state: FL

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
Pinellas Regional Juvenile Detention Center
(State-Operated)
5255 140th Avenue North
Clearwater, Florida 33760
Review Date(s): January 23-26, 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:
Marvin D. Bliss, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Paul Britten, Orange Detention Center, Superintendent (Standard 2)
Kara Brown, Office of Accountability and Program Support, Central Region Deputy
Supervisor (Interviews)
Evan Hald, Office of Education, Southwest Region Education Coordinator (Standard 2)
Luis Quinones, Lee Regional Juvenile Detention Center, Assistant Superintendent
(Standard 5)
Alexis Sapp, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Alissa Spearman, Collier Juvenile Detention Center, Juvenile Justice Detention Officer
Supervisor (Standard 5)
Bonita Williams, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Program Name: Pinellas Regional Juvenile Detention Center MQI Program Code: 364
Provider Name: Department of Juvenile Justice Contract Number: NA
Location: Pinellas County / Circuit 6 Number of Beds: 96
Review Date(s): January 23-26, 2024 Lead Reviewer Code: 173
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
5.03 Ten-Minute Checks*
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 56 (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 56 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 56 (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 56 (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 56 (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* Limited
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 56 (Revised July 2023)
Program Overview
Pinellas Regional Juvenile Detention Center is a state-owned detention facility, operated by the
Department, located in Clearwater, Florida. The center serves youth in Pinellas County in Circuit
6. Male and female youth who are detained pending adjudication, disposition, or placement in a
residential commitment program are housed in the ninety-six-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 Pinellas County School Board. The center’s management team
includes the superintendent, two assistant superintendents, one administrative assistant, and
nine juvenile justice detention officer (JJDO) supervisors. Mental health and healthcare services
are provided through the contracted provider, Vital Core Health Strategies. Mental health
services are provided by ten staff; one designated mental health clinician authority (DMHCA),
one back-up DMHCA, one full-time licensed mental health staff, five pro re nata (PRN) licensed
mental health staff, one travel licensed mental health staff and one non-licensed mental health
staff. Clinical services provided by the center include mental health and substance abuse
evaluations, mental health treatment planning, individual, group, and family therapy, mental
health crisis intervention services, on-site psychiatric services, and availability for substance
abuse services for youth with co-occurring disorders. Medical services are provided by two
designated health authority (DHA) positions (one serves as a back-up), one advanced practice
registered nurse (APRN), two registered nurse (RN), one licensed practical nurse (LPN) and
one medical records clerk. The medical clinic maintains nursing coverage seven days a week,
from 7:00 a.m. to 3:00 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 five living modules which are
divided by male and female. Four modules are currently in use, a fifth is vacant and under-going
renovations. The center has a total of 120 cameras, of which all were operational. The center
was clean and free from safety or security issues. At the time of the annual compliance review,
the center had nineteen vacancies, which included ten JJDO I positions, five JJDO II positions,
three JJDO supervisor positions, and one food service worker.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 56 (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.
A total of twenty-five staff and five contracted staff were reviewed for initial background
screening requirements. Reviewed personnel records for the thirty staff indicated each staff had
a completed background screening and documented criminal history report review prior to their
hire date in the Department’s Background Screening Unit (BSU). No exemptions were required.
Each staff was rated as eligible for hire. Twenty-five of the thirty total staff were applicable for
the pre-employment assessment tool. Two of the thirty staff were contracted staff hired as
nursing staff and three were hired as mental health staff and were not applicable for taking this
assessment. All twenty-five applicable staff had evidence of the passing assessment score in
their personnel records. The center administration reported having had no volunteers and one
intern eligible for screening during the annual compliance review period. The intern was one of
the five contracted staff who received the background screening and criminal history check prior
to their start date. The center submitted their Annual Affidavit of Compliance with Level 2
Screening Standards January 27, 2023. The school board submitted their annual Affidavit of
Compliance with Level 2 Screening Standards also on January 28, 2023.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center had a total of one staff applicable for five-year rescreening requirements. The one
staff personnel record was reviewed and had a completed rescreening. The re-screening was
completed within the twelve month requirement.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 56 (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.
Seven staff were reviewed for violations of the staff code of conduct. Three were found to be
applicable. Each staff personnel record was reviewed and found evidence management had
taken action with each staff for allegations and/or findings in direct violation of the center’s code
of conduct. All three staff had evidence in their records of signing the code of conduct form. All
three staff had violations of the code of conduct resulting in all three receiving written
reprimands. Four different staff were also reviewed for receiving commendations and/or awards
during the annual compliance review period. Three received the Pinellas Proud award and one
received the Department of Juvenile Justice food service staff of the year 2023 award. The
center’s superintendent was interviewed and stated the code of conduct is to treat and interact
with youth in a respectful manner which promotes socially accepted behaviors to reflect desired
behaviors for the youth. Seven staff were interviewed, and all stated youth are allowed to make
a call to the Florida Abuse Hotline or the Department’s Central Communications Center (CCC).
Six stated they allow the youth to make the call, four stated they notify the supervisor, three
stated staff can make the call, and one stated they notify the superintendent. When asked if
they have heard a staff use profanity when speaking with youth, four staff stated never, one
stated once, and two stated occasionally. When asked to clarify, the staff stated they never
heard staff use profanity directly at the youth, rather profanity was used around the youth. When
asked if they have heard staff use threats or intimidation when interacting with youth, all seven
staff stated never. Seven staff were asked about working conditions at the center in the past
year, and one stated they were fair, two stated the conditions were good, and four stated they
were very good. Seven youth were interviewed and all seven stated they have never had to
report abuse while at the center. All seven youth stated staff are respectful when speaking with
them and other youth. Four of the seven youth stated they have never heard staff use profanity,
two of the seven youth stated staff occasionally use profanity and one youth stated they heard
staff use profanity once. All seven youth denied staff have ever threatened them or other youth.
All seven stated they felt safe at the center. None of the seven youth reported having
exchanged social media information or telephone contact information with staff at the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 56 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center had a total of 111 incidents reported to the Department’s Central Communications
Center (CCC) for the annual compliance review period, ten of which were reviewed. All ten
reports were documented as reported to the CCC within the two-hour required time frame. All
ten reports were documented in the center’s master control logbook. The center’s
superintendent was interviewed and stated when a reportable incident occurs, they must be
called into the CCC within two hours. All proper notifications through the chain of command
must be made as well. A review of internal incidents and grievances found no additional
incidents which should have been reported to the CCC.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
Nine Protective Action Response (PAR) incidents were reviewed for reporting and documenting
requirements. All nine reports included statements from each staff involved. All nine of the
incidents had evidence the reports were completed by the end of the staff’s workday or shift.
None of the incidents had evidence there were injuries to either the youth or staff involved.
None of the youth required a medical review. None of the incidents involved mechanical
restraints. None of the reports had evidence the youth made allegations to the Florida Abuse
Hotline. All nine reports were reviewed by a supervisor or PAR certified supervisor. All nine
incidents had documentation the post-PAR interview was conducted within the thirty-minute
time frame from the time of the incident. All nine PAR incidents had evidence the
superintendent/designee reviewed the report within seventy-two hours from the date/time of the
incident. The center’s PAR rate during the annual compliance review period was 25.43, which is
above the statewide detention PAR rate of 16.29. The superintendent was interviewed and
stated the physical and mechanical uses are kept in a log maintained by the intake and release
department. Intake and release are responsible for the racking and inventory of handcuffs and
shackles. All PAR incidents generate an email notification. Administrators review all PAR
incidents and are required to sign off on the report in the Department’s Juvenile Justice
Information System (JJIS). An informal interview with the superintendent indicated the center
has not used mechanical restraints in a PAR. Seven interviewed staff stated staff try to speak
with youth prior to using physical restraints or mechanical restraints.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 56 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
Seven staff training records were reviewed for pre-service training requirements. Five staff
reviewed were juvenile justice detention officers (JJDOs) and two were JJDO supervisors. All
seven staff received pre-service training within 180 days of hire. All seven staff were certified in
Right Interactions (RI), formally known as Protective Action Response (PAR). All seven staff
were certified to use cardio-pulmonary resuscitation (CPR), first-aid, and the automated external
defibrillator (AED). Based on the Statewide Detention Center’s Annual Training Plan, each staff
received all the required trainings for their respective positions. Six of the seven staff completed
Phase Two training at the Department’s Academy, which consisted of 120 hours of training for
each staff. One staff was a transfer and completed the required trainings. All trainings were
documented within 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.
Seven staff training records were reviewed for in-service training requirements. Three of the
reviewed staff were juvenile justice detention officers (JJDOs), three of the staff were JJDO
supervisors, and one was an administrative staff. All seven staff exceeded the required number
of hours for in-service training and completed between sixty-two and seventy-six hours. All
seven staff received training in Right Interactions (RI), formally known as Protective Action
Response (PAR), as well as cardio-pulmonary resuscitation (CPR), first-aid, and automated
external defibrillator (AED) training. All seven staff received the required hours for suicide
prevention annual training. All seven staff had active shooter and human trafficking training. The
administrative and supervisory staff received an additional ten to thirteen hours of supervisory
specific training. All trainings were documented in the Department’s Learning Management
System (SkillPro). The superintendent was interviewed and stated staff are required to complete
mental health training, medical training, SkillPro training, CPR, AED and first-aid training, PAR,
civil rights, escape, and knife for life training. Staff are also provided recognizing medical and
substance abuse emergencies, developmental disabilities, and facility operating procedures.
The in-service training was approved by the Department’s regional director on December 15,
2023.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 56 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
A review of grievances for the annual compliance review period found a total of one completed
by youth. The grievance was completed by the youth on October 18, 2023, alleging complaints
on a named staff member. The grievance had documentation of a response and was resolved
within the specified time frame. In addition, a report was made to the Florida Abuse Hotline and
the Department’s Central Communications Center (CCC), resulting in an investigation which
resulted with the staff being terminated for breaching the center’s code of conduct. Grievances
were observed to be electronically entered into the Facility Management System (FMS) within
the Department’s Juvenile Justice Information System (JJIS). Hard copies of grievances were
also provided. Seven interviewed staff all summarized the grievance process. Seven youth were
interviewed concerning the center’s grievance process, and six of seven reported they have
never filed a grievance. The remaining one youth reported the grievance process was good.
Five of the seven youth summarized the grievance process. Two youth were unsure of the
process. The center’s superintendent was interviewed regarding the grievance process and
stated the youth have the right to grieve to ensure fair and equitable treatment from detention
staff. The process is three phases. Phase one, which is the informal phase, is between the staff
and youth, two is the formal phase between the youth and supervisor and the third phase is
submitted to administrators with findings and actions. Completed grievances will be reviewed
within seventy-two hours and uploaded into JJIS in the grievance file. Youth will be given a
signed hard copy for their records.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 56 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
Seven youth were selected for a review of alerts entered by the center. A total of seventeen
alerts were entered for the seven youth selected. All seventeen alerts had evidence the alert
was entered and/or closed on the date required. The center’s superintendent was interviewed
regarding entering alerts and sharing of alert information from the Department’s Juvenile Justice
Information Center (JJIS), and stated alerts are shared at shift briefings and a copy is given to
the lead staff. In addition, the superintendent stated the alerts are documented in the logbook.
Medical and mental health staff review alerts to ensure proper tracking. Food alerts are in the
kitchen for food allergies. Shift briefing minutes were reviewed and confirmed identification of
youth with alerts, with no issues noted. Seven staff were interviewed regarding alerts, and five
reported they are informed of youth alerts through alert forms and shift briefings; and two stated
they are informed by email or verbally. Four interviewed staff stated they are informed by
management about center-related issues through meetings. When asked about how effective
they believe this process is for communicating information to staff, four reported it was very
good and three rated it as good.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
An informal interview was completed with the superintendent at the center regarding the
center’s data trend analysis. The center utilizes information gathered from various reports found
in the Department’s Juvenile Justice Information System (JJIS) and information is discussed
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 56 (Revised July 2023)
during the superintendent’s monthly meetings, education meeting, mental health and medical
meeting, safety meeting, youth focus group and treatment team. The center’s management
team reviews the reports and any trends noticed are discussed during these management
meetings. Monthly meetings are held with administration and center staff during which an
agenda with specific topics is discussed, then the meeting is opened for staff to discuss any
issues, ask questions, and bring up any new topics. Documentation of meeting agendas of the
monthly meetings were provided for the annual compliance review period and found data trend
analysis topics discussed. The superintendent provided documentation of the data reviewed
which included Protective Action Response/Right Interactions model (PAR/RI) and confinement
data and trends, Behavior Management reports, and all staff reports.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 56 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures (FOPs) in place to ensure proper screening,
evaluation, and documentation of each youth, ensuring all youth are admitted into the center in
accordance with Florida Administrative Code. A review of seven Admission Wizard forms from
the Department’s Juvenile Justice Information System (JJIS) found documentation of a
Detention Risk Assessment Instrument (DRAI), Suicide Risk Screening Instrument (SRSI), and
an arrest affidavit or order to retain the youth in custody. Reviewed documentation, found in the
youth’s case management record, confirmed all seven youth had a full body visual search
and/or electronic search. Each youth record documented all youth received a telephone call and
were evaluated for medical, mental health, and substance abuse needs upon admission. An
observation of a youth admission process was completed during the annual compliance review
week which followed all required procedures.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 56 (Revised July 2023)
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures (FOPs) to ensure each youth admitted into the
center is informed of the center rules and regulations, grievance procedures, visitation,
telephone calls, expectations for behavior, related consequences for failing to meet behavior
expectations, and youth rights within twenty-four hours of admission. Seven youth case
management records were reviewed, and each included an orientation packet which was
completed within twenty-four hours of admission. All seven reviewed records had
documentation to validate the orientation was explained verbally and in writing by the juvenile
justice detention officer (JJDO). Each of the seven orientation packets included information on
rules and regulations, youth rights, dress code, personal hygiene, visitation, telephone calls,
education, daily schedule, mental health, grievance procedures, access to medical, mental
health, and substance abuse services, access to the Florida Abuse Hotline, access to the
Department’s Central Communications Center (CCC), the behavior expectations, the behavior-
related consequences, and prison rape elimination act (PREA) related information. Each of the
seven reviewed case management records had an orientation acknowledgement form signed by
the youth. Seven youth were interviewed regarding the orientation process and each youth
indicated they were provided information regarding the center’s rules and regulations, daily
schedule, education services, visitation, abuse reporting, and behavior management system. An
admission and orientation were observed during the week of the annual compliance review and
confirmed orientation was conducted as required. The seven interviewed youth reported center
staff explained rules and regulations, daily schedule, education services, visitation, abuse
reporting, and the behavior management system during the intake and orientation process.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 56 (Revised July 2023)
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) ensuring all youth admitted into the center
are classified to ensure the highest level of safety and security. The center’s policy listed all the
required elements, including human trafficking information. All youth are given a room
assignment based upon their classification and may be reclassified if there are any changes in
their status or behavior. The center reviews several factors prior to placing the youth into a room
inclusive of height, weight, age, gender, level of aggression, mental illness, developmental
disabilities, physical disabilities, history of violence, gang affiliation, criminal history, history of
sexual offenses, vulnerability to victimization, suicide risk identified or suspected, medical, and
security and escape risk. Youth with a history of committing sexual offenses, a victim of a sexual
offense and/or abuse, or youth determined to be physically or sexually aggressive are not to be
placed in a room with any other youth. Additionally, the policy requires a review of the
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) results documented by
the staff when making a youth’s room assignment. All room assignments are documented in the
Department’s Juvenile Justice Information System (JJIS). All youth requiring a single room shall
have an alert entered in JJIS. Seven youth case management records were reviewed for
classification. Each reviewed record contained a copy of the JJIS Admission Wizard
documentation, which included the classification results and the screening for VSAB. Each
reviewed youth case management record contained the VSAB form and the Suicide Risk
Screening Instrument (SRSI). Seven reviewed youth records contained a classification form
which identified the module or room classification of where the youth was placed. No youth
required a reclassification. An interview with the superintendent confirmed all youth are
screened and assigned to rooms according to age, size, VSAB results, and other possible
alerts. Any youth above eighteen years of age are housed in a single room. All other youth are
housed with youth who are within two years of their age; however, the size or additional factors
can take precedence as to how the youth are assigned to rooms.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 19 of 56 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures (FOPs) in place to ensure all information regarding
youth with suspected gang affiliation is shared with the circuit gang representative. The center
has designated one juvenile justice detention officer (JJDO) to serve as the gang representative
for the center. This JJDO communicates with the center’s superintendent who then corresponds
with the chief probation officer (CPO) regarding all suspected gang activity. The center is
required to enter the suspected gang affiliation alert into the Department’s Juvenile Justice
Information System (JJIS) if there is a youth suspected to have gang affiliation. Staff are notified
of all updates and alerts during shift briefings and on the daily alert sheet. An informal interview
with the superintendent confirmed the center’s practice. Seven youth case management records
were reviewed in which one record was applicable for gang affiliation. There was no additional
youth record applicable. The applicable youth record confirmed an alert has been entered into
JJIS. The informal interview with the center’s gang liaison revealed there has been no
suspected gang activity at the center during the annual compliance review period to warrant
communication with the circuit gang representative.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures (FOPs) in place ensuring the proper safe handling
and security of personal property, including valuables, which are collected and secured at the
time of a youth’s admission. All youth personal and valuable property are inventoried in the
Department’s Juvenile Justice Information System (JJIS), maintained securely, and returned to
the youth or the parent/guardian in a timely manner upon the youth’s release. Personal items,
such as clothing and shoes, are placed in a mesh bag and secured in the center’s inventory
locker room. Valuable items are listed and placed in a clear tamper-proof property bag,
identified with the youth’s name and Department identification number (DJJID), then secured in
the property cabinet located in the administrative office which is under video surveillance. The
center maintains a drop safe logbook to document the time, youth’s name, name of the juvenile
justice detention officer (JJDO) securing the property, and the JJDOs initials. Seven youth case
management records were reviewed, and each contained documentation of a letter of
acknowledgement of unclaimed property signed by the youth and staff. Each record contained a
property receipt form documenting the assigned locker for personal items. An observation of all
seven reviewed youth’s personal property bags was conducted and each contained an
inventory form. Two reviewed records contained a Property Receipt form for valuable items. The
remaining five youth did enter the center with valuable items; therefore, were not applicable.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 20 of 56 (Revised July 2023)
One admission was observed during the annual compliance review week and property was
inventoried and stored as required. The drop safe bound logbook contained all required
elements for both the applicable reviewed youth records and the admission observed. The two
applicable youth with valuable items had their items stored in a clear tamper-proof bag and
securely stored in the administration office. A review of the Department’s Central
Communications Center (CCC) reports since the last annual compliance review found no
incidents regarding youth property. All seven interviewed youth stated staff check the youth’s
property inventory and each youth signed the inventory verifying it is correct. The
superintendent interview confirmed the center’s property storage practice.
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 (FOPs) in place to ensure all releases from the
center occur promptly and accurately. Five closed youth case management records were
reviewed. The on-duty juvenile justice detention officer supervisor (JJDOS) verified each youth’s
release by reviewing the court order and signing the secure detention release form. Each of the
closed youth records reviewed had the appropriate documentation including a copy of photo
identification of the person taking custody, youth and parent/guardian notifications to any future
court dates, and all parties signed all required release forms. None of the released youth had an
alert reflecting an endangered person. The release date in the Department’s Juvenile Justice
Information System (JJIS) corresponded with the youth’s correct release date in each reviewed
record. A youth release was observed during the annual compliance review week with all
procedures being adhered to.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 21 of 56 (Revised July 2023)
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures (FOPs) in place to ensure all youth personal
property is released to the youth or the youth’s parent/guardian. The parent/guardian, youth,
and staff must sign a receipt acknowledging all property was returned upon the youth’s release.
A review of five closed youth case management records revealed each contained the required
information with all required signatures of receipt of youth’s personal property. Each record
contained identification documentation verifying the youth was released to an appropriate
person. None of the five closed case management records were applicable for the youth nor the
person the youth was being released to, for being reminded of any health or welfare issues,
including medical, mental health, and/or substance abuse needs, and any pending
appointments. The center did not have any inventory of unclaimed property held more than
thirty days during the annual compliance review period. An interview with the superintendent
confirmed if there is unclaimed inventory, a notice of impending disposal of property is sent to
the youth’s last known address for the property to be claimed. Unclaimed property would be
counted/inventoried and a record kept of any disposed property or unclaimed money, which
would be sent to the regional fiscal manager by money order. An observation of a youth release
was conducted during the annual compliance review week and confirmed the center’s practice.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures (FOPs) ensuring detention reviews are
conducted weekly for youth securely detained, placed on home detention, or placed on
electronic monitoring to ensure proper management of youth and the sharing of information.
Detention reviews are conducted on a weekly basis to address the status of each youth. The
center has a designated staff appointed to coordinate the weekly detention reviews. An informal
interview with a juvenile justice detention officer II (JJDOII) confirmed updates are provided
regarding the youth’s next court date, behavior while in detention, residential placement status,
and release status. Reviewed documentation since the last annual compliance review found the
reviews were conducted with the center’s staff including medical, education, mental health,
commitment, and representatives from probation. All staff attending in-person signed the sign-in
sheets. Attendees from outside the center participated virtually utilizing video conferencing. An
interview with the superintendent confirmed detention reviews are conducted weekly by video
call, sharing each youth’s status updates, and attended by all required participants.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 22 of 56 (Revised July 2023)
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures (FOPs) addressing the daily activity schedule. The
center’s daily activity schedule includes daily expectations in accordance with the behavior
management system (BMS), education, mealtimes, visitation, indoor and outdoor recreation,
shift changes, bedtimes, groups, and open program time. The center’s schedule was missing
wake-up and personal hygiene. The center provides and maintains weekday, weekend, and
holiday schedules. Observations during the annual compliance review week revealed schedules
are posted throughout the center along with a monthly activity calendar. Visitations are held
twice a week for youth. During the morning and early afternoon hours, youth are participating in
education. Reviewed documentation reflected activities included behavior management
incentive parties, and a variety of recreational activities. A review of the center’s logbook and
observations confirmed the center adheres to the daily activity schedule. Youth hygiene and
wake up was not consistently documented. Seven youth were interviewed, and each youth
indicated the center has a daily schedule which is followed. Nine staff were interviewed, and all
reported the daily schedule is followed unless circumstances do not permit.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures (FOPs) for education access. Interviews, logbooks,
and reviews of video footage confirmed five-hour daily instructional periods, reliable school
schedules with no cancellations, and 250 days of instruction per year, including ten dedicated
teacher training days. Minimal disruptions were documented, with classes running on time and
youth arriving and departing promptly. Interviews with seven staff and seven youth further
confirmed this, with all individuals interviewed verifying adherence to the daily schedule and
minimal interference with learning. The superintendent's interview results also verified minimal
school disruptions, painting a picture of a consistent and reliable school environment for youth.
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 (FOPs) to provide career education. An interview
with the lead teacher revealed the center provides Type 1 career education development
integrated into the education curriculum. This includes career learning strategies such as
interviewing skills and techniques, career interests, resume writing, and completing employment
applications. Seven youth were interviewed and asked how well they think the program is
preparing them for high school equivalency diploma (GED), high school, vocational school,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 23 of 56 (Revised July 2023)
employment, and/or college; five responded very well, one responded well, and one responded
not well, because as they don’t teach everything.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 24 of 56 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a contract with VitalCore Health Strategies to provide mental health services at
the center. The center has a contracted designated mental health clinician authority (DMHCA)
who coordinates services at the center and provides coverage at the center for forty hours each
week. The DMHCA is a licensed mental health counselor (LMHC) and has an active license
through the State of Florida, which expires on March 31, 2025. The center has a back-up
DMHCA whose license expires on March 31, 2025. The DMHCA provides oversight and
coordination of mental health services, including the completion of Assessments of Suicide Risk
(ASRs), supportive services, and individual therapy. The DMHCA also provides supervision of
non-licensed staff. During an interview, the DMHCA confirmed being on-site forty hours a week
and being on call twenty-four hours a day, seven days a week. In addition, the DMCHA
confirmed they oversee mental health and substance abuse services at the center.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has a contract with VitalCore Health Strategies to provide licensed healthcare staff
who provide mental health and substance abuse services at the center. The center currently
has four licensed mental health counselors (LMHCs) and two licensed clinical social workers
(LCSW) working under the direction of the designated mental health clinician authority
(DMHCA), who is also a LMHC. Both LMHCs and the LCSW have clear and active licenses in
the State of Florida with expiration dates of March 31, 2025. Since the last annual compliance
review (ACR), the site had six LMHC and one LCSW provide services.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has facility operating procedures (FOPs) in place on services provided by non-
licensed mental health and substance abuse clinical staff. The center has one non-licensed staff
who provides mental health services under the supervision of the designated mental health
clinician authority (DMHCA), who is a licensed clinician. The one non-licensed staff is a
master’s-level clinician. The licensed mental health clinicians provide substance abuse services;
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 25 of 56 (Revised July 2023)
therefore, a Chapter 397 is not required. A review of Clinical Supervision Logs verified the staff
received weekly supervision for at least one hour each week when providing services during the
past year. The non-licensed mental health and substance abuse clinician received twenty hours
of Assessment of Suicide Risk training. The weekly supervision was documented on the
required form. The one non-licensed staff did not provide substance abuse services at the
center.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures (FOPs) regarding the assessment of youth for
mental health and substance abuse needs upon admission. Seven youth mental health records
were reviewed, and each youth was screened using the Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2) and the Suicide Risk Screening Instrument (SRSI). All
assessments were completed by trained staff, reviewed by detention staff on the date of intake,
and entered into the Department’s Juvenile Justice Information System (JJIS). None of the
SRSIs or MAYSI-2s were invalid due to negative responses. Documentation found in each
youth record confirmed mental health clinicians reviewed all admission documents. In each
youth record, the SRSI included complete entries in all required sections, when applicable. Four
of the youth had positive responses on the SRSI and each was placed on suicide precaution. All
four were referred for and received a follow-up assessment through administration of an
Assessment of Suicide Risk (ASR) by a licensed clinical staff, as required. Alerts were entered
in JJIS for each youth placed on suicide precaution. Upon the completion of each referral, the
superintendent was notified. Two of the seven youth had an indication of elevated suicide risk
upon completion of the MAYSI-2, and both were referred for an ASR, as required. Each of the
four youth were noted on the MAYSI-2 as needing follow-up assessment for mental health and
substance abuse needs, each youth was referred for a comprehensive evaluation, and the
center and mental health staff were notified for all.
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 (FOPs) regarding mental health and substance
abuse evaluations. None of the seven selected youth were applicable; therefore, the center
provided three additional youth mental health records for review. Each of the three applicable
youth were identified as in need of a referral for a mental health and substance abuse
evaluation. Each youth received a new Comprehensive Evaluation within thirty days of their
admission. Each of the three Comprehensive Evaluations included all required elements. Each
evaluation included recommendations which corresponded with the youth’s diagnosed mental
health or substance abuse disorders.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 26 of 56 (Revised July 2023)
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 provides mental health and substance abuse treatment to any youth determined to
be in need of services and any youth who is in the center for more than thirty days. Three of
seven reviewed youth required a treatment plan. Each applicable youth’s Initial Treatment Plan
included all required elements. All three youth were discharged prior to their Individual
Treatment Plan being developed; therefore, three additional youth mental health records were
reviewed for Individualized Treatment Plans. Each of the three Individualized Treatment Plans
included all required elements. Each plan was signed by all required parties. One of the youth
refused services. Each of the three youth, despite one refusing services, had thirty-day reviews
as required. Each youth had documentation in the Department’s Juvenile Justice Information
System (JJIS) of participating in mini-treatment team meetings. The mini-treatment team
meetings were attended by all required parties. Each thirty-day review was signed by all
required persons. None of the youth were prescribed psychotropic medications; therefore,
psychiatric services were not addressed. None of the seven reviewed youth were applicable for
Mental Health/Substance Abuse Treatment Discharge Summaries. The center provided three
additional youth mental health records for review. Each of the three youth records included the
Department’s Mental Health/Substance Abuse Treatment Discharge Summary form. A copy of
each of discharge summary was provided to the juvenile probation officer (JPO),
parent/guardian, commitment program, and youth. It should be noted, two of the youth were
released to a residential program prior to clinical staff having the youth sign the discharge
summary. A mini-treatment team meeting was unable to be observed during the annual
compliance review week.
3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
Seven youth mental health records were reviewed for mental health and substance abuse
treatment. Three of the seven reviewed youth required treatment. Each youth had a signed
consent for treatment in their record, which included consent for mental health treatment,
substance abuse treatment, and a release of information. Each youth was assigned to a mini-
treatment team and each team consisted of all required parties. Each youth received mental
health and/or substance abuse treatment as prescribed on their treatment plan. Each youth’s
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 27 of 56 (Revised July 2023)
plan included individual, group, or family therapy prescribed at least weekly. All treatment notes
were documented on the Department’s Counseling/Therapy Progress Notes form. The mental
health staff had adequate access to youth and confidential space to provide treatment services.
A review of video for three separate dates confirmed groups were being held for about thirty
minutes. The groups did not have more than the required number of youth and were held on the
modules. Seven youth were interviewed, and one reported the mental health and substance
abuse services they are receiving are good, one reported they are very good, and five reported
they are not receiving any services. During the interview with the designated mental health
clinician authority, it was confirmed the process of providing mental health and substance abuse
treatment for youth by developing initial treatment plans, individual treatment plans and
additional assessments to provide appropriate services to the youth.
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 contract with VitalCore Health Strategies to provide mental health services,
including the provision of a psychiatrist to provide psychiatric services to youth at the center.
During an interview, the designated mental health clinician authority (DMHCA) confirmed the
center does not provide specialized treatment and youth are provided counseling services if
detained longer than fourteen days. The psychiatrist holds a clear and active license with the
State of Florida Department of Health with a specialty in child and adolescent psychiatry, which
expires January 11, 2026. The back-up psychiatrist holds a clear and active license with the
State of Florida Department of Health with a specialty in child and adolescent psychiatry, which
expires March 31, 2024. Three of seven reviewed youth entered the center on psychotropic
medication. The remaining four youth did not enter the center on medication and were not
referred for a psychiatric interview. All three applicable youth’s initial psychiatric interviews were
conducted within fourteen days of their admission to the center. Each of the three youth mental
health records included a completed Clinical Psychotropic Progress Note (CPPN) page three,
which stated Psychiatric Evaluation. Each initial psychiatric interview included reason for
referral, history, mental status examination, DSM-5 diagnosis, treatment recommendations,
prescribed medication, frequency of medication monitoring/management, medication name, and
explanation of the need for psychotropic medication. Each youth was applicable for an in-depth
psychiatric evaluation and each evaluation included all required elements. There were no
changes to medication for any of the applicable youth. None of the applicable youth were under
the supervision of the Department of Children and Families or eighteen years of age. Each of
the three youth had a signed Authority for Evaluation and Treatment in their mental health
record.
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 facility operating procedures (FOPs) to include suicide prevention, intervention,
and training. The plan was signed December 15, 2023, by the designated mental health
clinician authority (DMHCA). The plan addresses identification and assessment of youth, staff
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 28 of 56 (Revised July 2023)
training for at least six hours annually, suicide precautions (precautionary observation and
secure observation), levels of supervision (one-to-one supervision, constant supervision, and
close supervision), as well as the referral process, communication, notification, documentation,
immediate staff response, and review process.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has a Suicide Prevention Plan in place which outlines the procedures for youth
identified as at-risk, which includes a review process for any instances of a serious suicide
attempt, self-inflicted injury, or completed suicide. Two of seven interviewed youth reported
being placed on suicide watch and both confirmed staff watched them the entire time they were
on suicide watch. Seven staff were interviewed and indicated when a youth expresses suicide
ideations, they are to notify mental health, search the youth and room, document supervision,
place the youth on constant sight and sound supervision, and notify a supervisor. Three of
seven reviewed youth were identified as a suicide risk as a result of admission screening and/or
while in the center. Each of the three youth had alerts in the Department’s Juvenile Justice
Information System (JJIS), initiated upon discovery of the risk, which identified the youth’s
suicide risk and documented the youth’s precautionary observation (PO) status. Each alert was
closed appropriately following the youth’s removal from PO. Each youth was placed on constant
supervision as evident on the Suicide Precaution Observation Logs. The clinical staff were
involved in the process for each youth. Staff submitted a mental health and substance abuse
referral for each youth due to the youth being identified as having a risk of suicide. The
superintendent and clinical staff were notified for each youth. A review of logbooks confirmed
each youth had an entry about being placed on and stepped down from PO, which included
instructions on what staff were to do while the youth was on PO. None of the three youth were
released while on PO. During the interview with the designated mental health clinician authority
(DMHCA), it was reported communication in regard to change in youth supervision level, is
documented in the logbook, electronic medical record (EMR) and on the Assessment of Suicide
Risk (ASR). An ASR was completed for each applicable youth. Each ASR was documented on
the Department’s form which included all required elements. Each ASR was completed within
twenty-four hours of the youth being placed on PO, and no follow-up ASRs were required for
two of the three youth being stepped down. The remaining youth had follow-up ASRs as
required. Each ASR and follow-up ASRs included recommendations for supervision and follow-
up services. Staff entered the date and time each youth was placed on and discontinued from
PO in JJIS, The DMHCA and the superintendent consulted in regard to each youth being placed
on and stepped down from PO. The center had three youth placed in secure observation during
the annual compliance review period. The DMHCA authorized each placement prior to
placement. During an interview, the superintendent confirmed the center utilizes secure
observation, a youth may be placed on secure observation to prevent them for causing harm to
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 29 of 56 (Revised July 2023)
themselves or others. A staff is placed at the door and maintains constant sight and sound
during this time. Each youth’s parent/guardian and juvenile probation officer (JPO) were notified
of placement. Each youth’s placement had documentation of room assignment. Each youth had
an ASR completed within eight hours of placement. Each youth had a completed Health Status
Checklist and PO logs. None of the youth were placed in secure observation beyond twenty-four
hours. Mental health staff provided supportive counseling while each youth was in secure
observation. A conference was held with the superintendent and a licensed mental health
counselor prior to the reduction of supervision level for each youth. Each secure observation
was documented in the logbook as required.
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 (FOPs) for youth placed on suicide precautions.
Seven youth mental health records were reviewed for the completion of Suicide Precaution
Observation Logs. Five of the seven youth had been placed on precautionary observation (PO)
and were applicable for the completion of Suicide Precaution Observation Logs. Each youth had
one Suicide Precaution Observation Log. Each Suicide Precaution Observation Log was
maintained for the duration the youth was on PO. The appropriate level of supervision and
observations of each youth’s behavior was documented in real time and did not exceed thirty-
minute intervals. Each Suicide Precaution Observation Log was reviewed and signed by the
shift supervisor and mental health staff. One of the five applicable youth displayed warning
signs while on PO; therefore, the staff notified the superintendent/or designee and the mental
health clinical staff. Each Suicide Precaution Observation Log had documentation of safe
housing requirements. Video review and corresponding documentation of youth on PO or
secure observation confirmed proper supervision was maintained.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has a Suicide Prevention Plan which includes the training requirements for staff.
Seven in-service and seven pre-service staff training records were reviewed and each
completed required suicide prevention training. Each of the seven interviewed staff indicated the
suicide response kit is kept in master control, medical and each of the youth modules. The
center has six suicide response kits, including a knife-for-life, wire cutters, and needle nose
pliers, which are located on each module and in medical. Suicide drills were held no less than
quarterly on each shift. Two of the drills reviewed did not include life saving measures in the
scenario. The center had fifty-eight applicable staff for participating in suicide drills. Each staff
was reviewed for participation in a suicide drill during the first six months of the annual
compliance review period and the last six months of the annual compliance review period. For
the first six months, fourteen of the forty-one applicable staff did not participate in a drill. For the
second six months, eight of the fifty-eight staff did not participate in a drill. Each staff
participated in at least one drill which included the use of cardiopulmonary resuscitation (CPR)
annually. No documentation was provided indicating staff who were not present during a
quarterly drill had the opportunity to review each drill scenario and procedures in an effort to
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 30 of 56 (Revised July 2023)
understand the process and receive the necessary training to respond to an incident of a suicide
attempt or incident of serious self-inflicted injury in the center.
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 facility operating procedures (FOPs) regarding mental health crisis intervention
services. The center’s Crisis Intervention Plan was signed December 15, 2023, by the
superintendent. The plan includes notification and alert system, means of referral, including self-
referral, communication, supervision, and documentation and review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures (FOPs) regarding the process for emergency
mental health and substance abuse services which is accessible to all staff. The center’s
Emergency Care Plan was signed December 15, 2023, by the superintendent. The plan
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transport for emergency
mental health evaluation and treatment, transport for emergency substance abuse assessment
and treatment, documentation, training, and review.
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 (FOPs) to ensure a Crisis Assessment is
completed for any youth demonstrating acute psychological distress. Seven youth mental health
records were reviewed; however, none of the youth had been determined to be in crisis. An
additional three applicable records were provided. Each of the three youth was identified by staff
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 31 of 56 (Revised July 2023)
as having acute emotional or behavioral problems, or acute psychological distress. All three
youth had a Crisis Assessment, including the reason for assessment, a Mental Status
Examination and interview, determination of danger to self and others, initial clinical
impressions, supervision recommendations, treatment recommendations, recommendations for
follow-up or further evaluation, and was completed by a licensed mental health professional
within the required time frame. None of the crisis assessments had documentation the
parent/guardian was notified of follow-up treatment. A mental health alert was not entered in the
Department’s Juvenile Justice Information System (JJIS) for any of the three applicable youth
due each youth not being identified as having an acute emotional or behavior problems, or
acute psychological distress after the completion of the crisis assessment. All three youth were
alleged victims in a PREA event; therefore, were offered ongoing mental health treatment
services.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures (FOPs) ensuring individuals who are believed to be
in imminent danger to themselves or others because of mental illness or substance abuse
impairment, receive emergency mental health or substance abuse services. Seven youth
mental health records were reviewed; however, none of the youth required a Baker Act or
Marchman Act. An additional three records were provided for youth who required a Baker Act.
The center did not have any youth who required a Marchman Act since the last annual
compliance review. All three youth were placed on suicide precautions upon readmission from a
Baker Act and a mental health referral was completed for a Mental Status Examination (MSE),
which is conducted within the administration of the Assessment of Suicide Risk (ASR), for each.
Each youth’s MSE was completed by or under the direct supervision of a licensed mental health
professional. Each youth’s supervision levels were not lowered until an appropriate assessment
was conducted and mental health staff conferred with a licensed staff and the superintendent or
designee. The discontinuation of the suicide alerts in the Department’s Juvenile Justice
Information System (JJIS) for the two youth who had their supervision levels lowered were
based upon an ASR. One youth did not require a mental health alert to be entered in JJIS;
however, each of the applicable youth had a suicide alert entered in JJIS.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 32 of 56 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has facility operating procedures (FOPs) outlining the duties and requirements for
the designated health authority (DHA), and the sign-in/sign-out procedures for telemedicine.
The center has a contract with an outside provider to provide medical services, which includes
the provision of a physician to serve as the DHA. The DHA has a clear and active license in the
State of Florida, which expires January 31, 2025, and is board-certified in pediatric medicine.
The center has a back-up DHA who is board-certified in pediatric medicine and has a clear and
active license in the State of Florida, which expires January 31, 2025. The DHA has
collaborative practice protocols in place with an advanced practice registered nurse (APRN) to
provide clinical services at the center. The APRN is certified as a family nurse practitioner and
has a clear and active license in the State of Florida which expires July 31, 2025. A review of
sign-in logs since the last annual compliance review found the DHA was on-site weekly for at
least four hours, as contractually required. The program maintains a log of all telemedicine
visits. The DHA was interviewed and confirmed their duties of performing Comprehensive
Physical Assessments, conducting sick visits, period evaluations, and assisting with policy and
procedure development. According to the DHA interview, the DHA is on-site four hours weekly
and available by telephone when not on-site. Nursing staff communicate with the DHA daily
through telephone calls.
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 has facility operating procedures (FOPs) regarding all health-related procedures and
protocols used at the center which are reviewed annually. The designated health authority
(DHA) approved all policies and protocols on December 28, 2023, and the superintendent
reviewed and signed all policies on August 7, 2023. The Psychiatrist last reviewed and signed
the FOPs in April of 2022. There was a cover page on which medical FOPs, treatment
protocols, and other procedures were listed, which was signed by all nursing staff except the
advanced practice registered nurse (APRN). This was resolved while the annual compliance
review team was on-site. All healthcare staff hired during the annual compliance review period
received a comprehensive clinical orientation, provided by a registered nurse, to the
Department’s health care policies and procedures.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for the completion of an
Authority of Evaluation and Treatment (AET). Each record contained a valid AET which was
signed by the youth’s parent/guardian, and a Department representative. Each appliable youth’s
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 33 of 56 (Revised July 2023)
IHCR contained the original AET form and/or was stamped as “copy.” All the AET forms were
obtained prior to providing medical services to youth.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed, and six youth were
applicable for parental notifications. None of the applicable youth received over the counter
medications beyond those covered by the Authority of Evaluation and Treatment (AET). All six
IHCRs maintained verbal notification documented on each youth’s progress notes, written
notification sent utilizing the Department’s Parental Notification of Health-Related Care: General
or Parental Notification of Health-Related Care: Medications forms, and where applicable, the
Clinical Psychotropic Progress Note (CPPN) page three. Two youth were taking psychotropic
medication, and both applicable youth records contained documentation to support a staff
witnessed telephone calls for psychotropic medications. Five youth had new medications
ordered while in the center. Four of the applicable youth records contained documentation of
attempts to contact the parent/guardian in the progress notes, and a written notification was
sent regardless of telephone notifications. In the remaining record, there was no documentation
to support there were attempts to contact the parent/guardian when the youth began a new
medication, and no written notification was sent. Six youth were applicable for verification of
vaccines, and each had their vaccines verified within thirty days of admission. One youth's
vaccines were verified at another detention center prior to being transferred; there was no break
in the youth’s custody with the Department. The nurse interview indicated an AET is required
prior to providing medical services. The AET is to be signed by the parent/guardian and
witnessed by a Department representative. The AET is valid as long as the youth has remained
under any type of supervision, custody, or other form of legal control by the Department; or, for
one year after it was signed by the parent/guardian, whichever comes later; or until the youth’s
eighteenth birthday. The program’s process is to notify the juvenile probation officer (JPO) if a
new AET is required to enlist their assistance. The program also sends an AET to court with the
youth for the parent/guardian to sign if they are present in court. If the youth is in DCF custody,
the case worker is contacted to obtain a limited AET.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for admission screening
and rescreening. Each record contained documentation to support the Medical and Mental
Health Admission Screening form was completed on the day of admission by a juvenile justice
detention officer (JJDO) and a licensed healthcare staff reviewed the screening form within
twenty-four hours, as required. In all seven, the designated health authority was notified of each
youth admission, and this was documented in each IHCR. One youth was applicable for a
change in physical custody, and two additional records were requested. Each of the three
applicable IHCRs contained documentation indicating the rescreening was completed by a
JJDO the day each youth returned to the center. Two records contained documentation of a
licensed healthcare staff reviewing the screening form within twenty-four hours, as required. The
remaining record did not contain documentation to support the form was reviewed by licensed
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 34 of 56 (Revised July 2023)
healthcare staff. None of the three youth were applicable for a qualitative urine pregnancy
screening test. The nurse interview indicated parental notification should be made to inform the
parent/guardian of significant changes in the youth’s condition and obtain consent when new
medications are ordered, medications are stopped, youth is sent off-site for treatment whether
scheduled or emergency, and treatments are prescribed. The nurse contacts the parent/
guardian by telephone as soon as the change occurs, or the order is obtained when a
notification is required. Then a letter is sent out explaining the mediation or treatment rendered.
When the youth’s illness or injury requires emergency medical services or is life threatening all
staff shall have immediate access to contact emergency medical services by calling 9-1-1 under
any circumstances which require immediate medical attention or evaluation. The designated
health authority (DHA) is then notified of youth being transported to the emergency room. The
DHA will follow-up. When a new psychotropic medication is prescribed, is discontinued, or the
drug dosage is significantly changed, parental/guardian verbal consent for psychotropic
medication is documented on the Clinical Psychotropic Progress Note (CPPN) on page three.
Written consent is documented on the Acknowledgment of Receipt of CPPN Form. Any verbal
notification is documented on a written parental notification/consent, showing attempt to obtain
the signed parent/guardian consent. Immunization records are obtained during admission
through the website FLSHOTS and the practitioner reviews them during the youth physicals. For
vaccination exemptions the parent/ guardian presents certified documentation of exemption. It is
reviewed by nursing staff and the DHA and uploaded in the youth’s IHCR. Youth are first seen
by nursing staff the day of admission. If youth arrive after nursing staff are gone for the day the
youth is seen the following morning. Supervisors and/or master control staff notifies medical of a
newly admitted youth. Nursing staff also receive Medical and Mental Health Screening Form/
packets in their mailbox for each new youth. A supervisor completes the admission screening,
and the nurse signs on the third page of the screening form. When there is a change in physical
custody the youth are assessed for any changes in medical condition since last in current
physical custody. Vital signs are also obtained, and health related history (HRH) is reviewed
with youth. Any changes are documented in the HRH.
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 has facility operating procedures (FOPs) including access to medical care, sick call,
what constitutes an emergency and when to notify staff, medication process, the right to refuse
care and how it is documented, what to do in the case of a sexual assault or attempted sexual
assault, the non-disciplinary role of the healthcare providers, and review of the list of healthcare
contacts. Seven youth Individual Healthcare Records (IHCRs) were reviewed, and all received a
general healthcare orientation, including all required topics.
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.
Six of the seven Individual Healthcare Records (IHCRs) reviewed were applicable for
notification of the designated health authority (DHA) upon youth admission; the remaining one
was not applicable due to the youth having no chronic conditions. In the six applicable IHCRs
each youth was admitted with a chronic condition, the DHA was notified within twelve hours,
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 35 of 56 (Revised July 2023)
and this was documented in each IHCR. One of the six youth was taking psychotropic
medications upon admission and the psychiatrist was notified. None of the youth were identified
as requiring emergency care upon admission. The nurse interview indicated the nurse contacts
the DHA by telephone as soon as the youth is seen at the clinic. All nursing staff are responsible
for this notification, and it is documented on the intake log as well as the admission form.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion of a Health-
Related History (HRH) form. Six records contained an HRH form completed within seven days
of admission by a licensed healthcare staff on the Department’s form. The HRH was completed
prior to the Comprehensive Physical Assessment (CPA) in all six youth’s IHCR. The remaining
record was not applicable for completion of an HRH because the youth already had one
completed at another center prior to transferring to the center. The nursing interview indicated
nursing staff are responsible for completing the HRH and is normally completed within seven
days.
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 has facility operating procedures (FOPs) addressing when any part of the
Comprehensive Physical Assessment (CPA) is not conducted or refused by the youth, as well
as Tuberculosis (TB) screening. Seven Individual Healthcare Records (IHCRs) were reviewed
for completion of a CPA. Each record contained a completed CPA, which was documented on
the Department form, and each youth’s medical grade. Four of the seven youth received a new
CPA completed by the designated health authority (DHA)/advanced practice registered nurse
(APRN) within seven days of admission, marked with “O” and “X” and containing all required
elements. The remaining three youth had an updated CPA wherein the DHA/APRN reviewed,
signed, and dated the CPA after conducting a focused evaluation with each youth. The
Department’s Problem List was updated, as required. All seven IHCRs contained a Tuberculosis
Skin Test (TST) completed within the last year with the results having been documented on the
Infectious Communicable Disease (ICD) and the CPA forms. All seven youth received a TB
screening within seventy-two hours of admission with no further evaluation required. The nurse
interview indicated new youth will be seen and need a CPA completed within seven days of
admission. A new CPA is needed every two years if youth is a grade one. If youth grade
changes from a one, a new CPA is required yearly. For youth with a medical grade of two or
higher, the CPA is done yearly. TB screening shall be completed within seventy-two hours of
admission if one is not documented in the youth’s IHCR within the past year, and results are
documented on the CPA, ICD, and the TB tracking log.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 36 of 56 (Revised July 2023)
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) screening. Each record contained documentation to support the youth received
an STI screening upon admission. Three youth were referred for further evaluation, and the
referral was documented on the appropriate form. Testing was ordered for all three of the youth,
and testing, screening results, clinical evaluations, and diagnosis documented was on the
Infectious Communicable Diseases (ICD) form and filed in the lab section of the IHCR. None of
the applicable youth consented to a gynecological exam or were out of the center’s custody. Six
of seven reviewed records contained documentation to support the youth was offered
counseling and testing for human immunodeficiency virus (HIV). The remaining youth was
already offered HIV counseling and testing at another center before being transferred to the
center. One youth received HIV testing, and documented consent was obtained. The applicable
IHCR contained test results in a sealed envelope marked confidential, proof of review by a
practitioner, and documentation of pre-test/post-test counseling. Youth confidentiality was
protected in the testing process. Seven youth were interviewed, and each confirmed they are
able to request an 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 has facility operating procedures (FOPs) indicating the shift supervisor reviews all
sick call requests as soon as possible and within four hours after the request is submitted when
nursing staff are not on-site, and only licensed nurses conduct sick call. Two of the seven
Individual Healthcare Records (IHCRs) were applicable for sick call. One additional example
was requested. In the three applicable IHCRs, each sick call was documented on the Sick Call
Referral Log. None of the youth were experiencing similar sick call complaints three or more
times in a two-week period or had a complaint of severe pain with which the staff was unfamiliar
with. Two youth were in restricted housing, and both were questioned daily for sick call/health
complaints, which was documented in the IHCR. All three youth completed a Sick Call Request
form and each was completely filled out by a nurse. In one of three, a licensed practical nurse
(LPN) conducted the sick call and it was reviewed the same day by a registered nurse (RN) or
higher, which was documented on the form. The Sick Call Request forms were filed in each
IHCR and were documented according to the Health Service Rule. All sick calls were
documented on each youth’s Sick Call Index correlating with the Sick Call Request forms. The
center provides sick call every day from 8:30 a.m. to 10:30am, and 3:30 p.m. to 4:30 p.m. The
hours were posted on the wall in the medical office and supported this practice. The nurse
interview indicated when a youth notifies center staff of a medical complaint, the staff put a sick
call through the system. Nursing staff pull sick call twice a day and has twenty-four hours for the
youth to be seen by an RN or an LPN. The youth is assessed, and vital signs, treatment,
education, and follow-up plans are completed. If an RN will not be at the center within twenty-
four hours, the LPN will contact the designated health authority (DHA) by telephone to go over
the sick call for review. When the DHA is on-site, they conduct sick call. All sick calls are
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 37 of 56 (Revised July 2023)
conducted at the clinic inside the center. Youth presenting with similar sick call complaints three
or more times within a two-week period are referred to the DHA or APRN. Youth are added to
the list to be seen by the provider. Youth in confinement are assessed and evaluated for
medical complaints or distress every twenty-four hours and it is documented in an episodic note.
Any distress noted when medical is not on-site, center staff will contact the DHA. Seven youth
were interviewed. Two youth reported they are able to request a sick call immediately, four
youth reported they are able to request a sick call within a day, and the remaining youth
indicated they have never requested a sick call. Seven staff were interviewed, and all reported
the nurse reviews sick call, and only nursing staff conduct sick call. One sick call was observed
during the annual compliance review. Center staff escorted the youth to the clinic. The medical
provider identified themselves and explained why the youth was there. The youth was seen in a
private area with no other youth present to see or hear the examination. Exam equipment was
used to perform sick call, and the youth was examined by the nurse/practitioner. Medical staff
was able to maintain privacy.
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 has facility operating procedures (FOPs) which includes procedures for maintenance
and storage of first-aid kits, to prevent expiration or deterioration of contents. Seven youth
Individual Healthcare Records (IHCRs) were reviewed for episodic care, and five youth were
applicable. In the five applicable IHCRs each youth required an on-site episodic/first-aid care
event, and all episodic care events were conducted by a licensed nurse on-site and
documented in problem-oriented charting; subjective, objective, assessment, and plan (SOAP)
form. The five youth had nine episodic care events, which were all documented in the Episodic
Care Log. None of the youth required a follow-up evaluation because all episodic care was
conducted by a registered nurse. The center had eighteen first-aid kits, one in each of the five
living modules, one in master control, one in administration, on in the intake and release area,
one in the kitchen, and nine which are used for transportation. Three first-aid kits were checked,
and each was fully stocked with the Designated Health Authority (DHA) approved contents. A
review of first-aid kit checks since the last annual compliance review indicated they were
conducted monthly as required. The center has three automated external defibrillators (AED);
one in the clinic, one in one of the living modules, and one in master control. AED procedures
for each AED were located with the AED. All AEDs had a green light and were operational
during the annual compliance review. A review of AED checks since the last annual compliance
review indicated they were conducted monthly as required by the nursing staff. The AED
batteries for each AED were changed in August, 2022 and expire in August, 2026. The pads for
each AED were last changed in October, 2023 and expire in November, 2024. A review of
medical emergency drills since the last annual compliance review indicated drills simulated an
episodic care event which called for immediate first-aid and/or administration of
cardiopulmonary resuscitation (CPR) techniques and the initiation of the emergency procedures
to follow when a life-threatening emergency does occur. The center practices CPR/AED
demonstration at least annually and conducts drills at least quarterly on each shift. A list of
emergency telephone numbers was posted on the telephone where staff can access, and is
inaccessible to the youth. All authorized direct care staff were appropriately trained on the
administration of the epinephrine auto-injector. Seven pre-service and seven in-service staff
training records were reviewed, and each contained documentation to support the staff were
trained in first-aid, episodic, and emergency care. The center stores Narcan in the locked
medication cart in the clinic, and nursing staff inventory Narcan weekly. Nursing staff and staff
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 38 of 56 (Revised July 2023)
who are approved to provide medication have access to the Narcan. All staff with access to the
Narcan have been trained on when and how to use it. The center’s policy regarding the use of
Narcan is for the emergency treatment of a known or suspected opioid overdose emergency
with signs of breathing problems and severe sleepiness or not being able to respond. The
nursing interview indicated episodic care by licensed staff is documented in the Electronic
Medical Record (EMR) in an Episodic Care Progress Note and will cover all elements of a
SOAP note. If non-licensed staff conduct episodic care, it is documented on the Report of On-
Site Care by Non-Healthcare Staff form and a follow-up evaluation is completed by a nurse
when back on-site. Youth who require off-site emergency care are documented in the Off-Site
Care Log in the EMR. Seven staff were interviewed, and each reported they can contact 9-1-1 if
they feel it is necessary. Seven youth were interviewed, and six youth indicated the nurse
conducts sick call. The remaining youth indicated they have never requested a sick call. One
youth rated medical services at the center as fair, three rated the medical services as good, and
three rated the services as very good.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
None of the seven reviewed Individual Healthcare Records (IHCRs) were applicable for off-site
care; therefore, three additional IHCRs were requested. In the three applicable IHCRs each
youth required off-site care which was documented on the Summary of Off-Site Care form and
on the Episodic Care Log. All parental notification efforts were documented in each IHCR, as
well as notification to the designated health authority (DHA). Discharge instructions and findings
were maintained in each IHCR and the DHA/designee reviewed and signed all off-site
documentation. The youth required follow-up care, which was tracked in the center’s medical
schedule for all three youth. One youth had emergency off-site care, which was documented in
the episodic care log. The nursing interview indicated off-site care is tracked in the off-site care
log in the Electronic Medical Record (EMR). Hospital orders are reviewed with the DHA, who
then gives orders to follow in the facility. All follow-up is documented in a calendar and sent by
email communication to staff. The Summary of Off-Site Care form is utilized if a youth is sent
off-site and follow-up testing, referrals, or additional appointments are requested by the
provider.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for chronic conditions, and
six were applicable. Each applicable youth had a chronic condition, four of which were
documented on the Medical/Mental Health Screening form. One youth was not applicable for
listing their condition on the Medical/Mental Health Screening form because the program was
not made aware of the youth’s condition until two days after the youth’s admission. The
remaining youth should have had their condition listed on the form and did not for unknown
reasons. None of the reviewed youth were pregnant, took antituberculosis medication, or had
any communicable diseases. The Department’s Problem List was updated as required for each
youth. None of the youth were at the center long enough to receive a periodic evaluation.
Additional records were requested. During the annual compliance review period the center had
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 39 of 56 (Revised July 2023)
one youth at the center long enough to receive a periodic evaluation. This youth received
periodic evaluations as required with no lapses in care. The designated health authority (DHA)
interview indicated periodic evaluations are completed every ninety days or sooner, if needed.
The registered nurse (RN) manager tracks this and ensures the youth are seen. The nursing
interview indicated periodic evaluations are documented in a calendar and sent by email to staff.
The Summary of Off-Site Care form is utilized if youth is sent off-site and follow-up testing,
referrals, or additional appointments are requested by the provider.
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 has facility operating procedures (FOPs) regarding medication management which
prohibits standing orders, emergency treatment orders, and pro re nata orders for psychotropic
medications. Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication
management, and all were taking medication while at the center. One youth was taking
medication at the time of admission and the medication was verified prior to being admitted to
the center utilizing the Prescription Medication Verification Checklist/Medication Receipt
Transfer Disposition form; and the designated health authority (DHA) and psychiatrist were
contacted to obtain the order to continue the medication. Each youth’s medication
administration was tracked on the Department’s Medication Administration Record (MAR),
which contained all required information, utilizing start and stop dates. Every medication
administration entry was initialed by the youth and healthcare staff and the nurses documented
weekly side effect monitoring on each youth’s MAR. One youth had medication refusals, one of
which was not clearly documented on the MAR; however, the youth did sign a Refusal of
Treatment form. All medications for each of the seven youth had a current, valid order and were
given pursuant to a prescription. In one IHCR, current medications were continued,
discontinued, changed, or new ones were ordered, and the DHA/designee placed an order on
the Practitioner Order Form. Two youth were in restricted housing, and nursing staff completed
daily visits and additional required services and documentation for both youth while in restricted
housing. Neither youth was applicable for receiving medications while in restricted housing. One
youth received over the counter medications not listed on the Authority for Evaluation and
Treatment (AET), and the applicable IHCR contained documentation to support the medication
was administered according to practitioner’s orders or approved protocol. None of the youth
required parenteral medication. One youth was prescribed psychotropic medications prior to
admission, and the psychiatrist was notified upon admission. The psychiatrist conducted an
initial diagnostic psychiatric interview with the youth within fourteen days of admission. The
applicable youth received a medication monitoring every thirty days as required. Observations
of medication pass for two youth during the annual compliance review week indicated the center
staff escorts each youth to the clinic, and the nurse administers each youth’s medication, while
the center staff maintain security. Each youth approached the nurse individually when it was
their turn for medication. During the medication pass, the allergy and alert status were verified
for each youth. None of the medication was pre-poured and the nurse ensured each youth
swallowed the medication. The nurse and each youth initialed the MAR. The nursing interview
indicated if a youth arrives with medication, a medication receipt is filled out, and the nurse
reviews the medication to ensure it is from a licensed pharmacy with a current, patient specific
label intact on the original medication container in order to accept. Medications shall have a
current, valid order and are given as ordered on a current prescription or Practitioner Order. The
DHA or psychiatrist shall be contacted to obtain the order to resume the specified medications
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 40 of 56 (Revised July 2023)
youth is prescribed prior to admission. Seven staff were interviewed and three reported they
give medication to the youth. The remaining four reported they do not. Seven youth were
interviewed, and five youth reported the nurse gives them medication. The remaining two youth
reported they do not take medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center has facility operating procedures (FOPs) regarding the reporting criteria for
discrepancies and the disposal/destruction of medications. Observations made during the
annual compliance review week indicated the stock over-the-counter (OTC) medications and
sharps are stored in locked cabinets in the clinic. All youth medications are maintained in the
locked medical cart, as well as the additional OTC medications and sharps, which are separated
by topical, injectable, and oral medications. The center did not have any controlled substances
during the observation; however, has a locked box in the locked medical cart available for those
medications, which was confirmed through the nursing interview. A secured refrigerator in the
clinic is utilized for medications needing to be kept cold. A review of training documentation
indicated non-healthcare supervisory staff were trained in the delivery and oversight of
medication self-administration by a registered nurse or higher. An observation was completed,
where the nurse conducted a count of three OTC medications and three sharps, with all totals
matching the inventory numbers. The nursing interview indicated medications are disposed
between nursing staff and controlled medications are disposed with the pharmacy consultant.
Controlled medications are kept in a locked compartment in the medication cart, which is also
locked. The pharmacist is on-site monthly and reviews the medication cart, medication cabinets,
medication refrigerator, destroys medication, ensures labels are completed appropriately, and
ensures licenses are up to date.
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 program has facility operating procedures (FOPs) which includes needle stick post-
exposure evaluation and an exposure control plan. Seven youth Individual Healthcare Records
(IHCRs) were reviewed for infection control training. Each youth record contained
documentation to support the youth received infection control training within seven days of
admission, as well as hand-washing techniques, universal/standard precautions,
prevention/transmission of communicable diseases, Center for Disease Control and Prevention
(CDC) guidelines for infection control, and immunization training. The center’s Exposure Control
Plan was written in accordance with the Occupational Safety and Health Administration (OSHA)
standards and included all required elements of risk assessment and methods of compliance.
The center’s infection control procedures include prevention, containment, treatment, and
reporting requirements related to infectious diseases, according to OSHA and the CDC
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 56 (Revised July 2023)
guidelines. The plan also includes common infectious diseases of childhood, self-limiting,
episodic contagious illnesses, viral or bacterial infectious diseases, tuberculosis, Hepatitis A, B,
C, and human immunodeficiency virus (HIV), and infectious diseases caused by bloodborne
pathogens. The infection control plan also addresses other outbreaks or epidemics caused by
any other infectious agent, outbreaks of pediculosis and/or scabies, Methicillin-Resistant
Staphylococcus Aureus, and other antibiotic-resistant microorganisms, foodborne illnesses, bio-
terrorist agents, and chemical exposures in the workplace. The center did not have any
instances in which infectious diseases and sexually transmitted infections (STIs) were
reportable to the local health department, CDC, or the Department’s Central Communications
Center (CCC); or any instances involving the quarantining or hospitalization of at least ten
percent of the total population of youth or staff. The clinic maintains a separate file intended for
all documents when youth and staff have experienced a facility/occupational exposure;
however, the center has not had any exposures. Seven pre-service and seven in-service staff
training records were reviewed, and each completed training regarding the center’s specific
Exposure Control Plan. The nursing interview indicated a copy of the Exposure Control Plan is
available to staff in the binder with the policies, and a registered nurse (RN) conducts inflection
control training for staff. Infection control training for youth in provided during admission by an
RN. The center routinely uses the county health department for immunizations, HIV treatment,
dental care, and prenatal care.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has nursing protocols and treatment plans addressing pregnant youth. None of the
seven reviewed Individual Healthcare Records (IHCRs) were applicable for prenatal care.
Additional records were requested, and the center provided two applicable records from the
annual compliance review period. In both applicable IHCRs the youth received prenatal care
immediately upon determination of pregnancy until released from the center. Both youth were
placed on the alert log, and received a focused medical evaluation at least every thirty days.
Each youth received training in alcohol and drug use, smoking, nutrition, sexually transmitted
diseases, contraception, prenatal care, birthing process, postpartum and basic baby care,
child/infant development, and parenting skills. All education was documented on each youth’s
Health Education Record. Both youth received nutritious food in quantities appropriate for
pregnant youth, as well as routine monitoring of nutritional and weight status. Seven in-service
staff training records were reviewed, and each staff received training on observation and
monitoring of emergency care needs/symptoms of possible miscarriage and other prenatal
education topics. Seven pre-service staff training records were reviewed, and each received
training in prenatal education topics. The nurse interview indicated female youth are tested for
pregnancy upon admission as long as the youth verbally consents, as ordered by the
designated health authority (DHA). Prenatal care is set up for the youth once staff are aware the
youth is pregnant. Obstetric care is scheduled, the youth is started on a pregnancy diet
depending on the DHA’s order, and the youth is educated during her pregnancy. Education
topics for pregnant youth include orientation, shaken baby syndrome, difference of breast
feeding and bottle feeding, what to expect with body changes, dietary needs, post-partum care,
and other prenatal topics.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 42 of 56 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
The center maintains facility operating procedures (FOPs) to address active supervision of
youth. During the annual compliance review, youth supervision was observed each day of the
annual compliance review week. Youth and staff observations were made on the modules,
classrooms, during mealtime, intake area, on the large recreation field, and during line
movements throughout the center. The detention staff maintained continuous sight supervision
of the youth within their assigned areas. The interactions observed between staff and youth
displayed active supervision. Staff were positioned in the designated areas and during line
movements which supported active supervision. Authorization for all movements throughout the
center was communicated effectively through the juvenile justice detention officers (JJDOs) and
the master control operator. The master control logbooks were reviewed since the last annual
compliance review and documentation was provided to support headcounts were conducted on
a consistent basis, at the start, and end of each shift, hourly, and prior to movements. Seven
staff were interviewed, and each staff stated there was enough staff to provide for the safety
and security of the youth and staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 43 of 56 (Revised July 2023)
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations.
Each center shall implement and maintain a behavior management system to meet the needs
of the youth and the center. The system shall include rewards for positive behavior and
consequences for inappropriate behavior.
The behavioral norms and expectations for youth shall be posted in all living areas and shall
clearly specify appropriate and inappropriate behaviors.
The system restricts certain types of penalties on youth who demonstrate negative behaviors.
Group punishment shall not be used. However, corrective action taken with a group of youth
is appropriate when the behavior of a group jeopardizes safety or security, and this should
not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
The use of drugs to control the behavior of youth is prohibited. This does not preclude the
proper administration of medication as prescribed by a licensed physician.
The center maintains facility operating procedures (FOPs) requiring a behavior management
system (BMS) which offers a predictable set of rewards, privileges, and consequences for
behavior. The centers rewards, privileges, and consequences are to motivate the youth to meet
the centers expectations. Observations during the annual compliance review week revealed
postings of the BMS in all living areas which clearly specified appropriate and inappropriate
behaviors, rules, norms, and expectations. The BMS indicated rewards for positive behavior and
consequences for inappropriate behavior. Observations of daily activities revealed the staff
implement the BMS. A review of documentation confirmed positive rewards are given to youth
based on the BMS incentive calendar. A review of documentation confirmed the rewards and
consequences are given in accordance with the BMS. Reviewed documentation did not indicate
any instances of inappropriate use of restrictions or group punishment. Youth are given an
orientation during their intake process which explains the BMS. The BMS is a three-tiered level
system. Once the youth is admitted into the center the youth’s behavior level may increase or
decrease depending on the youth’s behavior. The incentive calendar can change based on the
centers needs for each month. Seven staff were interviewed regarding the BMS. Six of the
seven interviewed staff reported they feel the behavior management system is effective. One of
the seven staff reported it is effective when the youth take their level seriously. Seven youth
were interviewed regarding how they would rate the centers BMS. Four of the seven rated the
BMS as very good, one of the seven youth rated the BMS as good, while two of the seven youth
rated the BMS fair. The superintendent was interviewed about what the BMS is used for at the
center; the superintendent responded the BMS is to provide a uniform BMS which offers
predictable awards to youth through a level system which is based on individual youth behavior.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 44 of 56 (Revised July 2023)
5.03 Ten-Minute Checks (Critical) Limited Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures (FOPs) addressing ten-minute checks. Staff
utilize the electronic Guard One wand by tapping it on the check point sensors on the outside of
each youth’s door. The center has 120 cameras and all 120 are operational. Videos are stored
for thirty days. Video review indicated on January 20, 2024, on module B2 a 10-minute check
was conducted at 7:19 p.m., 8:13 p.m., and 8:32 p.m., with no checks in between. On January
9, 2024, on module B4 a 10-minute check was conducted at 10:02 p.m. and not again until
10:31 p.m. On January 18, 2024, on module G1 a 10-minute check was conducted at 9:19 p.m.
and not again until 9:52 p.m. Documents were provided to reveal weekly reviews of
management oversight was conducted. Wand checks were reviewed for a thirty-minute period
each month of the review period on each living module, for a total of thirty-six thirty-minute
periods. Thirteen of the reviewed periods had checks completed beyond the ten-minute
requirement. Seven staff were interviewed how often room checks are conducted when a youth
(non-suicidal) is placed in their room for sleeping or non-punishment reasons to which all seven
answered ten-minutes. The superintendent was interviewed and asked to explain the ten-check
process. The superintendent stated anytime a youth is secured behind a door, the ten-minute
supervision cycle will occur to promote safety and security of the youth and is documented by
the wand system primarily.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 45 of 56 (Revised July 2023)
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains facility operating procedures (FOPs) requiring staff to always know the
exact number and location of all youth under their supervision. Review of the master control
logbooks, since the last annual compliance review, showed documentation headcounts were
conducted at the beginning and end of each shift. Documentation was provided to reveal counts
were called at a minimum once per hour on each shift, following any emergencies such as a
power outage and evacuations. Review of the master control logbook revealed counts were
prior to and following group routine movement, anytime the population changes, and for youth
movements. Seven staff were interviewed and asked when youth counts are conducted and
what steps are taken if the count is not correct, staff one responded every hour, every module
will be contacted for head count and the logbooks will be reviewed. Staff two responded every
hour, if the number is incorrect the youth are recounted, and a physical count will be conducted.
Staff three responded every hour, if the number is incorrect, movement will be stopped, and a
physical headcount will be conducted. The shift reports will be reviewed. Staff four responded
any movement, they try to resolve the count, and figure out the location of youth. Staff five
responded recount, stop all movement, and notify the supervisor. Staff six stated throughout the
day, every movement, and all movement is stopped until the youth is located. Master control is
contacted, and notify everyone. Staff seven responded every hour, they look for the youth, and
make an alert.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 46 of 56 (Revised July 2023)
5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has facility operating procedures (FOPs) regarding logbooks. The center maintains
separate logbooks for each living module, master control, and transportation vans. A review of
logbooks was conducted for three days each month during the annual compliance review
period; however, did not exceed twelve months. Review of logbooks revealed in the module B4
logbook, nineteen out of 302 discrepancies were noted with dates missing. Module B1 logbook
from May 2023 to October 2023 is missing pages one through five. It is noted lines in multiple
logbooks were marked out; however, not “voided” or “initialed”. The superintendent initiated all
staff are to take a retraining of the FOP. The events were labeled with a.m./p.m. and not in
military time with the names of the staff and youth involved. A brief description of the events,
and the initials of the staff making the entries were identified on the pages. The entries
pertaining to the safety and security of the center, to include medical/special needs and mental
health alerts were all identified by highlights. Logbook review indicated the juvenile justice
detention office (JJDO) supervisor and/or lead officer record comments regarding the corrected
errors. Review of logbooks revealed the supervisors reviewed the master control logbook when
accepting responsibility for the center and the living area logbooks daily. The JJDOs reviewing
the logbook entries from the previous shift when accepting responsibility for the living area was
properly documented. Each logbook reviewed contained the name and position of the reviewer
and the date and time the review was completed. The master control logbook revealed
documentation of emergency situations, incidents, all drills, documentation of receipt of
medical/mental health alerts, population counts at the beginning and end of each shift,
population counts throughout shifts as count changes, youth group movements, admissions and
releases, presence of law enforcement, name of youth placed on confinement with the time of
confinement began and the time confinement ended, and the name of youth placed on
precautionary/secure observation along with the time initiated and time ended. Review of the
activity schedule and logbook documentation did not reveal any interference of educational
instruction and were on time according to the schedule. Times the youth attended and departed
school were clearly labeled in the logbook.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 47 of 56 (Revised July 2023)
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) regarding logbook requirements. The living
modules and master control logbook were reviewed from the last annual compliance review. For
each shift, the juvenile justice detention officer supervisor (JJDOS) documents a review of the
logbook was conducted. A review of the master control logbook revealed the supervisor
accepted responsibility of the facility at the beginning of shift. Review of the modules and master
control logbook revealed the superintendent or designee reviewed each on a weekly basis and
provided recommendations as to the completeness and accuracy of the information recorded.
Review of the module logbooks revealed the juvenile justice detention officers (JJDOs)
accepted responsibility for the living area at shift changes. The review revealed the
superintendent, assistant superintendent, or staff in charge of the center will tour the youth living
area at least once during each shift and document his/her visit in each area’s assigned logbook.
The superintendent was interviewed and asked what management’s role is in regard to
logbooks (center and living area logbooks), the superintendent replied his management team is
required to review logbooks in master control and all the living areas to have an idea of the
events which have occurred. While the review is being conducted, an unannounced prison rape
elimination act (PREA) visit is also part of the process and module review for safety and security
as well as the cleanliness of the area.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 48 of 56 (Revised July 2023)
5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys.
All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of
keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch.
The key(s) on these rings shall provide egress through facility exterior doors providing access
to evacuation areas.
A key inventory shall be maintained by the Superintendent or designee at all times.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center maintains facility operating procedures (FOPs) detailing the requirements of the
center’s key control, issuance of keys to staff, and inventory of keys and tracking. Key
assignment and usage pertain to the staff’s role. Each key ring has a tamper proof color
coordinated key ring hub. Juvenile justice detention officers (JJDOs), receive a blue ring hub
with four keys on it. The juvenile justice detention officer supervisors (JJDOS) receive a yellow
key ring hub which has ten keys on the ring. Keys which are not assigned are secured in the
supervisor’s office in a tamper proof lockbox, the staff are to give a key to receive a key at the
beginning of shift, and at the end of shift they give their keys back to the supervisor to receive
their personal keys. The keys assigned are logged on a paper log then placed in SharePoint for
the daily shift report. Both logs have the who the keys are assigned to, the checkout time, and
check in time. Supervisors assign keys to their staff on each shift. Review of the log revealed
the distribution and collection of the keys. When keys are missing, the facility goes on lockdown
and a sweep is conducted to locate the keys. The center has within two hours to contact the
Central Communications Center (CCC) if the keys are not located. When keys are broken or
damaged, a work order is placed for the keys and the keys are then taken offline. Review of the
key control book confirmed the number of keys within the facility, each key assigned to the set
of keys and their purpose and are label with the key number and how many keys are to be on
the key ring. Review of the keys displayed the assigned color to the purpose of keys; officer
keys are blue, supervisor keys yellow, administration keys black, medical, and mental health are
white, food service are green, education keys are brown, and emergency keys are red. During
observations, the week of the annual compliance review, it was revealed staff carry their keys
on their person at all times, don’t allow the youth to handle facility keys, and the staff do not
remove the keys from the facility or facility grounds without authorization from the
superintendent. If a staff leaves the facility with keys, the staff contacts the facility and speak to
a supervisor immediately and returned the keys to the facility within two hours. In the event a set
of keys go missing, the supervisors are immediately notified. Review of the CCC incident history
for the center did not have any instances of discrepancies of key control. Three staff were
formally interviewed about their keys, all three staff had the correct number of keys on their key
ring and knew the function of all the keys on their assigned key ring. Seven staff were
interviewed and asked what program keys are restricted, all seven staff responded all keys are
restricted. The superintendent was interviewed and asked if permeant keys are assigned to
staff, the superintendent answered if staff are assigned keys, the staff have to sign a
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 49 of 56 (Revised July 2023)
memorandum receipt to take home keys. This process is managed by the facility
superintendent.
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 maintains facility operating procedures (FOPs) to address transportation procedures
and the maintenance and operation of Department vehicles. The center has seven vehicles
used to transport youth. Two of the transportation vans were at the mechanic shop getting
repairs. Observations confirmed five of the seven center vehicles had the appropriate number of
seatbelts, a seatbelt cutter, a window punch, a fire extinguisher, and a first-aid kit containing
only approved items. Use of tobacco products is prohibited in the vehicles according to the
center’s facility operating procedures (FOPs). The center’s vehicles are to be securely locked
when not in use. A security check was conducted of five of the seven center vehicles not in use
and each was found to be securely locked. Reviewed documentation confirmed each vehicle
was inspected prior to transport. Reviewed documentation supported the maintenance
mechanic’s completion of weekly and monthly vehicle checks. A review of the vehicle
maintenance invoices revealed all vehicles received an annual inspection within the previous
year. Seven youth were interviewed regarding safety while being transported in center vehicles
and all seven youth indicated they feel staff drive safely.
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 maintains facility operating procedures (FOPs) to address tool inventory and tool
management requirements. All tools were secured in the locked and secured, maintenance
workshop. The interview with the superintendent revealed the only person authorized to have
keys to the maintenance shed are maintenance staff and administrators. Tools are stored on
shadow boards and are etched to identify them as Department property. The center maintains a
strict inventory of tools. All tools are checked out prior to use and checked in after they are
returned. Interviewed maintenance staff indicated an inventory is conducted monthly and is
forwarded to the center’s superintendent or designee for review. Kitchen tools include knives
and scissors which were stored in a locked box in the kitchen office which is locked and always
secured. A well-organized inventory of kitchen tools is maintained, and counts are documented
at the start, middle, and end of each day. Additionally, monthly inspections of the tool area were
documented. All tools were accounted for and there were no tools observed in the center which
were not listed on the inventory. The center reported they had no tools which needed replaced
since the last annual compliance review. An informal interview with the maintenance staff
indicated all service vendors are identified prior to entering the secure area of the center and
are always accompanied by a center staff. Seven interviewed staff could articulate the center’s
practice for when tools are missing or damaged; staff one responded to notify administration;
staff two responded report immediately, notify the supervisor who notifies administration and
then notify the Central Communications Center (CCC); staff three responded if damaged
maintenance staff would notify the superintendent for the tool to be replaced or discarded; if
missing staff notify administration and all movements are stopped and search a is conducted;
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 50 of 56 (Revised July 2023)
staff four responded administration is informed and will put in an order for the tool to be fixed;
staff five responded to inform the supervisor, administration, and maintenance and conduct a
search if missing staff six responded they would call maintenance; staff seven responded to put
a tag on the tool and turn it into the supervisor and then document it in the logbook.
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 (FOPs) to ensure youth do not have access to any
tool including kitchen or medical equipment. No tools were found unsecured, and youth were
not observed using any kitchen or medical equipment during the week of the annual compliance
review. The center only allows youth to have access to mops, brooms, and scrub brushes for
general cleaning under direct staff supervision. Observations were unable to be observed of
youth using cleaning tools during the week of the annual compliance review as this activity did
not occur while the annual compliance review team was on-site. Seven youth were interviewed
and all seven stated they use mops and brooms and three of seven indicated they use scrub
brushes. Seven staff were interviewed, and each staff indicated youth only use mops, brooms,
and scrub brushes.
5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center has a safety plan to ensure the proper use, storage, disposal, and inventory of
chemicals including poisonous, flammable, and toxic materials. During the annual compliance
review period, reviewed documentation revealed the center maintained an inventory of all
flammable, toxic, caustic, and poisonous items. An inventory check of five poisonous,
flammable, and toxic materials found each item was accounted for. Five items were reviewed
for Safety Data Sheets (SDS) and each were located in a binder, corresponding to the specific
item, next to the cabinet with the flammable, toxic, caustic, and poisonous items for all five
reviewed items.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 51 of 56 (Revised July 2023)
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center has facility operating procedures (FOPs) to ensure only authorized personnel are
permitted to access flammable, toxic, caustic, and poisonous items. Observation during the
week of the annual compliance review revealed all flammable, toxic, caustic, and poisonous
materials are stored in secure areas inaccessible to youth and only accessible to maintenance
staff and administrators. Seven youth were interviewed, and all seven youth stated they have no
access to flammable, toxic, caustic, and poisonous items. Seven staff were interviewed, and all
seven staff indicated youth are not allowed to clean with substances which are toxic, flammable,
or poisonous.
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) regarding the disposal of flammable, toxic,
caustic, and poisonous items. The center’s process of disposing of chemicals is by evaporation,
compaction, or by a local waste management company. The facility operating procedures detail
the procedures to follow in the event of a chemical spill. An informal interview with the
maintenance staff confirmed the center had no instances of chemical spills during the annual
compliance review period. An informal interview with the maintenance staff, kitchen staff, and
assistant superintendent revealed the center uses a local waste management company for
chemical disposal and a local company to dispose of grease and all flammable, toxic, caustic,
and poisonous items, and all materials are disposed of appropriately.
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures addressing the process of youth placed in
temporary confinement under twenty-four hours. The center had 1500 instances of confinement
under twenty-four hours during the annual compliance review period, fifteen of which were
reviewed. A review of fifteen Confinement Reports found each youth was afforded the right of
three meals a day plus snacks, counseling, clean clothing, bedding, and notice of right to grieve
a confinement. Ten youth were applicable for a shower based on the time and duration of
confinement; each applicable youth was afforded the right of a shower. Eleven youth were
applicable for education materials during education hours and eleven youth were provided
education materials while in confinement. For each of the fifteen reviewed confinements, the
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 52 of 56 (Revised July 2023)
supervisor approved all confinements, the staff placed only one youth in the confinement room
at a time, the reason for confinement was explained to youth, and the supervisor conducted an
initial Confinement Review with the youth within the required time frame. For each confinement,
the full report was completed within the required time frame, the supervisor conducted additional
reviews with the youth at a minimum of every three hours, and the supervisor/staff continually
counseled the youth to consider removing the youth from confinement. The center does not
have separate confinement rooms and youth are confined in their own room. A room search
was documented for all fifteen reviewed confinements prior to confinement placement. All fifteen
reviewed confinements had all required checks completed including checks every five minutes
during the first hour for confinement. The superintendent or designee reviewed all fifteen
reviewed Confinement Reports within the required time frame. The program had no pregnant
youth in confinement during the annual compliance review period. All seven interviewed staff
stated youth placed in temporary confinement are provided education materials. The
superintendent was interviewed and indicated confinements are required to be signed off by the
administrative staff.
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 (FOPs) to address the Continuity of Operations
Plan (COOP). Reviewed drill documentation revealed the center conducted at least two COOP
drills during the annual compliance review period, as required, including at least one drill
completed prior to the hurricane season. The drills included scenarios, any resulting critique or
corrective action, date and time of drills, and participants. Seven staff were interviewed, and
each confirmed they have participated in COOP drills since the last annual compliance review.
The superintendent was interviewed and indicated the COOP is updated yearly and reviewed by
regional leadership.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 53 of 56 (Revised July 2023)
5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures (FOPs) to address an escape prevention plan. The
escape prevention plan ensures the facility is prepared to address youth escapes, escape
notifications, and prevention. Reviewed drill documentation revealed the center conducted all
thirty-six required escape drills during the annual compliance review period with the logbook
documenting each drill.
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 facility operating procedures (FOPs) to address fire drills. Reviewed drill
documentation revealed the center conducted thirty-five of the thirty-six monthly fire drills during
the annual compliance review period. One drill was missing from August 2023 on the eleven to
seven shift. The center has forty-two fire extinguishers placed strategically throughout the facility
and reviewed documentation reveled fire extinguishers were inspected annually. Seven youth
were interviewed. Five youth indicated they have been instructed on what to do in the case of a
fire and the remaining two youth indicated they have not been instructed on what to do in the
case of a fire. The superintendent informed and provided youth orientation documentation
indicating each youth is educated on the fire evacuation plan at the time of orientation. Seven
staff were interviewed and each confirmed fire drills take place at least monthly. The seven staff
also confirmed they have participated in a fire drill.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 54 of 56 (Revised July 2023)
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) to address search and contraband
procedures. During the annual compliance review week, a youth admission was observed. A
youth frisk search was conducted prior to admission, and an electronic wand search, as well as
a strip search were done during the admission process as deemed appropriate and necessary.
The search consisted of two staff, one of the same gender as the youth. The additional staff was
of the opposite gender and was present for the search and positioned to observe the staff
person conducting the search. A review of documentation indicated searches are noted in the
logbook, as well as electronically. Observations during the annual compliance review week
indicated the center staff conducted a room search during which the staff wore gloves. The
center conducts electronic/wand searches on all persons entering the facility, with all items
entering the secure area being examined, prohibiting personal keys, personal cellular
telephones, and any additional contraband items. A review of room search documentation since
the last annual compliance review indicated room searches are conducted upon a youth’s
release, prior to placing a new youth in the room, and on each awake shift for contraband.
During the annual compliance review period the center had one instance which compromised
the safety/security of the center. The results revealed the search was documented in the
logbook and in the electronic system. Upon discovery and confiscation of contraband an
incident report identifying findings and the disposition of the contraband was completed, as well
as documented in the master control logbook. Law enforcement was contacted due to
contraband being considered illegal. Items used as evidence was secured by the discovering
staff and hand-delivered to the supervisor. The shift supervisor documented the chain of
custody for the items and gave the information to the responding law enforcement officer. The
Department’s Central Communications Center (CCC) and the regional director or designee was
notified. Observations during the annual compliance review week confirmed searches of staff,
visitors, and contractors/vendors were completed prior to entering the secure area. All members
of the annual compliance review team were electronically searched and physically searched
prior to entering the secure area of the center. The annual compliance review team was also
required to read, acknowledge, and sign paperwork regarding the Contraband Statement of
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 55 of 56 (Revised July 2023)
Attestation. The superintendent interview indicated youth searches shall take place as often as
necessary to control contraband and to ensure safety. When asked what the center's
procedures are for searching youth. the superintendent responded stating all detention facilities
follow FOP. When asked what the center's procedures are if a youth or staff is found with
contraband, the superintendent response was the center has a zero tolerance and dismissal is
immanent.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 56 (Revised July 2023)

source: DJJ

report_type: QI Detention

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)

rating: Limited Compliance