facility_name: Bay Regional Juvenile Detention Center

summary: QI Detention - FY23-24 - 4 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Bay Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
450 East 11th Street
Panama City, Florida 32401
Review Date(s): September 19-22, 2023
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Cedric Prince, Office of Accountability and Program Support, Lead Reviewer (Standard 1 and
Interviews)
Patrick Brock, Office of Education, Northwest Region Education Coordinator (Standard 2)
Jessica Gibson, Office of Accountability and Program Support, Regional Monitor (Standard 2)
LeAnn Gruentzel, Office of Accountability and Program Support, Regional Supervisor (Standard
1 and Interviews)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Ken Meyers, Office of Education, Northwest Region education Coordinator (Standard 2)
Courtney Preston, Okaloosa Regional Juvenile Detention Center, Superintendent (Standard 5)
Onazina Washington, Office of Accountability and Program Support, Regional Monitor
(Standard 3)
Program Name: Bay Regional Juvenile Detention Center MQI Program Code: 33
Provider Name: Department of Juvenile Justice Contract Number: NA
Location: Bay County / Circuit 14 Number of Beds: 32
Review Date(s): September 19-22, 2023 Lead Reviewer Code: 211
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
3.11 Suicide Precaution Observation Logs * 2.10 Educational Access*
5.14 Confinement Under Twenty-Four Hours 5.03 Ten-Minute Checks*
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 60 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 60 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Failed
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 60 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Limited
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 60 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 60 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Failed
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Limited
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 60 (Revised July 2023)
Program Overview
The Bay Regional Juvenile Detention Center is a state-owned detention facility operated by the
Department, located in Panama City, Florida. The center serves youth in Bay, Calhoun,
Washington, Holmes, Jackson, and Gulf counties in Circuit 14. Male and female youth who are
detained pending adjudication, disposition, or placement in a residential commitment program
are housed in the thirty-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 Bay County School
Board. The center’s management team includes the superintendent, two assistant
superintendents, one administrative assistant, one facility training coordinator, seven juvenile
justice detention officer (JJDO) supervisors, and thirty-one JJDOs. Mental health and healthcare
services are provided through the contracted provider, VitalCore. Mental health services are
provided by a licensed mental health counselor (LMHC) who serves as the center’s designated
mental health clinical authority (DMHCA), and three licensed mental health professionals.
Psychiatric services are provided by a licensed psychiatrist. Clinical services provided by the
center include mental health and substance abuse evaluations, mental health treatment
planning, individual, group and family therapy, mental health crisis intervention services, on-site
psychiatric services, and availability for substance abuse services for youth with co-occurring
disorders. Medical services are provided by one medical doctor who serves as the center’s
designated health authority (DHA), an advanced practical registered nurse (APRN), a full-time
registered nurse (RN) who serves as the clinic manager, two full-time RNs, and two part-time
licensed practical nurses (LPNs). The medical clinic maintains nursing coverage Monday
through Friday from 7:00 a.m. to 7:30 p.m., and on weekends from 8:00 a.m. until 4:30 p.m.
Food services are provided by Department staff and include menus, meal planning, meal
schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has two living modules which are divided by male and female.
There are sixty security cameras at the center, of which all were reported as operational,
however, due to a lightning strike, video is only observable in master control. No major
maintenance issues were observed. At the time of the annual compliance review, the center
reported having a total of eighteen staff vacancies, to include three JJDO supervisor positions,
eight JJDO I positions, and seven JJDO II positions.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 60 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
Eleven staff and one contracted staff were reviewed for initial background screening
requirements. Reviewed personnel records indicated each staff had a completed background
screening and documented criminal history report review prior to their hire date in the
Department’s Background Screening Unit (BSU). No exemptions were required. Each staff was
rated as eligible for hire. Eleven staff were applicable for the pre-employment assessment tool.
Each applicable staff had evidence of a passing assessment score in their personnel records.
Center administration reported having had no volunteers or interns eligible for screening during
the annual compliance review period. The center submitted their Annual Affidavit of Compliance
with Level 2 Screening Standards on January 13, 2023. The school board also submitted their
annual Affidavit of Compliance with Level 2 Screening Standards on January 13, 2023.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center had a total of two staff applicable for five-year re-screening requirements. The two
staff personnel records were reviewed, and confirmed both staff had an approved re-screening
completed within the required timeframe.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 60 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
Three staff records regarding the staff code of conduct were reviewed. All three staff had
evidence in their records of signing the code of conduct form. One staff was applicable for
violation of the code of conduct. The personnel record was reviewed and found evidence
management had taken action with the staff for allegations and/or findings in direct violation of
the center’s code of conduct. The one staff who received allegations of improper conduct was
ordered to have no youth contact and was eventually dismissed. An informal interview with the
assistant superintendent revealed the center is reintroducing Employee of the Month awards,
which one staff will be receiving by the end of the week. The center’s superintendent was
interviewed and stated staff must adhere to behavior which prohibits any forms of abuse,
profanity, threats, harassment, intimidation, or personal relationships with youth. Youth can file
grievances, and staff can be placed on no youth contact status until a management review is
performed. When there is suspicion or knowledge of abuse, the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC) will be contacted, and a report will be
made. If founded, disciplinary action, from written reprimands to termination, will take place.
Five staff were interviewed. Each staff was able to explain the process for reporting suspected
abuse. When asked if they had heard staff use profanity when speaking with youth, three staff
stated never, and two stated occasionally. When asked if they have heard staff use threats or
intimidation when interacting with youth, four staff stated never and one stated once. Five staff
were asked about the working conditions at the center in the past year. Three stated they were
fair, and two stated the conditions were good. Five youth were interviewed and three of five
youth stated they have never been stopped from reporting abuse while at the center, and two
stated they have never had to report abuse. All five youth stated staff are respectful when
speaking with them and other youth. Four youth denied staff ever threatened them or other
youth, and one youth stated it happened once. All five stated they felt safe at the center. None
of the five youth reported having exchanged social media information or telephone contact
information with staff at the center. When asked if they had heard staff use profanity, one youth
stated never, two stated once, and two stated they had occasionally heard it. The youth were
asked in what way the profanity was used, and each stated it was used once when the youth
were fighting and once when staff was trying to command the attention of the youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 60 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures in place regarding incident reporting. A tour of the
center was conducted, and observations reflected signs were posted throughout the center of
the Florida Abuse Hotline and the Department’s Central Communications Center (CCC)
telephone numbers. The center had fifty-three reportable incidents reported to the CCC during
the annual compliance review period, of which six were reviewed. All six incidents were reported
to the CCC within the mandatory two-hour timeframe and in accordance with the CCC reporting
procedures. All incidents were documented in the center’s master logbook. A review of internal
incidents/grievances for the review period determined there were no incidents which should
have been reported to the CCC which were not. An interview with the center’s superintendent
confirmed if there is an incident resulting in a need to contact CCC, it must be reported within
two hours of the incident or becoming aware of the incident. Any update to the incident is also
reported to the CCC the same day or by the next morning. The incident report is entered into
the Department’s Juvenile Justice Information System.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center has facility operating procedures to ensure staff use physical intervention techniques
in accordance with the Florida Administrative Code requirements. The center had 132
Protective Action Response (PAR) incidents since the last annual compliance review. A review
of nine PAR incident reports was completed. Seven of nine reports were completed on the
same day as the PAR incident and by the end of each staff’s shift. One PAR report was
completed the day after the staff’s shift, and one was completed five days later. Eight of nine
incident reports contained statements from all the staff involved. One report was missing a
statement from two staff. Three incidents involved a serious injury to staff or youth and were
reported to the Department’s Central Communication Center within two hours, as required.
Each of the nine reports was reviewed by a supervisor or a PAR instructor. Each PAR Report
documented a post-PAR interview was conducted with the youth by the center’s superintendent
and/or designee within thirty minutes after the incident. None of the reviewed PAR incidents
were applicable for mechanical restraints or a medical review. Four of nine PAR incidents were
reviewed by the superintendent/designee after completion within seventy-two hours, as
required. Five superintendent/designee were twenty-nine, thirteen, one, seven and one day late.
A review of internal incident reports, grievances, and logbooks indicated there were no
additional PAR incidents which did not have a report. The center’s PAR rate during the annual
compliance review period was 20.87, which is above the statewide Detention PAR rate of 17.52.
An interview with the center’s superintendent confirmed all incidents utilizing mechanical
restraints are documented in the logbooks and mechanical restraint log. All reports are reviewed
by administration to ensure incidents are in compliance, and statements are entered into JJIS
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 60 (Revised July 2023)
by all staff on the same day the incident occurred. Administration reviews all videos of incidents
prior to being signed off. Five interviewed staff indicated staff utilized verbal interventions before
the use of physical restraints or PAR techniques on a youth.
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.
Five staff training records were reviewed for pre-service training requirements. All staff reviewed
were juvenile justice detention officers (JJDO). All five staff completed all required pre-service
training within 180 days of hire, including phase one training and phase two at the academy.
The personal records indicated new staff orientation was completed within thirty days of hire. All
training were documented in the Department’s Learning Management System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
Five staff training records were reviewed for in-service training requirements. Three staff
reviewed were juvenile justice detention officers, and two were juvenile justice detention officer
supervisors. All five staff completed the required number of hours for in-service training, ranging
between forty-four and sixty-one hours. All five staff received training in Right Interaction (RI),
cardiopulmonary resuscitation (CPR), first aid, and automated external defibrillator (AED)
training. All five staff received the required hours for suicide prevention annual training. All five
staff completed active shooter, human trafficking, information security awareness, mental
health, substance abuse, Prison Rape Elimination Act (PREA), if applicable, ethics, sexual
harassment, and trauma-responsive practices training courses. The supervisory staff received
an additional eight hours of supervisory specific training. All training were documented in the
Department’s Learning Management System (SkillPro). The superintendent was interviewed
and stated they received management training in leadership development, manager training,
hiring, retaining, and including individuals with disabilities, mental health plan, recognizing
developmental disabilities, recognizing mental health and substance emergencies, officer
protocols, facility exposure, and girl’s health. All detention staff must complete twenty-four hours
of annual in-service training including RI, CPR, AED, First Aid, suicide prevention, mental
health, and professionalism training.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 60 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
A review of grievances during the annual compliance review period found a total of three
grievance completed, two of which were from the same day regarding the same incident. The
grievances had documentation of a response and were resolved within the specified timeframe.
In addition, a report was made by the center administration to the Department’s Central
Communications Center (CCC) regarding the incident and allegations made involving the staff.
Grievances are electronically entered into the Facility Management System (FMS) within the
Department’s Juvenile Justice Information System (JJIS). Grievance forms are available to
youth upon request. Grievance drop boxes were observed on each module. Five interviewed
staff were able to summarize the grievance process. Five youth were also interviewed regarding
the center’s grievance process. Three of the youth were able to describe the grievance process.
Two youth reported they knew of the grievance process but could not go through the steps.
Three of the youth have never filed a grievance. Two youth had filed a grievance and rated the
center's process as good. The superintendent was interviewed and described all three phases
of the grievance process. The superintendent stated the youth should sign a hard copy, which
should be uploaded into FMS.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 60 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures to ensure critical or special alerts are documented,
reviewed, and responded to appropriately. Alerts are entered into the Department’s Juvenile
Justice Information System (JJIS) and the internal alert system. Internal alerts and JJIS alert
reports are distributed and reviewed daily by the juvenile justice detention officer (JJDO)
supervisors and administration. Alerts are entered, downgraded, or discontinued in JJIS by the
appropriate staff on the date identified and/or when the alert is no longer applicable. All alerts
regarding youth medication or medical information are confirmed and verified between the
medical staff and the youth’s parents/guardians. The center's practice is to have a copy of the
detailed alert list for all direct care staff during each shift briefing. An observation of a shift
briefing could not be conducted during the annual compliance review week. Documentation
reviewed supported youth alert information was consistently discussed with the JJDOs at the
meeting, and JJIS was updated by medical, mental health, and other staff, as needed. Five
youth records were reviewed for case management, medical, and mental health alerts, with a
total of twenty-two alerts being reviewed. Each record documented all alerts were accurately
entered into JJIS on the same day identified, matching the center’s internal alert system.
Logbooks were reviewed and reflected alert documentation included gang affiliation, medical
status, Prison Rape Elimination Act (PREA) status, security alerts, mental health alerts, and
activity/sports restrictions. An interview with the center’s superintendent confirmed alerts are
created or updated during the intake process, validated by parent/guardian, and entered in JJIS
under the corresponding heading. Medical staff will complete or update medical alerts. Five
interviewed staff reported being informed by administration or clinical staff of alerts through shift
debriefing, alert forms, JJIS, school list, radio, emails, and throughout the day. Four interviewed
staff stated communication is very good at the center, and one staff indicated it is fair.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 60 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
An informal interview regrarding data trend analysis was completed with a captain at the center.
The center reviews incidents when they occur and analyzes trends to lower the number of
incidents by utilizing the behavior management system on a monthly basis. Information is
reviewed during monthly supervisor meetings, discussed during department head meetings, and
during quarterly advisory meetings. The center implements the collected data to improve their
processes by utilizingthe behavior management system to lower the number of incidents.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 60 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures (FOPs) for youth admissions. Five youth case
management records were reviewed for admission documentation. All five youth records had
the Department of Juvenile Justice Information System (JJIS) Admission Wizard printed and
placed in the youth record. All five youth records included documentation of the arrest
affidavit/custody order, Suicide Risk Screening Instrument (SRSI), youth full-body search and/or
electronic search conducted by an officer of the same gender, a meal being offered to the youth,
and a medical, mental health, and substance abuse screening. Four of the five youth records
included documentation of a Detention Risk Assessment Instrument (DRAI). One youth was
transferred in from a different center and did not require a new DRAI to be completed. Three of
the five youth records included documentation the youth received a telephone call. Two youth
records did not document a youth telephone call was offered or completed. An informal
interview with the superintendent confirmed after interviewing the two youth, they did receive
their phone call. The superintendent stated the supervisor who was on duty reported not
documenting the youth receiving their phone calls when they were admitted. A youth admission
was not observed as there were no new youth admitted while the review team was on-site.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 60 (Revised July 2023)
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures (FOPs) to ensure youth orientation occurs within
twenty-four hours of a youth being admitted into the center. Five youth case management
records were reviewed for the center’s orientation process. All five records included
documentation showing the center provided each youth with an orientation within twenty-four
hours of admission. All youth signed an orientation acknowledgement to document the contents
were discussed with the youth. A copy of the orientation acknowledgement forms was located in
each youth record. All five youth case management records confirmed orientation included the
rules and regulations of the center, grievance procedures, visitation, telephone calls, access to
medical, mental health, and substance abuse services, access to the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC), behavior expectations and
related consequences, possible new law violations for destruction of property, youth rights, and
Prison Rape Elimination Act (PREA) related information. Additionally, the PREA video was
viewed during all five youth orientations confirmed through each youth’s signature on the PREA
forms. Five interviewed youth indicated staff provided them with information regarding the rules
and regulations, daily schedule, education services, visitation, abuse reporting, and behavior
management system. A youth orientation was not observed due to the center not receiving
youth while the review team was on-site.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) to ensure all youth admitted to the center
are classified to provide the highest level of safety and security. Five youth case management
records were reviewed, and each contained documentation information concerning the youth’s
history and status, as well as all other required information. The Department’s Juvenile Justice
Information System (JJIS) Admission Wizards were completed and located in all five youth
records to be reviewed for room assignment based on potential safety and security concerns,
which included information on the youth’s sex, height, weight, age, and level of aggressiveness.
Considerations on the classification form included mental illness, intellectual disabilities,
physical disabilities, history of violent behavior, gang affiliation, criminal behavior, history of
sexual offenses, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
information, identified or suspected medical issues, identified suicide risk or suspected issues,
escape, and security. All five youth records indicated the youth were assigned to rooms based
on classification procedures, and if the youth had a history of committing sexual offenses or was
a victim of a sexual offense they were placed in a single room. None of the youth reviewed had
a reclassification at the time of the review. The superintendent was interviewed and reported to
maintain safety and security all classification factors are utilized when assigning youth to a
room. The superintendent also reported being notified of any related gang information during
the weekly detention reviews and through the JJIS alert system.
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2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has a screening process for youth newly admitted to the center to determine if the
youth is a gang member or gang affiliate. The circuit has a gang liaison, who is a senior juvenile
probation officer (SJPO). An informal interview was conducted with the SJPO regarding the
gang notification process. All gang-related information is disseminated through detention
reviews and by email. The SJPO reported the detention staff would complete and submit a gang
form. If the youth is identified as a gang member or associate while at the Juvenile Assessment
Center (JAC), the information would be provided to the gang liaison. The detention staff will also
announce any gang information during the weekly detention review meetings. The liaison
submits the gang form to the local sheriff’s department. The gang representative provided youth
information for two youth identified as having gang involvement for the annual compliance
review period. The gang liaison provided documentation of referrals for both youth which were
shared by email with the Circuit Gang Representative, indicating suspicions of gang activity.
The email documentation included pictures and written statements by the youth.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures (FOPs) to ensure a youth’s personal property is
maintained securely. Five youth case management records were reviewed and included
documentation the youth’s personal property was inventoried by the admitting juvenile justice
detention officer (JJDO). Each youth case management record included a personal Property
Receipt Form. Four of the five youth’s personal Property Receipt Forms included a youth
signature and staff signature. One of the forms did not have a youth signature, and another did
not have a staff signature. The superintendent provided documentation during the review week
of the youth and staff signing the personal Property Receipt Forms. All five youth case
management records included signed letters of acknowledgement regarding unclaimed
property. All five youth had their personal property, including clothes, placed in an assigned
locker and bag, which was documented on the Property Receipt Form. An observation of the
security and storage of personal property was completed. All five youth’s personal property
included a completed inventory form. An observation of three security and storage of valuable
property was also completed. All three youth had their property documented in the logbook with
all required elements and stored in a clear tamper-proof bag. An observation of a youth being
discharged and receiving personal and valuable property was conducted during the annual
compliance review week. The youth’s personal property was stored in a locker within the
sallyport, which remains secure. The youth was provided the property bag. The youth changed
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clothes, placed the center’s items back in the property bag, and provided it to the
superintendent. The youth also received valuable property from the center’s drop safe. One
captain is designated to submit and remove valuable property from the center’s drop safe. The
captain retrieved the tamper-proof bag from the drop safe, identified the youth receiving the
valuables, and provided the bag to the youth. The drop safe is under video surveillance. A
review of the center’s Central Communications Center reports did not include incidents
regarding youth property. Five interviewed youth reported when they arrived at the center, the
staff checked their personal property, and they signed a form stating the personal property was
correct. The superintendent was interviewed and reported when a youth is admitted to the
center, their valuables or property is placed in the drop safe or the secured lockers in the
sallyport. The receipt will have the youth’s name, the Department Juvenile Justice Identification
number (DJJID), locker location, and room location. All officers have access to the lockers in the
sallyport where all personal youth property is stored.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center maintains facility operating procedures (FOPs) to ensure all releases are verified by
the court’s authorization. Three closed youth case management records were reviewed for
release. All three closed youth case management records included documentation; the on-duty
supervisor reviewed all paperwork related to release prior to the youth being released from the
center. All three closed youth case management records included documentation the juvenile
justice detention officer supervisor (JJDOs) reviewed the release paperwork received from the
court, and the youth identification was verified prior to release. Two of the three closed youth
case management records included a photocopy of the identification (ID) of the parent/guardian
or responsible adult picking up the youth. One of the youth was being transported to the county
jail, therefore no ID was required. None of the youth had an endangered person alert. One of
the three youth and parents/guardians were reminded of future court dates. Two of the youth
reviewed did not have a known scheduled court date and were advised to follow up with their
assigned juvenile probation officer. All three closed case management records included
documentation of the required parties signing all applicable release forms. All admission and
release dates correlated with the Department’s Juvenile Justice Information System (JJIS). An
observation of a youth being released was conducted, and no exceptions were noted.
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2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center maintains facility operation procedures (FOPs) to ensure youth personal property is
maintained securely and is returned to the youth in a timely manner upon their release. Three
closed youth case management records were reviewed for the release of youth property. All
three records included documentation the parent/guardian signed the receipt of property form.
All three records included a photocopy of the identification (ID) of the parent/guardian or
responsible adult picking up the youth and the ID being verified. None of the youth reviewed
were on medications at the time of release from the center. For property held over thirty days, a
notice of impending disposal will be completed and delivered by certified mail to the parent/legal
guardian to pick up the property within ninety days of the letter date. The center’s property
disposal process includes any valuables sent to the Department of Juvenile Justice
Headquarters. All other property is donated to Goodwill. The center had no examples of
property being held for more than thirty days during the annual compliance review period. An
observation of the release process was conducted, which confirmed procedures were followed.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures (FOPs), ensuring all youth housed at the
center are reviewed to ensure proper management of the youth and appropriate sharing of
information. Weekly detention reviews are held on Wednesdays at 9:30 a.m. An observation of
a detention review was conducted during the annual compliance review week. The detention
review included representatives from administration, education, medical, mental health,
probation, and commitment. All youth in detention at this center and those housed in other
centers were reviewed. All information was shared between all parties. The center maintains
documentation of the weekly detention review meetings in a binder kept in the administrative
office. The superintendent was interviewed and reported detention reviews are held on
Wednesdays. The youth in secure detention and home detention status are reviewed. If there
are any medical or mental health issues, these are discussed, along with any potential release
dates, special circumstances, education issues, court orders, committed youth placement
status, behavior issues, or youth who were transferred to other facilities.
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2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center maintains facility operating procedures (FOPs) to ensure youth participate in
constructive activities which benefit the youth and the center. The daily activity schedule
outlines the daily schedule of activities and is posted in each living area and the dining hall. The
schedule included times for wake-up and personal hygiene, meal times, visitation, recreation
and physical activities, indoor activities, shift change, bedtimes, groups, and open program time.
Observations of youth engaged in various activities throughout the week were conducted.
These observations included youth movement, educational programming, mealtimes, and
hygiene. Five interviewed youth reported the center has a daily activity schedule. Four of the
youth reported the daily schedule is followed. One youth reported the daily schedule is not
followed due to the center being short staffed. Five interviewed staff reported the center has a
daily schedule and is followed. Two staff made additional comments stating the schedule is
followed most of the time.
2.10 Educational Access (Critical) Failed Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. The center provides
education services through the Bay County School District and the 250-day calendar, which is
distributed over twelve months, including ten days for teacher training and planning. A review of
the daily school schedule revealed the center provides six fifty-minute class periods daily with a
sixty-minute lunch from 11:00 a.m. to 12:00 p.m., fulfilling the weekly requirement of twenty-five
hours of instructional time. Three days of video and logbook were reviewed for educational
access. Two additional days of logbooks, outside the video capability scope, were also
reviewed. On the three days reviewed, school began twenty-six, twenty-nine, and fifty-two
minutes late, and on two days, school ended sixty-five and twenty-four minutes early. A
discussion was held with the lead teacher regarding the school days beginning late and/or
ending early as well as why school was being conducted in the living area. The lead teacher
reported on the day school started the latest, two youth were placed in confinement when the
youth were getting ready to walk to the classrooms. Due to this delay; school began late. School
was also conducted in the living area due to the facility being short- staffed and the youth in
confinement needing to be monitored. The lead teacher reported on another day the air
conditioning was out in part of the building, including the classrooms. The youth remained in the
living area due to the temperature in the other part of the building. The air conditioning being out
was confirmed by one of the center’s captains. Five interviewed youth reported they attend
school Monday through Friday at the center. Two youth reported the center is preparing them
very well for high school, taking the high school equivalent test, vocational school, employment,
or college, with one youth stating the preparation conducted being well and two youth stating it
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was not well. An interview with the superintendent as well as five staff all reported there is
minimal interference with education.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to provide career education. A discussion with the
lead teacher confirmed the facility offers Type 1 career education development, which includes
Career Learning Strategies such as: interviewing skills and techniques, entrepreneurship,
military options, and completing employment applications. Currently, the facility administers the
O*Net Interest Profiler by Next Move. Five interviewed youth reported taking core classes such
as math, science, history, reading, and social studies. They also reported they were taking life
skills and career choices.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has facility operating procedures ensuring there is a single licensed mental health
professional appointed as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services. The Department maintains a contract with VitalCore Health Strategies, LLC. to provide
mental health and substance abuse services to all applicable youth in the center. The DMHCA
is responsible for the coordination and implementation of mental health and substance abuse
services provided at the center. The center’s DMHCA is provided through VitalCore Health
Strategies, LLC. The DMHCA is a licensed mental health counselor (LMHC) who holds a clear
and active license in the State of Florida under Chapter 491, with an expiration date of March
31, 2025. The DMHCA is, at a minimum, scheduled to be on-site forty hours each week. The
DMHCA is on-site Monday through Thursday from 8:00 a.m. to 5:30 p.m. and Fridays from 8:00
a.m. to 10:00 a.m. A review of the sign-in log confirmed the DMHCA is on-site as required. A
review of the DMHCA’s job description found the DMHCA is responsible for oversight of all
clinical and administrative operations ensuring clinical quality and integrity of the therapeutic
program. An interview with the DMHCA indicated they are responsible for the coordination and
implementation of mental health and substance abuse services as well as providing
assessments, consultations, individual and group counseling, monthly reviews and reports,
discharge planning, training, and supervision. The DMHCA communicates regularly with staff
who cover part-time to ensure everyone is aware of daily responsibilities and updates on youth.
The interview validated the role of the DMHCA in the coordination and implementation of mental
health and substance abuse services at the center, which is to implement and follow the facility
operating procedures, Florida Administrative Code, and contract. The center has one backup
DMHCA in the event of absences, with a license expiration date of March 31, 2025.
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 Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to all applicable youth in the center. The designated
mental health clinician authority (DMHCA) ensures the licensed clinical staff are performing
services qualified to be provided based on education, training, and experience. The DMHCA,
back-up DMHCA, and three other clinical staff are all licensed mental health counselors
(LMHC). A review of licenses found each was clear and active in the State of Florida, with an
expiration date of March 31, 2025. The center’s contract requires a full-time regional mental
health director to provide detention center-specific technical assistance to each center, one full-
time DMHCA, and a part-time psychiatrist. The psychiatrist is scheduled to provide services for
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approximately two hours each week. The center’s psychiatrist has been providing weekly tele-
psychiatry services. The psychiatrist’s license was clear and active in the State of Florida with
an expiration date of January 31, 2024., and the back-up psychiatrist’s license was clear and
active with an expiration date of March 31, 2025
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC. to provide mental
health and substance abuse services to each youth in the center. The clinical supervisor is to
ensure the non-licensed clinical staff working under their supervision are performing services for
which they are qualified based on education, training, and experience. The center does not
have a Chapter 397 Florida Statute license with the Department of Children and Families at the
time of the annual compliance review. VitalCore Health Strategies, LLC., the mental health
department, is currently operating without the Chapter 397 license, according to an interview
with the designated mental health clinician authority (DMHCA). Reviewed documentation
showed only licensed mental health counselors (LMHCs) were conducting substance abuse
treatment and groups. The center does not have any non-licensed mental health clinical staff.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures to ensure the mental health and substance abuse
needs of youth are identified through a comprehensive screening process. Referrals are made
when youth are identified with mental health and/or substance abuse needs or are identified as
a possible suicide risk in accordance with Florida Administrative Code. Upon admission, a
juvenile justice detention officer (JJDO) will review each youth’s Massachusetts Youth
Screening Instrument, Second Version (MAYSI-2), face sheet, and alerts. The JJDO will then
complete their assigned section of the Suicide Risk Screening Instrument (SRSI). A review of
five youth mental health and substance abuse records documentation showed each youth had a
completed MAYSI-2 and SRSI during the youth’s admission process completed by the juvenile
probation officer (JPO). Each form was completed in the Department’s Juvenile Justice
Information System (JJIS). Each of the five SRSIs were reviewed by a mental health clinical
staff who documented their recommendation. Each SRSI had completed entries, a summary,
and recommendations were included in the screening results section. Four of the five youth
records were applicable for a positive response on the SRSI form. All four youth were placed on
suicide precaution, and a mental health referral was completed. Two of the five youth included a
“yes” response to any open or closed suicide risk alerts. None of the five youth were applicable
for having all negative responses on the MAYSI-2, invalidating the screening. Four youth
required further assessments, and the center notified mental health staff and the
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superintendent, as required. One of the five youth MAYSI-2s indicated an elevated suicide risk,
and the youth was referred, as required.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures outlining a process for identifying the mental health
and substance abuse needs of youth through a comprehensive screening. Youth with identified
needs at the juvenile assessment center (JAC) are referred for a further in-depth mental health
and/or substance abuse evaluation. A review of five youth mental health and substance abuse
records indicated four youth were applicable for a referral for mental health and substance
abuse services. One youth did not require referrals of any kind while at the center. Three of the
four youth applicable reviewed records had an updated mental health evaluation. One youth
was newly admitted; therefore, has not had an evaluation completed as of yet. The three
applicable reviewed records indicated they were applicable for treatment recommendations
which corresponded with all diagnosed mental health or substance abuse disorders. All three
reviewed records indicated the assessments/evaluations were completed in full and contained
all required elements, including the licensed mental health professional (LMHP) signature,
which satisfied the facility’s requirements.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center has facility operating procedures outlining a process for mental health and
substance abuse treatment and discharge planning. Each youth determined to need mental
health treatment, including psychotropic medications or substance abuse treatment, must be
assigned to a mini-treatment team. Five youth records were reviewed for mental health and
substance abuse treatment services, and three were applicable for treatment services. One
youth refused treatment. One additional closed file was reviewed for treatment services. All
three youth records included the initial treatment plan, which was initiated within seven days of
treatment and developed on the Department’s Initial Mental Health/Substance Treatment Plan
form. Each record documented a reason of referral for treatment, along with an initial diagnosis.
The initial treatment methods included counseling methodology, frequency, goals, and
psychiatric services. All three youth records included the MH/SA professional signature, the
youth signature, and members who were involved in the development of the treatment plan. All
three reviewed records documented an individualized treatment plan was developed by the
thirty-first day of the youth’s admission and signed by all required parties. Parent/guardian
participated by phone, if available, and mailed a copy of the plan. Each plan contained all
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required elements, including psychiatric services and medication matching prescribed
medication. Reviewed progress notes for all three youth validated the youth was receiving
treatment services stipulated on the treatment plan. Two of the three reviewed records were
applicable for treatment plan reviews. Both records indicated reviews were conducted every
thirty days by the treatment team. Modifications in both records were documented and clearly
identified on the review form. All review forms were signed by all required parties, and the
parent/guardian participated by phone, if available, and were mailed a copy of the plan. Three
applicable closed records were reviewed for mental health/substance abuse treatment
discharge summaries. Each applicable closed youth record documented the Department’s
Mental Health/Substance Treatment Discharge Summary form was completed. A treatment
team meeting was observed during the annual compliance review, and no exceptions were
noted.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center has facility operating procedures requiring each youth receiving mental health and
substance abuse treatment to be assigned to a mini-treatment team, which consisted of mental
health clinical staff and the youth’s parent/guardian. Five youth records were reviewed for
mental health and substance abuse services. Three of the youth records were applicable for
requiring treatment. All three youth were assigned to a mini-treatment team. Each reviewed
youth’s record was applicable for requiring mental health treatment, which consisted of
individual therapy, supportive counseling, and family therapy sessions. All three youth records
contained the proper consent treatment form, documented on the Department’s corresponding
form. Treatment notes were documented in all three applicable youth records on the
Department’s Counseling/Therapy Progress Notes form. An interview with five youth was
conducted, and two youth rated the center’s mental health and substance services as very
good, one youth rated the services as good, one youth rated it as fair, and one stated they’re
not receiving any mental health or substance abuse services. Three days of group therapy,
sign-in sheets, and video surveillance were reviewed. Two of the three days groups were
conducted as scheduled. For the remaining day, the sign-in sheet was observed with no
facilitator signature, and indicated group went from 2:45 p.m. to 3:35 p.m. A review of the video
showed group did not begin until 3:15 p.m. and ended at 3:35 p.m. The designated mental
health clinician authority (DMHCA) and assistant superintendent were made aware of the
discrepancy and initiated a call to the Central Communications Center. The interviewed DMHCA
stated mental health and substance abuse services provided within this facility include suicide
assessments, clinical consultations, individual and group psychotherapy to youths, initial and
individualized treatment plans with monthly reviews and updates, discharge planning, and
coordination of continuity of care for mental health and substance abuse services to each youth,
administration, and interpretation of psychological assessments and evaluations, completion of
clinical services reports, training in human behavior and mental health issues, complete and
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accurate clinical documentation in the mental health record, and clinical supervision of all
mental health and substance abuse services provided.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has facility operating procedures to address the provision of psychiatric services by
a licensed and certified professional. The provider’s contract outlines the required psychiatric
services provided to youth. Psychiatric services include psychiatric evaluation, consultation, and
medication management. Psychiatric services are provided to youth determined to need
services, as indicated by symptoms of mental disorder or substance-related disorder, or to
youth who are treated with psychotropic medication after their admission to the center, and of
the three youth, one youth was prescribed psychiatric medication after arrival to the center. The
center maintains a contract with VitalCore Health Strategies, LLC. for the provision of a licensed
psychiatrist to provide psychiatric services for applicable youth in the center. VitalCore Health
Strategies, LLC provides a part-time psychiatrist who is contracted to provide services for two
hours each week. The psychiatrist’s license was clear and active in the State of Florida, with an
expiration date of January 31, 2024. The facility did not utilize a back-up psychiatrist during this
annual compliance review period, and the center does not utilize a psychiatric APRN. A review
of five youth records revealed two of the youth were applicable for entering the center on
psychotropic medication, and one youth was prescribed psychotropic medication after
admission to the center. All three applicable youth had an initial psychiatric interview within
fourteen days of admission, which included the reason for the referral, the youth’s history, a
medical status examination, the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis, treatment recommendations, applicable prescribed medication,
explanation of the need for psychotropic medication, and the frequency of the medication. Each
youth’s record documented the psychiatric evaluation was conducted within thirty days of the
youth’s referral/admission, as required. Each youth’s evaluation was documented on the
Department’s Clinical Psychotropic Progress Note (CPPN) and contained all required elements.
Records reviewed for each of the three applicable youth prescribed psychotropic medications
confirmed page three of the CPPN documented each youth’s identifying data, diagnosis, all
elements of the prescribed medication, evaluation and description of effect of prescribed
medication, side effects, youth’s adherence to the medication regime, and triage information.
Each CPPN indicated the parent/guardian was contacted by phone to discuss medication and
gave consent for the medication. Each CPPN was signed by the conducting practitioner and
clearly identified as the Psychiatric Evaluation. All three youth were applicable for the monitoring
of Tardive Dyskinesia, and documentation supported monitoring was completed monthly. Each
of the three applicable youth records contained a current Authority for Evaluation and Treatment
(AET) form. All three youth were applicable for receiving tele-psychiatry, and there was
documentation of consent from the youth and parent/guardian in each case. Documentation
indicated the standard psychiatric care delivered through tele-psychiatry was the same as if
rendered in person. The designated mental health clinician authority (DMHCA) was interviewed
during this annual compliance review and stated the psychiatrist is available by phone twenty-
four hours a day and is contacted as needed. The psychiatrist meets with the youth weekly on
Wednesdays via Teams and meets with the DMHCA via Teams before and after each interview
so the youth’s progress can be discussed. The psychiatrist provides written Clinical Psychiatric
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Progress Notes and recommendations on Thursday mornings, which the DMHCA then reviews
and endorses.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written plan to safely screen, refer, assess, monitor, and protect youth with
elevated risk of suicide in the least restrictive means possible, which is reviewed and signed by
the designated mental health clinician authority (DMHCA) and the superintendent on an annual
basis. The plan outlines the center’s procedures addressing identification and assessment of
youth at risk, suicide prevention training, suicide precautions, levels of supervision, referrals,
communication, notification, documentation, immediate staff response, and a review process as
referenced in the Florida Administrative Code. The center also has an established review
process set in place for every serious attempt or serious self-inflicted injury, which may require
hospitalization or medical attention, and a mortality review, when applicable. This
multidisciplinary review process would include circumstances surrounding the event, procedures
relevant to the incident, relevant training, possible precipitating factors, and recommendations.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures requiring youth to be placed on suicide precautions
if they are displaying suicidal risk behaviors and/or having suicidal ideation. Five youth records
were reviewed. Only one of the five youth records was applicable for suicide prevention
services; therefore, two additional records were reviewed. Two of the applicable youth were
determined to be at risk during admission screening, and one was determined during staff
observation. All three youth were placed on precautionary observation (PO) at the time of being
identified to be at risk until an Assessment of Suicide Risk (ASR) was completed. Reviewed
documentation showed all three youth records contained a suicide risk assessment referral, and
each had a new suicide alert placed in the Department’s Juvenile Justice Information System
(JJIS). Each record verified an ASR was completed on the Department’s form within twenty-four
hours by a licensed mental health professional. The superintendent or designee was notified
immediately of each suicide risk. A review of all three youth’s Suicide Precaution Observation
Logs confirmed each was completed in their entirety to include documented safe housing areas
and all required signatures. None of the three records were applicable for a follow-up ASR.
Reviewed documentation showed all three youth records were conferenced by the
superintendent and licensed mental health professional to reduce the level of supervision to
close. The discontinuation of close supervision was documented in accordance with the center’s
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suicide prevention plan. A review of the center’s logbook and suicide risk assessment provided
instructions related to the suicide risk assessment findings and suicide precaution decisions. A
review of JJIS determined the alerts were appropriately entered when the youth was placed on
precautionary observation and removed when the youth was taken off precautionary
observation. The logbooks documented the beginning and ending times each youth was placed
on precautions. An interview with five youth was conducted, and each stated they have never
been placed on suicide watch while at the center. Five staff were interviewed, and each
indicated when a youth expresses suicidal thoughts, the staff are responsible for notifying the
mental health authority, maintaining the youth on constant sight and sound supervision,
documenting supervision, and entering alerts into the Department’s Facility Management
System. The superintendent was interviewed and advised secure observation is utilized when a
youth on PO is placed in a room due to their behavior being a safety and security risk.
3.11 Suicide Precaution Observation Logs [Detention
Limited Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures for youth placed on one-to-one or constant
supervision. Five youth records were reviewed, and only one record was applicable for having
been placed on suicide precautions. An additional two youth records were reviewed. A review of
the three applicable records and video footage found the youth were in sight and sound of the
staff during their duration on precautionary observation (PO); however, the staff did not
document on the precautionary observation log in real-time, for it appears the staff was not
filling out the log at the required intervals and the log was completed at a later time. No warning
signs were documented to being observed while the youth was on PO. Documentation showed
all suicide precaution observation logs were reviewed and signed by each shift supervisor and
mental health clinical staff. Each of the logs documented safe housing requirements.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures requiring all staff working with youth to complete
training to recognize verbal and behavioral cues indicating suicide risk, suicide prevention, and
implementation of suicide precautions. Reviewed documentation confirmed suicide drills were
held no less than quarterly on each shift. The center has two suicide response kits, including
knife-for-life, wire cutters, and needle nose pilers. The kits are located in master control and
electrical closet. Each suicide kit is co-located with first aid kits. Direct care staff participated in
at least one suicide prevention drill every six months, with which one included cardiopulmonary
resuscitation (CPR). The drills overlapped due to the center starting two twelve-hour shifts in
December 2022 due to staff shortage. Five interviewed staff stated the suicide kits are in master
control and electrical closet.
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3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The facility has a written combined crisis intervention plan and emergency service plan outlining
the response procedures for youth in crisis. The plan included procedures such as a notification
and alert system, means of referral, including youth self-referral, communication, supervision,
documentation, and review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has a written emergency care plan requiring youth who experience a mental health
or substance abuse emergency with imminent danger to themselves or others to receive
emergency care. The plan was last reviewed and signed by the superintendent and designated
mental health clinician on August 15, 2023, and was last updated on March 22, 2022. The plan
included immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health and treatment under Chapter 394, transport for
emergency substance abuse assessment and treatment under Chapter 397, documentation,
training, and reviews. Copies of the plan, which are accessible to all staff, are in the
administration’s office and mental health service office.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures requiring response to youth in crisis and the
administration of a Crisis Assessment. A review of five youth mental health records found none
were applicable for needing a Crisis Assessment; additional records were requested and found
only one applicable within the review period, which included the reason for the assessment,
mental status examination and interview, determination of danger to self, initial clinical
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impressions, supervision recommendations, treatment recommendations, recommendation for
follow-up, and notification to parent/guardian. A mental health alert was not required to be
entered into the Department’s Juvenile Justice Information System (JJIS). The crisis
assessment was conducted immediately by a licensed mental health professional once the
youth was identified as having acute emotional distress. This was not considered a Prison Rape
Elimination Act (PREA) event.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has a written Emergency Care Plan outlining mental health and substance abuse
emergency procedures for youth who are believed to be an imminent danger to themselves or
others because of mental illness or substance abuse impairment. A review of five youth records
found none were applicable for requiring a Baker Act or Marchman Act. Three additional
applicable records were reviewed. Each youth was placed on suicide precaution upon re-
admission. A Mental Status Examination (MSE) was completed by a licensed mental health
professional within the administration of the Assessment of Suicide Risk (ASR) for each youth.
All three applicable youth were maintained at a minimum of constant supervision until
transitioned to a lower level after an appropriate assessment was conducted and mental health
staff conferred with the licensed supervisor and superintendent or designee. A review of the
Department’s Juvenile Justice Information System (JJIS) indicated the suicide alert was
discontinued based on the ASR.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has a contract with VitalCore Health Strategies, LLC. The center has a board-
certified physician who is a licensed physician (MD) and serves as the designated health
authority (DHA). The DHA holds an unrestricted license, which meets all requirements for
independent and unsupervised practice in Florida. A review of the Department of Health
licensure verification portal reveals the DHA license is clear and active and expires on January
31, 2024. The DHA specialty training is family practice. The DHA has a collaborative practice
protocol in place with the center’s one advanced registered practical nurse (APRN); the protocol
was last reviewed on September 13, 2023. The center does not employ a physician assistant. A
review of the sign-in and out logs for the annual compliance review period confirmed the DHA
was on-site at the center once a week at a minimum of two hours a visit. Pursuant to the
contract, the DHA is required to be on-site weekly for two hours. There were no observed
instances of the DHA not being on-site for the contracted required timeframe. The review period
was from October 11, 2022, through September 19, 2023. The center did not utilize a back-up
DHA or APRN during the annual compliance review period. Specific duties outlined for the DHA
are denoted within the contract between the Department and VitalCore Health Strategies, LLC.
The provider’s practices pertaining to tele-medicine were reviewed. A log is maintained by
medical staff for documenting occurrences of tele-medicine utilized when youth are seen during
medical sessions, as required. An interview with the DHA indicated the role performed at the
center, consists of completing a comprehensive physical assessment (CPA), periodic
evaluations, seeing any sick youth, and the development of policies and procedures. The DHA
is on site weekly, has an APRN who is also on-site weekly, and is available by phone and in
person. The DHA ensures all off-site care is reviewed by documentation in the episodic care
notes, uploaded medical records, and follow up calls to the clinic nursing staff. In addition,
medical issues and documentation are reviewed with the medical staff weekly unless there is a
more immediate need, which would be discussed by phone.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center had current written facility operating procedures (FOP) for all health-related
procedures and protocols utilized at the center. The designated health authority (DHA),
superintendent, and psychiatrist each signed the appropriate section(s) of the FOPs. The review
of the health-related FOPs indicated the DHA reviewed and signed on September 12, 2023. The
review of the health-related FOPs indicated the superintendent reviewed and signed on
September 11, 2023. The review of the health-related FOPs indicated the psychiatrist reviewed
and signed them on September 20, 2023. The review of the health-related FOPs, to include
treatment protocols, and other medical procedures, indicated each of the nursing staff last
reviewed, signed, and dated a cover page on September 15, 2023. There was no indication of
any new policies or changes made during the annual compliance review period. At a minimum,
an annual review of health-related FOPs and protocols were completed. The medical
department at the center has not had any newly employed healthcare personnel during the
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annual compliance review period. The approval of treatment protocols or standing procedures
are authorized by only the DHA.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of the Authority
for Evaluation and Treatment (AET) form. Four of the five youth records contained an original
AET form filed in the youth’s IHCR. The fifth youth was eighteen and therefore, an AET was not
required. Each of the applicable AET forms were signed by the youth’s parent or guardian.
Additionally, each of the forms were signed by the Department representative. There were no
occasions of the center requiring a court order for the sample of youth records reviewed. Each
of the AET forms were obtained prior to providing any medical services to those youth reviewed.
All the forms reviewed were valid. One youth was eighteen at the time of the review and did not
consent to provide a release of information. There were no youth from the sample reviewed who
had been under the care of the Department of Children and Families (DCF).
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Five youth Individual Healthcare Records (IHCR) were reviewed for parental notification and or
consent when there was a significant change to the youth’s condition, new medication, and/or
treatments are prescribed. Four of the five youth reviewed were applicable for documentation of
parental notification for over-the-counter (OTC) medication beyond those covered by the
Authority for Evaluation and Treatment (AET); with no observed issues in notifications. The fifth
youth was eighteen, and consent was not required. Each of the applicable written notifications
were made utilizing the Department’s Parental Notification of Health-Related Care: General or
Parental Notification of Health-Related Care: Medications forms and or the Acknowledgment of
Receipt of the Clinical Psychotropic Progress Note (CPPN) as required with no observed
issues. Three of the five youth were applicable for taking psychotropic medications for a
duration of time while at the center. Each of these youth had documentation of staff witnesses to
all telephone call attempts for prescribed psychotropic medication. Three of the five youth were
applicable and for the issuance of new medications while at the center. Each of the youth were
ordered new medication, and subsequent notification and documentation of attempted contact
made to the parent or guardian in the youth’s IHCR. In addition, written parental notifications
were sent regardless of telephone contact. Two of the three youth taking psychotropic
medication were applicable for having had a change, added, or discontinued medication. As a
result, there was a verbal consent documented on page three of the CPPN. There were no
youth from the sample reviewed as having been under the care of the Department of Children
and Families (DCF). Four of the five youth had vaccines verified within thirty days of the youth’s
admission to the center. The fifth youth was not verified within thirty-days; verification was
conducted thirty-seven days late. Each of the five youth reviewed had up-to-date vaccinations.
None of the youth required any parental or guardian consent prior to administering any type of
vaccination.
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An interview with the nurse indicated parental notification of care without special consent shall
be accomplished by attempting verbal contact with the parent/guardian to notify them of care,
followed by written notification utilizing one of the appropriate parental notification forms
(general or medication). The center will inform the parent/guardian of significant changes in the
youth's condition and obtain consent when new medication and treatments are prescribed.
Written parental consent is required in certain circumstances. The appropriate parental
notification of health-related care form(s) will be used for consent purposes. Verbal attempt at
consent shall be documented in the chronological progress notes. Notifications or attempts are
completed and documented at the time of the episode. When reviewing for psychotropic
medication consent medical staff complete the CPPN, which will be sent to the parent/guardian
to provide consistent, updated information concerning the youth's progress and/or
recommendations for changes in medications. The nurse confirms vaccinations are not provided
on-site. Immunization records are found and reviewed through Florida Health. Should a
parent/guardian claim 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, authorized, then submit to the center. Copies of the exemption will
be filed in the youth’s 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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of a medical and
mental health screening form. All the reviewed medical and mental health screening forms were
completed on the date of admission. Each of the screenings were completed by a juvenile
justice detention officer (JJDO). The screenings were subsequently reviewed by a registered
nurse (RN) within twenty-four hours. All youth had documentation within the IHCR, and the
designated health authority (DHA) was notified of the youth’s admission. None of the five
reviewed youth showed a change in physical custody since arriving at the center. The sample of
youth reviewed were all males; therefore, a qualitative urine pregnancy screening test was not
required. An interview with the nursing staff indicated medical staff would see newly admitted
youth in less than twenty-four hours of admission. Medical is notified by receiving the medical
/mental health screens, the alpha list, the court first appearance schedule, youth clearance for
covid, and verbal notification from detention supervisors. At the time of admission to the center,
each youth will receive a facility entry screening by the intake officer. This screening is to be
performed using the medical and mental health admission form. A healthcare admission
rescreening will be completed each time the physical custody of the youth changes and is
subsequently returned or re-admitted to the center. A change in physical custody within secured
detention requires a complete rescreening by the receiving center, whenever they are moved
from one to the other with an anticipated stay of twenty-four hours or more; however, it does not
require a full completion of the intake process.
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4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
Five youth Individual Healthcare Records (IHCRs) were reviewed for completion of an
orientation to healthcare services at the center. All youth received a general healthcare
orientation at the center. Healthcare education topics were documented in each youth’s IHCR
on the appropriate Department form. A review of the center’s facility operating procedures found
documented, at a minimum, the following were included: access to medical care, sick call
practices, emergency situations, medication process, right to refuse care, what to do in case of
sexual assault or attempted sexual assault, the non-disciplinary role of healthcare staff, and a
list of healthcare related contacts.
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.
Five youth Individual Healthcare Records (IHCRs) were reviewed to ensure the designated
health authority (DHA) is notified when a youth is admitted, requiring emergency care or routine
notification. Two of the five youth were applicable for notification of a known or suspected
chronic condition. One additional record was requested and reviewed. Each reviewed applicable
IHCR found evidence of a referral in the chronological progress note to the DHA for a known or
suspected chronic condition. Each notification to the DHA was completed within twelve hours of
the youth’s admission to the center. None of the youth reviewed required emergency care upon
admission. Two of the six youth were currently taking psychotropic medication upon admission.
Subsequently, the psychiatrist was notified of the two admissions. An interview with the nursing
staff indicated the timeframe for notifying the DHA is no longer than twenty-four hours after
admission. In no case will notification exceed noon of the following day. Medical staff are
responsible for notifying the DHA of newly admitted youth during clinic hours, and non-
healthcare staff are notified after clinic hours. Notifications are documented in the youth’s
chronological progress notes.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of a Health-
Related History (HRH) form. All youth had an HRH completed within seven calendar days of
admission. The HRH was completed or updated prior to the completion of the youth’s
Comprehensive Physical Assessment (CPA) form. Each of the reviewed HRH was completed
by a licensed nurse or practitioner. A review of the HRH forms for all five youth confirmed the
signatures and dates for each youth’s current admission. An interview with the nursing staff
indicated the HRH is conducted or reviewed by a nurse through an interview of the youth,
completed no later than seven calendar days following admission and prior to the CPA or the
youth being subjected to extreme conditions including, but not limited to, high heat indexes or
frigid temperatures.
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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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of a
Comprehensive Physical Assessment (CPA) and tuberculosis skin test (TST). Each of the youth
had documentation completed on the Department’s CPA form. Three of the five youth had a
current CPA on file at admission with no needed changes in medical condition. In addition to
completing a focused evaluation, the current CPA was reviewed and signed by the physician as
each youth was examined. The remaining two youth had a CPA completed within seven
calendar days of admission. Each CPA documented the youth’s medical grade. All of the
sections for each of the CPAs reviewed were appropriately marked. Of all five youth, each had
refused the genital exam; subsequently, the clinician indicated the youth’s refusal on the form. A
refusal form was found in each youth’s IHCR. Four of the five youth were applicable for
inclusion of documentation within the Department’s Problem List form. All five youth had at least
one verified TST documented on the CPA and Infectious and Communicable Disease (ICD)
form. None of the reviewed youth required further evaluation prior to entering the general
population. A review of the facility operating procedures (FOP) as to whether or not appropriate
documentation of when any part of the exam is not conducted and/or refused by the youth, as
well as the FOP for tuberculosis screening and rescreening process, found no issues observed.
An interview with the nursing staff indicated the CPA is current if not performed within the last
two years if no identified chronic health conditions exist. If a CPA has not been performed or is
not current, or there are changes to the health condition of the youth, then the youth shall have
a CPA completed as soon as possible, but no longer than within seven calendar days of
admission. The Department's Medical and Mental Health Screening form will be utilized for a
youth's initial TST symptom screening. Emphasis should continue on thorough, standardized
symptom screening upon each admission to a detention center.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of sexually
transmitted infection (STI) and human immunodeficiency virus (HIV) risk factors. None of the
original five youth were sexually active at the last screening conducted for STI’s; therefore, three
additional youth records were requested and reviewed. The three youth were sexually active
and subsequently clinically screened and evaluated for STI’s. Each of the youth required further
evaluation and had been referred to the designated health authority (DHA). Each of the referrals
were documented on the Department’s STI form. Testing for each youth was ordered, and
screening results were documented on the Department’s Communicable Diseases form. None
of the youth were out of the Department’s custody or applicable for gynecological exam.
Eight youth were reviewed for and offered counseling, testing, and if indicated, treatment and or
referral for HIV. Four of the eight youth refused testing and signed a refusal form. The remaining
four youth consented to HIV testing. Each of the four youth had documented consent obtained
by the center. The HIV results were placed in a sealed envelope marked “Confidential,”
reviewed by the practitioner, and filed in the youth’s IHCR for all four youth. Each of the four
reviewed youth had documentation of pre and post-test counseling, indicated on the youth’s
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health education record. Each of the four youth’s confidentiality was protected by not including
an HIV status on the center’s internal alert system. Five youth were interviewed, and each
confirmed they could ask for an HIV/Aids test at the center.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed to ensure the completion of
sick call practices. Only one applicable record from the original five records was reviewed for
this indicator. An additional two records were requested and reviewed. Each of the three
reviewed youth records had one documented sick call. Each sick call was documented within
the Department’s Facility Management System generated sick call log. None of the youth
presented with a similar sick call complaint three or more times within two weeks. There were
no youth complaints of severe pain with which staff (nursing or non-healthcare) is unfamiliar and
treated as emergencies, and an immediate referral was necessary. In each of the three sick
calls reviewed, the youth completed a sick call subsequently completed by a registered nurse
on-site. Each of the sick call forms was found in the youth’s IHCR. None of the youth were in
restricted housing of any kind. Sick call forms were found to be documented in accordance with
Florida Administrative Code 63M-2. Each of the sick calls were found and documented on the
Department’s sick call index. The dates listed on the sick call index corresponded to the
completed sick call forms found in each youth’s IHCR.The hours of sick call are posted outside
the medical clinic door in the main hallway. The sick call hours are 7:00 a.m. and 4:00 p.m. daily
and as needed. The center has approved treatment protocols for all medical and non-medical
personnel. Only licensed nurses conduct sick calls. The center has procedures in place which
address when medical staff are not on-site, and the shift supervisor reviews all sick call requests
within four hours of being submitted. A sick call was observed during the on-site review. The
youth was escorted by one of the center’s juvenile justice detention officers (JJDO). The
registered nurse conducting the assessment of the youth identified themselves to the youth. The
youth was seen in a private area, on an exam table. The youth was examined by the nurse. The
JJDO was outside the doorway of the exam room. An interview with nursing staff indicated sick
calls are conducted daily at 7:00 a.m. and 4:00 p.m. Sick call is conducted in the medical clinic.
Youth presenting with similar sick call complaints three or more times within two weeks require
a referral to the DHA or APRN. The center has DHA approved treatment protocols on-site. Sick
call is routinely conducted by licensed nursing staff on duty at the time of the request. Should a
youth be in restricted housing, nursing staff are required to make daily visits and complete a
detailed narrative entry in the chronological progress notes of the IHCR for each youth who is
evaluated or treated. This entry will be evidence a thorough inquiry was made regarding the
youth’s health status and whether nursing care was indicated or conducted. Five youth were
interviewed. One youth indicated they could be seen for a sick call immediately. Two youth
stated they could be seen within one day. One youth stated they could be seen within two days.
One youth indicated they had never requested a sick call. The youth were able to articulate
either the DHA or nursing staff had conducted sick calls. Five staff were interviewed. All five
staff indicate nurses review and conduct sick calls. Three of the five staff indicated staff can
review sick calls. One of the five staff indicated the DHA conducts sick calls, and one staff
indicated supervisors complete sick call reviews to inform medical staff.
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Office of Accountability and Program Support Page 39 of 60 (Revised July 2023)
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of episodic, first-
aid, or emergency care. Each of the youth had an indication of requiring on-site first aid or
episodic care. Each of the events was conducted by a licensed healthcare staff while on-site
and documented in problem-oriented elements: subjective, objective, assessment, and plan.
There were no occurrences of non-healthcare staff providing any episodic or first aid care. Each
youth required episodic care which documentation contained the nature of the complaint,
findings or person rendering care, treatment rendered, education and or instruction to the youth,
and plans for follow-up or future care. None of the reviewed youth required an off-site care
referral. Parental notification was not required for any of the episodic care provided. In each of
the five events reviewed, an entry was found in the Department’s Episodic Care Log. A follow-
up evaluation was not required for any of the youth reviewed. The center has a total of twelve
first-aid kits, four of which are used for transportation. The remaining first-aid kits are located
throughout the center. A minimum of three first-aid kits were observed to be fully stocked and
approved by the designated health authority (DHA). Medical staff check first-aid kits monthly.
The review of first-aid kits is documented on the kit itself, and a log is kept in the medical office.
A list of contents is attached to each kit, which identifies the contents with expiration dates.
The center has two automated external defibrillators (AEDs), one located in the medical clinic
and one in the courtyard. Instructions on operating procedures are located with each of the
AED’s. The AED batteries and pads are checked by an outside provider; the last AED service
date for both units occurred on August 16, 2022. Each AED is monitored by on-site medical staff
monthly. Documentation of checks are logged and kept in the medical office. The medical staff
conducted a check and self-test of both AED’s while on-site during the review; no issues were
observed. Each of the AED’s have the same change out dates and expirations dates. The AEDs
batteries expiration date are August 2026. The last time the batteries were changed out was in
August of 2022. The AED pads expiration date are December 28, 2025. The last time the pads
were changed out was May 2023.
The center conducted mock episodic, first-aid, or emergency care drills at a minimum quarterly
for each shift. The reviewed drills included the demonstration of cardiopulmonary resuscitation
(CPR) and AED usage on each shift at least annually. In the event, staff is not present for a drill,
a review of drill scenario documentation is available to staff. A review of mock episodic, first-aid,
or emergency care drills from August 2022 through August 2023 was conducted. The center
conducts ongoing announced and unannounced drills. There is a list of emergency numbers
located in medical and master control, which are accessible to all staff. Five staff training
records verified staff are appropriately trained on the administration of the epinephrine auto-
injector, episodic, first-aid, and emergency care procedures.
The center’s policy on the use, access, and inventory of Narcan for the emergency treatment of
a known or suspected opioid overdose emergency with signs of breathing problems and severe
sleepiness or not being able to respond was reviewed and found Naloxone Nasal Spray, a
prescription strength medicine, is utilized. The center will maintain at least one prescribed stock
Nasal Spray Kit for emergency purposes of accidental overdose for use for youth in Department
care. It should not be ordered for each youth, and stock must be maintained in a designated
area, in the center’s locked medication cart accessible to both nurses and supervisory staff
trained to assist in the delivery of medications when the emergency arises. There must be a
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 40 of 60 (Revised July 2023)
process in place for supervisors to access the stock Naloxone Nasal Spray kit when there is no
medical staff on site. In addition, as with all stock prescription medications, a perpetual/daily
inventory of medication utilization must be maintained. The youth must go out via emergency
medical services if there is use of Naloxone Nasal Spray as well as be documented on the
youth’s Medication Administration Record. At the discretion of the center’s designated health
authority (DHA), a Naloxone Nasal Spray kit may be signed out from the medication cart during
transport. Observation found the center maintains Narcan locked in medical in a locked medical
cart. Only medical staff and trained supervisory staff have access to Narcan supplies. Narcan
inventory is addressed through weekly counts and documented on a log maintained in the
medication cart.
An interview with nursing staff indicated non-healthcare staff will complete episodic care
documentation utilizing the report of healthcare by non-healthcare staff and include all required
elements, documentation for off-site emergency care is kept in the clinic logbook, emergency
drills are conducted quarterly, and a list of emergency numbers is posted in the medical clinic.
The center has two AED’s, one located in the medical clinic and the other in the closet, and
procedures are located inside the AED jacket. Five staff were interviewed. All staff indicated
they were able to call 9-1-1 if they felt it was necessary. Five youth were interviewed. Three
youth rated the medical care at the center as good; the other two youth rated the care as very
good.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of referrals for
off-site healthcare. Only one of the five records reviewed was applicable for this indicator. An
additional two records were requested and reviewed. Each of the three applicable records had
indicated the youth required off-site care. Two of the three records had a completed summary of
the off-site care consultation report form. The third record did not have a completed form.
Reviewed records documented parental notification efforts, two of which were Department of
Children and Families notification. All three off-site emergency care were documented on the
episodic care log. Two of the three were applicable for discharge documentation and were filed
in the youth’s IHCR. Two of the three records were applicable for notifying the designated health
authority (DHA) of the event. The third youth was transported off-site for labs per the DHA
orders and did not require notification. In each of the three off-site events, the DHA or designee
reviewed and signed all of the off-site care findings, instructions, and information. In two of the
three events, the youth required follow-up care. Both events had documentation of care
documented within each of the youth’s IHCR. An interview with the nursing staff indicated the
medical staff should request and obtain the actual emergency room visit dictation or notes from
the off-site provider as soon as possible for review on the next available on-site visit by the
practitioner. Pertinent information about the referral must be documented within the progress
note. The DHA is given all records to review and sign on a weekly basis. Follow-ups for testing,
referrals, or appointments are kept in the clinic logbook and maintained on a tracking
spreadsheet.
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Office of Accountability and Program Support Page 41 of 60 (Revised July 2023)
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for care of youth with chronic
conditions. Only two of the five records reviewed were applicable for this indicator. An additional
record was requested and reviewed. Each of the three applicable reviewed records identified
the youth with a chronic condition. None of the youth were diagnosed with a communicable
disease. Only one youth was taking medication on an ongoing basis. The three youth were
classified with a medical grade of either two, three, or four. None of the youth were identified as
being pregnant. Each youth reviewed were placed on the chronic condition list. Only one of the
three youth was identified as needing to receive periodic ninety-day evaluations. The other two
youth had not been at the center long enough. The one applicable youth was in receipt of
periodic evaluation as required. None of the youth reviewed were taking medication for
tuberculosis. None of the youth required a periodic evaluation prior to renewing a prescription
medication which had expired. None of the youth required an evaluation be conducted off-site.
There was no indication of any youth having a lapse in care of missed periodic evaluation. The
Department’s Problem List form was updated, as required, for all three applicable youth. The
center maintains a tracking log for all youth identified with a chronic condition and or requiring a
periodic evaluation. An interview with the nursing staff indicated youth with chronic conditions
are kept in the clinic logbook and maintained on a tracking spreadsheet. An interview with the
designated health authority (DHA) indicated all youth with chronic conditions are seen for
periodic evaluation every ninety days and is tracked through a logbook in the clinic. The logbook
is reviewed and updated daily by the nursing staff in the clinic.
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.
Five youth Individual Healthcare Records (IHCR) were reviewed for implementation of
medication management. Each youth had a current and valid order, which was also
documented in chronological progress notes. The designated health authority (DHA) was
notified for each of the youth upon admission to the center. Two of the five youth at admission
were applicable for taking prescribed psychotropic medications, whereas the psychiatrist was
contacted to obtain an order to resume medications prior to admission. In the event the current
medications were continued, discontinued, changed, or new ones were ordered, the DHA
placed an order on the Department’s Practitioner Order form. In addition, there was
documentation of prescription verification in the chronological progress notes in each youth’s
IHCR. There was no indication of the youth reviewed as having been in restricted housing.
Three of the five youth had over-the-counter medications prescribed not listed on the
Authorization for Evaluation and Treatment (AET), which were subsequently administered
according to the practitioner orders. Each youth reviewed had a standard Department
Medication Administration Record (MAR), which contained all the required elements. There was
no indication of trained non-healthcare staff assisting in the delivery of medications. Nursing
staff are on-site from 7:00 a.m. through 7:00 p.m. daily. Nursing staff initialed for all
administered medication. There was no indication of any undocumented explanations of lapses
or errors in medication administrations in any of the reviewed records. Each of the youth had
documentation where nursing staff checked for side effect monitoring weekly on the youth’s
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Office of Accountability and Program Support Page 42 of 60 (Revised July 2023)
MAR. There were no indications of youth having refused any medications. Two of the five youth
were taking prescribed psychotropic medication at admission and were in receipt of an initial
diagnostic psychiatric interview within fourteen days of admission. One of the two youth were
applicable to receive medication monitoring every thirty days: no observed issues. The
remaining one youth had not been at the center for thirty days. A review of medical clinic facility
operating procedures, protocols, and ancillary documentation revealed no indication of any
standing orders for psychotropic medications. No indication of any emergency treatment orders
for psychotropic medication. No indication of any pro-re nata orders for psychotropic
medications.
An observation of medication administration pass was conducted during the on-site annual
compliance review week. Medical staff were observed administering medication with no other
duties at time of passing medication. Youth was escorted to medical by one of the center’s
officers. Youth approached the medical staff conducting medication pass individually. The
medical staff identified themselves to each youth and articulated the purpose for the medication
pass. The nurse reviewed with the youth the six rights of medication administration prior to
administering any medications. Both staff and youth initialed the MAR upon completion of
administering the medication. Staff observed youth to make sure medication was swallowed. No
medications were observed being pre-poured. Only medical staff were observed administering
medications to youth. An interview with the nursing staff indicated nursing verifies a youth’s
medication regimen through medication, receipt, and transfer disposition form. The center
utilizes the Department’s digital MAR. Non-healthcare staff do not provide medications to youth.
Medication pass are 7:00 a.m., 1:00 p.m., and 7:00 p.m. daily. The center utilizes a psychiatrist,
who is off-site, provided through tele-health. Five staff were interviewed. Two of the five staff
stated they give medication to youth. Three remaining staff stated they do not give medication to
youth. Five youth were interviewed. All five youth stated the nurse gives them medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The medical clinic was reviewed for inventory of medications and sharps. The center has
medical equipment classified as sharps (e.g., syringes, needles, scissors, and suture removal
kits) secured and inventoried utilizing a routine perpetual inventory descending count as each
sharp was utilized and disposed. Medications identified and secured in a locked area
designated for storage of medications was observed. The medical clinic medication cart was
observed to be clean and organized, with stock items separate from youth-specific medication.
Observation of controlled substances had a perpetual inventory and were stored separately
from other medication. Medications were observed stored in a separate, secured (locked) area,
inaccessible to youth. Narcotics and other controlled medications were observed stored behind
two locks. Oral medications were observed not to be stored with injectable or topical
medications. Medications which require refrigeration were observed stored in a secure
refrigerator, which is used for medication only. A count and inventory of three controlled
medications, three over-the-counter medications, and three sharps was observed. All counts for
each of the medications and sharps matched beginning and ending inventories. Medical staff
confirmed reporting criteria for any inventory discrepancies. Counts are conducted and verified
at a minimum of two medical staff. If a count is incorrect, an additional count will be conducted.
Should the inventory be incorrect, the director of nursing would be immediately notified. The
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Office of Accountability and Program Support Page 43 of 60 (Revised July 2023)
center administration would also be immediately notified of the inventory discrepancy. The
Department’s Central Communication Center would be contacted within two hours of the
identified inventory discrepancy. There are non-healthcare staff designated by name and title
who have been trained by the registered nurse in delivery and oversight of medication, if
necessary, as observed by the nursing training log. An interview with the nursing staff indicated
for female youth, gynecological exams are not routinely completed. Medications are disposed
with the pharmacy monthly. Controlled substances are secured in a lock box in the medication
cart. The medical clinic has a current agreement with a pharmacist and a copy of the pharmacy
consultant license in maintained on-site.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
Five youth Individual Healthcare Records (IHCR) were reviewed for completion of infection
control and education. All youth received required infection control training and education within
seven days of admission, as documented in each youth’s IHCR. The centers written exposure
control plan is in accordance with Occupational Safety and Health Administration (OSHA)
guidelines. The written plan includes risk assessment, methods of compliance, common
childhood infectious diseases, self-limiting, episodic contagious illnesses, viral or bacterial
infectious diseases, tuberculosis, Hepatitis A, B and C, human immunodeficiency virus (HIV),
bloodborne pathogens, other outbreaks and epidemics, outbreaks of pediculosis, methicillin
resistant staphylococcus aureus, food-borne illnesses, bioterrorism agents, and chemical
exposures in the workplace. The center’s process for needlestick post-exposure evaluation is
initiated when an employee incurs an exposure incident; it must be reported to their immediate
supervisor. All employees who incur an exposure incident will be offered post-exposure
evaluation and follow-up in accordance with the OSHA standard. The center makes available
Hepatitis B immunization for staff. Staff have access to protective equipment. There were no
incidents during the annual compliance review period were local health department, the
Department’s Central Communications Center (CCC), or the Centers for Disease Control and
Prevention (CDC), should have been notified. The superintendent maintains a separate file for
any youth and staff who have experienced a facility or occupational exposure. A review of five
staff pre-service and in-service training records revealed staff have been trained on the center’s
exposure control plan. An interview with the nursing staff indicated a copy of the exposure
control plan is located on the wall in the clinic. Infection control and exposure control training for
all staff is conducted by the clinic manager. Infection control training for youth is completed by a
nurse upon initial intake. Nursing described the process for secure storage, routine inventory of
medication, and use of locked medication cart.
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Office of Accountability and Program Support Page 44 of 60 (Revised July 2023)
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center had only one youth Individual Healthcare Record (IHCR) applicable for completion of
prenatal care and education during the annual compliance review period. The one youth’s IHCR
had documentation prenatal care began immediately upon determining the was pregnant. The
youth was seen by the advanced practice registered nurse (APRN) for first evaluation and
provided with orders from the designated health authority (DHA) for continued care. The youth
was at the center for approximately five days. The youth was placed on the center’s internal
alert system during the duration of time at the center. The medical staff provided daily
monitoring of the youth for any danger signs or pregnancy complications. The youth was also
provided with education related to pregnant youth and documented in the youths IHCR. The
youth was provided with nutritious food in quantities appropriate for a pregnant youth, as
ordered by the practitioner. In addition, licensed health care professional staff provided routine
monitoring of the youth’s nutritional and weight status during the course of the pregnancy.
Nursing staff provides in-service education on youth’s prenatal healthcare annually to all non-
healthcare staff; last training was completed in August 2023. A review of five staff in-service
training records revealed staff have been trained on observation and monitoring of emergency
care needs/symptoms of possible miscarriage. The medical department maintains nursing
protocols and treatment plans for pregnant youth. An interview with the nursing staff indicated
female youth are routinely tested for pregnancy upon admission. Weekly checks are routinely
conducted for monitoring of pregnant youth. A special diet is provided for pregnant youth. Five
youth were interviewed. None of the youth were female, therefore this question was not
applicable
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Office of Accountability and Program Support Page 45 of 60 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
Observations were made of youth supervision during the annual compliance review week, with
no exceptions noted. Staff were observed and verbally acknowledged the location of the youth
assigned to their supervision. Staff were observed monitoring the movements of youth in their
direct care from one location to another. Observations were made of staff always keeping youth
in sight of at least one juvenile justice detention officer (JJDO). Observations of staff and youth
interactions, along with supervision, included in the classroom, line movement, in the male
module, dining hall, medication pass, and youth transport. During the movement of youth,
master control was notified, and authorization was given. Observations of master control staff
along with JJDO’s within the center were made by conducting and documenting youth counts
and movements in logbooks. The center utilizes the Department’s Juvenile Justice Information
System (JJIS) as a method for tracking the daily census. Three of the five staff interviewed
believe there are enough staff to provide for the safety and security of the youth, however one
staff did state elaborate saying mostly but not all shifts. Two staff stated they do not believe
there is enough coverage or only sometimes due to staff vacancies.
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Office of Accountability and Program Support Page 46 of 60 (Revised July 2023)
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations.
Each center shall implement and maintain a behavior management system to meet the needs
of the youth and the center. The system shall include rewards for positive behavior and
consequences for inappropriate behavior.
The behavioral norms and expectations for youth shall be posted in all living areas and shall
clearly specify appropriate and inappropriate behaviors.
The system restricts certain types of penalties on youth who demonstrate negative behaviors.
Group punishment shall not be used. However, corrective action taken with a group of youth
is appropriate when the behavior of a group jeopardizes safety or security, and this should
not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
The use of drugs to control the behavior of youth is prohibited. This does not preclude the
proper administration of medication as prescribed by a licensed physician.
Observations were made of the center’s behavior management system (BMS), with no
exceptions noted. Observations were made of postings for the center’s BMS in all living areas.
The expectations specified appropriate and inappropriate behaviors, rules, and norms for the
youth to follow. The system included rewards for positive behavior and consequences for
inappropriate behavior. On-going daily activities were observed to determine the implementation
of the BMS process. A review of the center’s written facility operating procedures (FOPs)
concerning the BMS was conducted. The review confirmed the center maintains compliance
with the components outlined in the center’s FOPs. A review of activities along with youth point
cards confirmed positive rewards are given to youth to match the BMS incentive calendar. In
addition, the review of youth point cards confirmed rewards and consequences are given in
accordance with the BMS protocols. The review of documentation did not reveal any instances
of inappropriate use of restrictions or group punishment.
Five staff were interviewed, and each was able to explain the center’s BMS practices. In
addition, each staff was able to describe the types of rewards provided as part of the BMS. Four
out of five staff stated things cannot be taken away as a consequence. One staff stated things
can be taken away from a youth only if a major disruption occurs. All five staff believe the BMS
is effective, they speak with youth to discuss the consequences being imposed, youth are given
an opportunity to explain their behavior, and they speak with youth about alternative acceptable
behaviors. Each staff stated they received feedback on the implementation of the BMS. Four out
of five staff stated they receive feedback on the implementation of the BMS daily, and one staff
stated they receive feedback weekly. All five staff stated points and levels can be taken away as
a consequence, have never seen a co-worker take meals, snacks, clothing, education, or
medical care from a youth because they were acting out, and have never observed any staff
encouraging youth to beat up another youth.
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Office of Accountability and Program Support Page 47 of 60 (Revised July 2023)
Five youth were interviewed, and two youth rated the center’s BMS as fair, two youth rated the
BMS as good, and the fifth youth rated the BMS as very good. Each youth were able to explain
the difference between each level and how to move from level to level. In addition, each youth
was able to provide examples of how they are rewarded in the center and staff use the rewards
the same. All five interviewed youth stated the youth are never allowed to punish other youth.
Three out of five youth stated they have never been sent to their room for punishment, and the
two remaining two youth stated they had been sent to their room for punishment. Two out of five
youth agreed when they have received consequences, they were fair. The remaining three
youth stated they have never received consequences. The two youth who received
consequences went on to add they can lose level and points. For the two applicable youth who
had been sent to their room, one stated their door was shut and the youth stated their door was
shut and locked. Three out of five youth stated handcuffs or leg irons are not used on out-of-
control youth to prevent them from hurting themselves or others and two stated they have never
witnessed handcuffs or leg irons being used on out-of-control youth. The superintendent was
interviewed and stated the BMS system is utilized to promote positive behavior and
consequences for inappropriate behavior. The BMS system utilizes rewards and privileges for
positive behavior.
5.03 Ten-Minute Checks (Critical) Failed Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has sixty-two cameras, and sixty were operational during the annual compliance
review. The center has the capacity to store video recordings for up to thirty days. A sample of
three days of security footage and corresponding electronic wand logs and two additional days
of electronic wand longs were reviewed to verify ten-minute checks were conducted. None of
the reviewed days were conducted as required. One video observation found no checks were
conducted or documented for fifty-five minutes. During this time, one staff exited the module,
leaving the module unstaffed for thirty-eight minutes, when a different staff came on the floor
who conducted only one check. Continued video observation of an additional three hours and
thirty-two minutes found no other checks were conducted or documented as well as this staff
leaving the floor unstaffed for a time period of twenty-seven minutes. The second video
observation found no checks were completed for the first thirty minutes of the reviewed
timeframe, one check was completed at this time, however the next ten-minute check was not
conducted until twenty-two minutes later. The third video observation found one check was
completed within the hour timeframe viewed. Electronic wand logs were reviewed for two days,
one hour each day. The first day documented two late checks, both three minutes, and the
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Office of Accountability and Program Support Page 48 of 60 (Revised July 2023)
second day documented one check was reviewed five minutes late. A review of documentation
found administration had not completed weekly reviews for management oversight. Five staff
were interviewed, and all stated room checks are conducted every ten-minutes when a youth
(non-suicidal) is placed in their room for sleeping or non-punishment reasons. The interviewed
superintendent stated any time a youth is placed in a room during awake hours, a check sheet
will be placed outside the room door with the first check being when the ten-minute check starts.
Every ten minutes an officer will complete a check by looking into the room at the youth and
placing their initials and the time the check was completed. After 7:00 pm, sheets will be
removed, and the checks will be completed electronically with the hand-held wand every ten
minutes, with the officer looking at the youth and completing the check with the wand.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
During the annual compliance review week, observation of counts being conducted was
observed while youth were moving to and from classrooms, to and from the medical clinic, and
to and from intake for youth transport, with no exceptions noted. A sample of logbooks for
twelve months (one full day each month) was reviewed for the annual compliance review period,
with no exceptions found. The review revealed census counts were conducted, at a minimum, at
the beginning and of each shift. In addition, census counts were conducted prior to and
following routine group movement, following any emergency, anytime a population change
occurs, randomly during each shift, and head counts. Five staff were interviewed, and all agreed
youth counts were conducted at the beginning and end of the shift. In addition, staff stated youth
counts are conducted before and after school and before and after meals. All five staff stated
emergency counts would be conducted when visibility is hindered, such as an electrical outage,
after a major disturbance, and if a youth is believed to be missing.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 60 (Revised July 2023)
5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
A sample of logbooks for twelve- month (three full days each month) was reviewed for the
annual compliance review period, with no exceptions noted. The center maintains separate
logbooks in master control, each living area, visitors, and each vehicle. Logbooks were
observed to be bound with numbered pages and the date documented at the top of the page.
Each observed entry included the time of events in a.m. and p.m., with the name of the staff and
youth involved. In addition, logbook entries included a brief description of the events, along with
the initials of the staff making the entries. Logbook entries impacting the safety and security of
the center, including medical, special needs, and mental health alerts, were observed to be
highlighted. Any errors were struck through with a single line, and “void” was written after the
error, followed by the staff’s initials. In addition, the juvenile justice detention officer supervisor
(JJDOS) and/or lead officer recorded comments regarding the corrected errors. The center does
not utilize an electronic logbook. The reviewed logbooks documented the JJDOS, reviewed the
master control logbook when accepting responsibility for the center, and reviewed the living
area logbooks daily. In addition, the juvenile justice detention officers (JJDOs) reviewed logbook
entries from the previous shift when accepting responsibility for the living area. Logbook reviews
were observed to designate the name and position of the reviewer along with the date and time
the review was completed. The review of the master control logbook revealed the center
documented emergency situations, incidents (including the use of Protective Action Response
(PAR), the Florida Abuse Hotline, and the Department’s Central Communications Center
contacts), and drills (fire, escape, medical). In addition, documentation of receipt of
medical/mental health alerts, population counts at the beginning and end of each shift,
population counts throughout shifts as count changes, and youth counts following emergency
situations were included. Logbook documentation also included youth group movement,
admissions and releases, presence of law enforcement, names of youth placed in confinement
with the time of when confinement began and ended, and names of youth placed on
precautionary/secure observation along with the time initiated and time ended. A sample of all
types of logbooks for twelve months (three full days each month) were reviewed during the
annual compliance review. The center’s activity schedule and logbook document minimal
interference with educational instruction. A review of the logbook indicated education classes
were not conducted as scheduled. A review of the logbook did not reflect the youth arrived and
departed school on time.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 60 (Revised July 2023)
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
A sample of logbooks for twelve months (three full days each month) were reviewed for the
annual compliance review period, with no exceptions found. The review revealed the
superintendent or designee reviews all logbooks on a weekly basis and provides
recommendations as to the completeness and accuracy of the information recorded. The
juvenile justice detention officer supervisor (JJDOS) reviews the center’s logbook, which is
maintained at master control when assuming center responsibility. In addition, the JJDOS
and/or lead officer reviews logbooks maintained in each living area daily. The juvenile justice
detention officers (JJDOs) review the logbook maintained in their assigned living area when
accepting responsibility for the living area at shift change. Observations of logbooks noted the
superintendent, assistant superintendent, or staff in charge of the center would tour the youth
living areas at least once during each shift and document his/her visit in each area’s logbook.
The interviewed superintendent confirmed the superintendent or designee reviews all logbooks
on a weekly basis.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 60 (Revised July 2023)
5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys.
All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of
keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch.
The key(s) on these rings shall provide egress through facility exterior doors providing access
to evacuation areas.
A key inventory shall be maintained by the Superintendent or designee at all times.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center’s written facility operating procedures (FOPs) covering key control were reviewed.
The center’s FOP addressed key assignment and usage, including restrictions on usage,
inventory, daily tracking, reconciliation of keys, and secure storage of keys not in use. In
addition, the FOPs addressed procedures for missing or lost keys and the reporting and
replacement of damaged keys. The key inventory was reviewed to ensure the key rings
matched the actual key rings in use. Observation of the key storage area occurred during the
annual compliance review, which determined key storage is in master control and the
supervisor’s office. An observation of the distribution and collection of keys at shift change
showed staff turned in their personal keys in master control before obtaining facility keys. The
provisions for restricted keys were observed, with no exceptions noted. All facility keys are
maintained on tamper-resistant rings. The emergency key rings are located in the supervisor’s
office, and only the superintendent, assistant superintendents, supervisors, and maintenance
mechanic have access. The master key inventory included the ring number, the number of rings
on each ring, the capability of each key, and to whom the key ring was issued. In addition, all
keys’ rings were numbered, and indicated the number of keys on the ring. The center’s keys are
placed on a key ring hub system and are color-coded. The issuance of keys and key ring
numbers were documented on each shift report and included date and time of issue, name of
staff issuing the key ring, name of staff who received key ring, and the time key ring was
returned. During the annual compliance review, observation showed staff who were issued keys
carry on their person at all times, do not allow youth to handle facility keys, and not remove keys
from facility grounds without authorization from the superintendent. The center’s key box is not
easily accessible while locked. During the annual compliance review period, there were no
incidents reported to the Department’s Central Communications Center (CCC) or Program
Monitoring and Management (PMM) deficiencies related to key control concerns. A sample of
five staff key rings were reviewed, and all were present on the key log and had the correct
number of keys. An informal interview with three staff revealed they knew the number of keys on
their ring and knew each of the key’s function. An informal interview with the master control
operator was conducted to determine the process for restricting the usage of keys. The master
control operator reported medical, youth and staff records, and youth property locker keys are
restricted with only appropriate staff having access to these keys and are documented
accordingly.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 60 (Revised July 2023)
Five staff were interviewed, and each were able to identify which keys are restricted. Each of
the five staff interviewed was able to explain the center’s key control process. The interviewed
superintendent stated permanent keys are issued to some staff members which are tracked by
the maintenance mechanic. An acknowledgment is signed by the staff member and entered into
the facility key inventory log.
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center currently operates seven vans used for youth transport. All seven vehicles had an
annual vehicle inspection conducted. Each vehicle had documentation the maintenance
mechanic or designee conducted monthly visual checks of all required elements. All seven
vehicles were physically observed to ensure they had the appropriate number of seat belts, a
seat belt cutter, a window punch, and a current fire extinguisher. The center maintains first-aid
kits with items approved by the designated health authority (DHA) in intake for each vehicle.
When a transport is scheduled to depart, the transporting staff check out the vehicle log and
first-aid kit. All van logbooks contained acknowledgement the vehicle was checked, destination,
and a number of youth and staff names, as well as the name of the officer riding in the back of
the van, time transport began, and time transport ended. During the annual compliance review
week, a transport was observed. Prior to the transport, staff inspected the vehicle for
contraband, made sure the cage area of the vehicle is physically checked for objects and/or
contraband, ensured the vehicle has sufficient gasoline to reach the destination, and maintained
copies of current transportation procedures in each vehicle. In addition, transport staff verified
seatbelts were securely anchored, tested the security screen/cage to ensure it was secure, and
confirmed the vehicle folder contained the vehicle logs, vehicle and mechanical restraint keys,
gas credit card, and vehicle registration. Transport staff ensured a cellular telephone was
assigned to the vehicle, charged and turned on prior to departure, ensured the inspection was
documented in the vehicle logbook, ensured the vehicle was secure at all times, ensured all
youth were searched prior to being placed in a vehicle, and ensured youth and staff wear
seatbelts. Once returned, transport staff ensured the vehicle was searched for contraband,
locked to prevent the introduction of contraband, and searched the youth upon return to the
center, and observed youth and staff wearing seatbelts. The center’s seven vehicles were
checked to ensure the vehicles were locked when not in use. Five youth were interviewed, and
each youth reported they felt staff were driving safely when transporting. None of the youth had
ever seen anyone place contraband in a transport vehicle.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 60 (Revised July 2023)
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center has a written facility operating procedure (FOP) addressing maintenance and
kitchen tool practices. The center’s maintenance staff must have an area designated away from
the secure floor for tool and supply storage. The maintenance staff will have a shadow board of
all tools and a master inventory, which reflects what is on the shadow board. A monthly
inventory of all tools must be kept and provided to the superintendent or designee for review
and sign off. Kitchen knives and other hazardous kitchen sharps must be stored in a locked
sharps/knife cabinet. Inventory of the sharps/knife cabinet must be completed on the daily
inventory sheet in the morning, mid-day, and evening and documented on a daily inventory
sheet. During the annual compliance review week, an inspection of the tool room and kitchen
determines the level of security when tools are not in use.
The maintenance department had a total of seventy-five tools listed on the inventory maintained
by the maintenance mechanic. Upon review, none of the tools listed on the inventory were
missing, and there were no tools which were not listed on the inventory. Monthly inventories
were found to be completed and signed by the superintendent or designee. The kitchen staff
conducts an itemized inventory of all equipment, including knives and other implements, upon
reporting for duty. An informal interview with the maintenance staff confirmed service vendors
were accompanied by designated center staff at all times when in a secure area of the center. If
tools were lost or following the completion of a work project, the work area was cleaned and
inspected for contraband prior to allowing youth access. A review was conducted of the
inventory used to document the issuance and return of tools. An informal interview with the
maintenance and kitchen staff determined if there were missing or damaged tools. The incident
would be reported immediately to the supervisor, and the tool inventory would be updated to
reflect the missing tools, and a search for the tool would be conducted. Five interviewed staff
were able to explain the procedure for when there is a missing or damaged tool. The
superintendent was interviewed and stated the maintenance mechanic and staff have access to
facility tools after hours.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
During the annual compliance review, it was determined youth do not use tools, including
kitchen or medical equipment. The center’s youth use cleaning items such as mops, brooms,
and other common household items under direct staff supervision. There was no observation of
youth using cleaning tools during the annual compliance review. Five staff were interviewed,
and each of them identified only scrub brushes, mops, and brooms as tools youth might use.
Five youth were interviewed, and all five youth identified mops and brooms as the only tools
they used. Three out of five youth said they clean with cleaning agents such as bleach, laundry
soap, window or toilet cleaners however the staff spray the chemicals. The remaining two youth
stated they do not clean with any type of cleaning agent.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 60 (Revised July 2023)
5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center has a written safety plan included in their Continuity of Operations Planning (COOP)
plan addressing proper use, storage, and disposal of chemicals, including flammable, toxic,
caustic, and poisonous items. All flammable, toxic, caustic, and poisonous items are inventoried
and secured when not in use. A review of documentation determined the center maintained an
inventory of all flammable, toxic, caustic, and poisonous items. In addition, the center maintains
safety data sheets (SDS) located in a logbook, posted near the items, and available to staff. A
sample of inventory and SDS of five chemicals confirmed the items were secured with no
exceptions noted.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
During the annual compliance review, it was determined only authorized personnel were
permitted access to flammable, toxic, caustic, and poisonous items. In addition, it was
determined all flammable, toxic, caustic, and poisonous materials stored in secure areas were
inaccessible to youth. Five youth were interviewed, and each stated they do not have access to
flammable, toxic, caustic, and poisonous items. Five staff were interviewed and each stated
youth are not allowed to clean with substances are toxic, flammable, or poisonous.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 60 (Revised July 2023)
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has a written facility operating procedure (FOP) addressing the disposal of
flammable, toxic, caustic, or poisonous items. During the annual compliance review period, the
center did not have any instances of chemical spills or disposal of any flammable, toxic, caustic,
and poisonous items. There is no container in the kitchen designated for grease disposal as the
center does not use grease in the kitchen. An informal interview with maintenance personnel
determined flammable, toxic, caustic, and poisonous items and materials are disposed of
appropriately.
5.14 Confinement Under Twenty-Four Hours Limited Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center had a total of 280 confinements since the last annual compliance review. A sample
of twenty confinement reports were reviewed. Each report documented youth were afforded
basic rights to three meals a day plus school and evening snacks, access to mental healthcare
as requested or needed, daily showers, clean clothing, mattress/bedding, and notice of the
youth’s right to grieve a confinement placement. Twelve of the seventeen applicable
confinement reports did not have documentation of education materials provided. The remaining
three confinements were not during educational hours and, therefore, not applicable. Prior to
placing youth in confinement, each of the twenty reports reviewed documented the supervisor
approved all confinements, the staff placed only one youth in the confinement room, and the
room was searched with documentation of the search entered into the Department’s Facility
Management System (FMS). Fifteen out of the twenty confinement visual observation reports
(VORs) documented the youth in confinement were supervised every five minutes for the first
hour in confinement. The remaining five VORs were unavailable for review to confirm whether
checks were conducted. Eight applicable confinements documented youth receiving treatment if
a physical injury was observed. All twenty confinements documented the reason confinement
was necessary, which was explained to the youth. The supervisor conducted an initial
confinement review within one hour from the incident, with the exception of one report which
was conducted fifty-seven minutes late, as well as additional reviews with the youth at a
minimum of every three hours, documented in FMS. The supervisors/staff continually counseled
the youth and considered removing the youth from confinement. In addition, eight of the
applicable confinement showed every effort was made to communicate the confinement with the
parent/guardian if the confinement interfered with visitation. Twelve of the twenty confinement
reports were completed before the end of their shift. The remaining eight reports were not
completed before the end of their shift. Seven of the twenty confinement reviews were
conducted by the superintendent or designee within forty-eight hours. The remaining thirteen
reports had reviews documented after the required timeframes, between two and thirty-two days
late. None of the youth placed in secure observation were pregnant. Observations of the
center’s windows and cameras revealed they were free of obstructions/scratches, so the youth
may be visually observed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 60 (Revised July 2023)
The interviewed superintendent stated the use and appropriateness of confinements are tracked
in the center. All Protective Action Response (PAR) incident reports are reviewed by the
superintendent, assistant superintendents, and supervisors to ensure all staff involved in an
incident are in compliance with the PAR rule. All statements are entered into FMS by all staff,
witnesses, and/or participants on the same day as the incident occurred. All PAR incidents must
be reviewed by video prior to being signed off by the superintendent/designee within twenty-four
hours of the incident, excluding weekends and holidays. The superintendent also stated
regional detention management reviews of the use of confinement, lockdown, and restraints are
conducted monthly. Five staff were interviewed, and each staff was able to explain the center’s
step- by- step process for placing youth in confinement. All five staff stated youth placed in
temporary confinement are provided educational materials.
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have any confinement reports over twenty-four hours since the last annual
compliance review; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center documented having completed two Continuity of Operations Planning (COOP) drills
during the annual compliance review period, with no exceptions noted. A weather drill was
completed prior to hurricane season. Documentation of the center’s COOP drills included brief
scenarios, type of drill, date and time, and no notable critiques or corrective action required.
Five staff were interviewed. Three staff stated they participated in a weather drill, one stated a
major disturbances drill, four stated an escape drill, and all five staff stated they participated in
fire drills over the annual compliance review period. The superintendent was interviewed and
stated the center’s comprehensive safety/emergency program includes the COOP, the
pandemic plan, and the emergency plan.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 60 (Revised July 2023)
5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has a written escape prevention plan, which includes the Department’s policy and
procedures regarding escapes. The center conducted escape drills at a minimum of once a
quarter, with no exceptions noted. Documentation was found in the center’s logbooks for each
of the four escape drills. During the annual compliance review, a review of eight training records
ensured staff were trained in escape prevention annually. Five interviewed staff stated they had
participated in escape drills since the last annual compliance review.
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
A review of the center’s fire drills found the center conducted monthly fire drills on each shift,
with the exception of two fire drills for the first shift and one fire drill for the second shift.
Documentation was found in the center’s logbooks for each fire drill completed. Observations of
fire extinguishers in the center determined each was inspected annually. Five interviewed staff
stated they have participated in monthly fire drills. Four of the five interviewed youth stated they
had been instructed on what to do in case of a fire, and one said they have not.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 60 (Revised July 2023)
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
Documentation determined youth electronic and strip searches were conducted prior to each
admission. Youth frisk searches are conducted when deemed appropriate by the shift
supervisor when there is reasonable suspicion the youth was harboring contraband and during
facility-wide initiatives to reduce the introduction of contraband. All searches were documented
in the logbook and electronically. During the annual compliance review, observation of a youth
and room search was conducted. Staff wore gloves during the searches of two male youth
departing and arriving from court transport. Staff wore gloves during B1 mod room searches.
Reviewed documentation confirmed an incident report for any strip search conducted at any
time other than admission, two staff of the same gender of the youth were present when
conducting the search, and all strip searches were conducted individually and not in a group
setting. Electronic searches were conducted on all persons entering the facility; staff searched
all bags, cases, jacket pockets, and other items, and all personal keys, personal cell phones,
and other contraband items were prohibited from entering the secure area. Room searches
occurred upon a youth’s release, prior to placing a new youth in the room, and for contraband
on each awake shift.
A reviewed sample of room searches for one day of each month of the annual compliance
review period for each awake shift found the room searched was documented and completed as
required, with no exceptions noted. During the annual compliance review period, there have
been three instances which may have compromised the safety and security of the center. All
three instances were reported immediately to the on-duty supervisor and corrected. A review of
the center’s logbooks confirmed searches of all staff, visitors, and contractors/vendors were
completed prior to entering the secure area, as well as being documented in the
contractors/vendors logbook and on daily shift reports. The center documented the confiscation
of contraband in the master control logbook. Incident reports were completed to identify findings
and disposition of contraband. Law enforcement was contacted if any found item was
considered illegal as defined in Florida Statutes or if there was evidence of any type of unlawful
activity. Confiscated items were secured by the discovering officer and hand-delivered to the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 59 of 60 (Revised July 2023)
supervisor. The shift supervisor documented the chain of custody of confiscated items, and the
process was documented in the incident report. The Central Communications Center (CCC) and
the regional director or designee were notified of the discovery and confiscation of contraband.
The superintendent was interviewed and stated any item discovered during a search of youth or
staff would be removed from the secure area. Law enforcement shall be contacted if the
contraband found is considered illegal, and the CCC and regional director will be notified.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 60 of 60 (Revised July 2023)

report_type: QI Detention

program_name_raw: Bay Regional Juvenile Detention Center

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Failed Compliance

rule: Indicator 3.11

rating: Limited Compliance

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.14

excerpt: Confinement Under Twenty-Four Hours