor physical health, poor cognitive performance, or of a
vulnerable age shall be closely monitored by Department staff and placed as a single room only
if deemed appropriate. Any youth on suicide precautions shall not be assigned a room until
removed from precaution and deemed appropriate. No room assignment shall be made prior to
the review of the Victimization and Sexually Aggressive Behavior assessment.
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.
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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.”
A total of three youth records were applicable and subsequently reviewed for notification of
juvenile probation officer (JPO) circuit gang representative. Each of the three youth were
identified after admission, as a gang associate, and a referral was generated by the center’s
gang representative. The evidence provided for each youth, was a picture from the youth’s room
of what appeared to be gang graffiti as identified and documented by the center’s gang
representative. Referrals for each of the three-youth indicated having meet one of any single
defining criteria for a criminal gang membership; flashing gang signs, gang tattoos, gang-related
drawings, and or other related gang activity. Discussion held with the center’s gang
representative was in line with facility operating procedures (FOP) reviewed. The FOP has the
center notify the JPO designated as the circuit gang representative for suspected gang activity.
An email with the required referral was unable to be generated to probation, as the circuit does
not have a gang representative. The center, however, was able to address each youth’s
suspected gang activity. This was accomplished utilizing the centers behavior management
system. The center applied the appropriate consequences for the suspected gang activity,
which included taking away levels and or taking away points.
.
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.
A review of seven youth records found the center takes possession of youth’s personal property
during admission. An itemized personal property receipt was completed and signed by each
youth, staff, and located in each youth’s active record. One of the seven youth was applicable
for having money or personal item of value secured in a tamper proof property bag and placed
into a drop safe. The center has a bound logbook for documenting items placed in the drop
safe. The logbook was missing a column for time and officer’s initials as outlined within Florida
Administrative Code. No observation of the center having a youth receive personal property was
made; the center did not inform the reviewer of a release if one had occurred. Observation of
the center’s personal property was made, found to be locked, and located outside the secure
area. The center’s drop safe was observed to be under video surveillance twenty-four hours a
day and included contacting master control prior to opening and/or closing the safe. The youth’s
personal property was only accessible to designated supervisory staff. A review of Central
Communication Center reports confirmed no incidents regarding youth property valued over fifty
dollars were reported. Six of seven interviewed youth reported staff put their personal property
in a property bag and the youth signed for it. One youth did not remember signing a piece of
paper. The superintendent was interviewed and reported youth's personal property is collected,
documented, and the document is signed by youth and staff before being secured in the
property room or locked safe. All property is labeled with the youth's name and date it was
collected. Limited access is available to the property room and safe. A notification letter will be
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sent to the last known address of the youth, informing the youth they have thirty days to retrieve
the property left, or it will be considered abandoned and disposed.
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.
A review of three closed youth records found when releasing youth from the center, the on-duty
supervisor verifies the court’s authorization prior to release. In addition, the identification of the
parent/guardian or responsible adult receiving the youth, is verified prior to releasing the youth.
None of the sampled youth had an endangered person alert. Documentation verified the youth
and person to whom youth was being released to was reminded of any future court dates. It was
also observed, all required parties signed all applicable release forms. The date of admission
and the date of release documented in the case record correlated with the Department’s
Juvenile Justice Information System. No observation of the center having a youth release was
made; the center did not inform the reviewer of a release, if one had occurred.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
Three closed youth records were reviewed to determine if, upon release from the center, was
the personal property receipt form reviewed and signed by appropriate parties. Two of the three
records indicated the youth and parent/guardian signed the receipt. The remaining one youth’s
property receipt was not signed by the parent/guardian. In each of the three records reviewed,
documentation supported each youth was released to the appropriate person. None of the youth
reviewed were released with any medication. Each youth and the person to whom the youth
was released to, were reminded of any health or welfare issues, which may have included
medical, mental health, and/or substance abuse needs and any other pending appointments.
The center did not have any examples of properties being held for more than thirty days at the
center during the annual compliance review period. No observation of the center having a youth
release was made; the center did not inform the reviewer of a release, if one had occurred.
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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.
An observation of the weekly detention review was conducted. The review consisted of center
administration, medical, mental health, residential case management, juvenile probation officer,
and education. The center reviewed the current census of youth and, when necessary, ancillary
staff discussed pertinent information with the detention review team present. A review of weekly
detention documentation was conducted, which included sign-in sheets and notes. The review
revealed out of forty-eight separate dates, only four weekly meetings were missed or
documentation unaccounted for. During these weekly reviews there were approximately twelve
separate dates where either medical, mental health, or education were not present.
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.
Observation of activities appeared to follow the posted daily activity schedule. Activities
observed during the on-site review included youth in education, medicine pass, and outside
recreation. Logbooks were reviewed. The sample size for logbook entries included one date in
each month of the annual review period. The review revealed the center offers the following:
wake-up/personal hygiene, meals, visitation, recreation, education, bedtime, and free time. A
tour of the center identified the daily activity schedule is posted for youth to read. Seven youth
were interviewed regarding the daily activity schedule. All seven youth reported the center has a
daily activity schedule. Six of the seven youth reported the schedule is followed and one
reported it is not followed. The youth went on to report during physical education the staff leave
the youth in their rooms until the second shift is on duty. This youth also reported the youth go
to their rooms at different times. This changes every day. All seven interviewed staff reported
the center’s daily schedule is followed regularly.
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’s education program is directly managed and supervised by the Escambia County
School Board. It is required to operate on a year-round basis providing the youth with at least
250 days of instruction distributed over twelve months with a minimum of twenty-five hours of
weekly instruction. This schedule also allows the school board to use up to twenty days of the
250 days for teacher planning/professional development. Upon reviewing the annual academic
calendar and daily class schedule, the program’s annual calendar supports 240 days of
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instruction with ten additional days of teacher planning/professional development. A review of
the daily academic schedule confirmed the schedule offers 300 minutes of instruction hours of
weekly teaching. This meets the required educational hours each week. Documentation was
provided confirming the superintendent and school principal submitted the schedule to the
Department’s Office of Education upon taking over educational services July 1, 2024. Three
days of video were reviewed. The video showed classes being conducted with minimal
interference and youth were in class on time two out of three days in accordance with the
schedule. A review of the master control logbooks and living module logbooks for one day each
month of the annual compliance review period was conducted. Out of thirty-six youth
movements for school, twenty-seven were conducted timely. The times the youth were late
were due to staffing issues or an emergency on the living module. Also to be noted, only one of
the modules of youth were late to school, not all three. The administration was aware of the
youth being late and were able to explain why for the dates reviewed. According to the
superintendent’s interview, classes are conducted with minimal interference. Youth receive
educational services Monday through Friday from 8:25 a.m. to 2:57 p.m., excluding holidays
and teacher planning days. Seven staff were interviewed regarding educational instruction. The
staff reported there is minimal interference with education instruction. Staff reported it is only
interrupted due to school being out or a teacher planning day, and sometimes they are short
staffed on teachers. There are times classes are held on the living modules if the center and/or
teachers are short staffed. Seven youth were interviewed regarding education services at the
center. Four of the youth reported the center is preparing them very well for their education and
three reported they feel it is preparing them well. All seven youth reported they attend school
Monday through Friday.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
Under the supervision of the Escambia County School Board, the center provides youth an
appropriate career education curriculum based upon their age and assessed intellectual and
educational abilities. A career education course is offered which is categorized as a Type 1
career and vocational curriculum. This classification, which stresses soft skills, includes
activities centered on, but not limited to, youth learning or improving their interpersonal,
communication, and decision-making skills. The center is currently using Xello: College and
Career Readiness software. Students use computer laptops in the classroom to explore career
options and interests. The software is provided for use by the Escambia County School
system. Xello also teaches lessons about college information and readiness for students. The
teachers incorporate career studies for students enrolled in Personal, Career, and School
development classes at both the Middle and High School levels. Career studies are also
covered in Peer Counseling classes as well. Seven youth were interviewed regarding the
education classes they are attending while at the center. Seven youth reported taking math, six
reported reading, five reported history, and three reported science. Two youth also added taking
physical education.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a licensed mental health professional working as the designated mental health
clinical authority (DMHCA). The DMHCA is a licensed clinical social worker with an active and
valid license which expires March 31, 2027. The back-up DMHCA has a clear and active
license which expires on March 31, 2027. A copy of the DMHCA’s position description and
contract requirements were reviewed. A minimum of forty hours weekly was required and
confirmed. The DMHCA was on-site as required by contract to ensure coordination and
implementation of mental health services were taking place. An interview with the DMHCA was
conducted. The DMHCA reported their role as coordinating with the facility psychiatrist and
medical staff to ensure youth on psychotropic medications are receiving initial psychiatric
evaluations within fourteen days and a follow-up within thirty days, supervising all mental health
staff, and reviewing documentation to ensure timely, accurate, and thorough record-keeping is
completed. The DHMCA also conducts intake assessments, completes training with new mental
health staff and detention staff as necessary, on-going reviews with mental health staff to
ensure understanding of expectations, mental health and substance abuse comprehensive
assessments, provides ongoing treatment, crisis intervention, suicide risk assessments, and
participates in multidisciplinary team meetings. The DMHCA completes monthly schedules to
ensure contract hours and coverage is met, provides weekly updates of statistical reporting
instrument, and communication with clinical staff daily and on-going.
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 currently employs five licensed mental health and substance abuse clinical staff,
including the designated mental health clinician authority (DMHCA). The clinical supervisor
ensures the licensed clinical staff working under their supervision are performing services they
are qualified to provide based on their education, training, and experience. The licensed mental
health professionals are all licensed under the appropriate Florida statutes chapter. Copies of
licensed professionals were available on-site. All licensed mental health professionals and
licensed qualified professional’s licenses were reviewed with no noted issues.
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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 currently does not have any non-licensed mental health and substance abuse
clinical staff providing services. At the time of the annual compliance review, there was one
mental health counselor vacancy, and it has been vacant for eleven months.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
Seven youth records were reviewed for mental health and substance abuse admission
screening. All records were eligible for mental health and substance abuse admission
screening. Each record contained screening documents completed by probation. Each record
indicated screening documents were reviewed by detention staff. In each record, the suicide risk
screening instrument (SRSI) was completed at intake. Each record indicated the SRSI, and the
Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) were initiated within the
Department’s Juvenile Justice Information System (JJIS). In each record, documentation
reflects nursing and or mental health staff completed the required sections of the SRSI, and the
completed entries included accurate referral selections in the screening results section. All
seven records indicated youth had a positive response on the SRSI and each youth was placed
on suicide precaution and a mental health referral was completed which documented the youths
need for an assessment of suicide risk (ASR). Seven of seven records contained a SRSI
screening which included a yes response when the youth had an open or closed alert in JJIS. In
all seven records, the results of the SRSI and the MAYSI-2 indicated a need for further
assessment. Documentation confirmed the proper referral for each eligible youth requiring
further assessment was made and the superintendent was notified of each. The MAYSI-2
assessment results in all seven records indicated an elevated suicide risk subscale which
prompted the youth to be placed on suicide precautions and referral for an ASR. The screener
for each youth made a referral to the mental health clinical staff for comprehensive substance
abuse and mental health (SAMH) assessment.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
Seven youth records were reviewed for mental health and substance abuse evaluations. Each
of the seven youth were identified after admission and referred to the center’s provider for
comprehensive and or mental health evaluations. All seven of the comprehensive mental health
and/or substance abuse evaluations were classified as new. All comprehensive mental health
and/or substance abuse evaluations were completed by the center’s on-site provider by the
youth’s thirty-first day of admission. For all evaluations, treatment recommendations
corresponded to all diagnosed mental health or substance abuse disorders. All Comprehensive
Mental Health/Substance Abuse Evaluations consisted of the Substance Abuse and Mental
Health (SAMH) form documented within the Department’s Office of Health Services Electronic
Medical Record. An interview with the designated mental health clinician authority (DMHCA)
was conducted. The DMHCA reported should a youth be admitted to the detention center on
standard supervision but present with indicators on Massachusetts Youth Screening Instrument,
Second Version (MAYSI-2) outside of the thresholds established, a mental health referral will be
submitted at this time by detention staff to refer youth for a comprehensive assessment by their
thirtieth day; any suicide risk indicators necessitate immediate referral for assessment of suicide
risk. When mental health staff conduct intake assessments for youth and review the screening
tools provided, if youth require a mental health referral for a comprehensive evaluation due to
indicators on MAYSI-2 and detention staff has not submitted said referral, mental health will
notify detention staff to submit referral at this time. Should youth display any behaviors
indicating a comprehensive assessment is necessary, mental health will conduct a face-to-face
interview with youth to determine if youth's behavior necessitates an immediate comprehensive
assessment. If no immediate assessment is required, mental health will confer with detention
staff to submit a referral requesting a comprehensive assessment be completed by youth's
thirtieth day.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
Seven youth records were reviewed for treatment and discharge planning. Reviewed
documentation confirmed all mental health orientations were held within fourteen days of youth
admission to the center. Each record indicated youth required a treatment plan. One was
eligible for an Initial treatment plan. The remaining six youth refused participation in treatment.
The eligible youth’s initial treatment plan was in place within seven days of the onset of
treatment. The initial treatment plan was developed on the Department’s Initial Mental
Health/Substance Abuse Treatment Plan form and contained all required information such as
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reason for referral for treatment, initial diagnostic and statistical manual of mental disorder
(DSM-5) diagnosis/symptoms, initial treatment methods did include counseling and frequency,
and initial treatment goals. The youth was not applicable for psychiatric services including
psychotropic medications and frequency of monitoring. None of the reviewed youth were
admitted to the center with psychotropic medications. The eligible record indicated the initial
treatment plan was signed by the mental health and substance abuse professional as well as
each youth. The eligible youth was assigned to a mini-treatment team, and the mini-treatment
team members were involved in the development if the initial treatment plan. All seven youth
were eligible for an individualized treatment plan. Each eligible youth’s individualized treatment
plan was developed by the youth’s thirty-first day of admission. Each eligible individualized
treatment plan contained a DSM-5 diagnosis, symptoms which are treatment focused, treatment
goals included mental health services if the youth had a mental illness and substance abuse
services if the youth had a substance related diagnosis, and strengths and needs. None of the
seven individualized treatment plans indicated youth were eligible for psychiatric services. In all
seven records, progress noted did validate the youth was receiving treatment services as
stipulated on the treatment plans. Documentation confirmed each individualized treatment plan
contained signatures of the youth, mental health and substance abuse professional, treatment
team members, and parent/guardian. All seven records indicated youth were eligible for
treatment plan reviews. Each individual treatment plan review was completed and documented
on the Department’s Individualized Mental Health and Substance Abuse Treatment Plan Review
form. Each treatment plan review was reviewed every thirty days by the treatment team. All
seven treatment plans required modifications and, in each record, modifications were
documented on the review form and clearly identified as such. Each individualized treatment
plan review was signed by the clinical staff, youth, licensed mental health professional,
treatment team members, and parent/guardian. Each treatment plan included treatment
services provided by a licensed psychiatrist or a licensed certified psychiatric advanced
practiced registered nurse (APRN). There were no youth who were alleged victims of a Prison
Rape Elimination Act (PREA) event.
None of the reviewed records were eligible for discharge planning. A request for three additional
closed records was made and records were provided. Each record review indicated the
discharge plan was documented on the Department’s Mental Health Substance Abuse
Treatment Discharge Summary form and was completed upon the youth’s discharge. Evidence
supports a copy of the mental health discharge summary was provided to the youth,
parent/guardian as allowed and the juvenile probation officer (JPO). In each record,
documentation practices adhered to Department policy. In each record, all uploaded additional
information was completed within fourteen days, provided the completion date of service, and
contained signature of the licensed mental health professional. A mini treatment team review
was able to be reviewed during the week of the annual compliance review. No issues were
noted/reported. The designated mental health clinician authority (DMHCA) was interviewed and
reported the DMHCA works as a licensed clinical social worker (LCSW) to provide appropriate
supervision to all mental health staff. The DMHCA reviews tracking daily, caseload boards in the
mental health office, and obtains Office of Health Services (OHS) reports to ensure all
documentation was completed appropriately, according to established guidelines.
Documentation completed by mental health staff is reviewed by the DMHCA, to include but not
limited to, psychotherapy progress notes, all assessments and evaluations, initial and
individualized treatment plans and reviews, and discharge summaries. Additionally,
psychotherapy progress notes are reviewed by the DMHCA to ensure youth are receiving
treatment in accordance with their established treatment plan goals/objectives, and weekly
staffings with clinical staff are conducted to address any deficiencies noted during review.
Treatment plan reviews are completed once an individualized treatment plan has been
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established and are conducted every thirty days. Also, documentation reviewed includes youth's
psychotherapy progress notes, confinement reviews, discussion with detention staff and
administration regarding youth's behavior and/or progress and conferring with medical staff
youth receiving treatment with psychotropic medications are compliant with prescribed
medications. Further, after gathering the information needed to conduct a treatment plan review,
youth's diagnosis, symptoms, and goals and/or objectives will either be modified if a revision is
needed or will remain the same as prior should no clinical justification to make changes in a
youth’s diagnosis or treatment plan goals/objectives are identified.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
Seven youth mental health and substance abuse records were reviewed for mental health and
substance abuse treatment. All seven records were applicable for mental health and substance
abuse treatment. Documentation confirmed each youth was assigned to a treatment team which
consisted of mental health staff, educational staff, medical staff, and the youth’s
parent/guardian. All seven youth required mental health treatment and documentation revealed
each youth received individual, group, or family counseling provided according to the frequency
of the plan. Each plan included individual, group, or family therapy given at least weekly. Two of
seven youth required substance abuse treatment and documentation within each record
indicated each youth received individual, group or family counseling provided according to the
frequency of the plan. All seven records contained a current Authorization for Evaluation and
Treatment (AET). For the two youth requiring substance abuse treatment, the proper consent for
substance abuse treatment was signed. Each record contained treatment notes documented
on the Department’s Counseling/Therapy Progress Notes form. A video review of four groups
was conducted with a verified facilitator. The group durations were twenty-two minutes, nineteen
minutes, twenty-eight minutes, and eighteen minutes respectively. Mental health staff had
adequate access to youth and confidential space to provide treatment. Records review
confirmed group therapy was limited to ten or fewer youth with mental health diagnosis for
mental health groups and substance abuse groups was limited to fifteen or fewer for youth with
a substance abuse diagnosis.
Seven youth were interviewed. Five of seven youth reported mental health and substance
abuse services as very good. Two youth rated mental health and substance abuse services as
good. All seven of the youth provided additional information which included being able to see
the therapist regularly and had positive comments regarding the mental health staff. The
designated mental health clinician authority (DMHCA) was interviewed and reported youth's
comprehensive substance abuse and mental health evaluations are completed by their thirty-
first day and assist in identifying youth needs and determining recommendations for treatment.
Youth sign a consent for substance abuse treatment and release of substance abuse treatment
records prior to beginning the comprehensive evaluation. Utilizing a record review, mental
health staff reviews available records to complete comprehensive assessment if needed. Mental
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health staff will review initial treatment plans for any youth who were engaged in or are receiving
psychiatric services to ensure the diagnostic information from facility psychiatrist and current
psychotropic medications are carried over to youth's individualized treatment plan. Mental
health staff will concur with medical staff to verify youth's current psychotropic medications, to
include any holds, misuse, or noncompliance.
3.08 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 maintains a written plan detailing suicide prevention procedure. The center’s suicide
prevention plan was reviewed and signed by the designated mental health clinician authority
(DMHCA) and the superintendent. The plan includes identification and assessment of youth at
risk of suicide, staff training, suicide precautions, levels of supervision, referral, communication,
notification, documentation, immediate staff response, and review process as referenced. The
center has an established review process for serious suicide attempt or serious self-inflicted
injury and a mortality review for a completed suicide. The process includes the multidisciplinary
review of circumstances surrounding the event, center procedures relevant to the incident, all
relevant training received by involved staff, pertinent medical and mental health services
involving the victim, possible precipitating factors, recommendations, if any, for changes in
policy, training, physical plant, medical or mental health services and/or operational procedures.
3.09 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk. Any
youth exhibiting suicide risk behaviors must be placed on suicide precautions (precautionary
observation or secure observation), and at a minimum of constant supervision. All youth
identified as having suicide risk factors by screening, information obtained regarding the
youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Seven youth records were reviewed for suicide prevention services. All seven were eligible for
suicide prevention services. Seven of the eligible youth were determined to be at risk and were
exhibiting suicidal risk behaviors during the admission screening process. Each youth was
placed on precautionary observation (PO). The remaining youth self-reported suicidal risk
behaviors subsequently to admission and was placed on PO. In five records, a suicide risk
assessment referral was initiated as well as an alert entered in the Department’s Juvenile
Justice Information System (JJIS). In the remaining two records, a suicide risk assessment
referral was initiated however, an alert was not entered in a timely manner. Each Assessment of
Suicide Risk (ASR) was completed on the Department’s required form and information was
documented in real time. Six of the eligible youth were placed on constant supervision prior to
completion of the ASR. The remaining youth was placed on standard supervision after
completion of the ASR. Suicide PO logs in each record were completed in its entirety with
documented signatures and safe housing areas. In each case, a qualified mental health
professional was involved. In reference to procedural guidelines for ASR completion, there was
no evidence which indicated the eligible youth were released from PO prior to receiving an ASR.
There is evidence in each eligible record indicating staff documented a consultation with the
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designated mental health clinician authority (DMHCA) or licensed mental health professional on
the mental health and substance abuse referral summary, the superintendent was notified
immediately of suicide risk, the referral to the mental health professional contained a date and
time, and the date and time the youth was placed on PO was documented. Each ASR was
completed within twenty-four hours of referral. Follow-up ASRs were not required as no youth
were determined to be in crisis Each eligible record contained documentation to confirm a
conference was held by the center’s superintendent and a mental health professional to reduce
level of supervision, the date and time discontinuation of PO, and discontinuation of close
supervision was documented in accordance with the center’s suicide prevention plan. Each
youth was stepped down to standard supervision. All suicide risk assessments were completed
by a licensed mental health professional. All ASR’s provided results of the assessment including
recommendations for supervision and follow-up, there was evident in the center’s logbook and
the ASR indicating staff was provided specific instruction related to ASR findings and precaution
decisions. A review of JJIS determined all alerts were entered and removed following the
youth’s removal from PO. A review of logbooks determined the beginning and ending times for
youth placed on PO were documented. An interview with the DMHCA was conducted. The
DMHCA reported written concurrence of supervision level recommendations are communicated
by email and include all mental health clinicians and center administration. Additionally, seven
staff were interviewed and reported if a youth expresses suicidal thoughts, staff are responsible
for notifying the mental health authority and supervisor. Three of seven staff provided additional
information which included staff are responsible for constant sight and sound supervision. Also,
seven youth were interviewed. Two of seven interviewed youth reported they were placed on
suicide watch while at the center. Both youth’s stated staff watched them the whole time.
3.10 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.
Seven youth mental health and substance abuse records were reviewed for secure observation
documentation, none were applicable. Additional files were requested for review. The center
provided three records. No additional records were applicable for secure observation during the
scope of the annual compliance review period. Documentation in each relevant record
documented the youth’s placement in secure observation was authorized by the superintendent
and the designated mental health clinician authority (DMHCA), the secure room was designated
in writing, and the Department’s Health Status Checklist was completed prior to placement in
secure observation. The Suicide Precaution Observation Logs were completed in their entirety
for each reviewed record, and a follow-up Assessment of Suicide Risk (ASR) was completed
within eight hours of placement with parental and juvenile probation officer (JPO) notification
indicated. None of the records indicated the youth remained on secure observation beyond
twenty-four hours. Mental health staff did provide supportive counseling services during secure
observation, and observation logs did document supervision and the youth’s level was only
reduced after conference with the superintendent and licensed mental health professional. In
two of three records, discontinuation of secure observation and step-down to close supervision
was documented in the center’s logbook and youth’s mental health record by mental health
clinical staff. In the remaining record, discontinuation of secure observation and step-down to
close supervision was not applicable as the youth was released into the custody of law
enforcement officials due to arrest. This information was documented in the center’s logbook.
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3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Seven youth records were reviewed for suicide precaution observation (PO) logs. Seven
records were eligible for PO logs. In each eligible record, the PO logs were maintained for the
duration the youth was on suicide precaution, the appropriate level of supervision and
observations of the youth’s behavior was documented in real time and did not exceed thirty-
minute intervals. None of the seven youth were applicable for observed warning signs. PO logs
were reviewed and signed by each shift supervisor and mental health clinical staff. All PO logs
documented safe housing requirements. A review of video footage and corresponding
documentation of youth on PO or secure observation confirmed proper supervision was
maintained.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Fourteen staff training records were reviewed for suicide prevention training. Seven staff were
reviewed for pre-service and seven were reviewed for in-service training. Documentation
supported staff training included suicide drills held no less than quarterly on each shift. The
center maintains three suicide response kits. Each was observed during the scope of the annual
compliance review. One suicide response kit is located in medical, one in the hall near the girl’s
module, and one in the hall near the staff training room. The kits are co-located with the first aid
kits. The center’s suicide training does include mock drills for staff who have contact with youth
including kitchen and maintenance staff. All mock drills were in response to a suicide attempt or
incident of serious self-injury. There were no youth used in drill simulation related to mental
health or substance abuse care. The program provided semi-annual training on emergency
response procedures which include mock training in emergency response to a suicide attempt
or incident of serious self-inflicted injury. Staff who were not present during quarterly drills had
an 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 incident of
serious self-inflicted injury. Seven staff were interviewed and each reported suicide response
kits are in master control, medical, sub control, shift supervisors’ office, and the hallway.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
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pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center maintains a mental health crisis intervention plan which is combined with the
emergency services plan. The combined emergency services plan contained all required
elements such as a notification and alert system, means of referral including self-referral,
communication, supervision and documentation and review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center maintains an emergency care plan which includes all required elements such as
immediate staff response, notifications, communication, supervision, transport authorization
process for emergency mental health and substance abuse services, transport for emergency
mental health evaluation and treatment, transport for emergency substance abuse assessment
and treatment, documentation, training, and review process. The plan was noted as approved
and last updated on August 19, 2025. The plan is located in the staff conference room and in
the staff training office and is accessible to staff.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
Seven youth records were reviewed for crisis assessments. Only one of the seven reviewed
records were eligible for a crisis assessment. A request was made for two additional records to
meet the minimum requirement. The center provided two applicable records and reported it as
the only other eligible records for crisis assessment during the scope of the annual compliance
review period. The crisis assessment in the eligible records contained the date the youth was
determined to be in crisis, the date of the crisis assessment, mental status examination and
interview, determination of danger to self/others, initial clinical impressions, supervision
recommendations, treatment recommendations, and recommendations for follow-up. A review of
the Department’s Juvenile Justice Information System (JJIS) revealed a mental health alert had
been entered for each youth. None of the youth were applicable for identification by direct care
or clinical staff as having acute emotional or behavioral problem or acute psychological distress.
The crisis assessment was conducted by a licensed mental health professional, and the
assessment was conducted immediately or within two hours for emergencies, or within twenty-
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four hours based on the needs of the youth. In all three records there was evidence which
indicated each youth was an alleged victim in a Prison Rape Elimination Act (PREA) event and
each youth was offered ongoing mental health treatment services.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth records were reviewed for Baker and Marchman Acts. None of the reviewed
records were eligible for a Baker or Marchman Act. A request was made for additional records.
The center provided one record which qualified for Baker Act and reported it as the only eligible
record for the scope of the annual compliance review period. A suicide risk alert was entered
into the Department’s Juvenile Justice Information System (JJIS) while pending off-site
transport, the youth was placed on one-to-one supervision, supervision was documented on a
precautionary observation (PO) log until authorized release, the youth was placed on suicide
precautions upon re-admission from Baker Act, and a mental health referral (MSE) was made
for a mental status examination. The MSE was completed by a licensed mental health
professional, and the youth was maintained on a minimum of constant supervision until properly
transitioned to a lower level of supervision. The youths’ supervision level was maintained until
an appropriate assessment was conducted and mental health staff conferred with a licensed
supervisor and superintendent or designee. The discontinuation of the suicide risk alert entered
in JJIS was based upon an assessment of suicide risk. The discontinuation of the JJIS mental
health alert and constant supervision was based on the crisis assessment.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center’s designated health authority (DHA) is a board-certified physician who is a licensed
medical doctor (MD), specializing in family practice. The DHA license is unrestricted and meets
all requirements for independent and unsupervised practice in the State of Florida. The DHA’s
licensure expires on January 31, 2026. The center utilizes an advanced practice registered
nurse (APRN). Observation confirmed the collaborative practice protocol is in place.
Documentation review confirmed the DHA has been on-site at least twice a week as
contractually required. The center does not utilize a back-up DHA. The specific duties of the
DHA consist of being responsible for performing Comprehensive Physical Assessments (CPA),
conducting periodic evaluations, sick call, as well as policy and procedure development. Tele-
medicine was not utilized during the scope of the annual compliance review period. The DHA
was interviewed and stated performing CPA, conducting periodic evaluations, sick call, and
policy and procedure development as role responsibilities.
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 facility operating procedures (FOP) for all health-related procedures and
protocols. The designated health authority (DHA) and superintendent signed the FOPs on June
11, 2025, and the psychiatrist signed on June 12, 2025, for all respective treatment FOPs. No
new policies or changes were made during the annual compliance review period. The FOPs and
nursing protocols were reviewed annually as required and signed on September 11, 2025.
Newly employed healthcare personnel received a comprehensive clinical orientation to the
Department’s health care policies and procedures, which was conducted by a registered nurse
(RN). Nursing staff reviewed, signed, and dated a cover page between the dates of January 12,
2025, and July 15, 2025, of 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.
The center maintains facility operating procedures (FOP) addressing Authority for Evaluation
and Treatment (AET) or a Limited Consent for Evaluation and Treatment (LCET). Seven youth
Individual Healthcare Records (IHCR) were reviewed for requirements. Each IHCR contained a
filed Department AET. Each of the AETs was signed by appropriate parties, was obtained prior
to providing medical services, and was valid. The nurse was interviewed and was able to
describe the process for obtaining a new or current AET.
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4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains facility operating procedures (FOP) addressing parental
notification/consent. Seven youth Individual Healthcare Records (IHCR) were reviewed for
inclusion of requirements. A total of four IHCRs were applicable. Each IHCRs contained
documentation of parental notification for over-the-counter (OTC) medication beyond those
covered by the Authorization for Evaluation and Treatment (AET). Each of the four IHCRs
contained evidence written notification was sent using the Department’s Parental Notification of
Related Healthcare form. None of the youth were taking psychotropic medications at admission.
Four youth were on medications, with two of them being on psychotropic medications. All four
youth had prescribed medications, had medications discontinued, or had a significant change in
the dosage while at the center. Each IHCR contained evidence written notification/consent
showing an attempt to obtain signed parent/guardian consent was initiated. None of the youth
had any involvement with the Department of Children and Families. All seven IHCRs included
documentation confirming vaccinations were verified within thirty days of admission. One of
seven youth required consent for obtaining vaccinations. Consent was obtained prior to
administering the vaccination and the appropriate Department Parental Notification of Health-
Related Care form was utilized. The vaccination/immunization was provided as soon as
possible after receiving consent. None of the seven reviewed youth were applicable for
obtaining Religious Exemption from Immunization. The nurse was interviewed and was able to
describe the process of when parental notification is needed and for what situations, the
process for ensuring timely parental notifications are made when required, what procedures are
followed when the youth’s illness or injury requires emergency medical services or is life
threatening, and the procedures for informing the parent/guardian when obtaining consent for
new psychotropic medications, discontinuances, or psychotropic medication adjustments. The
nurse also indicated vaccines are not provided on-site and immunization records are obtained
online through Florida Shots. The nurse further stated the program has thirty days in which to
obtain consent for and administer necessary vaccinations. If a parent/guardian claims
exemption and does not consent to vaccinations for religious reasons, then they must complete
the Religious Exemption from Immunization form provided by the Health Department, have it
signed and authorized there, and then submit this to the center. Copies of the exemption will be
filed in the IHCR.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center utilizes facility operating procedures (FOP) to ensure youth are screened upon
admission for healthcare concerns which may need a referral for further assessment by
healthcare staff. Seven youth Individual Healthcare Records (IHCR) were reviewed for
requirements. Documentation review of each record confirmed the Medical and Mental Health
Admissions Screening form was completed on the date of each youth’s admission. A juvenile
justice detention officer (JDO) completed each screening. Each screening was reviewed with
the youth by a licensed medical staff within twenty-four hours. Each record contained
documentation the designated health authority (DHA) was notified. None of the seven records
reviewed were applicable for facility entry physical health screening re-screening. A request was
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made to the center to provide three additional records of applicable youth. The additional IHCRs
were reviewed for requirements. Documentation in each record confirmed there was a change
in physical custody since the youth’s arrival to the center. Each record contained evidence a
healthcare admission re-screening was completed each time a change in custody occurred.
One of three youth was applicable for a qualitative urine pregnancy screening test.
Documentation review confirmed youth’s consent. The nurse was interviewed and stated newly
admitted youth are seen generally within the first twelve hours and always within twenty-four
hours. Admission screening is completed by center staff and the information is documented on
the screening form.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains facility operating procedures (FOP) to ensure all youth are oriented to the
general process of healthcare delivery services. The center’s FOPs contained all the required
elements such as access to medical care, sick call process, what constitutes an emergency and
when to notify staff, medication process including side effect monitoring, the right to refuse care
and how it is documented, what to do in case of a sexual assault or attempted sexual assault,
non-disciplinary role of the health care provider, and general infection control/hygiene.
Documentation review confirmed each youth received a general healthcare orientation. Health
education topics were documented on the appropriate Department form and each youth
identified with a chronic condition was educated on their medical condition.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Seven youth Individual Healthcare Records (IHCR) were reviewed for designated health
authority (DHA)/designee admission notification. Only two youth were applicable and a request
to the center was made to provide an additional record to meet required minimum sample.
Each of the three applicable youth were admitted to the center with known or suspected chronic
conditions for which a referral to the DHA was made. None of the youth were identified as in-
need of emergency care upon admission. Notification to the DHA was documented in each
youth’s IHCR and the DHA was notified within twelve hours of admission. One of the three
youth were admitted to the center currently taking psychotropic medications. The one youth
being the additional record requested from the program to meet minimum requirements. The
psychiatrist was notified. The nurse was interviewed and was able to describe the process for
youth admitted to the center with serious or chronic conditions.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
Seven youth Individual Healthcare Records (IHCR) were reviewed for Health Related History
(HRH). Each IHCR contained a completed HRH form. Each HRH was updated and/or
completed within seven days of the youth’s admission. Each HRH form was updated and/or
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completed prior to the Comprehensive Physical Assessment (CPA) and focused evaluation as
evidenced by signature and date. Each HRH was completed by a licensed nurse practitioner.
Visual observation confirmed each HRH was reviewed by the designated health authority (DHA)
or advanced practice registered nurse (APRN). Each HRH form contained dates and signatures
for the most current admission. The nurse was interviewed and reported the HRH shall be
completed no later than seven calendar days following the date of admission and prior to the
youth being subjected to extreme outdoor weather conditions including, but not limited to, high
heat indices and frigid temperatures.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains facility operating procedures (FOP) addressing Comprehensive Physical
Assessment (CPA) forms and Tuberculosis screening (TB). Seven youth Individual Healthcare
Records (IHCRs) were reviewed for requirements. Each reviewed CPA was completed on the
Department’s required form. Three of seven youth had a current CPA on file at the time of
admission. The remaining four youth who had no current CPA on file had a CPA completed
within seven calendar days of admission. Six of the seven CPAs were completed by the
advanced practice registered nurse (APRN. Three of the six CPAs completed by the APRN
were current and were completed during previous admissions to the center. The remaining CPA
was completed by the designated health authority (DHA). Each CPA had the youth’s Medical
Grade documented with no missing or incomplete elements. Each of the three current CPAs
with no changes in the youth’s medical condition was utilized, and each of the three current
CPAs were reviewed as the youth was examined and signed off as reviewed by the DHA or
APRN. For each of the three youth who had current CPAs on file, a focused evaluation was
completed with each readmission where a new CPA was not initiated, and a current CPA was
used. All sections of each of the seven reviewed CPAs were marked with an X or O. Three of
seven youth refused part of the exam, and the clinician documented youth refused on each
CPA. Documentation confirmed each youth signed a refusal form which reflected the refused
portion exam. Each signed refusal form matched the date of the CPA exam. The Department’s
Problem List was updated as required in each IHCR. Five of the seven youth IHCRs contained
evidence a Tuberculosis (TB) skin test was administered within the past year. The remaining
two youth received a TB test within seven days of admission. The results of the TB test were
documented on six of the seven CPAs and the communicable disease form. The documentation
for the missing results on the one CPA was updated during the annual compliance review.
There was evidence to indicate each youth received a tier I TB screening completed within
seventy-two hours. No youth required further evaluation. The center’s FOPs regarding
appropriate documentation for refusal of any part of the exam and TB screening and
rescreening processes was reviewed. The nurse was interviewed and reported the CPA is
current if performed within the last two years. The nurse was further able to describe the
process and timeframe for TB screenings, and stated female gynecological exams are not
routinely completed.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center maintains facility operating procedures (FOP) addressing sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. Seven youth
Individual Healthcare Records (IHCR) were reviewed for requirements and three were
applicable. Each of the applicable youth reported being sexually active and each was screened
and evaluated for STIs. The designated health authority (DHA) reviewed each STI screening
tool, and each required further evaluation. Each referral was documented on the STI form.
Testing was ordered for each of the three youth. Testing for each applicable youth was ordered
with results documented on the Infectious and Communicable Disease (ICD) form and filed in
the appropriate section of the IHCRs. One of the three applicable youth is female and refused
the gynecological examination. None of the youth were out of the Department’s physical
custody requiring a re-screen. Documentation review confirmed each youth was offered
counseling and received HIV testing. Each of the three IHCRs contained a signed youth consent
form. HIV testing for each of the youth was completed within thirty days of the request. The
results were filed within the youth’s IHCR, there was documented proof the DHA reviewed the
results, and pre and post-test counseling was administered. Each youth’s confidentiality was
maintained and protected. Seven youth were interviewed. Six out of seven interviewed youth
reported they can request an HIV and/or Aids test when needed. One youth said no; however,
no further information was provided.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains facility operating procedures (FOP) addressing sick call process. Seven
youth Individual Healthcare Records (IHCR) were reviewed for requirements and five were
applicable. Each of the applicable youth sick calls were documented on the Department’s Sick
Call Referral Log. None of the youth presented with similar sick call complaints three or more
times within a two-week period. None of the sick calls were due to severe pain in which staff
were unfamiliar. Each of the youth completed a sick call on the Sick Call Request form. Each
IHCR contained evidence to confirm nursing staff completed the Sick Call Request form and
none of the youth sick calls were conducted by a licensed practical nurse (LPN). Each youth’s
sick call request form was filed in the youth’s IHCR in reverse chronological order. None of the
applicable youth were in restricted housing and all youth’s sick call forms were documented in
accordance with the appropriate Health Services rule. All reviewed sick calls were documented
on the Sick Call Index which corresponded with the Sick Call forms. Review of the center’s
posted schedule, as well as informal interviews with nursing, confirmed sick calls are conducted
Monday through Friday at 11:00 a.m. and 5:00 p.m., and on Saturday and Sunday at 10:00 a.m.
Sick call hours are posted in the medical station and in the living modules. Sick calls are only
conducted by a licensed nurse. 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. The center maintains a FOP for room
restrictions/confinement in which youth in restricted housing shall be afforded access to
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healthcare at equal or greater intervals of youth in regular housing. An observation of sick call
was conducted during the annual compliance review week. Prior to the observation, youth
consent was provided. The youth was escorted to the clinic by detention staff. Prior to initiation
of sick call, the medical provider did self-identify. The youth was seen in a private area with no
other youth present to see or hear the examination, and the exam was conducted in an area
which contained an exam table and equipment to perform the sick call. The staff escorting the
youth to sick call remained outside the medical station in the hallway. Seven youth were
interviewed regarding sick calls. Three reported they can be seen after three days of the request
being made, two reported within one day, one reported within two days, and one reported within
three days. One youth reported they have submitted a few sick call requests but never got a
response. The requests were submitted between two weeks and a month ago. Program
administration and medical was informed of youth responses. The documentation supports
medical staff is handling sick calls as required. Seven staff were interviewed regarding the sick
call process at the center. All staff reported medical staff reviews and conducts sick calls. The
nurse was interviewed and was able to describe sick call and the sick call process.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Seven youth Individual Healthcare Records (IHCR) were reviewed for episodic/first-
aid/emergency care requirements. Four of the seven youth required on-site first-aid or episodic
care. All four youth received episodic care or first-aid by a licensed healthcare staff and
documentation was written in subjective, objective, assessment, and plan (SOAP) format. None
of the applicable youth received episodic or first-aid care by a non-healthcare staff.
Documentation review confirmed each of the four youth complaints were documented with
findings of person rendering care as well as documented treatment rendered. None of the
applicable youth required a referral to off-site care. Education/instruction was documented in
each of the applicable youth’s IHCRs as well as documented plans for follow-up care. One of
four youth required placement on the center’s alert list and parental notification was
documented. Documentation review confirmed the Episodic/First-Aid Care Log contained entry
of each applicable youth’s episodic/first-aid care. Each youth received a follow-up evaluation
from a licensed healthcare staff. The were a total of nineteen first-aid kits located throughout the
center. First-aid kits were located in master control, each living module, kitchen, gym, principal’s
office, medical office, near the time clock, and each of six transport vehicles. Visual inspection
of a sample of three first-aid kits was conducted to ensure the kits were fully stocked with
approved contents. Each sampled first-aid kit contained designated health authority (DHA)
approved content. The center ensures content is maintained and stored in accordance with
guidelines. Guidelines include the process of first-aid kits and required content lists being
checked monthly. Reviewed checklist and confirmation is signed off by reviewer. Documentation
review confirmed the kits were monitored as required. There is a total of two automated external
defibrillators (AED) units at the center. One is in the medical clinic and the other in the hallway
leading to the module living area. The AED procedures are co-located with each AED. Both are
inspected monthly by nursing staff. A review of documentation confirmed the AEDs are
monitored as required. An expiration date inspection and self-test was conducted by nursing
staff during the annual compliance review week with no issues. The AED battery expiration date
is January 10, 2028. The AED batteries were last changed on January 10, 2024. The expiration
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date of the AED pads is April 28, 2027, and the AED pads were last changed on January 10,
2023. A list of emergency numbers, which included the number to Poison Information Center,
was posted and accessible to licensed and unlicensed staff. 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 epinephrin auto-injector. Seven staff records were reviewed which
showed training requirements were met regarding episodic care, first-aid, and emergency care.
Medical drills were not reviewed due to the center’s Outcome Based Corrective Action Plan
(OBCAP) being closed during the month of August 2025. The deficiency was assigned on June
12, 2025, for the following reasons: Master Control logbook entries were either not attached to
the Drill Report Summaries or incomplete of required entries in four (4) out of eight (8) drills
reviewed. Drills were not documented as simulated in five of eight drills reviewed. Rosters were
not attached to the Drill Report Summary in two of eight drills reviewed. Drills that were dated
for April 12, 2025, on alpha shift and April 12, 2025, on bravo shift were the exact same drill that
was copy and pasted to the Drill Report Summary. Drills that were dated for May 8, 2025, on
alpha shift and May16, 2025 on bravo shift were the exact same drill that was copy and pasted
to the Drill Report Summary.
The center’s policy on the use, access and inventory of Narcan states this medication must be
inventoried by a licensed nurse weekly. Narcan is administered when indicated and the
individual must be monitored for symptoms of overdose. Narcan is stored in the medication cart
and is accessible to the registered nurse and non-healthcare supervisory staff. Each staff with
access to Narcan has been trained on when and how to use it, which was evidenced by a
review of training sign-in logs. Seven staff were interviewed and all staff reported they can call
9-1-1 when they feel it is necessary. Seven youth were interviewed about the medical care at
the center. Two youth rated the medical care at the center poor, two rated it fair, one rated as
good, and two rated it very good. The nurse was interviewed and was able to describe the
process for on-site episodic care. For youth who are sent off-site for emergency care, their
names are written into the provider log to be seen for evaluation following the emergency care.
The nurse further reported the center does have AEDs and the procedures are located with
them. The nursing staff conduct checks to ensure AED batteries and pads are operable. The
nurse reported a list of emergency telephone numbers and cell phones numbers, including the
number of the statewide Poison Information Center, which should be posted or located so it is
accessible to all staff on all shifts. These numbers are posted in the clinic and were not
accessible to the youth
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center maintains facility operating procedures (FOP) addressing off-site care/referral.
Seven youth Individual Healthcare Records (IHCR) were reviewed for requirements. Two of
seven IHCRs were applicable for off-site care. A request was made for the center to provide an
additional applicable record to meet minimum requirements. Documentation review of the three
applicable IHCRs confirmed each youth required off-site care. Two of the three IHCRs
contained documentation of a completed Summary of Off-site Care Consultation Report form.
The remaining IHCR did not contain a completed form. Off-site emergency care for each of the
three youth was documented on the Episodic Care Log. Each IHCR contained evidence of
parental notification. Each IHCR contained discharge documents, and the designated health
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authority (DHA) reviewed all findings, instructions, and information as evidenced by signature
and date. No emergency event required notification to the DHA. Two of the three applicable
youth required follow-up testing, referrals, or appointments. Each follow-up referral was entered
on the Sick Call Log or referral tracking log. Each of the two IHCRs contained documentation to
verify referrals were tracked and the youth received appropriate, timely follow-up care as
needed. The nurse was interviewed and reported following off-site care; youth are added to the
providers log to be evaluated following the care. The nurse was able to further describe the
process for off-site care.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center maintains facility operating procedures (FOP) addressing chronic conditions/periodic
evaluations. Seven youth Individual Healthcare Records (IHCR) were reviewed for
requirements. Two of seven IHCRs were applicable for requirements. A request was made to
the center to provide an additional applicable record to meet minimum requirements. A total of
three records were reviewed. Each of the three applicable youth was identified on the
Medical/Mental Health Screening form as having a chronic condition. None of the three
applicable youth were diagnosed with a communicable disease. One of three youth was taking
prescribed medications on an on-going basis. The one youth taking medications on an on-going
basis is the additional record received from the program to meet minimum requirements. Each
of the youth were undergoing treatment for a physical condition and each was classified with a
Medical Grade between two and four. None of the youth were identified as pregnant. Each of
the three youth were placed on the chronic conditions list. Two of the three youth received
periodic evaluations as required. The remaining youth was at the center for an insufficient
amount of time to qualify for a periodic evaluation. Progress notes for the two applicable youth
receiving periodic evaluations were reviewed. Neither youth was taking anti-Tuberculosis (TB)
medications, was pregnant, had periodic evaluations conducted prior to renewing an expired
prescription medication, nor had an evaluation conducted off-site. The reviewed documentation
confirmed there were no lapses in care or missed periodic evaluations. The Department’s
Problem List for each youth was updated in accordance with the Health Services Rule and each
periodic evaluation was tracked. The nurse was interviewed and reported the center monitors
chronic conditions by way of a chronic condition log. The designated health authority (DHA) was
interviewed and reported periodic evaluations are completed every thirty days. Chronic clinics
are done every ninety days. The clinics are scheduled after each initial or follow-up visit.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center maintains facility operating procedures (FOP) addressing medication management.
Seven youth Individual Healthcare Records (IHCR) were reviewed for requirements. None of
the youth were taking medications at the time of admission. Five of seven youth were
prescribed medications subsequently to admission. Medication for each youth had a current
valid order and medications were administered pursuant to the current prescription. Three of the
five applicable youth had medications continued, discontinued, changed or new ones ordered.
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For each applicable youth, the designated health authority (DHA) or advanced practice
registered nurse (APRN) placed an order on the Practitioners Order form. None of the youth
were in restricted housing. Three of the five applicable youth were receiving over-the-counter
(OTC) medications not listed on the Authority for Evaluation and Treatment (AET) and each was
administered according to approved protocols or practitioner order. For each of the five youth
receiving medications, the Department’s Medication Administration Record (MAR) was utilized
to document all medications and treatments. Each MAR clearly indicated medication start and
stop dates. No medications were administered by non-health care staff. There were no
undocumented explanations for lapses or errors in medication administration and no refusals of
medication or treatment on any MAR. Each MAR contained all the required elements including
the youth’s name, Department identification number (DJJID), date of birth, youth allergies,
precautions, Medical Grade, medical alerts, and current picture of youth. Each MAR indicated
nursing staff documented weekly side effect monitoring and each MAR contained youth and
staff initials for each administered and provided medication entry. No youth required parenteral
medications. Documentation review confirmed there were no standing orders for psychotropic
medications, emergency treatment orders for psychotropic medication, or any orders pro re nata
(PRN) psychotropic medications. During the annual compliance review week, an observation of
medication administration was conducted. Youth consent was acquired prior to the observation.
The youth was escorted to the medical station by direct staff. The youth individually approached
the licensed medical staff administering the medication. The licensed medical staff identified
themselves and informed the youth why they were there. The same licensed medical staff
preparing the medication also administered the medication. The youth’s allergy status was
verified. Medications were administered by healthcare professionals. Prescription medications
were not pre-poured from original packaging. Nursing staff observed youth to make sure
medications was swallowed. After receiving medications, the staff and youth initialed the MAR.
The center’s process for medication disposal dictates prior to destruction, all medications are
identified for destruction. All medications are disposed of by use of an RX destroyer. Controlled
medications are destroyed by the pharmacist along with one nursing witness. Non-controlled
medications are destroyed between two nursing witnesses. Seven youth were interviewed. Six
youth reported the nurse gives them their medication. One youth did not take medications.
Seven staff were interviewed and all seven reported they do not give medication to youth. The
nurse was interviewed and was able to describe the process for nursing staff to verify a youth’s
medication regimen when admitted with medications, what type of MAR the program uses,
whether non-healthcare staff provides medication, and what is the training curriculum for the
non-healthcare staff. The nurse further reported medication pass times are seven days a week
four times a day. The nurse also described the medication procurement process
4.16 Psychiatric Services [Contract Provider] 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 maintains facility operating procedures (FOP) addressing psychotropic services.
Seven youth Individual Healthcare Records (IHCR) were reviewed for requirements. Two of
seven IHCRs were applicable. A request was made and the center provided an additional
applicable record to meet minimum requirements. A total of three records were reviewed. One
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of three applicable youth were admitted to the center on psychotropic medications. The one
youth being the additional record provided by the program. The initial diagnostic interview for
the youth who was admitted to the center was completed within fourteen days of admission. All
three applicable initial diagnostic interviews contained the reason for referral, history, Mental
Status Examination, diagnosis, treatment recommendations, and prescribed medications. Each
record contained the explanation of the need of the psychotropic medication and the frequency
of the medication management. One of three IHCRs indicated an in-depth psychiatric evaluation
was completed within thirty days of admission. The remaining two in-depth evaluations were
completed subsequent to thirty days as each of the two youth requested an evaluation after
admittance. The in-depth psychiatric evaluation in each record included the reason and factors
leading to
the referral, history, history of psychiatric illness, psychotropic medication management, mental
health treatment and or substance abuse treatment, Mental Status Examination, identification of
individual, family and or environmental factors which may potentially account for, influence, or
amelioration of difficulties, diagnostic formulation, treatment recommendation and interventions,
prescribed medications and frequency of medication management, and the explanation of the
need for psychotropic medications related to youth’s diagnosis, target symptoms, potential side
effects, risk, and benefits of taking medications. Documentation review also confirmed each of
the three applicable in-depth psychiatric evaluations contained the most recent applicable
therapeutic serum levels and signature of the practitioner conducting the evaluation. Two of the
applicable youth were prescribed new medication or had changes made to existing medications.
Page three of the Clinical Psychotropic Progress Note (CPPN) was completed and the CPPN
was clearly identified. Each applicable youth record contained all the required information when
psychotropic medications were prescribed, dispensed, or administered by the psychiatrist,
including identifying data, diagnosis, target symptoms, evaluation and description of effects of
prescribed medication on target symptoms, medication name, dosage and quantity, ordered
dosage, frequency and route of administration, reasons for changes in medications or dosages,
side effects, youth’s adherence to medication regime, height, weight, weight, blood pressure,
most recent serum drug levels or laboratory findings, whether telephone contact with youth or
guardian to discuss medication, signature of psychiatrist, and date of signature. The psychiatrist
and nursing staff documented monitoring for Tardive Dyskinesia monthly on the CPPN in each
of the applicable youth records. Each record contained an appropriate Department Authorization
for Evaluation and Treatment (AET). Two youth were prescribed new medications, medication
discontinued, or significant change in dosage. Each IHCR contained evidence the
parent/guardian provided verbal consent for the medications through the documentation on the
CPPN page three. None of the youth were involved with the foster care system or had
parent/guardian with terminated rights. None of the youth were over the age of eighteen. The
center utilizes tele-psychiatry. The standard of psychiatric care delivered through tele-psychiatry
was the same as rendered in person for each youth. Tele-psychiatry was utilized only for youth
who agreed to participate, and proper consent was obtained for each youth. The center has a
psychiatrist who is board certified in Child Adolescent Psychiatry with a license expiration date
of January 31, 2027. The center does not utilize a psychiatric advanced practiced registered
nurse (APRN). The back-up psychiatrist is licensed under chapter 458 with a license expiration
date of January 31, 2026. The back-up psychiatrist maintains equal education of the
psychiatrist. The designated mental health authority was interviewed and reported the DMHCA
meets with the facility psychiatrist twice weekly, on Wednesday or Thursday by email regarding
youth being referred to psychiatry for the following week to provide the psychiatrist with all
documentation and information needed to carry out evaluations on the following Monday. On
Monday prior to providing psychiatry services to the youth at 11:00 a.m., the DMHCA and/or
mental health staff discuss any issues with the youth’s mental health, behavior, and/or
medication compliance issues with the psychiatrist. Upon completion of all evaluations, the
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DMHCA and/or mental health and the psychiatrist discuss evaluation findings to ensure
understanding of any changes or issues reported by youth to psychiatrist.
4.17 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider] (Critical)
Any medical equipment classified as and stock medications shall be secured and inventoried
by using a routine perpetual inventory descending count as each sharp is utilized and
disposed of or when the medication is utilized.
The center maintains facility operating procedures (FOP) addressing medication/sharps
inventory and storage. Visual observation confirmed medical equipment classified as sharps
were secured and inventoried utilizing routine perpetual inventory with descending counts as
each sharp was utilized and disposed. All medications were identified and secured in the
appropriate designated storage area. The medication cart was clean and organized with stock
items separate from youth specific medications. Visual observation confirmed all controlled
substances were perpetually inventoried and stored separately from other medications. All
medications were stored in a separate secured area which was inaccessible to youth. Narcotics
and other controlled medications were stored behind two locks. Oral medications were not
stored with injectable or topical medications. Medications which required refrigeration were
stored in a secured refrigerator which was only used for medications. Visual observation
confirmed inventory of all sharps and stock over-the-counter (OTC) medications was conducted
perpetually and weekly. Pursuant to Board of Pharmacy regulatory requirements, a shift-to-shift
inventory count of all controlled substances was conducted and documented on the youth’s
individualized Controlled Medication Inventory Record. Documentation review confirmed non-
healthcare staff were trained in the delivery and oversight of medication self-administration
when non-licensed medical staff are not on-site. Non-healthcare staff training was conducted by
a registered nurse. A sample of three controlled medications were reviewed and counts of the
items matched the ending inventory numbers. A sample of three OTC medications were
reviewed and counts of the items matched the ending inventory numbers. A sample of three
sharps were reviewed and counts of the items matched the ending inventory numbers. The
reporting criteria and procedures regarding inventory discrepancies dictates any medication
inventory discrepancy shall require notification to the superintendent and the Department’s
Central Communications Center (CCC). The nurse was interviewed and was able to describe
the process for medication disposal and the process for securing controlled substances.
4.18 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center maintains facility operating procedures (FOP) addressing infection control/exposure
control and education. Seven youth Individual Healthcare Records (IHCR) were reviewed for
infection control, exposure control, and education requirements. Records review confirmed each
youth received infection control/exposure control training. Trainings for each youth included
infection control training within seven days of admission, handwashing techniques,
universal/standard precautions, prevention/transmission of communicable disease,
vaccinations, and the Center for Disease Control and Prevention (CDC) guidelines for infection
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control. The center’s Exposure Control Plan was written in accordance with Occupational Safety
and Health Administration (OSHA) and included a risk assessment, listing all job classifications
in which staff have the potential for occupational exposure, and tasks or procedures which
would cause staff in job classifications to have an occupational exposure. The center’s
Exposure Control Plan includes a method of compliance which includes infection control
practices and the required engineering and work practice controls. The center’s infection control
procedures currently in place include 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 for common infectious
diseases of childhood, self-limiting episodic contagious illnesses, viral or bacterial infections,
Tuberculosis, Hepatitis A, B, C, human immunodeficiency virus (HIV), other outbreaks or
epidemics caused by any other infectious agent, outbreaks of pediculosis and or scabies,
Methicillin-Resistant Staphylococcus Aureus (MRSA), food-borne illnesses, bio-terrorist agents,
and chemical exposure in the workplace. The center’s process for needle-stick post exposure
evaluation states post exposure follow-up is required when an employee incurs an exposure
incident. It must be reported to the immediate supervisor. All staff who incur an exposure
incident will be offered post exposure evaluation and follow-up in accordance with OSHA
standards. Hepatitis B immunizations are made available for staff and all staff have access to
protective equipment. During the interview, nursing staff reported there were no instances in
which infectious diseases and sexually transmitted infections needed to be reported to the local
health department during the annual compliance review period. There were no instances which
required reporting to the Department’s Central Communications Center (CCC). There were not
three or more cases of reportable infectious diseases which needed to be reported to the local
health department and/or CDC during the annual compliance review period. An informal
interview with the center’s superintendent was conducted and it was reported there is a
separate file maintained which contains all documents for youth and staff who have experienced
facility/occupational exposure for a ten-year period as required. Seven staff in-service and pre-
service training records were reviewed. Documentation confirmed each of the staff received pre-
service or in-service training on the center’s specific Exposure Control Plan. The nurse was
interviewed and reported a copy of the exposure control plan is available, the infection control
training for staff is conducted by the registered nurse (RN), youth training is conducted on
admission, and the RN is responsible for training staff on the exposure control plan. The nurse
was able to further describe the process for secure storage and routine inventory of
medications.
4.19 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
Seven youth Individual Healthcare Records (IHCR) were reviewed for prenatal care/education.
None of the youth were applicable. A request for three additional records was made to meet
minimum requirement. Documentation review of each of the three records indicated prenatal
care began immediately upon determination of pregnancy and continued until discharge/transfer
and through postpartum. One of three youth was applicable for focused medical evaluation
every thirty days and evaluations were conducted as required. The two remaining youth were
released/discharged prior to the needed focused medical evaluation. Documentation review
further confirmed each youth received prenatal care at recommended intervals, was placed on
the internal alert system for vital nutrition and health awareness for staff, and an alert was
entered into the center’s alert system regarding sleeping arrangements. One of three youth
complained of issues related to pregnancy and notification was immediately forwarded to the
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designated health authority (DHA). Documentation confirmed daily monitoring for signs of
pregnancy complications were conducted and a post-birth psychological and physical care plan
was documented for each youth. Each IHCR contained evidence of education related to
pregnant youth was provided and the educational topics included the required elements. All
education was documented in the IHCR in the health education record. Each youth received
nutritious food in appropriate quantities for pregnant youth and routine monitoring during the
pregnancy was conducted by a licensed health care professional. Annual in-service education
on youth’s prenatal healthcare to all non-healthcare staff involved in the supervision or
treatment of youth, was conducted by a licensed nurse. The in-service training included
observation and monitoring of emergency care needs/symptoms of possible miscarriage. The
center maintains nursing protocols and treatment plans for pregnant youth. Confirmation with
lead reviewer indicated staff training records were reviewed for related education topics. The
nurse was interviewed and was able to describe what services are provided to pregnant youth, if
female youth are routinely tested for pregnancy upon admission, and the center’s process for
routine monitoring of pregnant youth. The nurse reported the designated health authority (DHA)
or advanced practiced registered nurse (ARNP) shall provide a routine, focused medical
oversight evaluation of the youth’s pregnancy every thirty days. The nurse further described diet
provisions for pregnant youth. Nursing staff provides non-licensed healthcare staff education on
girls’ healthcare.
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.
Youth supervision was conducted each day of the annual compliance review week. Staff was
observed supervising youth throughout each day during line movements, school, restroom
breaks during school, youth movements, recreation, before a transport, and during two code
blue responses on the B-one living module. All observed interactions were positive between the
staff and youth. Youth were in the sight of at least one detention officer at all times, with the
exception of when placed in sleeping rooms and during secure placement. All youth were
accounted for and accompanied by staff at all observed times. Master control authorized all
movement of youth prior to the youth being moved. All observed interactions between youth and
staff demonstrated active supervision. Seven staff were interviewed regarding safety and
security of youth and staff. Five staff reported there are enough staff to provide for the safety
and security of the youth and staff and two staff reported there is not enough staff.
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5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
There were postings of the center’s behavior management system (BMS) in all living areas. The
BMS posters clearly specified appropriate and inappropriate behaviors, rules, norms, and
expectations. The system included rewards for positive behaviors and consequences for
inappropriate behaviors. Confirmation of positive rewards were confirmed through a review of
the incentive calendar, which was posted in each living module and throughout the center. The
facility operating procedures (FOP) outlined the requirements for the implemented BMS. The
observed daily activities determined the center is implementing the BMS. The documentation
reviewed throughout the annual compliance review week confirmed rewards and consequences
are given in accordance with the BMS. There were no instances of inappropriate use of
restrictions or group punishment. Seven staff were interviewed regarding the center’s BMS. All
seven staff were able to summarize the BMS used at the program. The staff reported the
following is utilized as rewards at the center: dinner with the major, chips, wings, pizza, later
bedtime, games, incentive calendar, special haircuts, canteen, nachos, donuts, popcorn day,
and being able to level up. All seven staff reported the BMS is effective at the center. All seven
staff reported they speak with the youth to discuss the consequences being imposed, alternative
and acceptable behaviors, and the youth are given the opportunity to explain their behavior. Six
of the seven staff reported the supervisors provide feedback regarding the implementation of
the BMS through monthly, quarterly, or daily evaluations, conduct individual briefings, or they
may give immediate feedback based on the situation or incident. Six staff reported feedback is
provided as needed, five staff reported feedback is provided daily, one staff reported monthly,
and one staff reported it is provided quarterly. Staff were interviewed regarding what
consequences can be provided to the youth which included taking away levels and taking away
points. One staff reported they utilize the BMS for consequences and youth needs cannot be
taken away as a consequence. All seven staff reported meals, snacks, clothing, education, and
medical care cannot be taken away as a consequence for behavior. All seven staff reported
staff have never encouraged youth to beat up another youth. Seven youth were interviewed
regarding the center’s behavior management system (BMS). Three youth rated the BMS as fair,
two rated it as good, one rated it as poor, and one rated it as very good. All seven
youth were able to summarize the level system within the center. One youth did report they did
not like the level system due to it being “overly exaggerated”. Six youth reported being rewarded
with canteen, one youth added they can receive a five-minute phone call, can stay up longer,
receive a special visitation, and can do other fun activities. Another youth also stated they can
participate in the incentive activities which were located on the incentive calendar. All seven
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youth reported they are not allowed to punish other youth. Four youth did report they have been
sent to their rooms for punishment, which was a result of fighting and were placed in
confinement. Three youth reported handcuffs and leg irons are used on out-of-control youth to
prevent them from hurting themselves or others. Three reported they have not. All four youth
also reported they were placed in confinement. Four youth reported the consequences they
received were fair, one youth said it wasn’t fair, and two youth reported never having received
consequences. One youth reported their level was taken away as a consequence, five youth
reported having their mats taken away, two reported covers or blankets, one reported socks,
two reported their sweater, and three reported shoes were taken away. All four of the youth
reported their doors were shut and locked. One youth reported they are not used and three
youth reported this has never been witnessed. The superintendent was interviewed regarding
the center’s BMS. It was reported the center uses a level based system. Youth enter the facility
on a level one status which allows youth their basic rights. As the youth’s level increases, so do
their privileges. This includes, but is not limited to, a later bedtime, canteen, extra phone call,
and additional BMS activities. Youth will advance or regress in level based on their behavior
throughout the day.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures (FOPs) requiring visual ten-minute checks to
be conducted on youth during sleep time or other times such as during an illness or room
restriction. The center has a total of sixty-four cameras which were operational during the week
of the annual compliance review. The camera system is required to retain video recordings for
thirty days; however, there was an issue with the recording system, and it only retains
recordings for twenty-eight days. The appropriate technicians were alerted to the issue. An
electronic wand system is used in the center to document and record the visual ten-minute
checks conducted during sleeping hours and when the youth are in their sleeping rooms. The
center provided documentation for wand checks to be reviewed for the annual compliance
review period. A review of thirty-minute timeframes for one day a month for each living module
for the annual compliance review period was reviewed. All reviewed checks were completed as
required. One month of the annual compliance review period had one check one minute late
and one month having only one check nine minutes late. A review of video coverage was
conducted for all three living modules for ten-minute checks. All the recording samples revealed
ten-minute checks during youth sleeping hours were conducted in a timely manner in
accordance with policy. The assistant superintendent was present during the review of camera
footage, and the superintendent was notified of the video review findings. The assistant
superintendent reported center administration provides management oversight by conducting
weekly reviews of ten-minute checks to ensure fidelity. Seven staff were interviewed and
reported when a youth is placed in their room for sleeping or non-punishment reasons, staff
conduct checks every ten minutes.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
Counts conducted by the master control operator were observed daily during the annual
compliance review week. Each count was started by stopping movement, master control
conducting the count, and ended when the count of youth was confirmed. A sample of logbook
pages for eleven months, one full day a month, was reviewed for the annual compliance review
period. All eleven reviewed months included documentation counts were conducted: at the
beginning of each shift, following any emergency, emergency drills, prior to and following routine
group movement, anytime a population change occurs, randomly, at least once on each shift,
and head counts. Seven staff were interviewed and all seven staff reported counts are
conducted at the beginning of each shift and six staff reported they are conducted at the end of
each shift. All staff indicated counts are also done randomly throughout the day. In the event a
count cannot be reconciled, staff indicated all movement stops and counts are done manually
until the count can be reconciled. Staff indicated emergency counts are also conducted after a
power outage, when a youth is believed to be missing, and after any major disturbance or drill.
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5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center maintains logbooks in master control and in all three living modules. One day of
each month of the review period was reviewed in each of the logbooks for a total of eleven
days. All reviewed days included all required applicable elements. All reviewed pages had
numbers, and the date was documented at the top of each page. All entries were in standard
time with the name of the staff and youth involved with a brief description of events. All entries
included the initials of the staff making the entries. The times were not consistently documented
with a.m. and p.m. in the master control logbooks. All entries which would impact the safety and
security of the center, including medical, special needs, and mental health alerts, were
highlighted. Any errors were struck through with a single line and “void” written after the error
followed by the staff’s initials. Each logbook reviewed included documentation the
superintendent or designee reviewed and signed the logbooks on a weekly basis and provided
recommendations as to the completeness and accuracy of the information recorded. The
juvenile justice detention officer supervisors (JJDOS) reviewed the facility logbooks in master
control when assuming center responsibility, reviewed the living module logbooks daily when
accepting responsibility for the living area at shift change as evidenced by their signature and a
statement about assuming responsibility of the center. There was documentation in the
logbooks to support the superintendent, assistant superintendent, or staff in charge of the center
toured the youth living areas at least once during each shift and documented their visits in each
area’s logbook. The superintendent reported the JDOS review all logbooks for the last two shifts
at least once each shift. Administration staff reviews logbooks, at a minimum of once a week.
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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.
A review of the facility operating procedures included key assignment and usage, including
restrictions on usage, inventory, daily tracking, reconciliation of keys, secure storage of keys not
in use, procedures addressing missing or lost keys, and reporting and replacement of damaged
keys. The key inventory was reviewed to ensure the key rings on the inventory matched the
actual key rings in use and included the emergency keys. The master key inventory included the
ring number, number of keys on each ring, capability of each key, and to whom the key ring is
issued. The facility keys placed on key rings followed the color-coded system: officer keys were
blue, supervisor keys were yellow, administration keys were black, medical and mental health
keys were white, food service keys were green, education keys were brown, and emergency
keys were red. The key storage is located in master control and is not easily accessible while
locked. An observation of the distribution of keys and collection of keys was observed during the
annual compliance review week. Staff were observed turning in their personal keys, which were
placed in the secured lock box. Restricted keys and emergency keys were observed to be
located in the lock box. All facility keys were observed to be on a tamper-resistant ring. The
issuance of keys and key ring numbers were documented on shift reports 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 staff throughout the annual compliance
review week revealed they carried issued keys on their person at all times, did not allow youth
to handle facility keys, and did not remove keys from the facility or the facility grounds without
authorization from the superintendent. Keys were not mistakenly taken from the facility during
the annual compliance review week. There was one incident during the annual compliance
review period where a set of keys were missing. A review of the Department’s Central
Communications Center (CCC) report indicated the staff brought the keys back to the detention
center. A sampling of four key rings were observed and compared to the inventory and key log,
and no discrepancies were found. Three staff were interviewed regarding their issued keys and
the functions of each key. All three staff knew how many keys they were issued and the function
of each key. The master control operator was informally interviewed regarding the process for
restricting usage of keys. It was reported medical keys are located in master control and youth
and staff records are stored in secured areas of the center. Seven staff were interviewed
regarding key control processes. Seven staff reported the following keys are restricted: medical
records, mental health records, case management records, administration, supervisory keys,
building keys, maintenance, and education. All seven staff were able to describe the center’s
key control process. The superintendent reported permanent keys are issued to administrative
staff and the maintenance mechanic. The security of keys is maintained by staff adhering to the
facility operating procedures.
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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 maintains facility operating procedures (FOPs) for transportation, operation, and
maintenance of each vehicle used to transport youth. The center has a total of six vehicles used
to transport youth. Currently, one vehicle is at another detention center. Five vehicles were
available to be observed by annual compliance review team members. Reviewed
documentation validated each of the five vehicles had an annual vehicle inspection and the
center’s transportation staff conducted weekly and monthly visual checks of all transport
vehicles which included all required elements. All five vehicles have the appropriate number of
seatbelts, a seatbelt cutter, a window punch, updated fire extinguishers, and a first-aid kit with
approved items by the designated health authority (DHA). The vehicle logbooks indicated each
vehicle was searched for contraband prior to use and again upon return, number of youth
transported, and the destination with date and time for each transport. An observation of a
transport was conducted during the week of the annual compliance review, and the transporting
staff were observed following all required transportation procedures prior to transport. During
the week of the annual compliance review, five center vehicle were checked to ensure they
were locked when not in use. Four out of the five vans were secured. One side door on a van
was unlocked and was secured at the end of the inspection. Seven youth were interviewed. All
seven youth stated they feel staff are driving safely during transportation. None of the youth
stated they had seen anyone place contraband in a transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures (FOP) which incorporate maintenance and kitchen
tools. The FOP dictates where and how tools and kitchen utensils shall be stored while at the
center. The FOP also incorporates procedures if a tool goes missing or is damaged. An
inspection of the tool room was conducted, and no issues were found. All tools were hanging on
a shadow peg board. Each tool had a label below and “EJDC” was etched in each of them. One
tool was missing due to being damaged and having to be destroyed. There was a paper in its
spot with the name of the tool on it along with “being replaced”. All tools present matched the
inventory kept by the maintenance mechanic. A separate inventory is kept for when tools are
checked out and returned. No tools were lost following the completion of a work project. Five
maintenance tools and five kitchen tools were compared to the inventories. All tools were
observed to be secured and matched the corresponding inventories with no discrepancies
noted. All tools had markings for easy identification. The superintendent or designee signed the
kitchen tool inventory; however, did not sign the maintenance tool inventory. This was discussed
with the maintenance mechanic and was remedied by the end of the review week. The
superintendent signed the inventory for the current month. Youth are not allowed to use tools or
medical equipment. The youth are allowed to use mops, brooms, and scrub brushes under
direct supervision. An observation of youth using cleaning tools was not conducted due to the
youth not cleaning during the times the annual compliance review team was on-site. The
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maintenance mechanic reported if a tool should be missing, the center is immediately locked
down until the tool is found. If a tool is damaged, it is destroyed and thrown away in the
dumpster. The superintendent reported the maintenance mechanic has access to facility Class
A tools. Seven staff were interviewed regarding the center’s practice for damaged or missing
tools. One staff stated it is reported to the supervisor but was unsure what the rest of the
protocol is for damaged and missing tools. Six staff reported if it is damaged, remove the tool,
inform the supervisor and maintenance manager, review cameras, and a new one will be
purchased. None of the staff indicated what to do if a tool is missing. All seven staff reported the
youth are allowed to use mops and brooms. One staff also indicated the youth could use scrub
brushes and a dustpan. Seven youth reported they are allowed to use mops and brooms. Three
youth reported they are allowed to use scrub brushes. Additionally, one youth stated they are
allowed to use sponges and another youth stated they can use Lysol wipes.
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 Safety Plan for the center is incorporated into the Emergency Care Plan, which was
provided for review. All flammable, toxic, caustic, and poisonous items were inventoried
throughout the annual compliance review period. Safety Data Sheets (SDS) were located in a
binder near the items and available to staff. Only authorized personnel are permitted to access
the flammable, toxic, caustic, and poisonous items, which are stored in areas inaccessible to the
youth. Five items were observed which were located in the kitchen custodial closet. The count
of all five items matched the inventory and had an SDS sheet located with them. Seven youth
were interviewed about flammable, toxic, caustic, and poisonous items. Six of the youth
reported they are able to use cleaning agents and one youth reported they cannot. Six of the
youth reported the staff handle the chemicals and they wipe down whatever has been sprayed.
All seven youth reported they do not have access to flammable, toxic, caustic, and poisonous
items. Seven staff reported the youth are not allowed to clean with toxic, flammable, or
poisonous chemicals.
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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 a facility operating procedures (FOP) which documents the disposal
requirements of all flammable, toxic, caustic, and poisonous items. The center did not have any
instances of chemical spills or disposal of flammable, toxic, caustic, or poisonous items during
the annual compliance review period. The center does not have a grease disposal container as
nothing is cooked in grease. The maintenance mechanic reported when chemicals are to be
disposed of or destroyed, the center follows the Continuity of Operations Plan (COOP)
approved by Department personnel.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center had a total of 935 confinements under twenty-four hours during the annual
compliance review period and fifteen were selected for review. Fourteen applicable youth
received meals and/or snacks as required based upon the time they were in confinement. Two
applicable youth received a daily shower, and one youth was applicable to receive medical care
while in confinement due to complaints of an injury. Four out of ten applicable youth received
educational materials while six youth did not receive the materials. It was not documented as to
why the education materials were not provided to the youth. Administrative staff was made
aware and set up training for the juvenile detention officers (JDO) to ensure all required items
are provided to the youth in confinement. All fifteen youth were notified of their right to grieve a
confinement placement, and the supervisors approved all the confinements prior to placement.
The center places youth in separate confinement rooms to ensure there is one youth to each
room. Documentation supported the rooms were searched prior to placement. Documentation
supported all fifteen youth were provided an explanation as to the reason for their confinement.
Seven out of fifteen initial supervisory reviews were completed timely. Eight were conducted
between five minutes and one hour late. Administration was made aware of this issue and
planned to set up training for the supervisors. Additional supervisory reviews were completed
every three hours and documented counselling the youth, as required. Fourteen out of fifteen
confinement reports were completed by the end of shift with one being late. One out of fifteen
confinements interfered with visitation due to the incident occurring during the youth’s visitation
time. Thirteen out of fifteen superintendent or designee reviews were completed within forty-
eight hours of the incident. Two reviews were conducted late due to all approved staff being in a
mandatory training off-site. The youth room windows were free of obstructions and scratches
which allowed staff clear visibility to monitor the youth. The superintendent reported in an
interview, the juvenile detention officer supervisors (JDOS) will review and initiate the
confinements. Five-minute checks will be completed on a visual observation report (VOR) for
the first hour and every ten minutes after the first hour. The youth’s behavior will be documented
on the VORs. The JDOS will conduct a review within the first two hours of the youth being
placed on confinement and then every three hours. The JDSO will then document their review in
the Department’s Juvenile Justice Information System (JJIS), documenting why continued
confinement is necessary. The superintendent or designee shall review all confinement reports
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within forty-eight hours, excluding weekends and holidays, and will determine whether each
confinement was appropriate or inappropriate. Regional detention management staff review
confinements when there is a request to extend a confinement past the twenty-four hour mark.
Regional detention management staff review the use of lockdown any time all youth are placed
inside their rooms during the normal facility schedule. Regional detention management staff
review the use of restraints any time mechanical restraints are used and requested to be used
for more than sixty-minutes. Seven staff were interviewed regarding youth placed in
confinements. Five staff reported they search the confinement rooms, two staff reported they
complete the confinement report, and one staff reported they are to conduct ten-minute checks.
Additionally, staff reported they notify the supervisor, remove items from the room, and escort
the youth to confinement. Six staff reported they provide the youth education material if they are
in confinement during education hours. One staff reported staff do not. Another staff reported a
supervisor has to approve giving the youth anything while they are in confinement.
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 confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
A review of documentation revealed the center conducted two Continuity of Operations Planning
(COOP) drills during the annual compliance review period. The drill scenarios were provided for
review which included the type of drill, date and time of the drill, all participants, a brief scenario,
and the findings and recommendations. Both drills were conducted with no issues noted. The
superintendent reported in the survey the center’s COOP is the process for the relocation and
continued operations of the facility during an emergency or disaster. This plan ensures staff are
trained on how to respond in emergency situations and understand their specific responsibilities
and tasks as they relate to the plan. The plan is used to identify all provisions needed to
maintain continuous operations during an emergency and ensures the center can continue
these operations if evacuated to a secondary location.
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Office of Accountability and Program Support Page 54 of 57
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’s Escape Prevention Plan was reviewed, and it includes the Department’s policies
and procedures regarding escapes. Six out of eight required escape drills were completed each
quarter for each shift. Three drills were conducted during the fourth quarter, two on first shift
and one on second shift. One drill was conducted during the first quarter on second shift. No
drills were conducted on the first shift during the first quarter of the review period. No drills were
conducted on either shift for the third quarter. Two drills were conducted on the current quarter.
One drill was missing from the first quarter on the first shift and two drills were missing from the
second quarter of the review period. A review of seven staff training records confirmed staff
were trained in escape drills annually. A review of the master control logbooks also confirmed
the escape drills were conducted as documented. Seven staff were interviewed regarding
participation in COOP drills. One staff reported participating in a weather drill, three staff
participated in an escape drill, and all seven staff participated in a fire drill. The staff also
reported they participated in medical and mental health drills at the center. One staff reported
staff do not. Another staff reported a supervisor has to approve giving the youth anything while
they are in confinement.
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.
A review of fire drill documentation revealed the center conducts them monthly on each shift. A
review of the master control logbooks confirmed the drills were conducted as documented.
Documentation was provided which showed the fire extinguishers were inspected annually at
the center. All seven staff reported during their interviews they have fire drills monthly. Seven
youth were interviewed regarding fire safety. Six youth reported they have been instructed on
what to do in case of a fire and one youth reported they have not been instructed.
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Office of Accountability and Program Support Page 55 of 57
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOP) for search and contraband which include
electronic searches, frisk searches, strip searches, cavity searches, room searches, and
searches for staff and visitors. Documentation for searches was maintained in the Department’s
Facility Management System (FMS). A search of a youth was observed prior to the youth being
transported. The staff wore gloves, and the search was conducted by a staff of the same
gender. All reviewed strip searches were conducted individually and not in a group setting.
Room search documentation showed they are searched upon a youth’s release and prior to a
new youth entering a room. One day a month of room searches were reviewed for the annual
compliance review period. All searches were conducted during the awake shift. Electronic
searches of visitors and staff were conducted prior to entering the facility. All bags, cases, jacket
pockets, and other items were searched along with personal keys and contraband items being
removed prior to entrance to the facility. The center’s visitor log does not contain an attestation
form. The center has the forms on a clipboard outside master control where visitors sign-in.
Each visitor is to sign a new attestation form each day they visit the center. A binder of visitor
attestation forms is maintained inside master control, which was reviewed, and no discrepancies
were noted. Seven staff records were reviewed, and all contained an attestation form. There
was one incident involving contraband during the annual compliance review period. The center
documented the confiscation of the item in the master control logbook, and an incident report
was completed. Law enforcement was contacted and came to the center, interviewed the
persons involved, and removed the contraband from the center. The shift supervisor
documented the chain of custody of the confiscated item, and the Central Communications
Center (CCC) was contacted. The superintendent was interviewed regarding the center’s
process for searching youth, staff, and visitors. When a youth is admitted to the center, youth
are frisk searched, electronically wanted, and stripped searched. Youth are subject to random
frisk searches during their stay at the center. Additionally, youth are searched following any
transport, before leaving the dining hall after each meal, before leaving the classroom, and
before exiting the outside courtyard. The center’s procedures for contraband include contacting
local law enforcement and the contraband is confiscated. All contraband discovered is to be
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 57
documented in the master control logbook and an incident report is to be completed. Notification
of found contraband is reported to the CCC and regional director. The center has also partnered
with a Sheriff’s Deputy and K-9 unit to conduct random contraband searches of the facility.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 57

source: DJJ

report_type: QI Detention

file_name: EscambiaRJDC-Final FY2526.pdf