state: FL

facility_name: Hillsborough Juvenile Detention Center West

summary: QI Detention - FY23-24 - 1 finding

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Hillsborough West Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3948 W. Martin Luther King Jr. Blvd.
Tampa, Florida 33614
Review Date(s): March 19-22, 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:
Gustavo Mazorra, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, Education Coordinator (Standard 2)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor (Standard
3)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 1,
Interviews, and Video Observation)
William Figueroa-Perez, Pasco Regional Juvenile Detention Center, Juvenile Justice Detention
Officer Supervisor (Standard 2)
Paula Friedrich, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Douglas Kane, St. Lucie Regional Juvenile Detention Center, Assistant Superintendent
(Standard 5)
Heather Molinario, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Hillsborough West Regional Juvenile Detention Center MQI Program Code:
294
Provider Name: Department of Juvenile Justice Contract Number: NA
Location: Hillsborough County / Circuit 13 Number of Beds: 80
Review Date(s): March 19-22, 2024 Lead Reviewer Code: 185
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures) and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
2.10 Educational Access*
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 58 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 58 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 58 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * 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 58 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 58 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58 (Revised July 2023)
Program Overview
The Hillsborough Regional Juvenile Detention Center is a state-owned detention facility,
operated by the Department, located in Tampa, Florida. The center serves youth in Hillsborough
County, located in Circuit 13. Male and female youth who are detained pending adjudication,
disposition, or placement in a residential commitment program are housed in the eighty-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 Hillsborough County School Board. The
center’s management team includes the superintendent, two assistant superintendents, two
administrative assistants, nine juvenile justice detention officer (JJDO) supervisors, and sixty-
one JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by one
psychiatrist, a licensed designated mental health clinician authority, two licensed therapists,
seven pro-re-nata (PRN) licensed therapists, one non-licensed master’s-level therapist, and a
bachelor’s-level intern. 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 four registered nurses (RNs), one medical doctor, one advanced practice registered
nurse (APRN), and three PRN RNs. The medical clinic maintains nursing coverage Monday
through Friday, from 6:30 a.m. to 8:00 p.m., and on weekends, from 7:00 a.m. to 8:00 p.m. Food
services are provided by Department staff and include menus, meal planning, meal schedules,
special diets, nutritional analysis, daily allowance, food preparation, health certifications, food
product standards, sanitation, and cleaning. Staff are responsible for the custody and control of
youth in their care, providing youth supervision twenty-four hours a day, seven days a week.
The center has four living modules which are divided by male and female. There are sixty-one
security cameras at the center, of which fifty-six were operational. During the tour, the facility
was clean and well maintained, with no immediate maintenance issues observed. The school
portables are being renovated; therefore, youth are attending class in two available classrooms,
the dining hall, the multi-purpose room, and the dayrooms of the living modules. At the time of
the annual compliance review, the center had seventeen vacancies, which included one JJDO
supervisor, twelve JJDO IIs, and four JJDO Is.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 58 (Revised July 2023)
Strengths and Innovative Approaches
• Youth are educated on raising and maintaining chickens and fabrication and
maintenance of a chicken coop.
• The behavior management system is utilized to offer a unique incentive for female
youth in the form of a spa day.
• The center held several holiday events, which included pie making contests, holiday
cookie decorating, special menus, and easter egg hunts.
• The center held special sporting event watch parties, which included pizza, wings,
hot-dogs, and hamburgers.
• The center hosted several guest speakers, local business owners, and professional
sports athletes to speak with the youth.
• The center provides a music instructor to interested youth, who teaches drumming.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 58 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures which require background screenings to be
conducted for all staff, volunteers, mentors, interns, and contracted providers with access to
youth and confidential youth records. The center did not have any contracted providers,
volunteers, mentors, or interns who assisted or interacted with youth on an intermittent basis
during the annual compliance review period who did not need to be background screened. The
center completed and submitted an Annual Affidavit of Compliance with Level 2 Screening
Standards to the Department’s Background Screening Unit (BSU) on January 30, 2024.
Teachers paid by the local school board received an Annual Affidavit of Compliance with Level
2 Screening Standards completed on January 30, 2024. The center had twenty-two newly hired
staff and four newly hired contracted staff since the last annual compliance review including one
administrative assistant, one food service worker, fourteen juvenile justice detention officer
(JJDO) Is, six JJDO IIs, one registered nurse (RN), one licensed clinical social worker (LCSW),
and two licensed mental health clinicians (LMHCs). A review of the BSU confirmed all newly
hired staff had a background screening completed prior to their hire date. One staff required an
exemption prior to working with youth, and the exemption was requested and granted. The
remaining staff were all eligible for employment and to work with youth. Twenty of the newly
hired staff were direct-care staff and required the staff to complete a pre-employment
assessment, with all receiving a passing score which was recorded in their employment record.
All four contracted staff were added to the Clearinghouse employee roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures requiring a five-year background rescreening to be
conducted on all Department staff, volunteers, contracted providers, mentors, and interns with
access to youth and confidential youth records. A review of the center’s staff, volunteer, and
contracted provider rosters indicated the center had eight staff requiring a background
rescreening during the annual compliance review period. All eight staff had a rescreening
completed within the required time frame and submitted to the Department’s Background
Screening Unit (BSU) at least ten business days prior to their five-year anniversary date.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58 (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 has facility operating procedures which ensure staff adhere to a code of conduct.
Seven staff personnel records were reviewed, and each included a signed code of conduct
form. None of the staff were applicable for a violation of the code of conduct; therefore, the
center provided three additional staff personnel records which were applicable. Each of the
applicable records contained a copy of the staff’s disciplinary action, which included the specific
violation, as well as the date of the violation. Each also contained management’s response with
regards to action taken because of the violation of the code of conduct. Two of the applicable
staff received oral reprimands and one was dismissed from their position. The center provided
records for three staff who received commendations during the annual compliance review
period. All three staff received employee of the month recognitions.
Seven youth were interviewed, and one said they have never been stopped from reporting
abuse to the abuse hotline. The remaining six said they have never had to report abuse. All
seven youth said staff are respectful when speaking to them. Four youth said they have never
heard staff use profanity when speaking to youth; two said they heard it once, and one said they
heard it occasionally. Seven youth said they have never been threatened or heard of other
youth being threatened by staff. Five youth said they feel safe at this program. One said they did
not feel safe because they are around youth they do not know, and one said they did not feel
safe because youth are constantly fighting. Seven staff were asked to explain the process for
allowing youth to call the Florida Abuse Hotline or the Department's Central Communications
Center (CCC), and all were able to articulate the process. Four staff said they have not
observed a coworker using profanity when speaking to youth. One said they observed it once
and two said they observe it occasionally. These staff said the occasions were accidental and
not directed towards youth. All staff said they have never seen coworkers using threats,
intimidation, or humiliation when interacting with youth. Two staff said working conditions are
very good, four said working conditions were good, and one said working conditions were fair.
The superintendent was interviewed and advised staff are to communicate and interact with
youth in a manner which is professional and sets a good example. Staff represent the
Department and are always expected to exhibit professional behavior and attitude. Physical
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 58 (Revised July 2023)
abuse of youth is prohibited by law and any knowledge of such shall be reported to both the
Florida Abuse Hotline and the CCC.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center maintains facility operating procedures which requires anytime a reportable incident
occurs, center staff are to notify the Department’s Central Communications Center (CCC) within
two hours of the incident occurring or within two hours of becoming aware of the incident.
During the annual compliance review period, a total of eighty CCC incidents were reported. A
random sample of eight of these CCCs were reviewed. Seven of the eight incidents reviewed
were reported within the required two-hour time frame. One incident was reported two-hours
and twenty-six minutes after the center became aware of the incident. Three incidents were
medical incidents, two were program disruption incidents, two were complaints against staff,
and one was a youth behavior incident. All the incidents were documented in the logbook as
required. A review of internal incidents and grievances found no additional incidents which
should have been reported to the CCC.
The superintendent was interviewed and advised whenever a reportable incident occurs, a
juvenile justice detention officer supervisor or higher notifies the CCC within two hours of
gaining knowledge of the incident or event.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
The center has a policy and procedures which requires the use of Protective Action Response
Right Interactions model (PAR/RI) to be in accordance with Florida Administrative Code.
Anytime staff use a physical intervention technique, a PAR/RI incident report is to be completed
and filed in accordance with the Florida Administrative Code. During the annual compliance
review period, the center had a total of 618 PAR/RI incidents. Nine incidents were reviewed. All
nine incident reports were completed by the end of the staff’s workday. Each report included
statements from all staff involved. None of the incidents resulted in serious injury to youth or
staff, and no youth alleged abuse. All nine incidents were reviewed by a supervisor or a PAR/RI
certified supervisor or instructor. A post-PAR/RI interview was conducted with each youth by an
administrator within thirty minutes of each incident. None of the incidents required a medical
review and none resulted in the use of mechanical restraints. The superintendent reviewed each
incident within seventy-two hours. There were no additional PAR/RI incidents which were not
documented by a report. The center PAR/RI rate during the previous quarter was 29.96, which
is above the statewide detention PAR/RI rate of 15.17, but lower than the previous year, which
was 31.53.
Seven staff were interviewed, and all said they try to talk to youth prior to using physical
restraints or mechanical restraints. The superintendent was interviewed and advised the use of
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 58 (Revised July 2023)
physical and mechanical restraints must be approved by the superintendent or assistant
superintendent. The regional director must be notified following the use of mechanical restraints.
Juvenile justice detention officers (JJDOs) shall complete the mechanical restraints supervision
log and ensure ten-minute circulation checks are completed. The superintendent shall consult
with medical, mental health, and the regional director prior to authorizing mechanical restraints
over sixty minutes. This process must be followed every sixty minutes. All information is to be
documented in either the logbook or on the mechanical restraints log. The superintendent also
advised a review by a certified PAR/RI instructor/supervisory staff is conducted. A post-PAR/RI
interview will be conducted with each youth by the superintendent or designee within thirty
minutes after each incident. A review of the PAR/RI Report is conducted by the superintendent
or their designee within seventy-two hours of the incident, excluding weekends and holidays. A
review of the PAR/RI incident video is conducted by the superintendent or designee, within
twenty-four hours of the incident, excluding weekends and holidays.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures requiring all detention staff to be trained in
accordance with Florida Administrative Code. Staff must satisfy all pre-service certification
requirements within 180 days of hire. Seven pre-service staff training records were reviewed. All
seven completed new staff orientation within thirty days of hire. All staff completed Phase One
training as required. Six completed Phase Two training which consists of 120 hours of academy
training. One staff is still within the 180 days of hire and has not yet attended the academy. Five
staff completed all required pre-service training requirements and were certified within 180 days
of hire. One staff is still within their 180 days and not applicable. The remaining staff was
certified 189 days after hire. This was due to having to retake the exam, and the center
requested and received approval for a waiver of the 180-day requirement. All staff’s trainings
were documented in the Department’s Learning Management System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures which require all direct care staff to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year. In addition, supervisory staff must complete an
additional eight hours of training in areas specified in Florida Administrative Code. Seven staff
training records were reviewed for completion of in-service training during the previous calendar
year. All staff completed a minimum of twenty-four hours of annual in-service training, with each
staff completing training hours between fifty-nine and 236 hours. All staff completed training in
active shooter preparedness, cardiopulmonary resuscitation (CPR), first-aid, automated external
defibrillator (AED), human trafficking intervention, mental health and substance abuse, Prison
Rape Elimination Act (PREA), Protective Action Response Right Interactions model,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 58 (Revised July 2023)
professionalism and ethics, standards of conduct, sexual harassment, suicide awareness and
prevention, and trauma responsive practices. Three supervisory staff were reviewed for required
supervisory level training. All three received a minimum of eight hours of additional training in
the areas of leadership, coaching, and personal accountability. All staff’s trainings were
documented in the Department’s Learning Management System (SkillPro). The center has a
licensed nurse who provides in-service education on girls’ healthcare to all non-healthcare staff
who supervise or treat girls. The list of in-service trainings, approved by the Department’s
regional director for this year, was reviewed and signed on November 17, 2023. The center
maintains an annual in-service calendar in the briefing area, and this calendar is updated as
changes occur.
The superintendent was interviewed and advised they have taken essential skills leadership
training, supervising for success, fundamentals of coaching, time management training,
delivering discipline training, and on the job training. The superintendent further confirmed pre-
service training consists of 120 hours of certification training, which is computer-based, and
instructor led. The academy is conducted by the Officer of Talent, Leadership, and Culture at an
approved Department training site. In-service training is required by all staff to successfully
complete on-going in-service training requirements.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures outlining how grievances are processed. The
center did not have any grievances since the last annual compliance review. A review of the
Facility Management System (FMS) in the Department’s Juvenile Justice Information System
(JJIS) confirmed the center did not have any grievances during the annual compliance review
period. During an interview with the superintendent, the superintendent advised there is an
informal phase and a formal phase for grievances. The informal phase is where a juvenile
justice detention officer (JJDO) attempts to resolve a complaint or condition with a youth using
effective communication skills. The formal phase is where a youth submits a written grievance
which results in a response from a supervisor. The JJDO supervisor will give a response by the
end of the shift, or within twenty-four hours. The JJDO supervisor shall forward each grievance
form to the superintendent or designee upon completion. The superintendent will review each
grievance within seventy-two hours of receipt excluding weekends and holidays. The
superintendent's decision is final. Grievance forms are available for all youth in each module.
Seven youth were interviewed, and all indicated they have never filed a grievance, but they do
know the grievance process. None of the youth rated the process because they have not
submitted a grievance while at the center. Seven staff were interviewed and described the
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Office of Accountability and Program Support Page 15 of 58 (Revised July 2023)
process of a youth filling out a grievance form, giving it to staff, and the staff giving it to a JJDO
supervisor.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures which require all critical and special alerts for youth
to be listed in the Department’s Juvenile Justice Information System (JJIS). Supervisory staff
are to review the alert report daily and share alert information with staff during shift briefing.
Medical and mental health staff are also required to review alerts to ensure each alert is
correctly tracked and managed. Seven youth records were reviewed for alerts. The seven youth
had a total of seventeen alerts. A review of alerts confirmed each alert was entered, updated,
and/or closed, as required. All alerts were documented in the logbook for each youth. The
center utilizes an alert report generated in JJIS as their internal alert system. All alerts entered
in JJIS are documented on the internal alert system once the alert is entered. All alerts matched
in JJIS and the internal alert system. All alerts were verified prior to being entered in JJIS. The
JJIS alert report is reviewed daily by supervisors and shared during shift briefing and in the
logbook. A review of shift briefing minutes and an observation of a shift briefing during the
annual compliance review week verified youth alerts are shared and reviewed with staff. Alerts
are updated as needed by mental health, medical, or supervisory staff. All alerts are reviewed
by the assistant superintendent or superintendent as well.
The superintendent was interviewed and advised detention staff enter alerts at admission based
on information provided by youth, parents/guardians, law enforcement, and the Juvenile
Assessment Center. The superintendent also advised healthcare staff shall review and ensure
alerts are up to date daily to ensure they meet all confidentiality requirements, are confirmed
with each youth's medical history, and are confirmed with parents/guardians. Seven staff were
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interviewed, and all said they are made aware of alerts during shift briefing. Six staff said they
also find out about alerts by reading the logbook and by looking in JJIS.
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 collects data in the Department’s Juvenile Justice Information System (JJIS) daily.
Data includes but is not limited to Protective Action Response Right Interactions model
(PAR/RI) Reports, the Department’s Central Communications Center (CCC) reports, alerts, staff
vacancies, overtime, and confinements. This data is compiled by headquarters into a report
card which is disseminated to the regional directors and then shared with center administration
on a weekly basis. Center administration shares this information with supervisors and
department heads during the monthly department head meetings and supervisor meetings. The
information is then shared by department heads and supervisors with their staff during their shift
or department meetings. The center shares pertinent information with stakeholders quarterly
during the community advisory board meetings. Agendas and meeting minutes are maintained
for reference.
During an informal interview, the superintendent advised the center uses the collected data to
improve their processes by incorporating this into policy changes, training, coaching, and
mentoring in areas falling behind, additional programming, adjustments to staff scheduling, and
for recruiting/retention.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures which ensure all youth are admitted to the program
in accordance with Florida Administrative Code through a process, at a minimum, addressing
the review of required paperwork from law enforcement and screening staff. Seven youth case
management records were reviewed, and the Admission Wizard documented all youth had an
arrest affidavit or custody order, all had a Detention Risk Assessment Instrument completed, all
had a Suicide Risk Screening Instrument, were electronically searched, frisk searched, and
received a full body visual searched by an officer of the same gender as the youth. All youth
were allowed to place a telephone call and all youth were given a meal during the admission
process if the process was completed two hours or more before the serving of the next
scheduled meal. All youth were screened to identify medical, mental health, and substance
abuse needs. A youth admission was observed during the annual compliance review week, and
the youth received their meal within fifteen minutes of the scheduled mealtime at the center. The
youth was also afforded a telephone call and all procedures were followed during the admission.
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
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The center has facility operating procedures in place for the orientation process, requiring
orientation to occur within twenty-four hours of a youth being admitted. A total of seven youth
case management records were reviewed. Each youth was provided an orientation within
twenty-four hours of admission. Each youth signed the orientation acknowledgement, which
confirmed the orientation contents were discussed with the youth. An orientation was observed
during the annual compliance review week, the juvenile justice detention officer was observed
explaining the orientation packet to the youth and had the youth sign to acknowledge receipt of
orientation. Orientation included rules and regulations, grievance procedures, visitation,
telephone calls, available medical, mental health, and substance abuse services, as well as how
to assess the services, and how to access the Florida Abuse Hotline and the Department’s
Central Communications Center (CCC), if eighteen years of age or older. Seven youth were
interviewed and six said they had been informed of these things and one said they had not
been.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures to ensure all youth admitted to the detention center
are classified to provide the highest level of safety and security. Seven youth case management
records were reviewed. The classification process for all youth included a review of information
concerning the youth’s history and status. The consideration of potential safety and security
concerns with regards to youth room assignments included the youth’s sex, height, weight, and
level of aggressiveness. The classification form also included considerations for mental illness,
developmental disabilities and physical disabilities, history of violent behavior, gang affiliation,
criminal behavior, history of sexual offenses, Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB), medical concerns, suicide risk identification or suspicion, and past
escapes or escape attempts. Youth were assigned to a room based on their classification and
reclassified if behavioral or status changes were observed. Any youth with a history of
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committing or being a victim of a sexual offense is placed in a single room. The superintendent
remains informed on how to identify and address local youth gangs by reviewing alerts,
attending detention reviews, and receiving emails from the facility’s gang representative. The
superintendent was interviewed and advised a review of the VSAB results is documented by the
person making a youth room assignment. Youth are assigned to a room based on their
classification and reclassified if changes in behavior are observed.
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 facility operating procedures to ensure suspected gang involvement is
documented and reported to the juvenile probation officer (JPO) who is designated as the circuit
gang representative. A total of seven youth case management records were reviewed and only
one was applicable for suspected gang involvement. The center provided an additional two
applicable youth case management records. All three applicable youth were reported to the
circuit gang representative and JPO through email by the center’s gang representative. The
email included pictures, copies of written statements, drawings, and graffiti. An informal
interview was conducted with the center’s gang representative, and she confirmed information is
shared with the JPO through email. A gang suspicion alert was generated for all three youth.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures requiring youth personal property to be maintained
securely. Seven youth case management records were reviewed, and each record documented
the property was inventoried by the admitting juvenile justice detention officer (JJDO) and
entered in the Department’s Juvenile Justice Information System (JJIS). A property receipt was
printed and signed by the youth and the JJDO in all records reviewed. All records contained a
letter of acknowledgment regarding unclaimed property. Currency and other personal items of
value are placed in a clear tamper proof bag and placed in a drop safe which is under camera
surveillance. Each tamper proof bag was labeled with the youth’s name, Department
identification number, and a listing of the items in the bag. A log is maintained to document
items placed in the drop safe and includes the date, time, youth name, name of the officer who
secured the property, and the officer’s initials. The property storage room is only accessible by
authorized staff. None of the youth refused to sign the property receipt. All personal property
was placed in an assigned bag, documented on the property receipt form, and a copy of the
receipt was placed in all seven youth records reviewed. An observation of a youth admission
during the annual compliance review week was completed and confirmed intake staff followed
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all guidelines along with the youth signing the tamper proof property bag and the bag being
dropped in the safe and logged into the property logbook. Seven youth were interviewed, and
two acknowledged staff checked their personal property and then had them sign a property
receipt form acknowledging their property was correct, while five said they did not. The
superintendent was interviewed and stated when any youth is admitted to the center, all
personal and valuable property is inventoried and documented in JJIS. A property receipt form
is signed by the youth and staff. Valuable property is placed in clear, tamper proof bag, and is
placed in a drop safe which is under video surveillance until the youth is released from the
center. A copy of the property receipt form, which lists all the youth’s property, is placed in the
youth’s record. Any property which is not picked up within thirty days is considered abandoned.
After thirty days, a notice of impending property disposal in mailed to the youth’s last known
address. If a youth is on supervision, it is also acceptable for their juvenile probation officer to
sign for and deliver the property to the youth.
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 facility operating procedures to ensure officers verify the court authorization to
release a youth. Three closed youth case management records were reviewed. All three
records contained documentation showing the on-duty supervisor reviewed all paperwork
received from the court prior to the youth’s release. The identifications of the youth and
parent/guardian were verified prior to each youth being released. All youth and their
parent/guardians were reminded of future court dates. All required parties signed all applicable
release forms. The date of admission and date of release documented in each record correlated
with the Department’s Juvenile Justice Information System. A youth release was observed, and
all procedures were followed during the observed youth release.
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2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center ensures there are provisions in place to ensure prescribed medications, along with
medical instructions, accompany detained youth upon their release. Three closed youth case
management records were reviewed. All contained a receipt of property form signed upon
release by the youth and parent/guardian. All records contained documentation verifying the
youth was released to an appropriate person with a copy of their identification. None of the
released youth were taking medication when they were released. All parents/guardians were
reminded of any health or welfare issues, including medical, mental health, or substance abuse
needs, and any pending appointments. There were three examples of property held more than
thirty days for youth. The center followed their property disposal process for all three youth. A
release was observed during the annual compliance review week and all procedures were
followed.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures in place to ensure proper management of youth
placed in secure detention as well as the appropriate sharing of information. An observation of
the weekly Detention Review was conducted. All required participants attended the meeting
either in person, virtually, or by telephone. A review of the weekly Detention Review was
documented in the Department’s Facility Management System (FMS). The superintendent was
interviewed, and advised a weekly audit is held every Thursday at 1:00 p.m. During the audit all
youth reflected on the Department’s Juvenile Justice Information System (JJIS) census for
secure detention are reviewed to monitor each case and to ensure appropriate placement,
release information, possible lock outs, reviews of committed youth, and information regarding
physical or behavioral issues are discussed.
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 facility operating procedures in place to ensure youth are provided the
opportunity to participate in constructive activities which will benefit each youth and the center.
Daily activity schedules were posted in all living areas, outlining days and times for each youth
activity. Staff adhere to the daily facility schedule. Documentation of all activities was found in all
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applicable logbooks. Seven youth were interviewed and six said the center follows the daily
activity schedule. One youth said the center does not follow the daily activity schedule. Seven
staff were interviewed, and all said the center has and follows a daily activity schedule. Seven
staff were asked if there was minimal interference of educational instruction and four said yes.
Three staff said youth are sometimes disruptive, don’t follow rules, and start fights in the
classroom.
2.10 Educational Access (Critical) Limited Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. The center
integrates education into the daily schedule in such a way to ensure the integrity of the required
minimum instruction time is distributed over a twelve-month period. The district approved
calendar and daily school schedule were reviewed, which incorporated the required 250 days of
instruction, with ten days used for teacher planning, and a minimum of twenty-five hours of
instruction weekly. A random sample of three video and eight logbook reviews showed youth
are being released on average of eight minutes early each day, which falls short of the required
twenty-five hours of instruction weekly. Seven youth were interviewed, and each indicated they
attend school Monday through Friday. Youth are enrolled in academic courses through
Hillsborough County Public Schools and receive credit, as appropriate, when courses are
completed. Seven staff were interviewed and four staff stated there is minimal interference of
education instruction. The remaining three staff indicated there is interference of educational
instruction, as youth follow the rules sometimes, and sometimes they are disruptive or will start
fighting in the classroom. The superintendent was interviewed and stated the daily activity
schedule and education schedule are designed to minimize interference of youth access to
education. Only in the event of court, medical, or emergency jeopardizing safety and security
will the educational schedule be interrupted.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to provide for career education. Career educational
services are provided through the Hillsborough County School District. The program provides
vocational competency development programs to all youth. Seven youth were interviewed and
all seven indicated the center is preparing them for the high school equivalency diploma (GED),
high school, vocational school, employment, and/or college very well.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has identified one licensed individual to serve as their designated mental health
clinician authority (DMHCA) as required. The DMHCA is responsible and accountable for
ensuring appropriate coordination and implementation of mental health and substance abuse
services in the center. The DMHCA’s position is under the contracted provider, VitalCore Health
Strategies, LLC. The center’s DMHCA is a licensed clinical social worker with a clear and active
license, which expires March 31, 2025, and is required to be on-site forty hours each week.
Additionally, the DMHCA is on-call when not on-site for emergency mental health and
substance abuse related needs. The center has had only one DMHCA during the annual
compliance review period. The center’s back-up DMHCA is the regional mental health and
substance abuse director for the contracted provider who is a licensed clinical social worker with
a clear and active license, which expires March 31, 2025. A review of the DMHCA’s sign-in logs
for the annual compliance review period and the DMHCA’s contract requirements/job
description was conducted. This review confirmed the DMHCA, or back-up DMHCA, is providing
the required weekly forty-hour coverage as specified by the contract.
The DMHCA was interviewed and described their role at the center as providing oversight for
the mental health and substance abuse services provided to youth and families. In this position
the DMHCA conducts mental health and suicide risk assessments, develops treatment and
discharge plans, provides supportive counseling, brief support and crisis support/interventions,
and ensures each juvenile probation officer (JPO) receives treatment information and updates.
The DMHCA confirmed the clinical services provided to the youth at the center, as needed,
include Assessment for Suicide Risk (ASR) and Follow-Up ASRs, initial and individualized
treatment plans, discharge summaries with community-based service referrals, supportive,
group, and crisis counseling, and treatment team meetings. The DMHCA and the clinical staff at
the center communicate daily and have meetings weekly as needed. The DMHCA
communicates with the center’s superintendent or designee on a daily and weekly basis, as
needed.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center’s superintendent is responsible for ensuring mental health and substance abuse
services are provided by qualified staff. The center has a contracted provider who hires all
mental health and substance abuse clinical staff for the center. The contracted provider has two
full-time clinical mental health staff (one licensed during the entirety of the annual compliance
review period, and one became licensed in February of 2024), in addition to the designated
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mental health clinician authority (DMHCA). The DMHCA built up a base of seven licensed
mental health clinicians who are utilized on an as needed basis. All nine of these licensed
mental health clinicians were utilized during the annual compliance review period, and each
clinician has a clear and valid license, all expiring on March 31, 2025. The DMHCA was able to
provide each clinician’s license as they are available in a binder within the DMHCA’s office.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center’s superintendent is responsible for ensuring mental health and substance abuse
services are provided by qualified staff. The center has a contracted provider who hires all
mental health and substance abuse clinical staff for the center. The contracted provider assures
all non-licensed mental health clinical staff are working under the supervision of a qualified
licensed clinical staff, and the non-licensed staff have the required education, training, and
experience described in the job description. The center has had two non-licensed mental health
clinical staff this annual compliance review period; one full-time mental health clinical staff and
one graduate-level intern. A review of the job descriptions and staff records confirmed both non-
licensed mental health clinical staff met all the required qualifications. The designated mental
health clinician authority (DMHCA) provided documentation of all the weekly supervision for
both non-licensed mental health clinical staff for the annual compliance review period. Each
weekly supervision log was completed on the required Department form. The full-time mental
health staff became licensed in February of 2024. The center, nor the contracted provider, have
a Chapter 397 license. The DMHCA confirmed only licensed mental health clinical staff would
provide substance abuse treatment; however, there were no youth who requested or
participated in substance abuse treatment during the annual compliance review period.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures to ensure all youth have a mental health and
substance abuse comprehensive screening process at admission to identify any needs the
youth may have. A review of seven youth mental health records was conducted to verify this
process. All seven youth records contained a completed Suicide Risk Screening Instrument
(SRSI) and Massachusetts Youth Screening Instrument, Second Version (MAYSI-2) which were
completed by the Department’s probation staff prior to each youth being admitted to the center.
During the center’s intake process these documents are reviewed by detention staff, and
detention staff complete the required sections on the SRSI in the Department’s Juvenile Justice
Information System (JJIS). The center’s medical staff and/or mental health staff are also
responsible for completing a required section on the SRSI. All seven reviewed youth mental
health records contained documentation of both the SRSI and MAYSI-2 having been completed
in JJIS, and each required section of the SRSI was completed by the appropriate staff. Six of
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seven reviewed youth records had at least one positive response on the SRSI; the remaining
youth record did not have any positive responses noted. All six applicable youth records
contained documentation confirming each youth was placed on suicide precautions and
detention staff initiated a mental health referral which indicated the youth’s need for an
Assessment of Suicide Risk (ASR) at intake. Three of six applicable SRSIs also included a
positive response for having any open or closed suicide risk alerts in JJIS; the remaining three
applicable records did not have a positive response for alerts. Two of the seven youth records
contained an invalid MAYSI-2 due to the youth providing all negative responses; the remaining
five records did not have an invalid MASYI-2. Two of the remaining five youth records had an
elevated score in at least one domain on the MAYSI-2, the remaining three did not have any
elevated score. Six of seven reviewed youth required a referral based on the SRSI or MAYSI-2.
All six applicable youth records had documentation on the mental health referral, initiated at
intake by detention staff, of the MASYI-2 results requiring further assessment. The
superintendent or designee notification was documented in all six of the reviewed youth records
as evidenced by the electronic signature in JJIS. All screenings located in the seven reviewed
youth records were completed by a trained staff, which was confirmed in the Department’s
Learning Management System (SkillPro).
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures to ensure all youth identified through the required
screening instruments as having a mental health or substance abuse need or risk receive an in-
depth mental health and/or substance abuse assessment shortly after the completion of the
intake process. A review of seven youth mental health records was conducted. Three of seven
reviewed youth records were identified and referred to the center’s provider for further
assessment; the remaining four youth records were not identified for or referred for further
assessment. All three of the applicable youth records contained documentation of a referral for
assessment created on the date of admission. All three applicable youth records contained a
comprehensive assessment, received at admission, from a community provider, completed
within thirty days prior to admission; and each had an updated comprehensive evaluation
completed by the center’s contract provider prior to each youth’s thirty-first day at the center.
The community provider completed assessments each contained all of the required elements
including the clinician’s signature. Each updated assessment completed at the center contained
treatment recommendations which corresponded to all mental health or substance abuse
related diagnoses.
The designated mental health clinician authority (DMHCA) confirmed the juvenile probation
officer (JPO) is responsible for ensuring youth identified through preliminary screening as in
need of further mental health and/or substance abuse assessment are referred for a
comprehensive assessment by the contracted provider. The JPO is responsible for ensuring the
comprehensive assessment of a detained youth is forwarded to the detention center. If an
assessment is not received by the JPO by the fourteenth day after the referral was made, the
DMHCA shall contact the JPO and request the status of the assessment. The DMHCA is
responsible for ensuring a thorough review of any received comprehensive assessments; and if
the assessment is not received by the youth’s thirty-first day after admission, is responsible for
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the completion of comprehensive assessment. The DMHCA stated in the interview, if while a
youth is in the center and exhibits behavior or information is obtained which indicates the youth
needs in-depth mental health or substance abuse assessment, the DMHCA is responsible for
ensuring the youth receives an in-depth comprehensive assessment prior to the youth’s thirty-
first day, unless a comprehensive evaluation is available and already in the youth’s mental
health record.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The center’s superintendent and designated mental health clinician authority (DMHCA) are
responsible for ensuring the development and review of an initial and/or individualized treatment
plan for each youth receiving mental health and/or substance abuse services in the center.
Each youth who receives mental health and/or substance abuse services in the center is
required to have a completed discharge summary upon release. The discharge summary should
include the focus of treatment received in the center and recommendations for community-
based services. Four of seven reviewed youth mental health records required the youth to have
a treatment plan because the youth was receiving services in the center. All four youth records
contained an initial treatment plan completed within seven days of the onset of treatment which
was documented on the required Department form. Each plan had the reason for the treatment
referral, initial Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnoses/symptoms, initial treatment method and goals, and the signature of the licensed
clinician, youth, and assigned mini-treatment team members. Three of four reviewed initial
treatment plans also included psychiatric services and medications; the remaining plan was not
applicable for psychiatric services. Two of four reviewed youth mental health records with initial
treatment plans were applicable for individualized treatment plans to be developed as the youth
had been receiving services appropriating thirty-one days; the remaining two records had not
been receiving service for the required length of time. The two applicable youth records
contained an individual treatment plan developed prior to the youth’s thirty-first day of services.
Both individual treatment plans were documented on the required Department form and
contained all the required elements to include the DSM-5 diagnoses and treatment-focused
symptoms, treatment goals, youth’s strengths and needs, psychiatric services and medications,
and pharmacological interventions. Each applicable youth record also contained progress notes
validating the treatment services the youth has received as outlined in the treatment plan. Both
individualized treatment plans contained the dated signatures of the mini-treatment team and
youth. Neither individualized treatment plan required any thirty-day reviews; however, one of
two did have a thirty-day review completed during the annual compliance review week, and the
reviewed documentation contained the dated signatures of the mini-treatment team and youth.
Neither of the reviewed treatment plans were applicable for Prison Rape Elimination Act (PREA)
services. A review of three closed youth mental health records was conducted and found each
youth received a discharge plan documented on the Department’s required form, documentation
of copies provided to the youth, parent/guardian, and juvenile probation officer (JPO) was also
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located. A mini-treatment team meeting was not observed as the center was conducting these
prior to and during the annual compliance review entrance meeting.
The DMHCA confirmed treatment services are initiated prior to discharge for youth determined
to need mental health and/or substance abuse services while in the center. An initial treatment
plan is developed within seven days of initiation of services. The DMHCA provides information
to parents/guardians of all youth in need of such services upon release. The center provides an
array of services for identified youth at risk youth of mental health and substance abuse
problems. An information packet is given to each parent/guardian upon the youth’s release. The
DMHCA stated the center demonstrates its commitment to provide care to youth through the
review of mental health and substance abuse screenings, completion of mental health/special
need/suicide risk alerts, Assessment of Suicide Risk and follow-ups, completion of a
comprehensive assessment, if applicable, transition/discharge planning, delivery of mental
health/substance abuse services including suicide prevention services, coordination of ongoing
treatment with existing community providers, if applicable, short-term individual and/or group
therapy, and individual psychotherapy or crisis short term counseling, if applicable. The
interview with the DMHCA also confirmed the reviews of individualized treatment plans are
conducted every thirty days and any modifications/updates are recorded on the required
Department form.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
The center has facility operating procedures for mental health and substance abuse treatment
planning to ensure interventions are provided to reduce or alleviate a youth’s mental health
and/or substance abuse issues. Four of seven reviewed youth mental health records indicated
youth required treatment; the remaining three records were not applicable. Each of the four
applicable youth mental health records contained documentation the youth was assigned a
mini-treatment team which included mental health clinical staff, center staff for a different
service area, the youth, and the parent/guardian, if possible. Each youth received mental health
treatment in the prescribed frequency and delivery method, at a minimum of once a week. Each
record contained a proper consent for treatment and treatment notes documented on the
required Department form. A review of video, logbooks, and records was conducted and
confirmed mental health groups were conducted as scheduled with ten or fewer youth in each
mental health group session. The center has not had any substance abuse groups conducted
during this annual compliance review period. Mental health staff have adequate access to youth
and confidential space to provide treatment service in the center.
Seven youth were interviewed; four of seven stated the mental health services received have
been very good. The remaining three youth were not applicable as they do not receive mental
health services. The designated mental health clinician authority (DMHCA) interview confirmed
the center’s procedures regarding required treatment plans and reviews, comprehensive
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assessments, mini-treatment teams, intervention/strategies of service delivery, and
modifications/updates for treatment plans. The DMHCA also confirmed the procedures for
treatment plans addressing substance dependence are the same, except for the requirement of
a licensed clinician who must conduct those groups and groups should be fifteen youth or fewer.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has a facility operating procedures for psychiatric services to include psychiatric
evaluations and consultations, medication management, and medical supportive counseling for
youth with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnoses/symptoms. Psychiatric services were provided by a physician with a clear and active
license, under Chapter 458, with an expiration date of January 31, 2025, from the completion of
the last annual compliance review period through July of 2023. Since July 1, 2023, psychiatric
services were provided by a different physician with a clear and active license, under Chapter
458, with an expiration date of January 31, 2026. The back-up psychiatrist has remained the
same for the annual compliance review period, and back-up services are provided by a
physician with a clear and active license, under Chapter 459, with an expiration date of March
31, 2026, and with equal education to the primary psychiatrist. The center had a contract with
tele-medicine/tele-psychiatry inclusion from the completion of the last annual compliance review
through November of 2023. As of the annual compliance review week, the center was not
utilizing tele-medicine/tele-psychiatry services, as all services are provided in-person. The
designated mental health clinician authority (DMHCA) interview confirmed the psychiatrist is on-
site once a week and is available on-call if needed.
Seven youth mental health records were reviewed and three contained documentation showing
youth were prescribed psychotropic medications and required medication management
services. The remaining four records were not applicable. All three applicable youth mental
health records contained documentation to confirm each youth was admitted to the center with
psychotropic medication and was referred for and participated in a psychiatric interview within
fourteen days of admission. Each initial psychiatric interview was completed on the required
Department form and contained all the required elements to include referral reason, youth
history, mental status, DSM-5 diagnoses, treatment recommendations, the prescribed
medication name, explanation of need, and frequency of monitoring. Each applicable record
also contained a completed psychiatric evaluation. The center utilizes the entire three-page
Clinical Psychotropic Progress Note (CPPN) form to document each evaluation. All three initial
CPPNs were observed to be fully completed with all required elements, dated signatures, and
parent/guardian notifications, if applicable. All medication management reviews were also
completed on a CPPN every thirty-days or as needed. All three youth records contained a
proper Authority for Evaluation and Treatment form. None of the youth received tele-psychiatry
services.
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3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a facility operating procedures for ensuring the safety and protection of youth
with an elevated risk of suicide. The center’s suicide prevention plan is reviewed and signed by
the superintendent and the designated mental health clinician authority (DMHCA) annually. The
plan contains all the required elements to include identification of youth with suicide risk, staff
training, suicide precautions, referral, communication and notification, documentation,
immediate staff response, and a review process. The center has an established review process
for every serious suicide attempt or serious self-inflicted injury requiring hospitalization and a
mortality review for completed suicides. The multidisciplinary review includes circumstances
surrounding each event, center procedures relevant to the incident, all relevant training received
by involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendations, if any to changes in policy, training, 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 has facility operating procedures for suicide precautions, which include methods
utilized for supervising, observing, monitoring, and housing identified suicide risk youth. Six of
the seven reviewed youth mental health records contained documentation of youth identified at
admission with an elevated risk of suicide. The remaining record did not have any suicide
prevention services documented. All six applicable youth were immediately placed on
precautionary observation (PO), with a constant level of supervision at the time of admission. A
suicide alert was entered into the Department’s Juvenile Justice Information System (JJIS)
within minutes of identification, and a referral for an Assessment of Suicide Risk (ASR) was
made for each. Each ASR was completed on the required Department form, and a PO log was
also generated and completed on the required Department form for each applicable youth. Each
form was observed to be completed in its entirety. A qualified and licensed mental health
clinician completed each ASR within twenty-four hours and the notification to the superintendent
or designee was documented in each youth record. Consultation with the designated mental
health clinician authority (DMHCA) was documented on the referral summary in five of the six
applicable records; however, a referral summary was not located for the remaining youth. Each
reviewed ASR contained all of the required elements, to include the recommendations. All six
applicable youth records contained documentation of the conference with the superintendent
and DMHCA to reduce the level of supervision. The discontinuation of PO and closing the JJIS
suicide alert in each record was completed after this conference and in a timely matter. None of
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the applicable youth records were recommended for a Follow-Up ASR and none of the youth
were released from the center while on PO status. One PO event was not located in the
logbook.
Seven youth were interviewed and all seven reported they had not been placed on suicide
watch at the center. Seven staff were interviewed, and all stated they would search the youth
and their room for sharp objects if a youth expresses suicidal thoughts. Six of seven stated staff
begin the documentation of supervision. Five of seven stated the youth is placed on constant
sight and sound supervision. One of seven stated a youth can be placed in a locked room.
Three of seven specified the requirement of entering a mental health alert, and to contact the
supervisor and mental health. The staff answer regarding the locked room was addressed
informally with the superintendent, who stated clarification would be provided to staff. The
superintendent’s interview confirmed the center does not utilize the secure observation room for
youth who present an imminent threat of suicide.
The DMHCA interview confirmed the initial screening process begins at the Juvenile
Assessment Center (JAC) with the administration of the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2) to assess mental health and substance abuse issues,
and the Suicide Risk Screening Instrument (SRSI) to assist in identifying youth at-risk of suicide.
If the intake screener at the JAC determines a youth is a suicide risk the youth is placed on
suicide precautions and is maintained on a minimum of constant supervision at admission to the
center. Intake screening continues at the center and intake staff immediately review all
screening instruments and forms upon each youth’s arrival. The intake officer reviews the
MAYSI-2 and the SRSI, and if assessment is indicated by the SRSI or information obtained at
intake suggests a youth is a potential suicide risk, the youth is placed on suicide precautions
and maintained on a minimum of constant supervision until an ASR is completed by a mental
health clinical staff. A suicide risk alert is entered into JJIS. Staff are trained to use screening
tools to identify youth entering the center at risk of suicide, and staff are trained in verbal and
behavioral warnings. Staff maintain a PO log for each youth on constant supervision. Mental
health is notified through JJIS when a SRSI indicates any issues and when a mental health
referral is generated. The DMHCA is on call when not on-site. Staff are notified when a youth is
potentially suicidal in writing through a logbook entry, by receiving a PO log, and verbally
through shift briefing. Mental health staff communicate with the supervisor on duty. If mental
health staff are on-site, mental health notifies each parent/guardian by telephone, and the
youth's juvenile probation officer through email. If mental health staff are not on-site, the
supervisor calls the parent/guardian, and a mental health referral is submitted. If necessary, the
Department’s Central Communications Center (CCC) is notified.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures to maintain precautionary observation (PO) for
youth identified with a suicide risk. Six of the seven reviewed youth mental health records
contained documentation which confirmed the youth was on PO. The remaining record did not
have any suicide prevention services documented. All six applicable youth were immediately
placed on PO and a PO log was maintained for each. Each PO log was observed to have each
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youth’s behaviors documented at intervals not exceeding thirty-minutes. Each PO log contained
all the required elements of documentation to include review and signature of each shift
supervisor, review and signature of mental health clinical staff, safe housing requirements,
warning signs, and superintendent and mental health notifications. A review of video footage
and corresponding documentation was conducted. This review confirmed each youth was
properly supervised and maintained on PO.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures to ensure all staff who work with youth receive
training to recognize verbal and behavioral cues indicating suicide risk, suicide prevention, and
implementation of suicide precautions. Fourteen staff training records were reviewed and each
staff received the required two hours of suicide prevention on the Department’s Learning
Management System (SkillPro) and four hours of in-person suicide prevention training. The
center held suicide drills monthly on each shift, exceeding the requirement of no less than
quarterly on each shift. The center has six suicide response kits with all the required items, and
each suicide kit is co-located with a first-aid kit in master control, medical, and in each of the
four-housing module sub controls. Thirty-four staff training records were reviewed for the first six
months of the annual compliance review period. Twenty-eight staff completed at least one
suicide drill in the first six months. Forty-five staff training records were reviewed for the second
six months of the annual compliance review period. Forty-four staff completed at least one
suicide drill in the second six months. Staff who are not on shift when a drill is conducted have
the opportunity to review the conducted drill; however, this does not count as participation.
Seven staff were interviewed about the location of the suicide response kits. Four of seven staff
indicated a suicide response kit is located in master control. Six of seven staff indicated suicide
response kits are located in the living unit module sub controls. Two of seven staff indicated a
suicide response kit is located in medical. Three of seven staff indicated suicide response kits
are located in each first-aid kit. An informal interview was held with the staff responsible for
training, and it was stated a review of suicide response kit locations would be conducted with all
staff.
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 facility operating procedures to ensure they respond in the least restrictive
means possible to protect the safety of each youth and others while maintaining control when a
youth is in crisis. A review of the center’s combined emergency services plan confirmed the
combined plan contains all the required elements, to include notification and alert systems,
means of referral, communication, supervision, documentation, and incident review.
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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 facility operating procedures to ensure youth determined to be an imminent
danger to themselves or others due to mental health or substance abuse issues receive
emergency care services in accordance with the center’s emergency care plan. A review of the
center’s combined emergency care plan and crisis intervention plan was conducted and
confirmed the combined plan contains all of the required elements to include immediate staff
response, notifications, communication, supervision, authorization to transport for emergency
mental health or substance abuse services, transport for Baker Act and Marchman Act,
documentation, training, and review procedures. The center’s combined plan was approved and
last updated on March 20, 2022. All staff have access to the approved plan. Copies are located
in master control and in each of the four housing module sub controls.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures to ensure youth demonstrating acute psychological
distress receive a detailed evaluation conducted by a licensed mental health professional, or
non-licensed staff under the supervision of a licensed mental health professional, to determine
the level and severity of risk. A Crisis Assessment is only utilized when the presenting acute
psychological distress is not related to suicide risk factors. None of the seven reviewed youth
mental health records were applicable for a Crisis Assessment. The center had one youth who
received a Crisis Assessment during the annual compliance review period. This youth’s mental
health record was requested and reviewed. The reviewed record confirmed the Crisis
Assessment was conducted within twenty-four hours of the crisis identification by a licensed
mental health clinician. The completed Crisis Assessment contained all the required elements
and information to include the reason for the assessment and identified acute emotional or
behavioral problems, the youth’s Mental Status Examination interview, determination of
danger/risk, initial clinical impressions, supervision and treatment recommendations,
recommendations for follow-up or further evaluation, and notification of the parent/guardian. The
required mental health alert was entered into the Department’s Juvenile Justice Information
System (JJIS) at the time the youth was placed on precautions. This youth was not identified as
an alleged victim of a Prison Rape Elimination Act (PREA) event.
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3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures to ensure youth believed to be an imminent danger
to themselves or others due to mental health or substance abuse issues receive emergency
services through Baker or Marchman Act procedures. None of the seven reviewed youth mental
health records were applicable for Baker or Marchman Acts. The center had one Baker Act and
no Marchman Acts during the annual compliance review period. The one youth mental health
record was requested and reviewed. When the youth was identified to be in danger and in need
of emergency mental health services the center immediately began to maintain constant
supervision and entered a suicide alert in the Department’s Juvenile Justice Information System
(JJIS). The center staff initiated a mental health referral. A licensed clinical staff completed an
Assessment of Suicide Risk (ASR) which included a Mental Status Examination. Based on the
ASR the youth was sent to the Crisis Stabilization Unit for Baker Act services; however, the
youth did not return to the center. The youth was taken to a different center after being
discharged.
The designated mental health clinician authority (DMHCA) interview confirmed only one youth
was required to be transferred to the Crisis Stabilization Unit for Baker Act services and no
youth required Marchman Act services during this annual compliance review period.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains facility operating 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 which subcontracts with a licensed physician
(MD) to serve as the center’s DHA. The DHA holds an unrestricted, clear, and active license
which meets all requirements for independent and unsupervised practice in the State of Florida
which expires January 31, 2025. The center utilizes a part-time advanced practice registered
nurse (APRN) whose license expires July 31, 2024. The APRN and the DHA signed the
Collaborative Practice Protocol agreement on February 13 and 16, 2024. The center’s DHA is
contracted to be on-site for at least four hours once a week, with a week defined as the seven-
day period beginning on Sunday and ending on Saturday; however, at no time are more than
nine days to pass between on-site visits. The DHA is on-call twenty-four hours a day, seven
days a week. A review of the center’s healthcare staff sign-in sheets since the last annual
compliance review showed the DHA was consistently on-site for the required four hours, and
frequently more. When the DHA was on vacation or on a scheduled absence, a back-up
licensed MD was designated by VitalCore Health Strategies, LLC to provide clinical services. An
interview with the DHA revealed they are on-site at least once every nine days to provide clinical
services, and are available by telephone twenty-four hours a day, seven days a week. The DHA
is responsible for communication with the center’s staff regarding youth medical needs and is
available for consultation by electronic means twenty-four hours a day, seven days a week for
acute medical concerns, emergency medicine, and coordination of off-site care. The interviewed
DHA reported the specific duty of the DHA is to perform Comprehensive Physical Assessments
(CPAs) and CPA updates, provide consultation and advice to nursing staff with urgent matters,
medication questions, medical condition questions, provide consultation to Department staff
when nursing staff are not available, follow-up on urgent and acute issues with detained youth,
provide oversight to the APRN when needed for questions, review and make recommended
changes to policy, and procedure development. The center has four full-time registered nurses
(RNs) one of whom serves as the center’s clinical nurse manager, and three pro-re-nata (PRN)
RNs, all of whom held unrestricted, clear, and active licenses.
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 facility operating procedures (FOPs) for all health-related procedures and
protocols. Reviewed documentation reflected the designated health authority (DHA) reviewed,
signed, and dated the FOPs, on February 13, 2024, the superintendent signed on March 19,
2024, and the psychiatrist signed on February 27, 2024. Reviewed documentation validated the
advanced practice registered nurse (APRN), clinical nurse manager, and two registered nurses
(RNs) reviewed, and respectively signed and dated the FOP and treatment protocol cover page
in February 2024. The remaining RN and two pro-re-nata RNs signed during the annual
compliance review week. VitalCore Health Strategies, LLC has an established comprehensive
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clinical orientation for all newly employed healthcare staff, which includes the Department’s
healthcare policies and procedures, which is provided 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 facility operating procedures requiring parents/guardians to be afforded
the right to give or withhold consent regarding the healthcare provided to youth. A review of
seven youth Individual Healthcare Records (IHCRs) found each record had a signed, valid
Authority for Evaluation and Treatment (AET). Each AET was obtained prior to providing
medical services for each youth. There were no youth applicable for being under the care and
custody of the Department of Children and Families (DCF) whose parents/guardians had their
rights terminated. An interview with the clinical nurse manager indicated nursing staff obtain a
valid AET upon each youth’s admission into secure detention, which may include enlisting the
assistance of the assigned juvenile probation officer (JPO) in obtaining the parent/guardian
signature. When a youth reaches eighteen years of age, the youth will provide consent at the
point of contact for healthcare.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains facility operating procedures outlining requirements for parental/guardian
notification of significant changes in each youth’s condition and for obtaining written consent
from a parent/guardian when new medications and treatments are prescribed. A review of
seven youth Individual Healthcare Records (IHCRs) showed none were applicable for any over-
the-counter (OTC) medication beyond those covered by the Authority for Evaluation and
Treatment (AET). Three youth records were applicable for taking a psychotropic medication, for
whom staff witnessed all telephone call attempts and conversations with each parent/guardian
regarding psychotropic mediations and whenever a new psychotropic medication was
prescribed or discontinued, or the drug dosage was significantly changed, the parental/guardian
verbal consent for psychotropic medication was documented on page three of the Clinical
Psychotropic Progress Note (CPPN). Two youth records were applicable for having orders for a
new medication and three were applicable for significant changes to existing medications, and
each documented the parental/guardian notification was sent, as required. Seven youth IHCRs
were reviewed for vaccination status, and each contained a vaccination record from Florida
Shots, which was reviewed by medical staff within thirty days of each youth’s admission. The
clinical nurse manager was interviewed and described the center’s process for documenting
attempted parental/guardian notifications.
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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 facility operating procedures requiring each youth, at the time of
admission, to receive a Facility Entry Physical Health Screening utilizing the Department’s
Medical and Mental Health Admission Screening form in the Department’s Juvenile Justice
Information System (JJIS) Admission Wizard. A review of seven youth Individual Healthcare
Records (IHCRs) found each had a Medical and Mental Health Admission Screening form
completed on the date of admission. Each reviewed form was completed on the date of
admission by a juvenile justice detention officer (JJDO), and each indicated the screening was
reviewed by a licensed medical staff within twenty-four hours. Each youth screening form was
completed in JJIS, as required. The center reported there were no youth applicable for a change
in physical custody since the last annual compliance review. An interview with the clinical nurse
manager validated the admission screening practice.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains facility operating procedures requiring all youth to be oriented to the
process of general healthcare delivery services at the center. A review of seven youth Individual
Healthcare Records (IHCRs) showed each youth received a general healthcare orientation on
their day of admission to the center. Each record contained a completed Department Health
Education Record form documenting each youth’s orientation to the center’s healthcare services
within twenty-four hours of admission to the center. Each youth orientation included topics
addressing access to medical care, sick call, instances which constitute an emergency and
when to notify staff, the medication process and side-effect monitoring, the right to refuse care
and how refusals are documented, what to do in the case of a sexual assault or attempted
sexual assault, and the non-disciplinary role of the healthcare providers. Healthcare staff
reviewed each youth’s list of healthcare contacts to ensure accuracy.
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 facility operating 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 seven Individual Healthcare Records (IHCRs) reflected three youth
were applicable for a known or suspected chronic condition upon admission. An interview with
the clinical nurse manager indicated the DHA is notified immediately whenever a youth is
admitted and identified with an emergency or chronic condition. When the DHA is notified by the
nursing staff, it is to be documented in the healthcare record on the Chronological Progress
Note. It is the center’s practice to notify the DHA of all new admissions regardless of medical
condition and the notification is documented in the Chronological Admission Progress Note. All
seven records documented the DHA was notified of each youth’s admission. Three youth
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records were applicable for the youth having been admitted while taking psychotropic
medication and the psychiatrist was notified of each youth’s admission, as well.
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 facility operating procedures requiring completion or review and updating
of the Department’s standard Health-Related History form (HRH). The center utilizes and
completes the standard Department HRH form for all youth admitted into the center’s physical
custody. A review of seven youth Individual Healthcare Records (IHCRs) found four contained a
new HRH form and three youth had been transferred from another detention center where the
HRH was completed. Reviewed documentation indicated each HRH form was reviewed by a
licensed nurse. The applicable HRH forms were completed prior to or at the same time as the
Comprehensive Physical Assessment (CPA) for each youth and reflected the most current
admission. Each applicable HRH form was completed by a licensed nurse within seven days of
the youth’s admission to the center. An interview with the clinical nurse manager confirmed a
HRH is completed within seven calendar days of each youth’s admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains facility operating procedures requiring a Comprehensive Physical
Assessment (CPA) to be completed or updated for all youth admitted to the center to determine
the health and wellbeing of each youth. A review of seven Individual Healthcare Records
(IHCRs) was completed. Three records contained a current CPA on file at the time of admission
due to the three youth having been directly transferred from another secure detention center.
Four of seven records required a new CPA. Each CPA was completed or reviewed within seven
days of the youth’s admission and signed by the designated health authority (DHA) or the
advanced practice registered nurse (APRN). Each CPA was completed in full to include the
Medical Grade, Tanner stage, cardiovascular, body mass index, visual acuity field, and most
recent Tuberculosis (TB) Skin Test (TST). Four records had all sections of the CPA completed
at the center or any section not completed was noted by the APRN as not being clinically
indicated. The Department’s Problem List was updated in each reviewed instance, as required.
The center’s policy and procedures for TB control and screening requires the routine screening
of all youth for latent and active TB and outlines environmental controls in the case of a youth
with suspected active TB. Each of the reviewed records documented a TST was completed
within the last year. None of the reviewed youth required further evaluation prior to entering
general population. An informal interview with the clinical nurse manager indicated the DHA or
designee completes the CPA at the time of admission and yearly thereafter for youth who have
not been out of the Department’s custody. Nursing staff indicated TB screenings are provided to
youth within seventy-two hours of arrival to the center and for female youth, gynecological
examinations are not routinely completed.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
The center maintains facility operating procedures requiring all youth to be evaluated and
treated, if necessary, for sexually transmitted infections (STIs). All sexually active youth are
clinically screened and evaluated for STIs. After the screening, youth are referred to the
designated health authority (DHA) or advanced practice registered nurse (APRN) to determine if
further testing is indicated. A review of seven Individual Healthcare Records (IHCRs) indicated
three youth were clinically screened and evaluated for STIs prior to being transferred to this
center and four youth were screened upon their admission to this center. Three youth records
indicated no further evaluation was required. One youth record included a referral and ordered
testing. STI screenings, evaluations, and referrals are documented and maintained in each
youth’s IHCR. There were no youth applicable for being out of the Department’s custody for
thirty days or more needing a rescreening since the last annual compliance review. All seven
reviewed records validated each youth was offered counseling and testing for human
immunodeficiency virus (HIV); three prior to their transfer to this center, and four upon
admission to the center. The four applicable youth all declined consent for HIV testing. An
informal interview with the clinical nurse manager indicated youth are required to read and sign
a HIV form to indicate whether they consent or not to being tested for HIV. If the youth consents,
they are added to the HIV testing log. The APRN performs the testing and documentation.
Documentation of pre/post-test counseling is recorded on the Individual Health Education
Record. Seven youth were interviewed, and all reported being able to request a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains facility operating procedures regarding the sick call process and requests.
The center conducts sick call seven days a week for a healthcare professional to respond to
youth medical illnesses or injuries of a non-emergent nature. Postings on the medical clinic door
indicated sick call takes place daily at the center from 8:30 a.m. to 10:30 a.m. Shift supervisors
are trained in the center’s sick call procedures and are to review the sick call requests in the
absence of the healthcare professionals. A review of seven Individual Healthcare Records
(IHCRs) indicated none were applicable for submitting a sick call; therefore, three applicable
records were requested for review. There were no instances of a youth presenting with a similar
sick call complaint three or more times within a two-week period. Sick calls were conducted by a
licensed nurse either immediately or within twenty-four hours of the sick call request submission
and documented on the Sick Call Referral Log for each youth. Observations of sick call could
not be conducted as the center had no sick call requests submitted during the week of the
annual compliance review. An informal interview with the clinical nurse manager confirmed sick
call is conducted by a registered nurse within twenty-four hours of the request and documented
on the Sick Call Referral Log; however, it is the center's practice to provide episodic medical
care to each youth as quickly as possible rather than waiting for youth to submit a sick call
request through the electronic system. All sick calls are conducted in the medical clinic to
ensure the youth’s privacy. The center maintains treatment protocols appropriate to the level of
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the provider conducting sick call, which were approved by the designated health authority
(DHA). Seven youth were interviewed and six reported never having requested a sick call. One
interviewed youth indicated they could be seen more than three days after submitting a sick call;
however, a search of the Department’s Juvenile Justice Information System (JJIS) electronic
medical records for the seven interviewed youth indicated none of the youth had submitted a
sick call request at the center. The clinical nurse manager was interviewed and advised youth
notify staff of medical complaints by completing a sick call request. Staff then input each sick
call request in JJIS. Nursing staff pull sick call lists twice a day, and have twenty-four hours to
see each youth, but normally see them sooner. Youth are assessed and vital signs, treatment,
education, and follow-up plans are completed. The nurse advised the DHA will conduct sick call
if it is scheduled when the DHA is on-site. The nurse advised sick call is conducted daily from
8:00 a.m. to 10:30 a.m., or more frequently, if needed, and is conducted in the clinic. Any youth
who present with similar sick call complaints three or more times within a two-week period are
referred to the DHA and added to a list to be seen by the provider. Seven staff were
interviewed, and all indicated nursing staff review sick call requests and conducts sick calls.
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 facility operating procedures detailing a comprehensive process for the
provision of episodic care, first-aid treatment, and emergency care. The center utilizes an
Episodic Care Log to document episodic care and first-aid treatment. A review of seven youth
Individual Healthcare Records (IHCRs) showed three youth were applicable for episodic or
emergency care. The nature of the complaint was documented, and the findings of the
healthcare staff rendering care were included for each youth. One of the three applicable
instances of episodic care indicated no treatment was needed, while two documented the
treatment rendered. None of the reviewed instances of episodic care required referral to off-site
care. Each reviewed instance documented the education/instruction provided to the youth, and
an entry in the Episodic Care Log was completed. None of the three reviewed instances of
episodic care required any follow-up. The center maintains two automated external defibrillators
(AEDs). The center’s AEDs are maintained in wall-mounted AED boxes in the medical clinic and
master control. The AED procedures are stored with the AED, and each AED provides audible
instructions when utilized. Nursing staff check the AED batteries and pads each month to
ensure each AED is operational and the checks are documented. A review of the center’s AED
tracking sheets since the last annual compliance review period documented the center’s
practice. The AEDs were self-tested in front of the annual compliance reviewer to ensure they
were operational. The batteries in the center’s AEDs do not have expiration dates; however,
each AED has an LED indicator which is lit green when the unit is fully functional and able to
rescue. Both observed AEDs displayed green LED indicator lights during the week of the annual
compliance review. The center’s AED pads expire July 28 and November 28, 2025. Reviewed
documentation and an interview with the clinical nursing manager indicated the AED batteries
were last installed on August 19, 2022, and the pads were last changed on October 31, 2023.
AED maintenance was last conducted by an outside medical equipment company on October
31, 2023.
The center maintains a total of fourteen first-aid kits which are located on each of the three living
modules, intake, the teacher’s office, the kitchen, master control, and in the medical clinic.
Seven first-aid kits for use in the transport vehicles are stored within the intake office. The
center’s first-aid kits are sealed with breakaway tabs. When a first-aid kit seal is broken, the kit
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is inspected and restocked. An informal interview with the clinical nurse manager indicated
nursing staff check the kits at least monthly. The sealed first-aid kit from master control was
opened and found to contain all items approved by the DHA, as required. A review of seven pre-
service and seven in-service staff training records found each was trained and held current
certifications in cardiopulmonary resuscitation (CPR), first-aid, and AED. All non-healthcare staff
and nursing staff are required to maintain certifications. A review of emergency drills since the
last annual compliance review supported drills were conducted at least quarterly on each shift
through July 2023, and monthly on each shift thereafter. Mock use of CPR was demonstrated
as part of drills twice or more often on each shift since the last annual compliance review;
however, only one of the total twenty-eight drills conducted since the last annual compliance
review documented an AED was brought/demonstrated as part of a mock drill, as required. In
the reviewer comment section of the drill reporting forms, the clinical nurse manager
documented the lack of AED and noted the need for staff to bring an AED when responding to
codes. Reviewed drill documentation and interviews indicated non-healthcare staff typically
conduct fire, medical, and other drill types consecutively within a thirty-minute period on the
same date. Additionally, drills are conducted nearly exclusively when healthcare staff are not
on-site to observe the drills at the center, thereby eliminating the opportunity for skills evaluation
by the healthcare staff.
Observations confirmed emergency contact telephone numbers were posted out of the view of
youth in the medical clinic. Only licensed healthcare and trained non-healthcare supervisory
staff can administer the epinephrine auto injector for youth requiring administration, when
indicated. A review of seven in-service and seven pre-service training records supported each
staff received the required training on the center’s Emergency Care Plan and the designated
supervisory staff received training on 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. Seven staff were interviewed, and each
indicated they can call 9-1-1 if needed. Prior to the policy revision, Narcan training was
embedded within the Department’s Learning Management System (SkillPro) CPR course. The
center’s licensed clinical nursing manager provided instruction to the supervisors trained and
approved for medication administration on how and when to use Narcan. Seven youth were
interviewed, and one rated the medical care at the center as very good, one rated it as good,
and five reported they had not received medical care at the center.
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 has facility operating procedures to provide for referrals and coordination of medical
services to ensure youth have timely access to off-site care services. A review of seven youth
Individual Healthcare Records (IHCRs) found none of the youth were applicable for off-site care;
therefore, three additional applicable records were selected for review. The center maintained
documentation in all three applicable records of notification made to the designated health
authority (DHA) and each record had a completed Summary of Off-Site Care form and
discharge paperwork for each instance of off-site care. Parental/guardian notification efforts
were also documented. The DHA or advanced practice registered nurse (APRN) reviewed and
initialed the off-site findings, instructions, and information for each instance of off-site care. Two
of the three applicable records indicated follow-up testing, referral, or an appointment was
necessary, and each referral was entered on the center’s referral tracking log. The two youth
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records applicable for required follow-up care documented the youth received appropriate and
timely follow-up care, as needed. An interview with the clinical nursing manager indicated the
center documents follow-up testing, referrals, and appointments in a calendar and sends e-mail
communication to staff. The Summary of Off-Site Care form is utilized if a youth is sent off-site
for follow-up testing, referrals, or additional appointments requested by the provider. A review of
the center’s Off-Site Care Log indicated each youth medical transport was documented.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center maintains facility operating procedures to ensure youth identified with chronic
conditions receive regularly scheduled evaluations and necessary follow-up care. A review of
seven youth Individual Healthcare Records (IHCRs) found three were applicable for the
existence of a chronic condition. The youth were placed on the chronic list; however, the youth
did not remain in secure detention long enough for a periodic evaluation; therefore, three
additional records applicable for chronic conditions were selected for review. All three youth
were found to have been placed on the chronic conditions list; however, two of the youth were
not held in secure detention long enough for a periodic evaluation to take place. The remaining
youth received periodic evaluations as required. There were no youth applicable for taking anti-
tuberculosis medication. The Department’s Problem List was updated for each youth, as
required. An interview with the designated health authority (DHA) and the clinical nurse
manager indicated the center maintains a chronic conditions binder and all youth who have
chronic conditions receive regularly scheduled evaluations every ninety-days which are
documented in Focused Evaluation Progress Notes. There was no indication of lapses in care
or missed periodic evaluations in the reviewed records.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center maintains facility operating procedures requiring all medication and pharmaceutical
products to be 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 each medication has a current, valid order, and are given according to a current
prescription or practitioner’s order. A Medication Receipt, Transfer, and/or Disposition form is
used to document medication received in the original packaging from a licensed pharmacy with
a current, legible, patient-specific label affixed. All medication is delivered to the center in sealed
blister packs. A review of seven Individual Healthcare Records (IHCRs) showed there were
three youth taking medication upon admission. A review of the three applicable records
indicated the designated health authority (DHA) and, when applicable, the psychiatrist were
contacted to obtain an order to resume the specified medication prescribed prior to admission.
Each medication had a current, valid order, and was administered pursuant to the current
prescription. Each reviewed record validated a prescription verification was completed and
documented in the Chronological Progress Notes of the related IHCR. One youth record was
applicable for the youth having been in restricted housing and documentation validated the
youth received all prescribed medications, as ordered and on time. There were no youth
applicable for over-the-counter (OTC) medications not listed on the Authority for Evaluation and
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Office of Accountability and Program Support Page 42 of 58 (Revised July 2023)
Treatment (AET) form. When current medications were continued, discontinued, or changed,
the reviewed records indicated the DHA placed an order on the practitioner order form, as
required. The center utilizes the standard Department Medication Administration Record (MAR)
for each youth receiving either prescription medications on a routine basis or OTC medications.
The center maintains a written policy and procedures to ensure the usage of the MAR by
licensed healthcare staff and non-licensed staff. Seven youth records were reviewed and three
were applicable for having MARs documenting administered medications. There was no youth
record applicable for trained non-healthcare staff assisting in the delivery of medications when
licensed healthcare staff were not on-site. There were no undocumented explanations for
lapses or errors in medication administration. The healthcare staff documented side effect
monitoring at each medication administration on the MAR. A review of the standardized MAR
form showed the form included the youth’s name, Department identification number (DJJID),
date of birth, youth allergies, precautions, Medical Grade, medical alerts, and a current picture
of the youth. Each youth electronically initialed each provided medication entry, without
exception. One youth was applicable for having refused medication and the refusal was clearly
documented on the MAR and the youth signed a Refusal of Treatment form, as required. There
were no applicable records for youth requiring parenteral medication. The center did not have
any standing, pro-re-nata (PRN), or emergency treatment orders for psychotropic medication.
Three records were for youth on psychotropic medication, two of which had been at the center
for more than thirty days. Reviewed progress notes validated the DHA and the psychiatrist were
both notified at the time of all three youth admissions. The psychiatrist conducted an initial
diagnostic psychiatric interview within fourteen days of each youth's admission, as required.
Youth prescribed psychotropic medication upon admission to the center are to be seen at least
every thirty-days by the psychiatrist for medication management. Three youth were applicable
for requiring medication monitoring and two had been at the center for more than thirty days,
while one had been in the center for only sixteen days. Reviewed records indicated both
applicable youth received medication monitoring, as required. Observations of a medication
pass were conducted during the week of the annual compliance review. Medication delivery was
the sole responsibility of the nurse at the time of administration. The youth was escorted to the
medication administration area by a direct care staff. The youth approached the nurse
administering medication individually and the same nurse prepared and administered each
medication. The nurse and youth both electronically initialed the MAR.
An interview with the clinical nursing manager indicated the center has a process for verifying
each youth’s medication regimen once admitted to the center. Additionally, the center has non-
healthcare supervisory staff who are trained by medical staff to provide medication to youth. The
clinical nurse manager last conducted the training of non-healthcare supervisory staff on March
14, 2023. An interview with the clinical nurse manager indicated the center utilizes a chemical
pharmaceutical drug disposal system to dispose of expired medication in the presence of a
consultant pharmacist. An interview with seven staff regarding medication administration was
conducted, and five non-supervisory staff stated they do not give medication to youth, while two
supervisory staff confirmed they have been trained and they are able to provide medication to
youth. Seven youth were interviewed and two indicated the nurse gives them their medication
while five youth indicated they do not take medication.
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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 facility operating procedures regarding the requirements for the storage
and inventory of medications and sharps ensuring all medication is inaccessible to youth at the
center. Observations of the medication cart showed it was clean and organized, with stock items
separate from youth specific medications. An observation of the medication cart found all
medications were stored in the locked cart which is kept in the locked medical clinic. All non-
controlled medications were stored in the secure, locked medication cart. Narcotics and other
controlled medications are securely stored and double locked within the medication cart.
Observations found all medications were securely stored in the medical clinic which is
inaccessible to youth. The center had no medication requiring refrigeration during the week of
the annual compliance review; however, the program has a refrigerator which is used only for
medication, if needed. Perpetual inventories with running balances are maintained on all
controlled substances with a shift-to-shift inventory conducted by the nurses. The program had
one youth prescribed one controlled medication at the time of the annual compliance review,
and the reviewed inventory was accurate. A review of three OTC medications was conducted,
each of which validated the related inventory was accurate. Syringes and sharps are counted
through a perpetual inventory and are verified weekly. Observations of a count were conducted
with nursing staff. A review of three sharps verified all three matched the count on the perpetual
inventory. During an interview, the clinical nurse manager stated controlled medications are
disposed of by nursing staff and the pharmacy consultant. Non-controlled medications are
disposed of by nursing staff. The clinical nurse manager indicated the controlled medications
are stored in a locked compartment in the locked medication cart. The center maintains a
contract with a pharmacist who visits the center monthly to review the medication cart,
medication cabinet, medication refrigerator, sharps, and the Medication Administration Records,
destroy medication, ensure everything is labeled correctly, and ensure licenses are up to date.
An informal interview with the clinical nurse manager revealed the center has an innovative and
best practice inventory process by which all inventory items are labeled with an alpha numeric
code. Weekly counts are conducted and documented in a “double blind” method by
documenting the count on pages separate from the inventory forms. This allows for counts to be
documented without the healthcare staff able to view the count log during the count. This avoids
any preconceived expectation on counts.
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 facility operating procedures requiring proper procedures to be followed to
prevent the spread of infectious diseases or illnesses and provide staff with the knowledge of
appropriate prevention, containment, treatment, and reporting requirements of infectious
diseases. A review of seven youth Individual Healthcare Records (IHCRs) was conducted.
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Reviewed documentation indicated 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 Centers for Disease Control and Prevention (CDC) guidelines for infection
control. A review of the center’s Exposure Control/Infection Control Plan showed the plan was
written in accordance with Occupational Safety and Health Administration (OSHA) guidelines to
include risk assessment and methods of compliance. The plan addressed common childhood
infectious diseases, self-limiting, episodic contagious illnesses, viral and bacterial infectious
diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV), blood-borne
pathogens, other outbreaks and epidemics, and outbreaks of pediculosis. In addition, the plan
addressed Methicillin Resistant Staphylococcus Aureus (MRSA) and other antibiotic-resistant
micro-organisms, food-borne illnesses, bioterrorism agents, chemical exposures in the
workplace, and protocols for needlestick post-exposure intervention and treatment. The center
ensures Hepatitis B immunizations are available for staff and staff have access to protective
equipment as needed. There were no reportable incidents for which the local county health
department, CDC, or the Department’s Central Communications Center (CCC) were notified
relating to an infectious disease since the last annual compliance review. A review of seven pre-
service and seven in-service staff training records confirmed each staff completed Exposure
Control Plan/Infection Control Plan training. An interview with the clinical nursing manager
indicated youth are provided with infection control training upon admission, and nursing staff are
responsible for the provision of staff training on the center’s Exposure Control Plan.
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 maintains facility operating procedures for the care of pregnant youth to include
procedures for medical issues, nutrition, education, and medication. The center had one
pregnant youth admitted since the last annual compliance review. The applicable youth was
provided prenatal care beginning immediately after admission, which continued through
discharge from the center. The youth was in the center for less than thirty days; however, the
advanced practice registered nurse (APRN) provided routine focused medical evaluations of the
youth’s pregnancy sooner than every thirty days. The youth was placed on the center’s internal
alert system for the provision of all nutrition and staff health awareness. Reviewed
documentation indicated it is the designated health authority’s (DHA’s) practice to order weekly
vital signs and weights and additional daily snacks after the twenty-fourth week of pregnancy.
Nursing staff documented the pregnant youth’s weight as part of regular and episodic care
visits, as well as during focused evaluations. Reviewed healthcare education information
showed the applicable pregnant youth completed prenatal education including the topics of
alcohol and drug use, smoking cessation, nutrition, sexually transmitted infections (STIs),
contraception, prenatal care, birthing process, postpartum care, basic baby care, child/infant
development, and parenting skills. All youth education was documented in the youth’s Individual
Healthcare Record (IHCR). A review of seven pre-service and seven in-service staff training
records validated each staff received training specific to working with pregnant youth. Staff
training documentation reflected training was provided by the clinical nurse manager. An
interview with the clinical nurse manager indicated, dependent upon the DHA’s orders, pregnant
youth will be provided with a special diet, obstetrical care scheduled, and monthly monitoring of
the youth by the DHA. The center provides educational topics to pregnant youth including safe
pregnancy, nutrition, prenatal, and postnatal care.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
The center has facility operating procedures to address active supervision of youth. During the
annual compliance review week, youth supervision was observed each day. Youth and staff
observations were conducted on the modules, in the classrooms, in the cafeteria, in the
transportation area preparing for transport, and line movements throughout the facility. There
were always two or more staff with each group of youth. Detention staff maintained continuous
sight supervision of all youth in their assigned area. The interactions between staff and youth
demonstrated active supervision. Staff were positioned in the areas and line movements which
supported active supervision. The juvenile justice detention officers and master control
operators communicate to receive authorization for all movement within the center. The master
control logbooks for the past twelve months were reviewed; there was documentation to support
headcounts were conducted on a consistent basis during the beginning and ending of each shift
and prior to youth movement.
Seven staff were interviewed and all seven responded they think there are enough staff at the
center to provide for the safety and security of all youth and staff.
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.
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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 maintains facility operating procedures requiring a uniform behavior management
system (BMS) which offers a predictable set of rewards, privileges, and consequences for
behavior. The center has a system of rewards, privileges, and consequences to motivate youth
to meet the center’s expectations. Observations conducted during the annual compliance review
week revealed the center has the BMS posted in each living module. The postings specify
appropriate behaviors and rewards for such behavior, and inappropriate behavior and
consequences for such behavior. Youth are informed of the BMS during the admission process
through an orientation. The BMS is a three-tiered level system. Each youth enters at level two
when admitted, and their level moves up or down, depending on their behavior in the center.
There are incentives for youth obtaining level three status, such as later bedtime, extra
telephone calls, extra visitation, participation in special events, and canteen food items. The
incentives can be changed or updated according to the center’s needs. The center has an
incentive calendar outlining the daily incentives for each month. A review of the level sheets and
logbooks confirmed the center’s practice. The center’s BMS prohibits the use of group
punishment, corporal punishment, and use of drugs to control youth behavior. A review of
documentation did not reveal any instances of inappropriate use of restrictions or group
punishment.
Seven youth were interviewed regarding the BMS. Four youth stated the BMS is very good. Two
youth stated the BMS is good. One youth stated the BMS is fair. All seven youth were able to
articulate their understanding of the BMS. Two youth reported the consequences they received
in the center were fair. One youth reported the consequences were not fair. Four youth stated
they have never received a consequence during their time in the center. All youth were able to
articulate how youth are rewarded in the center. All youth confirmed all staff use the rewards the
same way. All youth further indicated losing points or having levels reduced due to inappropriate
behaviors. Each of the youth stated they are not allowed to punish other youth. All youth stated
they have never witnessed a youth placed in mechanical restraints, except for transports. Seven
staff were interviewed regarding the BMS. All staff reported they feel the BMS is effective. All
staff stated they speak to each youth to discuss the consequences imposed and alternative
acceptable behaviors. Each interviewed staff stated youth are provided an opportunity to explain
their behavior. All staff reported points/levels can be taken away because of negative behavior.
All staff were able to articulate the rewards provided for youth as part of the BMS. All staff were
able to explain the centers BMS. Six staff stated they receive feedback daily regarding the BMS.
One staff stated they receive feedback weekly. All staff stated they have never seen a coworker
take meals, snacks, clothing, education, or medical care from a youth because they were acting
out. All staff stated they have never observed any staff encouraging youth to beat up another
youth. The superintendent was interviewed and described the three-tiered level system,
including the process for progressing and earning more privileges.
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5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures addressing ten-minute checks. The center uses an
electronic wand system to document ten-minute checks. A review of the documentation and
video surveillance coverage was conducted for three randomly selected dates from the thirty
days prior to the annual compliance review, across three shifts, and on four different youth living
modules. One check, out of thirty-six reviewed, was conducted late, by twenty-nine minutes.
The other checks were conducted within the policy. In addition, written documentation of checks
was also reviewed for one thirty-minute increment from each shift, each month, for the other
eleven months of the annual compliance review period. These checks were also consistently
documented in periods of ten minutes or less.
Seven staff were interviewed, and six responded room checks are conducted every ten-
minutes when a non-suicidal youth is placed in their room. One staff responded the room
checks are conducted every five-minutes. The superintendent was interviewed and stated
checks are done every ten-minutes or less when a youth is in a room.
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).
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The center has facility operating procedures in place to ensure staff always know the exact
number and location of all youth under their supervision. A review of one full day in the master
control logbooks from each month of the annual compliance review period confirmed census
counts of youth are conducted at the beginning and at the end of each shift. Additionally, counts
are conducted and documented, at a minimum, one additional time randomly on each shift.
Counts were documented following emergencies, disturbances, and drills. Census counts were
documented upon any change of population. Living module counts were recorded in their
assigned module logbooks. An observation of counts being conducted during the annual
compliance review week found master control called for a count at the beginning of shift, staff
on each module called in an accurate visual count, and the count was documented in each
logbook.
Seven staff were interviewed. All seven said emergency counts are conducted when a youth is
believed to be missing. Four staff said emergency counts are conducted when visibility is
hindered, such as during an electrical outage. Two staff said emergency counts are conducted
after a major disturbance. Five staff responded emergency counts are conducted following any
code called (escape, disturbance, medical/mental health emergency). All staff responded counts
are conducted at the beginning and end of shift. Four staff also responded counts are
conducted following school and meals.
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 facility operating 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 staff. A review of three full days of logbooks each month for the last twelve months
revealed each logbook was bound with numbered pages, all entries included the date and time
of the event or incident with the name of the staff and youth involved, a brief description of the
event, and the initials of the staff making the entry. Logbook entries included a.m. or p.m.
following each time entry. All reviewed entries for the last twelve months revealed safety and
security of the facility, including medical, special needs, and mental health alerts were
highlighted. Reviewed logbooks reflected all errors are struck through with a single line and
dated and initialed by the person correcting the error. 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, and name of youth placed on precautionary/secure observation,
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including the time precautionary/secure observation began and the time precautionary/secure
observation was discontinued.
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has facility operating procedures regarding logbooks. Three full days each month in
the master control and living unit logbooks for the past twelve months were reviewed. The
logbook review found a juvenile justice detention officer supervisor reviews 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. The superintendent or designee reviewed the
logbooks on a weekly basis. The juvenile justice detention officer assigned to each module
reviews the logbook upon accepting the shift.
The superintendent’s interview provided an understanding of the role the administrator has
regarding logbooks.
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 facility operating procedures detailing the requirements of the center’s key
control, issuance of keys to staff, inventory and tracking, key restrictions, storage, missing keys,
lost keys, and reporting and replacement of damaged keys. All keys are stored on a tamper
resistant key ring which inhibits the removal of keys and is color coded specific to the position to
which the keys are assigned. The center maintained 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
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whom the keys are assigned and issued. Emergency keys which provide egress through
exterior doors are stored in the foyer near master control which staff can access. A review of the
Key Control Log and observations of the distribution and collection of keys confirmed the
issuance of keys and key rings were documented on the Key Control Log on each shift with the
date and time of issue, name of the staff issuing the key, name of staff receiving the key ring,
and the time each was returned. Key issuance and return were also documented on the daily
shift reports. During the annual compliance review, staff were observed carrying the keys on
their person and youth did not have access to facility keys. The program keys carried by three
staff were examined and were confirmed to have the correct number of keys on the ring, as well
as the correct assigned key ring number documented for the shift. A review of the master key
control inventory confirmed the inventory report matched the actual key rings in use. An
observation of five key rings found each key ring was present on the Key Control Log and had
the correct number of keys. There was one reported incident of missing keys since the last
annual compliance review. Procedures were followed within the scope of the policy. The keys
were located five days later in master control. The superintendent confirmed there was no
incident of a staff taking their keys home with them. Personal keys are stored in master control
in the non-secure area of the center.
An informal interview with master control staff found all restricted keys are kept in a locked
cabinet and only certain staff are authorized to check them out. Seven staff were interviewed,
and all knew restricted keys included keys which access medical records, mental health
records, case management records, and the kitchen. Six staff also said restricted keys include
keys which access the youth property area. All staff interviewed could articulate the daily
process for tracking keys at the center, including the usage of a key control log. During an
interview, the superintendent indicated permanent keys are controlled by a signed receipt.
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures (FOPs) in place for transportation procedures and
operation of Department vehicles. The center has six vehicles utilized for transporting youth,
and each has the appropriate number of seatbelts, a seatbelt cutter, a window punch, a fire
extinguisher, and a first-aid kit with approved items. Use of tobacco products or electronic
vaping devices is prohibited by FOPs. An observation of pre-transport activities was conducted
during the annual compliance review week. The vehicle was searched by staff prior to the
transport. Staff searched the youth prior to placing the youth in the van. Staff assisted the youth
in securing the seatbelt. The transport staff were in possession of the vehicle logbook and a
binder containing the vehicle log, gas credit card, and vehicle registration. Each vehicle logbook
documented all required information. The center’s vehicles are locked when not in use. A
security check was conducted of all vehicles when not in use, and all were locked. Reviewed
documentation found each vehicle is inspected prior to transport. Documentation supports the
maintenance mechanic completed monthly vehicle checks on the mandatory inspection form,
which included all required elements. A review of the vehicle maintenance invoices revealed all
vehicles received an annual inspection within the previous year.
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Seven youth were interviewed, and all stated they feel staff are driving safely when transporting
youth. All youth also stated they have not seen anyone placing 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 facility operating procedures addressing tool inventory and management. All
tools were secured in the locked and secured maintenance workshop which is accessible to the
maintenance staff and administrators. Tools are stored on shadow boards and are marked with
a number to identify them as Department property. The center maintains a perpetual inventory
of tools. All tools are checked out prior to use and checked in after they are returned.
Interviewed maintenance staff indicated inventory is conducted monthly and forwarded to the
superintendent or designee for review. Kitchen tools included knives and scissors which are
stored in a locked box in the kitchen which is also always locked. 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 day. All tools were accounted for, and inventory sheets reviewed. There
were no tools missing or documented as being missing from the center, and there were not any
tools in the center not listed on the inventory. A random sample of ten tools were reviewed, and
each was properly secured and had accurate markings for easy identification. Each inventory
was accurate and signed by the superintendent.
Seven staff were interviewed, and all were able to articulate the practice when tools are missing
or damaged. The superintendent was interviewed and advised only the superintendent,
assistant superintendent, and maintenance mechanic have access to tools.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center has facility operating procedures addressing youth access to, and the use of tools
and cleaning items. Youth only have access to mops, brooms, buckets, and cleaning rags. An
observation of youth performing cleaning detail also supported the policy is implemented, and
youth do not access to any inappropriate tools or cleaning items. The observation further
supported all approved cleaning tools are used under direct supervision of staff.
Seven youth were interviewed, and all said they use mops and brooms. Six youth said they also
use scrub brushes. Six interviewed youth stated they clean with cleaning agents such as
bleach, laundry soap, window, or toilet cleaners; however, five of them indicated staff spray the
chemicals and youth wipe it off. The remaining youth indicated they do not clean with any type
of cleaning agent. Seven staff were interviewed, and all said youth are allowed to use mops and
brooms. Six staff said youth are also allowed to use scrub brushes.
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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 facility operating procedures to address the inventory of flammable, toxic,
caustic, and poisonous items. Flammable, toxic, caustic, and poisonous items are maintained in
secure areas with limited access. Safety Data Sheet (SDS) logbooks are located at each
location chemicals are stored. Inventories of flammable, toxic, caustic, and poisonous items are
maintained by the maintenance mechanic. Five SDSs and inventories were compared to items
on-site and were found to be accurate and complete.
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.
This center has facility operating procedures for toxic materials which prohibit youth access to
flammable, toxic, caustic, or poisonous items. Youth are not permitted to access any materials
which are flammable, toxic, caustic, and/or poisonous. No toxic materials were observed in the
center in any place accessible to youth during four walk-through tours conducted on each day of
the annual compliance review week. The superintendent confirmed all flammable, toxic, caustic,
and poisonous materials are stored in the maintenance department under lock and key and are
only accessible to administrators and maintenance staff.
Seven youth were interviewed, and all said they do not have access to flammable, toxic,
caustic, or poisonous items. Seven staff were interviewed, and all said youth are not allowed to
handle with flammable, toxic, caustic, or poisonous substances.
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5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures addressing proper use, storage, and disposal of
flammable, toxic, caustic, and poisonous items. The plan addresses what procedures to follow
in the event of a chemical leak or spill. Through an informal interview, the maintenance
mechanic confirmed materials are disposed of by evaporation, compaction, or taken to
recycling. The kitchen has a container outside to store grease and this is disposed of through a
local vendor. Biohazardous medical materials are disposed by a contracted vendor monthly.
The superintendent stated there have been no chemical spills or leaks within the annual
compliance review period.
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 maintains facility operating procedures to address requirements for behavioral
confinement of less than twenty-four hours. The center had 1,740 confinements lasting less
than twenty-four hours during the twelve months prior to the annual compliance review week.
Twenty confinements were reviewed. Documentation indicated all youth rights were afforded in
each instance including three meals a day plus school and an evening snack, access to mental
healthcare as needed,
daily shower, clean clothing, bedding, and the notice of each youth’s right to grieve a
confinement. Only one youth was placed in each confinement room, each youth was told why
confinement was necessary, and a supervisor approved each confinement. The center
documents confinements under twenty-four hours in the Facility Management System (FMS)
within the Department’s Juvenile Justice Information System (JJIS). All twenty confinement
reports documented the confinement room was searched prior to each youth being placed, and
each confinement report was completed prior to the end of the staff’s shift. Nineteen youth had
an initial confinement review with a juvenile justice detention officer supervisor (JJDOS) within
one hour. One initial supervisor review was conducted five minutes late. Documentation
indicated all youth were supervised while in confinement with the supervision documented on a
Visual Observation Report (VOR) Log at least every five-minutes for the first hour and every
ten-minutes thereafter. Fourteen of twenty reviewed confinements were applicable for affecting
the youth’s attendance in school, and in each instance school personnel were notified, and
educational materials were provided to each youth. Nineteen of twenty reviewed confinements
documented a review conducted by the supervisor at least every three hours, including the
reason for continued confinement based on severity of rule infraction, past disciplinary history,
or behavior confinement on all reports. One confinement had a supervisor complete a continued
review late by thirty-five minutes. Documentation indicated each youth was continually
counseled and staff considered removing youth from confinement as soon as each youth was
able to safely rejoin the population. All twenty reports were reviewed by the superintendent or
designee within forty-eight hours excluding weekend and holidays. One youth was applicable
for being pregnant while in confinement under twenty-four hours. Documentation included
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contact to an on-call practitioner, whether they objected to the placement and a plan of care.
Documentation found services were provided as required.
Seven staff were interviewed, and all stated when a youth is placed in confinement, staff must
search the confinement room prior to placing the youth, staff must conduct and
document ten-minute room checks while youth remain in confinement, and a confinement report
must be completed when a youth is placed in confinement. All staff said youth in confinement
are provided educational materials during school hours. The superintendent was interviewed
and advised a supervisor or higher must approve all confinements. Staff conduct five-minute
checks during the first hour of confinement. Supervisors will conduct a review one hour after
youth is placed in confinement then within three hours after initial counseling and attempt to
have the youth returned to programing. The superintendent or designee shall review all
confinement reports within forty-eight hours, excluding weekends and holidays, and shall
determine whether each confinement was appropriate or inappropriate. The superintendent was
also asked how often regional detention management reviews the use of confinement,
lockdown, and restraints, and advised regional detention management staff are alerted by email
for all confinements once they occur. No lockdowns or restraints have been utilized during this
annual compliance review period. In the event a lockdown or restraints were needed, regional
detention staff would be notified immediately.
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures to manage various emergencies and disaster
events. Three Continuity of Operations Plan (COOP) drills were conducted within the prior year.
Hurricane drills were conducted in May 2023, August 2023, and January 2024. One of the drills
was conducted in May, just prior to the beginning of hurricane season. There were written
scenarios, drill forms, critique forms, and emails used to document the drills. Each drill form
included all required elements.
Seven staff were interviewed; one staff responded they have participated in a major disturbance
drill. Four staff responded they have participated in an escape drill and in a fire drill. One staff
said they have participated in a flooding drill. Two staff said they have participated in a weather
drill. One staff said they have participated in a bomb threat drill. One staff said they have
participated in a hostage situation drill. One staff said they have participated in a chemical spill
drill. One staff said they have participated in a terrorism drill. The superintendent was
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interviewed and described the comprehensive safety/emergency program as consisting of
COOP drills, fire drills, escape drills, medical drills, and suicide prevention drills.
5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures (FOPs) to address escape drills and escape
prevention. The FOP requires the center to conduct quarterly escape drills. Escape drill
documentation for the past twelve months was reviewed. The center completed quarterly
escape drills throughout the annual compliance review period. A total of fifteen escape drills
were conducted during the annual compliance review period, with at least one on each shift,
which exceeded the requirement of at least one drill each quarter. The documentation of the
drills included scenarios, as well as the dates and times of the drills. The drill documentation
form included the signatures of the supervisors and the staff coordinating the drill. Drills are
reviewed with staff at the shift briefings. Recommendations and critiques of the drills were
included in each report. A review of the logbooks revealed all escape drills were documented in
the logbook as required.
Seven staff were interviewed and six staff responded they have participated in an escape drill.
Training records of seven staff were reviewed and all seven staff had received escape
prevention training during the previous year.
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 fire prevention and evacuation plan which addresses fire prevention and
safety of the program. The plan was reviewed and approved by the local fire official. A review of
documentation supported the center conducted fire drills every month, on each shift, for the
prior twelve months, with the exception of two drills which were not completed in July 2023, on
the first and second shifts. Each fire drill was documented in the master control logbooks. Staff
sign-in sheets were used to document staff participation in the drills. A review of documentation
found all fire extinguishers were inspected annually.
Seven staff were interviewed and four responded they have participated in fire drills in the prior
twelve months. All seven staff said fire drills take place at least monthly. Seven youth were
interviewed, and all said they have been instructed what to do in the case of a fire. Training
records of seven staff were reviewed and all seven staff had received fire prevention training
during the previous year.
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5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures addressing illegal contraband and prohibited items.
Upon admission to the detention center, youth are searched by detention staff. During the
annual compliance review week, a search was observed, and the staff thoroughly searched the
youth with gloves on and reported the search to master control. Since the last annual
compliance review, there were no strip searches conducted by the center outside of the initial
strip search at admission. Electronic searches were conducted on all persons entering the
center. All bags, cases, jacket pockets, and other items were searched. All personal keys were
collected by master control before entering the secure floor. Personal cellular telephones and
other contraband items were prohibited. Room searches are completed upon releasing a youth
and prior to placing a new youth in a room. Room searches were also conducted on each shift
where youth are awake. A review of room searches was conducted for one day each month
during the annual compliance review period and confirmed both shifts where youth are awake
completed and documented room searches. Since the last annual compliance review there
were five instances which compromised the safety or security of the center. A review confirmed
all instances were reported to the on-duty supervisor and to the Department’s Central
Communications Center (CCC) in a timely manner. A review of the master control logbook
confirmed the center was documenting confiscation of contraband. A review of incident reports
confirmed staff were completing incident reports when contraband was discovered in the center.
Law enforcement was notified when necessary. Confiscated items were secured by either the
on-duty supervisor or administration, and then turned over to law enforcement. Chain of custody
was documented on incident reports by the shift supervisor. The CCC was notified for all
incidents involving contraband in the center. The regional director or designee was notified
regarding contraband in the center. The superintendent was interviewed and advised youth
searches, including frisk searches, are conducted by searching on top of clothing and shall be
conducted by staff of the same gender as the youth being searched. Electronic searches utilize
the handheld-wand device to locate metal objects. Strip searches consist of a visual of a youth
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without clothing. These searches shall be conducted during admission or if there is a
reasonable suspicion a youth is harboring contraband. If a strip search is conducted at any time
other than at admission, an incident report must be completed. Contraband will immediately be
confiscated and turned over to the shift supervisor. Supervisors or above will report incidents to
the CCC upon gaining knowledge of any introduction of contraband into the facility. Law
enforcement will be notified. If it was a youth was in possession of the contraband,
parent/guardian will be notified.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 58 (Revised July 2023)

source: DJJ

report_type: QI Detention

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance