summary: QI Detention - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Miami-Dade Regional Juvenile Detention Center
"Department of Juvenile Justice"
(State-Operated)
3300 Northwest 27th Avenue
Miami, Florida 33142
Review Date(s): January 9-12, 2024
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Rondarrell George, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Nicos Antonakos, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Rosa Flores, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Peter Keelan, Office of Education, Regional Education Coordinator, South Region, (Standard 2)
Troy McGee, Office of Accountability and Program Support, Regional Monitor (Interviews and
Standard 1)
Tyler Mocere, Brevard Regional Juvenile Detention Center, Assistant Superintendent (Standard
2)
Samuel Sainvil, Collier Regional Juvenile Detention Center, Superintendent (Standard 5)
Program Name: Miami-Dade Regional Juvenile Detention Center MQI Program Code: 490
Provider Name: Department of Juvenile Justice Contract Number: NA
Location: Miami Dade County / Circuit 11 Number of Beds: 98
Review Date(s): January 9-12, 2024 Lead Reviewer Code: 179
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 59 (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 59 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 59 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in
a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 59 (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 59 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will
result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 59 (Revised July 2023)
Program Overview
The Miami-Dade Regional Juvenile Detention Center is a state-owned detention center,
operated by the Department, located in Miami, Florida. The center serves youth in Miami-Dade,
and Monroe counties in Circuits 11 and 16. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
ninety-eight-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 Miami-Dade County School
District. The center’s management team includes the superintendent, two assistant
superintendents, one administrative assistant, twelve juvenile justice detention officer (JJDO)
supervisors, and seventy-one JJDOs. Mental health and healthcare services are provided
through the contracted provider, VitalCore Health Strategies, LLC. Mental health services are
provided by one designated mental health clinician authority (DMHCA), six licensed staff, and
one non-licensed staff. Clinical services provided by the center include mental health and
substance abuse evaluations, mental health treatment planning, individual, group, and family
therapy, mental health crisis intervention services, on-site psychiatric services, and availability
for substance abuse services for youth with co-occurring disorders. Medical services are
provided by one designated health authority (DHA), one advanced practice registered nurse
(APRN), four registered nurses (RNs), and one licensed practical nurse (LPN). The medical
clinic maintains nursing coverage seven-days a week from 7:00 a.m. to 7:30 p.m., Monday
through Friday, and from 7:00 a.m. to 5:30 p.m. on weekends. 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 five
living modules which are divided by male and female. There are 163 security cameras at the
center, of which 159 were operational. Observations were made during the annual compliance
review week which included youth movements, medication administration, sick call, searches,
key control, video surveillance footage, and staff and youth interactions. A completed tour of the
center’s buildings, grounds, all youth living modules, administrative offices, recreation areas,
kitchen, and maintenance areas found there was no graffiti. At the time of the annual
compliance review, the center had six vacancies, which included four JJDO I positions, and one
JJDO II position.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 59 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center maintains a written policy and procedures requiring compliance with the
Department’s background screening requirements. A review of the initial background screenings
for twenty-five newly hired staff found the center received background screening results from
the Department’s Background Screening Unit (BSU)/Clearinghouse prior to each staff’s hire
date. Documentation revealed the center added all of the staff to the employment roster in the
Clearinghouse. There were no volunteers applicable for background screenings since the last
annual compliance review. None of the staff were applicable for a background screening
exemption. All required documentation was reviewed prior to each staff’s hire date. None of the
twenty-five staff were applicable for a break in service. The center utilizes an ergometric pre-
employment assessment tool for all direct care applicants. Twenty-one of the applicants were
applicable and documentation indicated each received a passing score and a copy of the pre-
employment assessment was maintained within each staff’s record. The Annual Affidavit of
Compliance with Level 2 Screening Standards was submitted to the Department’s
BSU/Clearinghouse on December 1, 2023, meeting the annual requirement. The Annual
Affidavit of Compliance with Level 2 Screening Standards for school board teachers was
submitted to the BSU on December 4, 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 maintains a written policy and procedures to ensure all staff, contracted providers,
and volunteers with access to youth undergo a criminal history background check every five
years. The center had seven staff applicable for a five-year rescreening since the last annual
compliance review. Each staff’s rescreening was completed and submitted to the Department’s
Background Screening Unit (BSU)/Clearinghouse within the required time frames. There were
no volunteers or contracted staff applicable for a five-year rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 59 (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.
The center maintains a written policy and procedures addressing the staff code of conduct. Staff
are required to adhere to the code of conduct which prohibits any type of abuse, profanity,
threats, harassment, intimidation, horseplay, or personal relationships with youth. A review of
nine staff personnel records documented the staff had signed a code of conduct prohibiting any
form of abuse, profanity, threats, harassment, or intimidation. The code of conduct also
addressed officer professionalism, poor performance, negligence, insubordination, conduct
unbecoming of a public employee, and misconduct. Reviewed documentation for three staff
supported management took immediate corrective action to address the staff code of conduct
when staff violated policies and procedures. In three reviewed instances, with three different
staff, one received an oral reprimand, and two staff received a written reprimand and were
retrained. Three staff at the center, to include one juvenile justice detention officer (JJDO) II and
two JJDO Is, received commendations for regional employee of the month for their dedication
and outstanding work performances, while going above and beyond for the Department. Nine
youth were interviewed, and three youth reported never being stopped from reporting abuse to
the Florida Abuse Hotline, and six youth reported they never had to report abuse. Each youth
reported feeling safe at the center and stated staff are respectful when talking to them. Four
youth stated they never heard staff use profanity when speaking to the youth. Two youth said
once, two youth said occasionally, one said they often heard staff use curse words. The use of
profanity was addressed with the superintendent at the center. Each youth reported never
hearing any staff threaten youth at the center. All nine youth denied ever having exchanged e-
mails, telephone numbers, or social media information with staff. Nine staff were interviewed,
and each was able to explain the process for allowing youth to call the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC). Six of nine staff reported they
have never heard staff use profanity when speaking with youth, one said once, and two reported
occasionally hearing staff use profanity when speaking to youth. According to two of the three
staff profanity was only heard occasionally, and one staff stated once; however, they stepped in
to deescalate the staff. None of the staff reported observing another staff using threats,
intimidation, or humiliation when interacting with a youth. Four of nine interviewed staff rated the
working conditions at the center as fair, four rated working conditions as good, and one rated
working condition as very good. An interview with the superintendent confirmed the staff code of
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 59 (Revised July 2023)
conduct is to ensure staff communicate and interact with youth in a manner which provides a
role model of socially accepted behaviors, and staff behavior shall be respectful of others and
reflect desired behaviors for youth. Officers shall not verbally abuse, demean, or otherwise
humiliate any youth and shall not use profanity in the performance of their job.
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 maintains a written policy and procedures to ensure when a reportable incident
occurs the center notifies the Department’s Central Communications Center (CCC) within two
hours of becoming aware of the incident. The center had seventy-four reportable incidents since
the last annual compliance review. A review of seven incidents found all were reported to the
CCC within two hours of the incident except for one, which was an hour late. Each incident was
documented in the center’s CCC logbook. A review of the center’s internal incident/grievance
reports found there were no additional incidents which should have been reported to the CCC
and were not. The center’s superintendent was interviewed and was able to explain the process
for allowing a youth to call the Florida Abuse Hotline and/or the CCC.
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 maintains a written policy and procedures ensuring detention staff use of physical
intervention techniques is in accordance with Florida Administrative Code. Any a time staff uses
a physical intervention technique, such as countermoves, control techniques, takedowns, or
application of mechanical restraints, with the exception of regular transports, a Protective Action
Response (PAR)/Right Interactions (RI) Report is completed. The center had a total of 379
PAR/RI incidents since the last annual compliance review. A review of nine PAR/RI Reports
found all involved staff completed appropriate statements by the end of their shift. Each PAR/RI
Report was reviewed and processed within seventy-two hours by each staff involved. Each of
the nine PAR/RI Reports documented a post-PAR/RI interview was conducted with the youth by
the center’s administration within thirty minutes after the incident. Two reports were applicable
and contained a post-PAR/RI medical review, which was completed and documented in the
Individual Healthcare Records (IHCRs). No records were applicable for the use of mechanical
restraints. A review of internal incident/grievance reports and logbooks indicated there were no
additional PAR/RI incidents which did not have a report. No reviewed PARs/RIs resulted in
injury. The center’s PAR/RI rate during the previous quarter was 16.66, which is above the
statewide Detention PAR/RI rate of 16.29. Nine staff were interviewed, and each staff reported
staff try to talk with youth prior to using PAR/RI. An interview with the center’s superintendent
revealed PAR/RI incidents and mechanical restraints are monitored and tracked through the
PAR/RI Report. A report will be generated any time an officer places their hands on a youth,
with the exception of the sole use of the straight arm, close, or extended escort. In the event a
PAR/RI technique is not able to be used due to the rapid escalation of dangerous behavior, a
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 59 (Revised July 2023)
detailed description of the use of physical intervention shall be documented on the PAR/RI
Report with subsequent entries reflecting the appropriate level of PAR/RI used.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center maintains a written policy and procedures regarding pre-service training. Staff are
trained in accordance with Florida Administrative Code. Detention staff satisfy pre-
service/certification requirements specified by Florida Administrative Code within 180 days of
hire. Phase One training consists of instructor-led and web-based courses. Phase Two training
consists of 120 hours of academy instructor-led training. A review of nine applicable staff
training records for pre-service training indicated each staff completed all required trainings
within 180-days of hire, except for one staff who was still within the 180-days. Reviewed
documentation confirmed each applicable staff completed all trainings required by the
Department prior to having contact with youth. All pre-service trainings were documented in the
Department’s Learning Management System (SkillPro). The center did not have any returning
direct care staff applicable for the specified training when returning less than one year from
separation.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center maintains a written policy and procedures which require staff to complete twenty-four
hours of in-service training each calendar year after completion of pre-service certification
training. The policy also requires supervisors to complete eight hours of supervisory training
annually. The center provides in-service training to staff through a combination of the
Department’s Learning Management System (SkillPro) and instructor-led classes. Nine staff
training records were reviewed for in-service trainings, including six direct care staff and three
supervisory staff. All nine staff records reflected staff completed the mandatory training topics.
Three staff were applicable for a minimum of eight hours of supervisory training. Each staff
completed the required eight hours of supervisory training. All trainings were entered into
SkillPro. The center has an annual in-service training calendar which is updated as changes
occur. The in-service training was approved by the Department’s regional director on November
29, 2022. The center’s practice was confirmed through an interview with the superintendent.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 59 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center maintains a written policy and procedures to guarantee each youth has the right to
file a grievance and ensure all youth are treated fairly, respectfully, without discrimination, and
their rights are protected. The grievance process is displayed in each living module and
explained to each youth during the admission and orientation process. Grievance forms are
accessible to youth on each module of the center. The initial step in the grievance process is the
informal phase, where the juvenile justice detention officer (JJDO) and the youth try to resolve
the issue using effective communication. If the grievance is not resolved, the grievance is
entered into the Department’s Facility Management System (FMS) on behalf of the youth by the
staff. The written grievance will be submitted to the JJDO supervisor within two-hours, beginning
the formal grievance process. Next, the appeal phase requires a response from the
superintendent or designee. The center had three formal grievances since the last annual
compliance review. Reviewed documentation confirmed the grievances were reviewed and
handled in accordance with the Department’s policy. The center’s practice was confirmed
through an interview with the superintendent. Nine youth were interviewed regarding the
grievance process and each youth stated there is a form on the living module for youth to fill out
then give to the staff. Two out of nine youth reported never filing a grievance. Nine staff were
interviewed and were able to explain the center’s grievance process. Each staff stated they
allow the youth to fill out the form and then turn the form into the supervisor.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 59 (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 maintains a written policy and procedures to address entering an alert into the
Department’s Juvenile Justice Information System (JJIS) for youth who require an alert which
may not have been previously identified prior to the youth’s admission. The alerts entered into
JJIS are verified by medical staff, juvenile justice detention officer (JJDO) supervisors, or the
mental health staff, as applicable. Nine youth records were reviewed for case management,
medical, mental health, and substance abuse alerts. Each reviewed youth record documented
all alerts were accurately entered into JJIS. The reviewed youth were applicable for twenty-
seven separate alerts. The JJIS alerts are printed daily by the on-duty supervisor, copies are
provided to all staff during their shift, and all staff have access to the alert system. Reviewed
documentation indicated alerts were discussed during shift briefings. An observation of a shift
briefing was conducted during the annual compliance review week and supported youth alert
information was consistently discussed with the JJDOs at the meeting. All applicable alerts were
downgraded and removed by the medical staff and/or the mental health staff. Nine staff were
interviewed, and each staff reported being informed of youth alerts through the shift debriefing
and JJIS alert forms. All the staff reported management informed the staff about issues within
the center through shift debriefing meetings and staff meetings. During an interview with the
superintendent, it was stated medical alerts are entered in JJIS and are designed to be a quick
reference. Detention staff enter alerts at admission based on information provided by the youth,
the parent/guardian, law enforcement, and the Juvenile Assessment Center. Healthcare staff
shall review the alerts on a daily basis to ensure they are up to date, meet all confidentiality
requirements, confirmed through the youth's medical history, and confirmed with the youth's
parent/guardian.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 59 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has a structured method for analyzing data trends. The center's practice regarding
data trends is to collect information in monthly management meetings, staff meetings,
parent/guardian visitor surveys, and through staff input. The information collected is used in
decision making practices. Reports capture the data and necessary changes are made. The
information is then shared with center staff through monthly management meetings and daily
shift briefings. A review of surveys, meeting agendas, and data collection software confirmed
the center’s practices. The center also participates in a community advisory meeting, in which
information is shared with stakeholders at least quarterly.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 59 (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 written operating procedures regarding youth admission. A review of nine active
case management records indicated eight records contained an arrest affidavit. The remaining
youth record contained a detention order. Each of the eight applicable records contained the
Detention Risk Assessment Instrument (DRAI). All nine records had the Suicide Risk Screening
Instrument (SRSI) present. Reviewed documentation confirmed the nine youth had their full
body search conducted by a staff of the same gender. Each record confirmed all youth were
offered a phone call to their parent/guardian and each youth was offered a meal upon
admission. Each record contained a medical/mental health/substance abuse screening
completed upon admission. During the annual compliance review, an observation of a youth
admission was conducted. All required procedures of the process were followed, the youth was
afforded the opportunity to make a telephone call to their parent/guardian, and a meal was
provided.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 59 (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 written operating procedures regarding youth orientation. Nine youth case
management records were reviewed, and each youth was provided orientation within twenty-
four hours of admission and signed the brochure provided by the center. During the annual
compliance review week, an observation of a youth orientation was observed. All procedures
were followed and consistent with the center’s operating procedures for youth orientation. The
youth was informed of the center’s rules and regulations, grievance procedures, visitation hours,
telephone calls, how to access mental health and medical services, access to the Florida Abuse
Hotline and the Department’s Central Communications Center (CCC), behavior expectations
and consequences, possible new law violations, youth rights, and Prison Rape Elimination Act
(PREA) related information. During the observation, the required PREA videotape was played
for the youth to watch. Nine youth were interviewed, and all reported during the orientation
process they were informed of the rules and regulations, daily schedule, education services,
visitation, abuse reporting, and the behavior management system (BMS).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 59 (Revised July 2023)
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has written operating procedures regarding classification. Nine youth case
management records were reviewed, and the classification process for each youth included a
review of information concerning the youth’s history and status. Nine classification forms were
reviewed and each confirmed the center takes each youth’s gender, height, weight, age, level of
aggression, mental illness, intellectual disabilities, physical disabilities, history of violent
behavior, gang affiliation, criminal history, history of sexual offenses including sexual battery
charges, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB), medical,
identified or suspected suicide risk, escape, and security risks into consideration before placing
a youth in a room. Each of the reviewed records confirmed youth were assigned a room based
on classification. None of the youth were reclassified due to changes in behavior. One case
management record was applicable for a youth with a history of committing sexual offenses and
the youth was placed into a room by themself. The superintendent is informed of how to identify
local gangs through trainings with the local police department. The superintendent is informed of
gang activity and alerts by email. The interviewed superintendent explained youth shall be
assigned to a room based on their classification and youth are reclassified if changes in
behavior or status are observed. Living area/room assignments shall be documented in the
Department’s Juvenile Justice Information System (JJIS) and in all applicable admission
paperwork and logs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 19 of 59 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has written operating procedures regarding newly admitted youth to determine gang
affiliation. The center has designated a juvenile justice detention officer (JJDO) II as the gang
representative for the center. During the annual compliance review week, an informal interview
was conducted with the gang representative for the center. The gang representative stated staff
are informed of youth involved in gangs through shift briefings. The center’s gang representative
informs the juvenile probation officer (JPO) through e-mail when a youth is admitted to the
center and is involved in a gang. Nine youth case management records were reviewed, and
three of the youth were applicable for gang involvement. Each applicable reviewed record
contained an e-mail sent from the gang representative to the proper JPO containing the
required information in accordance with the center’s operating procedures. The center has a
binder documenting all current youth with gang involvement and training rosters from trainings
on gangs provided by the Miami-Dade Police Department.
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 written operating procedures regarding the admission and storage of youth
personal property. All youth’s personal and valuable property is inventoried and documented in
the Department’s Juvenile Justice Information System (JJIS), maintained securely, and returned
to the youth or the parent/guardian in a timely manner upon the youth’s release. Personal items,
such as clothing and shoes, are placed in a green property bag and secured in the center’s
property room. Valuable items are listed and placed in a clear tamper-proof property bag,
identified with the youth’s name and Department identification number (DJJID), then secured in
the center’s property safe, which always remains on camera view. Nine youth case
management records were reviewed, and each record contained youth and staff signatures on
the JJIS property sheet. Each record contained a letter of acknowledgement regarding
unclaimed property with youth and staff signatures. Three reviewed records contained personal
property forms, with all three containing documentation of the property being dropped in the
center’s safe. During the annual compliance review week, a youth admission with property was
observed. During the observation, the youth’s personal property was stored in a clear tamper
proof bag, signed by the staff and youth, and then dropped into the property safe on camera
view. Access to the youth’s personal property is limited to shift supervisors and administration.
A review of the Department’s Central Communication Center (CCC) reports since the last
annual compliance review found no incidents regarding youth property. Nine youth were
interviewed, and each youth reported when they arrived at the center, staff checked their
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 20 of 59 (Revised July 2023)
property and signed a property sheet ensuring their property was accurate. The interviewed
superintendent stated the superintendent and admission staff are responsible for ensuring the
youth’s personal property and valuables are maintained according to the center’s policy. The
superintendent also stated all youth have a signed copy of the JJIS property sheet in their youth
file. If a youth refuses to sign the property sheet, admission staff must document and report it to
the shift supervisor.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center has written operating procedures regarding the release of youth in secure detention.
Five closed youth case management records were reviewed. Each record had a copy of the
Department’s Detention Release form, which documents the supervisor has reviewed all
paperwork related to the youth’s release and court documents. All five youth had their
identification verified prior to release. The parent/guardian identification was verified prior to
release for each youth, and a photocopy of the parent/guardian identification was placed in each
youth’s case management record. None of the reviewed records identified the youth as an
endangered person. Each youth and the person to whom the youth was released to were
reminded of future court dates and signed the release forms. The date of admission and the
date of release documented in each youth’s record correlated with the dates documented in the
Department’s Juvenile Justice Information System (JJIS). All five case management records
indicated all required parties signed all applicable release forms. During the annual compliance
review week, a release was observed, and it was confirmed the releasing staff was following the
center’s procedures for a youth release from the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 21 of 59 (Revised July 2023)
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has written operating procedures regarding the release of youth personal property,
medication, and aftercare instructions. Five case management records were reviewed. Each
record contained a Property Receipt form signed by the youth and parent/guardian upon
release. Each record contained documentation verifying the youth was released to an
appropriate person to include a copy of their identification. One record was applicable for a
youth being released with medication. The medication receipt was signed by the person taking
custody of the youth and the person was informed of an upcoming appointment for the youth.
During the annual compliance review period there were examples of abandoned property. Three
examples were reviewed, and for each the center’s operating procedures were followed for the
disposal of abandoned property. During the annual compliance review week, a youth released
with property was observed. The shift supervisor retrieved the youth’s property from the safe
and the youth and parent/guardian signed the appropriate documentation for taking custody of
the property. The parent’s/guardian’s identification was confirmed by the issued driver’s license
and a copy was made. All of the center’s release procedures were followed during the
observation of the youth release.
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 has written operating procedures regarding the review of youth in secure detention.
The center has an officer assigned as the detention review specialist (DRS). During the annual
compliance review week, an observation of the weekly Detention Review meeting was not able
to be conducted. An informal interview was conducted with the DRS who stated the weekly
meeting is held Tuesday mornings virtually. Each week, all youth in the center are discussed
during the Detention Review meeting with mental health, medical, education, and juvenile
probation officers (JPOs). A review of the center’s Detention Review uploads confirmed the
center is conducting Detention Reviews on a weekly basis with all the required participants
attending the meeting. The interviewed superintendent stated Detention Reviews are conducted
on a weekly basis by the DRS. The superintendent stated mental health, clinic management,
education, and the DRS attend the meeting, and the superintendent and assistant
superintendent are encouraged to attend; however, they are not required. The purpose of the
Detention Review is to discuss the youth in the center and any questionable court orders, as
well as capacity/overcrowding issues which may arise.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 22 of 59 (Revised July 2023)
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has written operating procedures regarding the daily activity schedule. During the
annual compliance review week, a center tour was conducted, and the daily activity schedule
was posted on all the youth living modules. Youth were also observed attending school and
open programming. Logbook documentation confirmed activities such as wake-up/personal
hygiene, mealtimes, visitation, recreation, education, shift change, bedtime, and groups were
conducted as scheduled. Nine youth were interviewed and confirmed the center has a daily
schedule and it is being followed. Nine interviewed staff reported the center follows the daily
activity schedule.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center maintains a written policy and procedures to provide educational access. The
center’s educational program is directly supervised and managed by the Miami-Dade County
School District. Instruction is provided on a year-round basis, with 250 days of instruction
distributed over twelve months, and a minimum of twenty-five hours of weekly classroom
instruction. The annual academic calendar includes the provision for up to ten days dedicated to
teacher planning/professional development. The center has implemented a daily academic
schedule designed to minimize interruptions to ongoing classes. Upon review of the annual
academic calendar, as well as the daily classroom schedule, it was verified education was
adhering to the required days and hours of instruction. A review of the center’s logbooks and
video footage was conducted for three randomly selected dates. Observations confirmed the
classes were following all established schedules with minimal disruptions or interference. The
interviewed academic principal, lead teacher, and superintendent verified classes were
occurring in accordance with the schedule. Eight of nine interviewed youth stated the center
prepares the youth for the high school equivalency diploma (GED), high school, vocational,
employment, and/or college “well,” and one youth stated, “very well.” Nine staff were
interviewed, and each indicated the center provides minimal interference in educational
instruction. An interview with the superintendent confirmed there is minimal interference with
educational instruction.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 23 of 59 (Revised July 2023)
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has a career education competency development program provided by Miami-Dade
County School District to all youth in secure detention. The center offers Type I career
education. Reviewed documentation confirmed the career education programming included
communication, interpersonal, and decision-making skills. This classification which stresses
“soft skills” includes activities focusing upon, but not limited to, the youth’s learning or improving
their interpersonal communication and decision-making skills. Furthermore, this component
provides to the youth various career exploratory exercises centered upon the investigation of
creating career choices based upon their interests and the appropriate preparation prerequisites
of such choices. Nine youth were interviewed, and each youth stated they are taking math,
science, and reading. Three youth stated they are taking career choice, four youth stated they
are taking history, and six stated they are taking social studies.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 24 of 59 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center maintains a written policy and procedures requiring a single licensed mental health
professional to serve as the designated mental health clinician authority (DMHCA). The DMHCA
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 contract
requires a full-time licensed professional to serve as the DMHCA for forty hours each week. The
center’s DMHCA is a licensed mental health counselor with a clear and active license in the
State of Florida which expires March 31, 2025. The center has not utilized a back-up DMHCA
since the last annual compliance review; however, the center has six additional licensed mental
health staff at the center qualified to provide coverage and one is designated as the back-up
DMHCA. The DMHCA’s position description details the clinical and administrative oversight
responsibilities of all contractual requirements. The DMHCA is scheduled to be on-site Monday
through Friday and is on-call twenty-four hours each day for emergencies and consultation. A
review of mental health staff sign-in logs verified the DMHCA was on-site as required. The
interviewed DMHCA reported they are responsible for ensuring youth at the center receive
mental health treatment. Treatment services are tracked by the DMHCA, and caseloads are
staffed with mental health staff. The DMHCA additionally utilizes a large wall-mounted white
board as an at-a-glance visual status of all youth in the center who are on psychotropic
medication, receiving mental health and substance abuse services, the youth on each
therapist’s assigned caseload, each youth’s next scheduled treatment team meeting date, when
any comprehensive evaluations are pending, and the youth with pending discharge dates. The
DMHCA maintains communication with the clinical staff throughout each day and clinical
supervision is conducted once a week for the one non-licensed clinician.
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 contractual
licensed positions, in addition to the designated mental health clinician authority (DMHCA),
include six licensed mental health staff and a part-time psychiatrist. Two staff are licensed
clinical social workers and four are licensed mental health counselors. All six staff licenses were
clear and active in the State of Florida with expiration dates of March 31, 2025. The pro-re-nata
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 25 of 59 (Revised July 2023)
(PRN) psychologist holds a clear and active license in the State of Florida with an expiration
date of January 31, 2026.
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 all applicable youth in the center. All mental health
services must be provided by a licensed mental health professional or a non-licensed mental
health clinical staff person who is working under the direct supervision of the licensed mental
health professional. The center has one non-licensed mental health staff. The one non-licensed
therapist holds a master’s-level degree in forensic psychology. Reviewed documentation
verified the non-licensed staff received twenty hours of training and supervised experience in
assessing suicide risk, mental health crisis intervention, and emergency mental health services.
The training included the administration of Assessments of Suicide Risk (ASRs) conducted on-
site in the physical presence of a licensed mental health professional which was documented on
the Department’s Non-Licensed Mental Health Clinical Staff Person’s Training in ASR form. A
review of the supervision logs reflected the DMHCA provided at least one-hour of weekly face-
to-face supervision to the non-licensed staff each week since the last annual compliance review,
with the exception of one week when the non-licensed staff was on medical leave. All
supervision was documented on the Department’s Licensed Mental Health Professionals and
Licensed/Certified Substance Abuse Professionals Direct Supervision Log. At the time of the
annual compliance review, the center did not have a Chapter 397 license with the Department
of Children and Families. According to the interviewed DMHCA and caseload assignments, only
licensed staff provide substance abuse treatment at the center.
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 maintains a written policy and procedures requiring the identification of youth mental
health and substance abuse needs through a comprehensive screening process and referrals to
be made when youth are identified with mental health and/or substance abuse needs or are
identified as a possible suicide risk. 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 is to then complete their assigned section of the Suicide
Risk Screening Instrument (SRSI). A review of nine youth mental health and substance abuse
records showed each youth had a completed SRSI and eight youth had a completed MAYSI-2
during the youth’s admission process. One youth was a direct admission to the detention center;
therefore, a MAYSI-2 was not applicable for admission. Each form was completed in the
Department’s Juvenile Justice Information System (JJIS). Each of the nine SRSIs were
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 26 of 59 (Revised July 2023)
reviewed by a mental health clinical staff and included their documented recommendation. Each
of the SRSIs had completed entries which also had a summary and recommendations included
in the screening results section. Five youth were applicable for positive “yes” responses on the
SRSI form. Three records were applicable for an elevated suicide subscale on the MAYSI-2.
Each was placed on suicide precautions, and a mental health referral was generated. None of
the reviewed youth were applicable for having all negative responses on the MAYSI-2,
invalidating the screening. Three youth required a comprehensive assessment, and the center
notified mental health staff and the superintendent, 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 maintains a written policy and procedures outlining a process for identifying the
mental health and substance abuse needs of youth through a comprehensive screening. The
center utilizes the Department’s Mental Health and Substance Abuse Referral Summary form.
Youth who are identified at the Juvenile Assessment Center (JAC) as needing further
assessment are referred for a comprehensive assessment. A review of nine youth mental health
and substance abuse records reflected one youth was applicable for referral for mental health
and substance abuse services. A review of two additional youth mental health and substance
abuse records was completed. All three records showed each youth was screened, and a
referral was made for each youth to receive a comprehensive mental health evaluation based
on the Massachusetts Youth Screening Instrument, Second Version (MAYSI-2). All three youth
received a completed evaluation documented on the Substance Abuse and Mental Health
Assessment (SAMH) form within thirty days of the referral’s completion by the center’s provider.
The center had no youth records applicable for a community provider assessment since the last
annual compliance review. Each of the evaluations were completed by each youth’s thirty-first
day in the center and contained treatment recommendations which corresponded to all
diagnosed mental health or substance-related disorders.
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 provider’s contract requires the superintendent and designated mental health clinician
authority (DMHCA) or mental health/substance abuse clinical staff to ensure the development
and review of an initial and/or individualized treatment plan for each youth receiving mental
health/substance abuse treatment in the center. Nine youth mental health and substance abuse
records were reviewed for mental health and substance abuse treatment services. Two youth
records had an initial treatment plan in place within seven days of initiation of treatment which
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 27 of 59 (Revised July 2023)
was developed on the Department’s Initial Mental Health/Substance Abuse Treatment Plan
form. Both reviewed youth records were applicable for treatment with individual or group
counseling. Each initial treatment plan contained the reason for treatment referral, the initial
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, initial
treatment methods and goals, and psychiatric services. The plan was signed by the youth and
the mini-treatment team members. Neither of the two reviewed records were applicable for
individualized treatment plans (ITPs) as both youth had been in the center for less than three
weeks. The program provided three additional youth records and each record documented an
ITP was developed within the required time frame and documented on the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan form. Each ITP identified a
DSM-5 diagnosis, treatment-focused symptoms, treatment goals, and strengths/needs. None of
the three records were applicable for psychiatric services or pharmacological interventions. All
three ITPs were signed by the youth, mental health professional, treatment team members, and
the parent/guardian, when applicable. The three youth records were applicable for an ITP
review completed every thirty days by the treatment team. The ITP reviews for all three youth
were signed by all treatment team members and the youth. No youth were applicable for having
been an alleged victim of a Prison Rape Elimination Act (PREA) incident. Three youth were
applicable for having a discharge summary which was completed on the Department’s Mental
Health/Substance Treatment Discharge Summary form upon each youth’s transition/discharge.
A copy of the discharge summary was provided to each youth’s juvenile probation officer. A
copy of the discharge summary could not be provided to the youth’s parent/guardian as each
parent/guardian could not be reached or was not present when the youth was released to a
residential program. An observation of a treatment team meeting was conducted during the
annual compliance review week and confirmed the meeting involved all required parties. Due to
the center’s large population, it is the center’s practice to contact each parent/guardian after the
conclusion of each treatment team meeting to inform them of the results.
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 provider’s contract requires mental health and substance abuse treatment planning to focus
on provisions of treatment to reduce or alleviate youth’s symptoms of mental disorder or
substance abuse impairment and enable youth to function adequately in the juvenile justice
setting. Nine mental health and substance abuse records were reviewed and two were
applicable for receiving initial treatment services; however, one youth was released from the
center prior to the completion of the comprehensive evaluation and the other youth had been in
the center for only two weeks. The center provided three additional applicable records. Each
reviewed record contained the properly executed consents for mental health and/or substance
abuse treatment services and each youth was assigned to a mini-treatment team as required.
Each record contained progress notes documented on the Department’s Counseling/Therapy
Progress Notes form. Reviewed progress notes validated youth were receiving treatment
services as stipulated on their treatment plan. An interview with the designated mental health
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 28 of 59 (Revised July 2023)
clinician authority (DMHCA) and observations of video surveillance footage confirmed the center
conducts groups in the required size, frequency, and length of time. Mental health groups are
limited to ten or fewer youth and substance abuse groups are limited to fifteen or fewer youth.
Nine youth were interviewed, and four youth rated the center’s mental health and substance
services as very good, four rated the services as good, and one youth stated they were not
receiving mental health or substance abuse services.
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 provider’s contract outlines the required psychiatric services to be available to youth.
Psychiatric services are to 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. 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, 2026, and the back-up psychiatrist, an osteopathic physician, holds a clear and
active license with an expiration date of March 31, 2024. The contract was reviewed and
confirmed the inclusion of tele-psychiatry. A review of the center’s Tele-Psychiatry Log and
observations validated the psychiatrist is providing weekly services, as required, through tele-
psychiatry. A review of nine youth mental health and substance abuse records found two youth
applicable for entering the center on psychotropic medication; therefore, the center provided
one additional applicable record for review. All three youth had an initial psychiatric interview
which included the reason for referral, the youth’s history, a Mental 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 record documented
the psychiatric evaluation was completed within thirty days of the youth’s referral/admission. All
three youth were applicable for the prescription of medications and each psychiatric interview
documented the most recent applicable therapeutic serum drug levels, signature of the
practitioner, page three of the Clinical Psychotropic Progress Note (CPPN), target symptoms of
each medication, evaluations and description of effect of prescribed medication on target
symptoms, normal dosage range, ordered dosage, frequency and route of administration, side
effects, adherence to medication regime, and whether there was telephone contact with the
parent/guardian to discuss medication. Each youth’s evaluation was documented on the
Department’s CPPN) and completed within the required time frame. All three youth records
contained a current Authority for Evaluation and Treatment (AET) form. Two youth were
applicable for the monitoring of Tardive Dyskinesia which was documented monthly on the
CPPN for each youth. All three youth were applicable for receiving tele-psychiatry, and there
was documentation of consent from the youth and parent/guardian in each case.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 29 of 59 (Revised July 2023)
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a written Suicide Prevention Plan to safely screen, refer, assess, monitor,
and protect youth with elevated risk of suicide in the least restrictive means possible. The plan
identifies the center’s procedures for required suicide prevention training, suicide precautions,
levels of supervision, referrals, communication, notification, documentation, immediate staff
response, and a review process as referenced in Florida Administrative Code. The plan also
outlined emergency contact telephone numbers to include the superintendent, on-call
administrator, designated mental health clinician authority (DMHCA), Miami-Dade Police
Department, designated health authority, licensed mental health professional, psychiatrist, a
local emergency room, the crisis stabilization unit, and Poison Control. Copies of the plan are
maintained in master control, the superintendent’s office, the medical clinic, and the mental
health office. Although the center reported not having any incidents involving suicide attempts
since the last annual compliance review, the center has an established review process for every
serious suicide attempt or serious self-inflicted injury and a mortality review for any completed
suicides. The multidisciplinary review is to examine the circumstances surrounding the event,
center procedures relevant to the incident, relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations for changes in policy, training, the physical plant, medical or mental health
services, and/or operational procedures.
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 maintains a written Suicide Prevention Plan to safely screen, refer, assess, monitor,
and protect youth with elevated risk of suicide in the least restrictive means possible. A review
of nine youth mental health and substance abuse records showed five youth were applicable for
having been placed on precautionary observation (PO) at the time of admission until an
Assessment of Suicide Risk (ASR) was completed. Reviewed documentation showed three
youth records had a new suicide alert placed in the Department’s Juvenile Justice Information
System (JJIS) and two youth already had an open alert in JJIS when they arrived at the center.
Documentation showed an ASR was completed using the Department’s form. Each youth
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 30 of 59 (Revised July 2023)
began on constant supervision based upon the Suicide Risk Screening Instrument (SRSI)
results and after the completion of the ASR, three youth were placed on standard supervision.
Four ASRs were completed by licensed mental health professionals. One ASR was completed
by the non-licensed clinician, which was reviewed by a licensed mental health professional, as
required. Each youth’s ASR was completed within twenty-four hours, as required. A review of all
five youth’s Suicide Precaution Observation Logs confirmed each was completed in its entirety
to include documented safe housing areas and all required signatures. Two of the five records
were applicable for a Follow-Up ASR, which was completed prior to the removal of the youth
from precautionary observation. Each ASR documented a conference held between the
licensed mental health professional and the superintendent pertaining to reducing the level of
supervision. A review of the center’s logbooks revealed the starting and ending time of each
youth’s precaution period was documented in the logbook. An interview with the assistant
superintendent confirmed the center utilizes secure observation; however, none of the reviewed
records were applicable for placement in secure observation. An interview with the
superintendent confirmed suicide precautions are the method utilized for supervising, observing,
monitoring, and housing youth identified 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, PO, secure observation, or at least 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 ASR. The
center staff completed the Suicide Precaution Observation Logs in their entirety and in real time.
Nine youth were interviewed, and each youth stated they had never been placed on suicide
precautions while at the center. Nine staff were interviewed and each confirmed if a youth
expresses suicidal thoughts, they are to notify the mental health authority, and document
supervision. Five staff reported having to maintain the youth on constant sight and sound
supervision. One staff indicated they would notify the supervisor, one would complete a mental
health referral, one would communicate with the youth, and one would call a code white.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center maintains a written Suicide Prevention Plan, which details the process to safely
screen, refer, assess, monitor, and protect youth with elevated suicide risk in the least restrictive
means possible. A review of nine youth mental health records showed five were applicable for
having been placed on suicide precautions and each had a Suicide Precaution Observation Log
maintained. Each youth’s log was documented in real time. Four logs documented observations
conducted at least every thirty-minutes. One log documented two checks conducted as
required, followed by a forty-two-minute period immediately preceding the youth’s step down
from precautions, which was missing an observation. No youth were applicable for having
warning signs documented on the logs. All logs were signed by the shift supervisor and
reviewed and signed by mental health clinical staff. Each log documented safe housing
requirements. Observations of video surveillance footage on three dates and corresponding
documentation of youth on precautionary observation (PO) confirmed the youth were placed on
constant supervision and placed in the center of the day room in front of staff at all times.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 31 of 59 (Revised July 2023)
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 maintains a written Suicide Prevention Plan to safely screen, refer, assess, monitor,
and protect youth with elevated risk of suicide in the least restrictive means possible. Suicide
prevention trainings are completed and documented in the Department’s Learning Management
System (SkillPro). Nine pre-service and nine in-service staff training records were reviewed. All
reviewed staff records documented staff completed suicide awareness and prevention training.
Reviewed documentation of “mock” suicide drills conducted since the last annual compliance
review showed the center completed drills on all three shifts at least quarterly, as required. The
center exceeded the requirement with all but one shift in the month of March by conducting drills
on each shift at least once each month since the last annual compliance review. The center has
seven suicide response kits located in master control, each of the five living modules, and in the
medical clinic. Suicide response kits are co-located with the center’s first-aid kits. Reviewed
documentation supported the center had 125 applicable staff requiring participation in a suicide
drill semi-annually. All 125 of the center’s staff participated as required, and many exceeded the
requirement. Documentation supported the direct care staff participated in at least one drill
which included the use of cardiopulmonary resuscitation (CPR) annually. Staff who are not
present during a drill have the opportunity to review each drill scenario, procedures, and critique
in an effort to understand the process and receive the necessary training to respond to an
incident of a suicide attempt or incident of serious self-inflicted injury. An interview with nine staff
was conducted and all stated the suicide response kit is located in sub control.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a written Crisis Intervention Plan, which details the response procedures for
youth in crisis. Staff response must be done in the least restrictive means possible to protect the
safety of the youth and others while maintaining control and safety of the center. The center’s
procedures require the completion of a Crisis Assessment to evaluate any youth presenting with
acute emotional or psychological distress which is extreme and does not respond to ordinary
interventions. Assessments are to be completed by a mental health clinician to determine the
severity of the youth’s distress, symptoms, level of risk to self or others, and recommendations
for treatment and follow-up care. The plan details crisis intervention procedures including a
notification and alert system, means of referral including youth self-referral, communication,
supervision, documentation, and review. Additionally, the plan outlines requirements for
response to Prison Rape Elimination Act (PREA) incidents. Copies of the plan are in master
control, transportation, intake, mental health, and medical offices, accessible to all staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 32 of 59 (Revised July 2023)
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has a 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. The policy and plan were
signed by the designated mental health clinician authority (DMHCA) and the superintendent on
August 7, 2023. The center’s plan includes procedures for immediate staff response,
notifications, communication, supervision, authorization to transport for emergency Baker Act or
Marchman Act, documentation, training, and review. A copy of the approved plan is located in
master control, the superintendent’s office, medical clinic, and mental health offices.
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 a written Emergency Care Plan stipulating the response procedures for youth in
crisis. Staff response is to be in the least restrictive means possible to protect the safety of the
youth and others while maintaining control and safety of the center. Any youth presenting with
acute and extreme emotional or psychological distress are to receive a Crisis Assessment to
evaluate the severity of the youth’s distress and symptoms, level of risk to self or others, and
recommendations for treatment and follow-up care. The center had only one Crisis Assessment
since the last annual compliance review. A review of the single Crisis Assessment was
conducted. The assessment was completed the same day the youth was determined to be in
crisis and was documented on the Department’s Crisis Assessment form. The assessment
included the reason for assessment, a Mental Status Examination, a determination of the
youth’s danger to self/others, initial clinical impressions, supervision and treatment
recommendations, recommendations for follow-up, and notification to the parent/guardian. The
assessment indicated a potential safety or security risk; therefore, a mental health alert was
warranted and was entered into the Department’s Juvenile Justice Information System (JJIS).
The assessment was completed by a licensed mental health staff. The assessment was not
related to any allegation of a Prison Rape Elimination Act (PREA) event. An examination of
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 33 of 59 (Revised July 2023)
Assessments of Suicide Risk, logbooks, and the Department’s Central Communications Center
(CCC) incidents did not reveal any events where a Crisis Assessment should have been
completed and was not.
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 maintains a written Emergency Care Plan outlining mental health and substance
abuse emergency procedures for youth believed to be an imminent danger to themselves or
others because of mental illness or substance abuse impairment. A review of nine youth mental
health records revealed none were applicable for requiring Baker Act procedures. The
designated mental health clinician authority (DMHCA) provided three additional youth records
which were applicable for a Baker Act since the last annual compliance review. All three youth
were placed on suicide precautions upon re-admission following the Baker Act placement. A
Mental Status Examination was conducted within the administration of the Assessment of
Suicide Risk for all three youth. All three youth were maintained on constant supervision until
properly transitioned to a lower level of supervision. Documentation showed supervision levels
were lowered for each youth after an appropriate assessment was conducted by a licensed
mental health professional, and mental health staff conferred with the licensed supervisor and
superintendent or designee. The center had no Marchman Act proceedings since the last
annual compliance review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 34 of 59 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains a written policy and procedures requiring a contractual agreement with a
licensed physician to serve as the designated health authority (DHA). The center maintains a
contract with VitalCore Health Strategies, LLC. (VitalCore) which subcontracts with a medical
doctor (MD) to serve as the center’s DHA. The MD holds an unrestricted license which expires
on January 31, 2025, and meets all requirements for independent and unsupervised practice in
the State of Florida. The MD has specialty training in pediatrics and family practice. The DHA
ensures all medical and mental health policies and protocols are reviewed and signed annually,
and ensures all appropriate medical staff receive training on all medical policies. The MD serves
as the center’s DHA and is clinically responsible for the medical care of all youth. A review of
the contract with VitalCore, effective March 17, 2022, indicated the DHA is required to be on-site
each week for four hours a week, in accordance with Florida Administrative Code. with the
contract defines a week as the seven-day period beginning on Sunday and ending on Saturday,
and requires no more than nine days between on-site visits to conduct periodic evaluations,
Comprehensive Physical Assessments (CPAs), sick call referrals, and administrative duties.
The DHA is responsible for communication with the center and the medical staff regarding the
youth’s medical needs. The DHA is available on-call twenty-four hours a day, seven days a
week for consultation. The DHA is on-site on Tuesdays from 12:30 p.m. to 4:30 p.m. at least
weekly. Reviewed attendance logs from January 28, 2023, through January 9, 2024, supported
the DHA was on-site weekly as required. The center utilizes an advanced practice registered
nurse (APRN), who is on-site once a week and holds an unrestricted license in the State of
Florida, with an expiration date of April 30, 2025. The APRN has Collaborative Practice
Protocols in place with the DHA. The APRN and DHA signed the collaborative agreement
renewal on October 17, 2023. The APRN is on-site on Thursdays from 3:00 p.m. to 8:00 p.m. on
a weekly basis. Nursing coverage is provided on-site from 7:00 a.m. to 7:30 p.m., Monday
through Friday, and from 7:00 a.m. to 5:30 p.m. each Saturday and Sunday. The back-up MD,
who provides coverage when the DHA is on scheduled absences or vacation, holds an
unrestricted license in the State of Florida, which expires on January 31, 2026. A tele-health
agreement was established between VitalCore and the Department for DHA’s from other
centers to oversee the center’s APRN completing the CPAs and sick calls, and being on-call for
evaluation consultations and episodic, first-aid, and emergency care. A log of tele-health
services was maintained at the center. An interview with the DHA confirmed they complete
CPAs, focused medical reviews, periodic evaluations, as well as sick call when requested by the
nursing staff during the routine weekly clinic visits held on Tuesdays. The DHA confirmed they
were on-call twenty-four hours a day, seven days a week. Additionally, VitalCore provides for
back-up coverage when the DHA is on scheduled leave. The DHA and the APRN stated they
are on-site once a week to provide clinical services and communicate often with nursing staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 35 of 59 (Revised July 2023)
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 maintains written facility operating procedures (FOPs) for all utilized health-related
procedures and protocols. Reviewed documentation reflected the designated health authority
(DHA) reviewed, signed, and dated the FOPs on August 15, 2023. Reviewed documentation
supported the superintendent signed and dated the updated FOPs on August 15, 2023.
Reviewed documentation validated the registered nurse (RN) signed the cover page on October
5, 2023, and the advance practice registered nurse (APRN) on October 4, 2023. All other
medical staff documented their review of the center’s VitalCore Health Strategies, LLC.
(VitalCore) healthcare FOPs and protocols on a cover page which was signed and dated
between October 5, 2023, and December 14, 2023. The center’s treatment protocols were
signed and dated by the DHA on August 15, 2023. The center’s non-healthcare staff protocols
were signed and dated by the DHA on June 30, 2023. Training records supported all eight
nursing staff completed and maintained current certifications in cardiopulmonary resuscitation
(CPR) and automated external defibrillator (AED). VitalCore has an established comprehensive
clinical orientation for all newly employed healthcare staff which includes the Department’s
healthcare policies and procedures. A review of each medical staff’s training records verified
each newly employed medical staff received the clinical orientation conducted by a RN.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center maintains a written policy and procedures ensuring parents/guardians are afforded
the right to give or withhold consent regarding the healthcare provided to the youth. A review of
nine youth Individual Healthcare Records (IHCRs) found seven were applicable for requiring a
signed Authority for Evaluation and Treatment (AET). Two of the reviewed youth were over
eighteen years of age. All seven reviewed IHCRs contained a signed AET. There were no
applicable IHCRs which required a Limited Consent for Evaluation and Treatment (LCET) due
to involvement with the Department of Children and Families. Each applicable AET was
obtained prior to providing medical services to the youth. The seven applicable signed AETs
were clearly marked as a “copy” on the form. The interviewed nurse indicated the AET is signed
by a parent/guardian and witnessed by a Department representative. In the event a
parent/guardian refuses to sign an AET, then a court order is obtained. Furthermore, if a
parent/guardian cannot be located a diligent search is completed by the Department and a
limited consent form can be obtained. An interview with the clinical manager confirmed the
center’s practice of obtaining a new or current AET or documenting consent when a youth is
eighteen years of age.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 36 of 59 (Revised July 2023)
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains a written policy and procedures outlining requirements for
parental/guardian notification of significant changes in the youth’s condition and for obtaining
written consent from the parent/guardian when new medications and treatments are prescribed.
A review of nine youth Individual Healthcare Records (IHCRs) found three youth were
applicable for prescribed over-the-counter medications not covered by the Authority for
Evaluation and Treatment (AET). All three reviewed IHCRs supported the center notified the
parent/guardian of significant changes in the youth’s condition and obtained applicable consent
when new medications and/or treatments were prescribed. Each of the reviewed applicable
IHCRs contained chronological progress notes documenting the parents/guardians were notified
by telephone and followed up with a written Parental Notification/Consent form showing an
attempt to obtain the signed parent/guardian consent. All nine of the reviewed IHCRs contained
the required vaccinations/immunizations. Each of the reviewed records indicated immunization
records are obtained through the Florida Department of Health website and reviewed within
seven days of the youth’s admission. An informal interview with the clinical manager, indicated
there were no Religious Exemption from Immunization forms submitted since the last annual
compliance review. An interview with the clinical manager confirmed the center’s practice of
parental/guardian notification and obtaining parental/guardian consent.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains a written policy and procedures requiring each youth, at the time of
admission, to receive a Facility Entry Physical Health Screening and the Department’s Medical
and Mental Health Admission Screening (MMHS) in the Department’s Juvenile Justice
Information System (JJIS). The purpose of the screening tools are to ensure the youth does not
have any emergency medical conditions requiring immediate medical attention. In the event a
youth is admitted, and an injury is discovered with the listed signs and/or symptoms, there will
be immediate communication with the designated health authority, and a request will be made
for an urgent assessment of the youth if licensed healthcare staff are available on-site.
Immediate transfer of the youth to the nearest emergency facility will occur if the licensed
healthcare staff are not on-site or after the evaluation if the condition so warrants. A review of
nine youth Individual Healthcare Records (IHCRs) found each contained a MMHS form
completed on the date of admission by a juvenile justice detention officer (JJDO) and reviewed
and signed by the JJDO supervisor. Each MMHS indicated the screening was reviewed by a
registered nurse (RN) within twenty-four hours. Each screening form was completed in JJIS.
There were no records applicable for a change in physical custody since the youth’s admission.
There were no youth applicable for a qualitative urine pregnancy screening test, for which
chronological progress notes included documentation of verbal consent. An interview with
nursing staff confirmed the center’s practice for admission screening and rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 59 (Revised July 2023)
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains a written policy and procedures requiring all youth to be oriented to the
general healthcare delivery services at the center. A review of nine youth Individual Healthcare
Records (IHCRs) supported each contained a completed Department Health Education form
documenting the youth’s orientation to the center’s healthcare services. Each youth received a
general healthcare orientation on the day of admission to the center. Reviewed documentation
supported each youth’s orientation included access to medical care, sick call, what constitutes
an emergency and when to notify staff, medication process and side effect monitoring, the right
to refuse care and how it is documented, and what to do in the case of a sexual assault or
attempted sexual assault. Additionally, youth are oriented on the non-disciplinary role of the
healthcare providers, availability of healthcare staff, dental hygiene, sexually transmitted
infections, personal hygiene, immunizations, infection control, nutrition, self-examinations, and a
review of healthcare 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.
The center maintains a written policy and procedures which require notification to the
designated health authority (DHA) of all youth admitted with chronic health conditions or youth
in need of emergency care. A review of nine Individual Healthcare Records (IHCRs) indicated
there were three youth identified with a chronic medical condition. In each instance, the DHA
was notified within twelve hours of the youth’s admission and a notification was documented in
the IHCR. There were no youth identified as in-need of emergency care upon admission. Each
of the three youth were referred to the advanced practice registered nurse (APRN) or the DHA.
Notification was documented on the nursing admission chronological notes in each IHCR. None
of the reviewed youth were taking psychotropic medications at the time of admission. An
interview with the nursing staff indicated the DHA is notified, by nursing staff, immediately after
intake and notifications to the DHA are documented in the admission 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.
The center maintains a written policy and procedures requiring the completion or review and
updating of the Department’s standard Health-Related History (HRH) form. The center utilizes
and completes the HRH form for all youth admitted into physical custody. A review of nine youth
Individual Healthcare Records (IHCRs) found each contained a HRH form completed
electronically by a licensed nurse within seven days or less of the youth’s admission to the
center. All nine of the HRH forms were reviewed by the designated health authority (DHA) or
advanced practice registered nurse (APRN) and were maintained in the youth’s IHCR. Each of
the applicable HRHs were completed before the Comprehensive Physical Assessment (CPA)
and reflected the most current admission into detention. A review of the nursing interview
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 38 of 59 (Revised July 2023)
confirmed the HRH is completed by the medical staff within seven days of the youth’s admission
and are made available for the DHA to review prior to the completion of the CPA.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains a written policy and procedures requiring a Comprehensive Physical
Assessment (CPA) form to be completed or updated for all applicable youth admitted
determining the health and wellbeing of each youth. A review of nine youth Individual
Healthcare Records (IHCRs) validated two youth had a current CPA on record at admission and
seven youth required the completion of a new CPA. Each of the seven reviewed youth records
verified the DHA completed the CPAs within seven days of admission to the center. Reviewed
documentation supported the two current CPAs documented a review by the DHA. Each of the
CPAs were completed in full to include the Medical Grade, Tanner Stage, cardiovascular, body
mass index, visual acuity field, and most recent Tuberculosis Skin Test. Four of the nine
reviewed youth records indicted a refusal to any portion of the examination, and each contained
a signed refusal form reflecting the refused portion of the CPA. The center’s policy and
procedures for Tuberculosis (TB) control and screening address the routine screening of all
youth for latent and active TB, as well as environmental controls in the case of a youth with
active TB. A review of nine youth IHCRs validated each of the youth had a TB screening
completed. There were no applicable IHCRs reviewed which contained a refusal for TB
examination. There were no applicable youth with any symptoms of active TB in the center at
the time of the annual compliance review. The results of the TB tests were documented on the
CPAs and Infectious and Communicable Diseases (ICD) forms. A review of the center’s practice
reflected when the CPAs are completed the Department’s Problem List is updated. Reviewed
documentation validated the center’s practice. An interview with nursing staff verified a CPA is
completed within seven calendar days of admission and it is valid for at least one year or
depending on the youth’s Medical Grade. Additionally, the nursing staff indicated youth are
tested for TB at least once a year.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center maintains a written policy and procedures requiring all youth to be evaluated and
treated, if necessary, for sexually transmitted infections (STIs). All sexually active youth will be
clinically screened and evaluated for STIs. After the screening, the youth is referred to the
designated health authority (DHA) or advanced practice registered nurse (APRN) to determine if
further testing is necessary. A review of nine youth Individual Healthcare Records (IHCRs)
indicated six youth were applicable and were screened for STIs. Each applicable youth required
further evaluation and were referred. Each of the applicable youth’s screening results were
documented on the Department’s STI form and Infectious and Communicable Disease (ICD)
form located in the IHCR. None of the reviewed youth were applicable for a gynecological exam.
A review of nine youth IHCRs found none of the youth were out of the Department’s physical
custody for more than thirty days. The center maintains a written policy and procedures
providing each youth with the opportunity to receive counseling, testing, and treatment for
human immunodeficiency virus (HIV). Nine youth records were reviewed and showed four youth
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 39 of 59 (Revised July 2023)
were applicable and requested to have a HIV test, as documented on the Department’s Human
Immunodeficiency Virus Antibody Test Youth Consent form. Reviewed documentation of the
four applicable IHCRs verified written consent was obtained by the center and confirmed each
of the applicable youth were offered counseling, testing, and treatment for HIV. A review of the
four applicable records validated each of the HIV results were placed in a sealed envelope
stamped “Confidential” and filed in the youth’s IHCR. The pre-test and post-test counseling were
documented in each youth’s IHCR. Nine youth were interviewed, and each stated they can ask
for an HIV test. An interview with nursing staff indicated orders are obtained from the DHA for
STI testing, a urine sample is collected, and STI screenings, evaluations, and referrals, are
documented on the ICD form. Additionally, HIV testing results are maintained confidentially
enclosed in the youth’s IHCR. An informal interview with the nurse indicated youth are able to
request an HIV test at any time while in detention. Additionally, HIV results are maintained in a
confidential manner and screening information for STIs are documented on the youth’s ICD
form.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains a written policy and procedures regarding the sick call process and
requests. The center conducts sick call seven days a week to respond to a youth’s medical
illness or injury of a non-emergent nature by a healthcare professional. Postings throughout the
center indicate sick call takes place seven days a week on Monday through Friday from 9:00
a.m. to 11:00 a.m. and 4:00 p.m. to 5:00 p.m., and on Saturday and Sunday from 9:00 a.m. to
11:00 a.m. when youth are securely detained at the center. The shift supervisors and authorized
staff are trained by a registered nurse (RN) on the center’s sick call procedures and are to
review the sick call requests in the absence of the healthcare professionals. Youth who require
a sick call will inform staff of their complaint and staff will generate a sick call request in the
Department’s Juvenile Justice Information System (JJIS). When the level of need for the youth
cannot be determined, the on-call practitioner/designated health authority (DHA) shall be
contacted for guidance and referral to the emergency room or off-site emergent care. A review
of nine youth Individual Healthcare Records (IHCRs) indicated five youth had submitted sick call
requests. Documentation in each of the five IHCRs indicated the sick call was conducted by the
registered nurse (RN) within twenty-four hours and was documented on the Sick Call Referral
Log. There were no instances in which a youth presented with a similar sick call complaint three
or more times within a two-week period or of a youth complaining of any severe pain with which
staff were unfamiliar. There was one applicable youth who was treated where an immediate
referral was needed to be made to the DHA and the DHA was notified immediately of the
youth’s medical condition. Sick call forms documented the nature of the complaint, assessment,
and plan to include the subjective, objective, assessment, and plan (SOAP) note format. All
applicable sick call events were documented on the Sick Call Index and Sick Call Referral Log
and dates correlated. Sick calls for two youth were observed during the annual compliance
review week. The youth were escorted by direct care staff to the clinic. The registered nurse
(RN) discussed the nature of the sick call with the youth. The youth was seen in the medical
clinic for privacy which contains an examination table and equipment to perform sick calls. The
medical office contains a private examination area where youth are examined, where a direct
care staff is able to maintain supervision. An interview with the RN indicated if a youth has
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 40 of 59 (Revised July 2023)
health complaints, they are able to make a sick call request and nursing staff will see the youth
within twenty-four hours. The clinical manager indicated if there are youth with repeated similar
sick call complaints, a referral is submitted to the DHA. The nursing staff indicated all sick calls
are conducted by the nursing staff and in the event of any sick calls when the DHA is on-site,
the DHA will conduct the sick call requests. Nine staff were interviewed, and each stated the
doctor and/or nurse conducts and reviews sick calls. Nine youth were interviewed, and six
indicated they can see a nurse immediately after requesting a sick call, and three stated they
have not made any requests.
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.
The center maintains a written policy and procedures ensuring a comprehensive process for
episodic care, first-aid treatment, and emergency care. The center utilizes an Episodic Care Log
to document episodic care and first-aid treatment. The log contains information to include the
date, name of youth, the youth’s Department identification number, nature of illness or injury,
treatment rendered, staff initials, nurse initials, verification of who provided episodic care, and if
the youth was recommended for off-site care. When licensed staff are not on-site to assess the
youth, the designated health authority (DHA) approved non-healthcare protocols shall be
utilized to provide on-site care and reported on the Report of On-Site Care by Non-Healthcare
Staff form. When the level of need for the youth cannot be determined, the on-call
practitioner/DHA shall be contacted for guidance and referral to the emergency room or off-site
emergent care is made. Nine youth Individual Healthcare Records (IHCRs) were reviewed, of
which three were applicable for seven different episodic or first-aid care events. Each applicable
IHCR documented problem-oriented elements which were used to capture pertinent information
pertaining to the nature of the youth’s ailment including identification of the subjective, objective,
assessment, and plan (SOAP) elements to address the complaint for each incident. A review of
the applicable youth IHCRs indicated the center had no applicable episodic care events
conducted by non-healthcare staff. Each reviewed applicable record had a documented
progress note identifying first-aid or emergency care, the date and time of care, nature of the
complaint, findings regarding care, and treatment rendered. One of the three applicable IHCRs
contained an off-site care referral. Each of the three applicable IHCRs contained follow-up plans
for future care, alert list documentation, and/or parental/guardian notifications. The center has
seventeen first-aid kits strategically located in areas frequented by youth. Nine of these kits are
designated for the center’s transport vehicles. Observations of three first-aid kits from the
medical office, master control, and one vehicle, verified each kit was stocked with approved
supplies with no expired contents. Reviewed documentation confirmed the kits were monitored
monthly by the nursing staff and were replenished as needed. The center has three automated
external defibrillators (AEDs) located in the medical clinic, classroom l, and classroom II. Each
AED is equipped with automated instructions. The medical staff monitor the AEDs monthly to
ensure the devices are operable. A review of the AED check logs since the last annual
compliance review validated this practice. The AEDs are maintained by a contracted provider
who checks the devices on an annual basis to ensure they are operable, and the battery and
pads have not expired. During the annual compliance review week, observations were
conducted while the nurse completed a self-test on the devices with no issues. The AED’s
batteries are monitored by the contracted provider annually, and were last replaced in July
2022, with an expiration date of August 2026. The AED pads were last changed on March 6,
2023, and each have an expiration date of July 28, 2025. The center conducts emergency
medical drills at least once quarterly on each shift, and emergency drills including
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 59 (Revised July 2023)
cardiopulmonary resuscitation (CPR)/AED are conducted at least once a year on each shift. A
review of quarterly emergency drills from January 28, 2023, to January 8, 2024, verified the
center conducted drills, as required. Emergency contact numbers were observed to be posted in
the medical clinic. Nine staff training records verified staff received CPR/AED/first-aid training. A
review of nine training records supported each staff received the required training on the
center’s Emergency Care Plan. A review of supervisory staff records documented each received
training on administration of an epinephrine auto injector. Reviewed documentation supported
the DHA, the advanced practice registered nurse (APRN), and all nursing staff maintained
current certifications in CPR and AED. The nursing clinical manager confirmed all nursing staff
and authorized supervisory staff are trained in the NARCAN® procedures and NARCAN® is
stored within the medication cart. An interview with the nursing staff validated the center’s
practice regarding first-aid/emergency care, and episodic care. Nine staff were interviewed, and
each stated they can call 9-1-1 if they feel it is necessary. Nine youth were interviewed, and
three stated the medical services at the center are very good, four stated good, one stated fair,
and one indicated they were not receiving medical services.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center maintains a written policy and procedures to provide for timely referrals and
coordination of medical services to ensure youth have timely access to off-site care services. A
review of nine Individual Healthcare Records (IHCRs) found two youth were applicable for off-
site care; therefore, one additional applicable youth record was reviewed. Each applicable youth
was taken off-site for medical care. The designated health authority (DHA) was notified of each
healthcare event. A Summary of Off-Site Care Consultation Report form was completed, and
discharge documentation was filed in each of the applicable IHCRs. Each reviewed applicable
IHCR contained discharge documentation and instructions. The DHA documented a review of
the off-site care findings, instructions, and information. Each instance of off-site emergency care
was documented on the Episodic Care Log. None of the three applicable youth required follow-
up care. An interview with nursing staff confirmed all off-site referrals are assessed upon return
and the DHA is notified. Additionally, all off-site care needs are reviewed by the DHA, and
follow-up appointments are tracked utilizing the center’s tracking log.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center maintains a written policy and procedures to ensure youth identified with chronic
conditions receive regularly scheduled evaluations and necessary follow-up care. The frequency
of the periodic evaluation is determined by the youth’s condition, clinical needs, and clinically
appropriate medical standards. Youth are screened during the intake process for medical
conditions warranting periodic evaluations and follow-up care. A review of nine youth Individual
Healthcare Records (IHCRs) indicated three youth were identified with a chronic condition.
None of the reviewed youth were diagnosed with a communicable disease. One applicable
youth received on-site care for a physical health condition which was documented in the IHCR
chronological progress notes with clearly written treatment orders. Three youth were applicable
for taking a prescribed medication on an on-going basis. Three youth had a Medical Grade
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 42 of 59 (Revised July 2023)
between two and four. An interview with the clinical manager verified the center did not have
any youth who were pregnant since the last annual compliance review. Each of the applicable
youth were placed on the chronic conditions roster. A review of the Chronic Physical Health
Conditions Roster indicated there were no youth applicable for periodic evaluations as the youth
were not due for periodic evaluations. There were no youth applicable for taking Tuberculosis
(TB) medication, which required monthly evaluations. Two applicable youth had an off-site
evaluation, and each applicable youth contained a documented Summary of Off-Site Care form,
which was filed within the youth’s IHCR. The reviewed documentation confirmed they were
tracked with no indications of missed or lapsed periodic evaluations. Reviewed records reflected
each youth’s Department Problem List was updated, as required. In an interview, the
designated health authority (DHA) reported youth with chronic medical conditions are seen at a
minimum of every ninety-days. Additionally, they indicated if the youth require periodic
evaluations for chronic medical conditions, they are tracked by nursing staff for follow-up.
Interviewed nursing staff confirmed the center’s practice of chronic condition evaluations and
periodic evaluations.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center maintains a written policy and procedures ensuring all medication and
pharmaceutical products are procured, dispensed, administered, and stored safely, accurately,
and in accordance with state, federal, and industry standards. The center’s practice is for
nursing staff to verify all medications have a current, valid order and are given according to a
current prescription or practitioner’s order. Nursing staff are to verify medication with the
parent/guardian when they deliver the medication to the center. The Medication Receipt,
Transfer, and Disposition form is used to document medication received in the original
packaging from a licensed pharmacy with a current legible patient-specific label affixed. Youth
who are taking medication while in the care of the center will have medication administered by
the healthcare professionals. The center utilizes the Department’s Medication Administration
Record (MAR) for each youth receiving either prescription medications on a routine basis or
over-the-counter (OTC) medications. A review of nine youth Individual Healthcare Records
(IHCRs) identified three youth who were taking prescribed medication upon admission and were
applicable for medication management. Each applicable IHCR contained documentation
indicating the medication was verified by a licensed pharmacist or the designated health
authority (DHA). In each instance, the DHA was contacted to obtain an order to resume the
medication and consent was documented in the youth’s IHCR. The three applicable youth
records indicated the youth were taking OTC medications which were administered according to
the DHA’s order. None of the youth were in restricted housing requiring medication. Each of the
three reviewed records verified all medication and treatment was documented in the MAR.
Three applicable reviewed youth records indicated there were no lapses or errors in
administered medication. The reviewed policy and procedures indicated when a youth refuses
the medication administration, the refusal will be clearly documented on the MAR and the
Department’s Refusal of Treatment form will be completed. Three reviewed records indicated
one of the youth refused medication. Documentation confirmed the refusal was documented on
the MAR, and on the Department’s Refusal of Treatment form. The center utilizes a licensed
psychiatrist who provides tele-psychiatry for medication management. Two of the three youth
were applicable for having a current psychiatric medication. Reviewed documentation confirmed
the DHA, and/or psychiatrist were notified upon admission. Each applicable youth record
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 43 of 59 (Revised July 2023)
contained an Initial Diagnostic Psychiatric Interview completed within fourteen days of
admission. One of the two youth were applicable to receive medication monitoring every thirty
days; however, during the annual compliance review week, they had not yet met this time
frame. Each of the MARs documented the youth’s name, Department identification number
(DJJID), date of birth, allergies, precautions, Medical Grade, medical alerts, youth’s current
picture, start and stop dates, and monitored side effects. Reviewed documentation reflected the
nursing staff, and the youth initialed each administered medication entry on the MAR. The
center did not have any standing orders for psychotropic medications, no pro re nata (PRN)
orders for psychotropic medications, or emergency treatment orders for psychotropic
medications. The center has authorized and trained supervisory and authorized staff to assist
youth with self-administration of medication, in the absence of the healthcare professionals.
None of the reviewed youth records indicated a non-healthcare staff assisted in the delivery of
OTC medications when licensed medical staff were not on-site. The nursing staff interview
confirmed the registered nurse (RN) clinical manager provides training to the non-licensed
healthcare staff. A review of supervisory training records verified each of the authorized staff
were trained in medication administration. The center maintains a list of staff who are required
to have access to the clinic and medications. Medication administration for one youth was
observed during the annual compliance review week. Medication administration is scheduled
every day beginning at 8:00 a.m.,12:00 p.m., and 8:00 p.m. and is held in the medical office.
Observations confirmed the youth was escorted to the medical clinic by the juvenile justice
detention officer (JJDO). Observations supported the youth approached the nurse administering
medication individually and the nurse adhered to the Six Rights of Medication
Delivery/Administration by inquiring with the youth to identify themself, identify the medication
prescribed, applicable side effects, and then gathered the prescribed medication and placed it in
a small cup. None of the medication was pre-poured from the original packaging or placed in
another container. The nurse poured a cup of water and handed it to the youth, who then took
the medication. The nurse had the youth open their mouth for inspection prior to the youth’s
departure. Observations of medication storage indicated all medications were separated by
type, stored in a locked area designated for storage, and inaccessible to youth. The center
maintains a contract with a licensed pharmacy who comes on-site to dispose of all biohazard
material. An interview with the nursing staff confirmed the center's process for securing all
medications and the process for the center’s disposal process for all discontinued medication.
Nine youth were interviewed, and all indicated they do not take medication. Nine staff were
interviewed, and one supervisory staff stated they administer medication to youth and eight staff
indicated they did not administer 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 center maintains a written policy and procedures requiring medications and any medical
equipment classified as sharps to be secured and inventoried. The center maintains a perpetual
daily inventory of medications to include prescribed and over-the-counter (OTC) medications.
Documentation of each individual dosage of medication administered to youth is maintained on
the Medication Administration Record (MAR) to demonstrate the distribution of medications. Any
medical equipment classified as sharps are secured and inventoried utilizing a routine perpetual
inventory with descending count as each sharp is utilized and disposed. Observations of the
medical clinic indicated it is secured and only accessible to the healthcare professionals and
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 44 of 59 (Revised July 2023)
approved supervisory staff. The juvenile justice detention officer supervisors (JJDOS) are non-
healthcare, authorized staff who are trained by the registered nurse (RN) to assist youth with
self-administration of OTC medication and, in an emergency, the epinephrine auto injector. A
locked medication cart is maintained in the medical clinic and stores oral prescription and OTC
medications prescribed for youth. Medication in the cart is stored in separate sections for each
youth. The center has a secure refrigerator inside the locked medical office. All medication
requiring refrigeration is stored in a secured refrigerator used for medication only. Nursing staff
track daily temperatures of the refrigerator. A review of three OTC medications verified the
counts were accurate. The center’s practice is for two nursing staff to conduct shift-to-shift
inventory counts of all controlled medications. All controlled medications are maintained within
the locked medication cart within a separate locked storage box. At the time of the annual
compliance review there were no applicable controlled medications stored in the secured
second locked medication box. A review of the daily inventory of prescribed, stock, and OTC
medications determined inventories are conducted as required, since the last annual
compliance review. The center maintains an inventory of all sharps and medical equipment
classified as sharps. Items designated as sharps are stored in a designated locked cabinet in
the medical clinic and are inaccessible to youth. A review of three random sharps found the
inventory counts were accurate. A review of the perpetual inventory since the last annual
compliance review found the sharps inventory counts to be accurate. An informal interview with
nursing staff validated the center’s practice and procedures as to when inventory discrepancies
occur. The center maintains a contract with a licensed pharmacist. The center’s disposal
practice for controlled medications and non-controlled medications is for the licensed consultant
pharmacist and the on-site nurse to dispose of the expired medication(s) utilizing a chemical
medication disposal agent. All disposals are documented on the Disposition and Destruction of
Medications form. An interview with the nursing staff confirmed the center's process for the
security and disposal of all medication at the center.
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.
The center maintains a written policy requiring proper procedures to be followed to prevent the
spread of infectious diseases or illnesses and provide staff with knowledge of appropriate
prevention, containment, treatment, and reporting requirements of infectious diseases. The
center maintains a separate Exposure Control Plan/Infection Control Plan, approved by the
designated health authority on August 15, 2023. Reviewed documentation supported the
Exposure Control Plan/Infection Control Plan was written in accordance with Occupational
Safety and Health Administration (OSHA) guidelines to include risk assessment and methods of
compliance. The plan also addressed 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 (MRSA) and
other antibiotic-resistant micro-organisms, food-borne illnesses, bioterrorism agents, chemical
exposure in the workplace, and protocols for needlestick post-exposure intervention and
treatment. The community health department completes all infectious disease and sexually
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 45 of 59 (Revised July 2023)
transmitted infections testing, who would then report to the Centers for Disease Control and
Prevention (CDC). The local county health department, CDC, and the Department’s Central
Communications Center (CCC) are notified of all incidents related to infectious/communicable
diseases. The center had no incidents of occupational exposure or quarantining of at least ten
percent of the population reported since the last annual compliance review. The center ensures
Hepatitis B immunizations are made available for staff and staff have access to protective
equipment. A review of nine youth healthcare records supported each youth received infection
control training within seven days of admission. The infection control training included hand-
washing techniques, universal/standard precautions, prevention/transmission of communicable
diseases, vaccinations, and the CDC guidelines for infection control. A review of nine pre-
service and nine in-service staff training records supported each staff received training on the
center’s Exposure Control Plan/Infection Control Plan. An interview with the nursing staff
confirmed the center maintains an Exposure Control Plan and indicated it is located within the
medical office. Nursing staff are also responsible for providing infection control training to both
youth and staff.
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 has a written policy and procedures for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. Nursing staff ensure all
pregnant youth receive prenatal education to include alcohol and drug use, smoking, nutrition,
sexually transmitted infections, contraception, prenatal care, birthing process, postpartum care,
basic baby care, child/infant development, and parenting skills. While at the center, nursing staff
monitor each pregnant youth for weight and nutritional status. An informal interview with the
clinical manager, indicated the center has not had any pregnant youth since the last annual
compliance review. A review of nine staff training records verified each staff received women’s
health training specific to working with pregnant youth. Staff training was provided by the
registered nurse (RN) at the time of hire and annually, thereafter. Nine youth were interviewed,
and none were applicable. The interviewed nurse confirmed the center’s practice for women’s
health evaluations and prenatal care.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 46 of 59 (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.
The center has a written policy and procedures which outline supervision of youth requirements.
Observations were conducted each day of the annual compliance review week of staff
supervising youth. Youth were observed in the classrooms, in the living modules, at sick call,
during medication pass, eating breakfast and lunch, going to and from school, going to and from
court, during admission, and orientation. There was proper supervision during each of these
observations and staff were aware the number of youth they were supervising. All youth
movements were communicated to master control prior to movements. Master control
authorizes each movement, and each entry is logged in the master control logbook. Daily
counts are tracked in the master control logbooks, living module logbooks, and the
Department’s Juvenile Justice Information System (JJIS). Nine staff were interviewed, and all
stated the center has enough staff to provide safety and security of the youth and staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 47 of 59 (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.
The center has a written policy and procedures which provide a system of rewards, privileges,
and consequences to encourage youth to fulfill the center’s expectations. During this annual
compliance review week, youth and staff observations were conducted in the classrooms, in the
living modules, during transport, preparing for transport, and returning from transport. Line
movements throughout the center were observed and there were positive interactions between
staff and youth. Postings of the behavior management system (BMS) were in all living areas
and areas where youth are housed. The BMS outlines appropriate and inappropriate behaviors,
rules, norms, and expectations. The master control and module logbooks were reviewed since
the last annual compliance review, and there was documentation to support youth were
receiving rewards and participated in events for positive and appropriate behaviors. There was
documentation confirming youth also received consequences for inappropriate behaviors. The
center’s incentive calendar was posted in the living modules and throughout the center. Nine
youth were interviewed, and two youth stated the BMS is very good, two stated it was good, and
five stated it was fair. Nine youth were interviewed and all nine understood the expectations and
knew how the levels move up and down. All nine stated they receive canteen as part of a
reward, one youth stated they are able to go to the game room, and two youth stated they
participated in parties. Eight youth stated staff were fair and one youth stated staff are not fair
when using rewards. All nine stated youth are not allowed to punish other youth. Five stated
consequences were fair, three youth stated they have never received consequences, and one
youth stated the consequences are not fair. Four youth stated they had been sent to their room
for punishment reasons and five stated they have never been sent to their rooms for
punishment. Youth responses were discussed with the assistant superintendent. Nine staff were
interviewed and all responded they believed the center’s BMS is effective. All nine staff reported
they discuss the consequences being imposed with youth. All nine staff responded they have
dialogue with youth regarding alternative acceptable behaviors. The interviewed superintendent
reported the center uses a standardized BMS, which enhances safety and security as it relates
to youth’s behavior, and promotes the health and well-being of youth, by providing an
environment which fosters social, emotional, intellectual, and physical development.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 48 of 59 (Revised July 2023)
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has a written policy and procedures addressing ten-minute checks. The staff utilize
the electronic wand system by tapping on the check point sensors on the outside of each
youth’s room. The data from the wand is downloaded daily to ensure no data is lost. The officer
must observe the youth behind the closed door before the check is conducted and is recorded
by the wand. A review of documentation and surveillance coverage was conducted for nine
randomly selected dates, across three shifts, and on three different youth living modules. The
review revealed the ten-minute checks were consistently conducted at intervals of ten minutes
or less. Documentation supported there was a weekly management review of ten-minute
checks. Nine staff were interviewed and all nine responded room checks are conducted every
ten minutes when a non-suicidal youth is placed in their room. The interviewed superintendent
reported staff shall visually observe youth on standard supervision at least every ten minutes
while they are secured in their sleeping rooms during sleep time or other times such as medical
confinement. Staff conduct observations in a manner ensuring the safety and security of each
youth and document each check in real time either manually or electronically. Documentation
must include the actual time of each visual observation and initials of the staff conducting the
check. Additionally, preprinted times are prohibited.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 59 (Revised July 2023)
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has a written policy and procedures in place to ensure staff always know the exact
number and location of all youth under their supervision. A review of the module’s logbooks and
master control logbooks confirmed counts are conducted and documented randomly, when
youth are being moved, after emergency drills, and after any major disruptions. A full day of
each month since the last annual compliance review confirmed counts were being conducted
and documented as required. Census counts were documented upon any change of population.
Living module counts were documented in their assigned module logbooks by detention staff.
The center also conducts status checks of the areas, during which the counts are also
documented. Nine staff were interviewed, and all stated counts are conducted at the beginning
of each shift, end of each shift, before and after school, and before and after meals. If counts
are not correct, all activities are stopped, and a recount is done. Nine staff stated emergency
counts are conducted when a youth is believed to be missing, when visibility is hindered, during
an electrical outage, and when there is a major disturbance. An observation of counts was done
during the week of the annual compliance review, and staff completed counts before and after
meals. In addition, counts were done before and after classes were completed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 59 (Revised July 2023)
5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has a written policy and procedures regarding logbooks. The center maintains
separate logbooks in master control and for each living module, as well as one for visitors, and
one for contracted and education staff. A review of logbooks since the last annual compliance
review revealed each logbook was bound with numbered pages, all entries included the date
and time of the event or incident, the name of the staff and youth involved, and the initials of the
staff making the entry. All reviewed entries revealed the safety and security of the center,
including medical, special needs, and mental health alerts were highlighted. Reviewed logbooks
reflected all errors were struck through with a single line, voided, and initialed by the person
correcting the error. The reviewed master control logbooks included emergency situations,
incidents, fire and escape drills, population counts at the beginning and end of each shift, group
movements, admissions and releases, presence of law enforcement, name of youth placed in
confinement including the time confinement began and the time confinement ended, name of
youth placed on precautionary/secure observation including the time precautionary/secure
observation began, and time precautionary/secure observation ended. Logbook documentation
also indicated adherence to the educational schedule.
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has a written policy and procedures regarding logbooks. The master control and
module logbooks for twelve months were reviewed. The supervisors review the logbooks each
shift, including the master control logbook when accepting the shift, to document they are aware
of current relevant situations in the center. Observations from the center’s logbooks confirmed
the superintendent or designee reviewed the logbooks on a weekly basis. The officer assigned
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 59 (Revised July 2023)
to the modules conducted reviews of the logbook upon accepting the shift documenting the
pages reviewed. Logbooks contained documentation to support the superintendent or designee
toured the youth living modules at least once during each shift. Three full days of each month
for the annual compliance review period reflected no issues noted. The interviewed
superintendent confirmed the logbook review requirements.
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 maintains a written policy and procedures on key control, which includes the
issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys,
and reporting and replacement of damaged keys. All keys are kept in a locked box in master
control. The center maintains a master key inventory which accounts for all key rings by ring
number, the number of keys on each ring, the capability of each key, and to whom the keys are
assigned and issued. Emergency keys which provide egress through exterior doors are stored
in master control. A review of the Key Control Logs and observations of the distribution and
collection of keys during the annual compliance review week confirmed the issuance of keys
and key rings were documented in the center’s shared network drive. A form is also used to
track staff keys. Staff sign-out the keys at the beginning of the shift and sign-in at the end of the
shift. At each shift briefing the shift supervisor documents the name and initials of the staff, and
the time the issuance of the key to the staff. A review of the shift reports confirmed they
matched the keys in use. Observations indicated keys were on the staff to whom the keys were
issued, and youth did not have access to center keys. A review of the master control inventory
revealed the inventory report matched the actual key rings in use. There were no reported
incidents during the annual compliance review period of lost keys or missing keys. Personal
keys are stored in staff lockers and visitor keys are stored inside master control on a hook.
Once the visitor departs, the keys are returned. Supervisors, administration, and maintenance
mechanic staff have access to emergency keys. The center has a process in place for reporting
lost or missing keys. There were no incidents reported relating to key control for the past twelve
months. An interview with the master control staff verified the center’s practices. Nine staff were
interviewed, and all stated the restricted keys do not provide access to medical or mental health
records or the property room. All staff reported they knew the key control process and were able
to explain the process for reporting missing or damaged keys as outlined in the policy. A
random review of three staff and their assigned keys confirmed they matched the key log. Each
reviewed staff knew the function of each key on the key ring. The superintendent was
interviewed and confirmed no permanent keys are issued to staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 59 (Revised July 2023)
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has a written policy and procedures in place for transportation procedures and
operation of Department vehicles. The center has nine vehicles assigned to transport youth.
Reviewed documentation verified each of the transportation vehicles underwent an annual
inspection from a certified mechanic. Documentation showed the mechanic inspected the tires,
lights, and brakes ensuring the vehicles were safe to transport youth. Reviewed documentation
verified the center’s maintenance staff conducted monthly visual checks for all transportation
vehicles. During the monthly maintenance checks staff visually checked the vehicle’s water
coolant, lights, oil, emergency equipment, brakes, horn, interior/exterior, and cleanliness. In
addition, the tires, battery, windshield and wipers, windows, mirrors, and vehicle damage were
visually inspected. The inspections were documented on the Monthly Inspection SharePoint
form which were maintained digitally by the maintenance staff. Each inspected vehicle had the
appropriate number of seatbelts, and a current fire extinguisher. Transportation staff take the
emergency transport kit prior to transporting youth which included the window punch, first-aid
kit, and seatbelt cutter. An observation of a youth transport was conducted. Prior to transporting
youth, staff inspected the vehicles for contraband, conducted a fuel check, maintained copies of
transportation procedures in the vehicle, verified the seatbelts were operational, ensured the
security screen was secure, confirmed the vehicle folder included the logs, vehicle and
mechanical restraint keys, gas credit card, and vehicle registration. In addition, staff had a
center-issued cellular telephone, documented the inspection in the logbook, ensured the vehicle
was secured at all times, ensured the youth were searched prior to being placed in the vehicle,
and ensured youth and staff were wearing their seatbelts. A check of six center vehicles found
all were locked when not in use. Nine youth were interviewed, and each youth stated they feel
staff are driving safely when they are being transported. The nine interviewed youth stated they
have never seen anyone place contraband in a transport vehicle.
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 policy and procedures to ensure all tools and equipment related to
maintenance and the kitchen area are properly maintained, stored, and inventoried. All tools
were secured behind two secure doors accessible to the maintenance staff, supervisors, and
administrators. Tools are stored on a shadow board which can help to easily identify missing
tools. The center maintains a perpetual inventory of tools. A review of the inventory logs
included documentation of the issuance and return of tools. Kitchen tools included knives and
other sharps which were stored in a locked box in the kitchen area. A perpetual inventory of
kitchen tools is maintained, and counts are documented at the beginning of the day, midday,
and at the end of the shift. Observations of the tool room and the kitchen verified all tools were
secured when not in use. A review of the tool inventory lists verified there were no tools found to
be missing. There were no tools which were not listed on the inventory sheets. In an informal
interview, the assistant superintendent verified service vendors are accompanied by center staff
at all times when in the secure area of the center. The center’s policy and an informal interview
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 59 (Revised July 2023)
with the assistant superintendent stated if tools are lost, or following the completion of the work
project, the area is cleaned and inspected for contraband prior to allowing youth access.
Informally interviewed food service and maintenance staff were able to explain the process for
missing or damaged tools. In a formal interview the superintendent stated the center follows the
center’s policy regarding tool inventory and management. Nine interviewed staff stated if a tool
is damaged or missing, they would complete an incident report, notify the supervisor, document
in the logbooks, and conduct searches. A review of ten unique tools in the maintenance room
verified each was secured, had marking for easy identification, the inventory was accurate, and
the inventory log was signed by the superintendent or designee.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center has a written policy and procedures regarding youth access or use of any tools.
Youth may use Class B tools which include mops, brooms, buckets, and other common
household items. When youth are using Class B tools, they are under direct care supervision.
An observation of a youth using a broom, mop, and bucket was observed by video. The youth
was supervised by staff while sweeping and mopping the common area of the living module.
Nine staff were interviewed, and each stated youth can use mops and brooms, and one staff
stated youth can use a scrub brush. Nine youth were interviewed, and four stated youth can use
mops and brooms, and five stated youth do not use any tools.
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 policy and procedures regarding the inventory of all flammables, toxic,
caustic, and poisonous items. Flammable, toxic, caustic, and poisonous items are maintained in
secure storage areas with limited access. Safety Data Sheet (SDS) logbooks are located where
the chemicals are stored. Monthly Inventories of flammable, toxic, caustic, and poisonous items
are maintained by the maintenance staff and reviewed and signed by the superintendent or
designee. The inventories were compared to the items on-site and were found to be accurate
and complete. A review of five unique chemicals found the chemicals were secured, the actual
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 59 (Revised July 2023)
count matched the ending count on the inventory list, and the SDS was present for each item
reviewed.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center has a written policy and procedures which state flammable, toxic, caustic, and
poisonous fluids and other dangerous substances may only be drawn or acquired by authorized
staff and prohibit youth from using or handling these items. A review of the flammable, toxic,
caustic, and poisonous materials storage area confirmed the area is inaccessible to youth. The
inventory and check out logs were also reviewed and verified only authorized staff are permitted
access to these items. All caustic, flammable, toxic, and poisonous items are stored in the
locked maintenance area and in a locked laundry room. Entry doors to areas unauthorized and
inaccessible to youth are designated by a red dot throughout the center. Nine youth were
interviewed, and each stated they did not use any type of cleaning agent such as bleach,
laundry soap, window, or toilet cleaners. All nine interviewed youth stated they did not have
access to flammable, toxic, caustic, and poisonous items. Nine staff were interviewed, and each
staff stated youth were not allowed to clean with substances which are toxic, flammable, or
poisonous.
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 policy and procedures which designate the maintenance mechanic as
the authorized staff trained for handling and disposing of hazardous waste and/or solid waste
and is responsible for disposing of hazardous items and toxic materials in accordance with
Occupational Safety and Health Administration (OSHA) standards. Reviewed documentation
and an informal interview with the maintenance mechanic verified there were no toxic spills
during the annual compliance review period. The maintenance mechanic stated all chemicals
are used up and the center did not dispose of any chemicals during the annual compliance
review period. The kitchen has a container for grease designated for disposal.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 59 (Revised July 2023)
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has a written policy and procedures which outline the process of placing youth in
confinement under twenty-four hours. The procedure requires staff to 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 themself. During the annual compliance review period, the center
had a total of six hundred thirty-seven confinement placements. Twenty youth confinement
records were reviewed. Each of the twenty reviewed youth confinement records contained
documentation which ensured each youth had the right to have three meals a day plus evening
snack, access to mental health care as needed and requested, daily showers, clean clothing,
mattress/bedding, education materials during school hours, and right to grieve a confinement
placement. Documentation verified the supervisor approved the confinements, staff placed only
one youth in the confinement room, the room was searched, and documentation of the search
was entered in the Department’s Facility Management System (FMS) prior to placing a youth in
confinement for all twenty reviewed records. A review of twenty Visual Observation Reports
(VORs) verified staff were observing youth in confinement at least every five minutes for the first
hour of confinement. After the first hour, youth were observed according to the Detention
Supervision Matrix. None of the reviewed records documented a physical injury was observed
prior to placing youth in confinement. Each of the reviewed confinement records documented
the reason for the confinement which was explained to the youth. All twenty reviewed records
verified the supervisor conducted an initial confinement review with the youth within one hour of
the incident, a full report was completed before and after the end of each shift, the supervisor
conducted additional reviews with the youth at a minimum of every three hours, and all reviews
were entered in FMS. All twenty reviewed confinement reports documented staff and
supervisors continually counseled the youth and considered removing the youth from
confinement as soon as the youth was able to safely rejoin the population and was no longer a
threat to safety. Reviewed documentation verified the confinement did not interfere with
visitation. The center did not have any pregnant youth in confinement under twenty-four hours
during the annual compliance review period. An observation of the confinement rooms verified
the cameras and plexi-glass windows were free of obstructions. Some plexi-glass windows had
scratches; however, the youth were still visible in the confinement room. The interviewed
superintendent stated behavioral confinement is an immediate, short-term, crisis management
strategy for use during situations in which one or more youth’s behavior imminently and
substantially threatens the physical safety of others or compromises security. The
superintendent or designee reviews all confinement reports within forty-eight hours, excluding
weekends and holidays, unless it is their regularly scheduled workday, and determines whether
each confinement was appropriate or inappropriate. Nine staff were interviewed, and each
stated a confinement report is completed, staff conduct and document ten-minute checks, and
search the confinement room when placing youth in confinement. In addition, two staff stated
youth are counseled while in confinement. All nine staff stated youth are provided education
materials when placed in temporary confinement during school hours.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 59 (Revised July 2023)
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has a Continuity of Operations Plan (COOP) which requires drills to be conducted
and documented, at minimum, twice a year, with one drill being completed prior to the hurricane
season. Reviewed documentation verified the center conducted three drills during the annual
compliance review period, and two were completed prior to hurricane season. The Emergency
Drill Reporting form included the type of drill, date and time of the drill, participants, a brief
scenario, findings and recommendations, and reviewer comments. Nine staff were interviewed,
and each stated they participated in COOP drills during the annual compliance review period.
The superintendent was interviewed and stated each center has a planned and comprehensive
approach to effectively manage emergencies and disaster events, including those which require
the center to relocate its youth and staff while maintaining operations, safety, and security.
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 policy and procedures regarding developing, implementing, and
maintaining an Escape Prevention Plan. A review of the center’s Escape Prevention Plan
verified it included the Department’s established policies and procedures regarding escapes. A
review of the center’s drills confirmed escape drills were conducted quarterly during the annual
compliance review period. The Emergency Drill Reporting form included scenarios, a synopsis
of the incident, start and end date and time of drill, detailed information of problems and
concerns during the drill, and a staff sign-in attendance roster. Logbooks were reviewed and
revealed each escape drill was documented in the logbook. A review of nine staff training
records confirmed the staff were trained in escape prevention annually. Nine staff were
interviewed, and eight stated they participated in escape drills since the last annual compliance
review.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 59 (Revised July 2023)
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a written policy and procedures for the implementation of disaster preparedness
and fire prevention plans. A review of the Emergency Drill Reporting forms verified fire drills
were conducted monthly on each shift since the last annual compliance review. The Emergency
Drill Reporting forms contained all the essential elements which included the type of drill, a
synopsis of the incident, start and end date and time of each drill, detailed information of
problems and concerns during the drill, and a staff sign-in attendance roster. A review of the
logbooks verified the reviewed fire drills were documented. The center had an annual fire
extinguisher inspection conducted on January 11, 2024. Observations confirmed the annual
inspection of fire extinguishers was completed as reported. Nine staff were interviewed and
each stated fire drills take place at least monthly, and each participated in a fire drill. Nine youth
were interviewed, and each stated they were instructed on what to do in case of a fire.
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has a written policy and procedures which address illegal contraband and prohibited
items and reducing the introduction of contraband into the center. A review of the center’s policy
and observations verified prior to admission, a full body search and electronic search are
completed. In addition, searches are conducted when deemed appropriate by the shift
supervisor, when there is a reasonable suspicion, the youth is harboring contraband, and during
center-wide initiatives to reduce the introduction of contraband. An observation of a new
admission into the center verified staff wore gloves during the search. There were two same
gender staff present when the search was conducted. The observation verified the search was
conducted individually in a private area and not in a group setting. An informal interview with the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 59 (Revised July 2023)
assistant superintendent verified an incident report is completed for any full body search
conducted at any time other than admission. A review of the center’s policy and observations
verified staff and visitors were electronically searched when entering the secured area of the
center. All bags, cases, jacket pockets, and shoes were searched. All personal keys, personal
cellular phones, and other contraband items were prohibited in the secured area of the center.
Youth room searches are documented on the shift reports and are uploaded electronically. A
review of random shift reports for one day for each month of the annual compliance review
period during each awake shift verified youth room searches were documented and completed
as required. In an informal interview, the assistant superintendent stated there were no
instances which may have compromised the safety and security of the center throughout the
annual compliance review period. A review of the Department’s Central Communications Center
(CCC) reports since the last annual compliance review found there were two instances of
contraband found at the center. The contraband and the calls to the CCC were documented in
the master control logbook. Documentation verified incident reports were completed identifying
findings and disposition of the contraband found. Confiscated items were secured, and hand
delivered to the supervisor. Reviewed documentation showed the shift supervisor documented
the chain of custody for the contraband items and the regional director was notified. Local law
enforcement was contacted for the items considered illegal as defined by Florida Statute. An
interview with the superintendent stated staff shall be diligent in their efforts to prevent the
introduction of contraband into the center. Staff are to stay alert at all times, be observant in all
supervision, and conduct appropriate search techniques which greatly enhances the ability to
maintain a safe and secure center, staff, and youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 59 of 59 (Revised July 2023)

report_type: QI Detention