facility_name: Pasco Juvenile Detention Center

summary: QI Detention - FY24-25 - 2 findings

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Pasco Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated )
28534 State Road 52
San Antonio, Florida 33576
Review Date(s): August 27-30, 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:
Justin Terziu, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Kara Brown, Office of Accountability and Program Support, Co-Lead (Standard 1)
Crystal Blair-Gallon, Office of Accountability and Program Support, Operations Review
Specialist (Standard 5)
Marvin Bliss, Office of Accountability and Program Support, Operations Review Specialist
(Standard 5)
Cheryl Francis, Office of Accountability and Program Support, Co-Lead (Standard 1)
Evan Hald, Office of Education, Northeast Education Coordinator (Standard 2)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Operations Review
Specialist (Standard 4)
Heather Molinario, Office of Accountability and Program Support, Operations Review Specialist
(Standard 2)
Luis Rodriguez, Office of Accountability and Program Support, Operations Review Specialist
(Standard 4)
Sandra Thompson, Office of Accountability and Program Support, Operations Review Specialist
(Standard 3)
Bonita Williams, Office of Accountability and Program Support, Operations Review Specialist
(Standard 3)
Program Name: Pasco Regional Juvenile Detention Center MQI Program Code: 363
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Pasco County / Circuit 6 Number of Beds: 36
Review Date(s): August 27-30, 2024 Lead Reviewer Code: 214
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures) and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
2.10 Educational Access* 5.11 Confinement Under Twenty-Four Hours
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 52 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
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 Right Interactions (RI) 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 52 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Limited
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 52 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
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 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 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 52 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
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 52 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Failed
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 52 (Revised July 2023)
Program Overview
The Pasco Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in San Antonio, Florida. The center serves youth in Pasco 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 thirty-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 Pasco County School Board. The center’s
management team includes the superintendent, two assistant superintendents, two
administrative assistants, seven juvenile justice detention officer (JJDO) supervisors, and thirty-
eight JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore. Mental health services are provided by one designated mental health
clinician authority (DMHCA), four licensed mental health counselors (LMHCs), and two licensed
clinical social workers (LCSW). The center reported not having non-licensed mental health and
substance abuse clinical staff since the last annual compliance review. Clinical services
provided by the center include mental health and substance abuse evaluations, mental health
treatment planning, individual, group, and family therapy, mental health crisis intervention
services, on-site psychiatric services, and availability for substance abuse services for youth
with co-occurring disorders. Medical services are provided by one designated health authority
(DHA), one advanced practice registered nurse (APRN), eight registered nurses (RNs), and one
licensed practical nurse (LPN). The medical clinic maintains nursing coverage seven days a
week. Food services are provided by Department staff and include menus, meal planning, meal
schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has three living modules which are divided by male and female.
There are sixty-five security cameras at the center, of which all were operational. The center
appeared clean, free of graffiti, and in good repair. At the time of the annual compliance review,
the center had ten vacancies, which included one food service worker, eight JJDO Is, and one
JJDO II.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 52 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures to ensure background screenings are conducted
for all Department staff, contracted staff, volunteers, mentors, and interns who have access to
youth and confidential youth records. Since the last annual compliance review, the center has
hired fourteen new staff members and four new contracted staff. Background screenings were
completed for each newly hired staff member and contracted staff before their start dates, and
criminal history reports were reviewed for each individual. All fourteen staff and all four
contracted staff were deemed eligible for hire; therefore, no exemptions were required.
Additionally, all fourteen newly hired staff underwent pre-employment assessments, with
passing scores documented in their personnel records. All four contracted staff were added to
the center's employment roster with the Agency for Healthcare Administration Clearinghouse.
The center completed and submitted an Annual Affidavit of Compliance with Level Two
Screening Standards to the Department’s Background Screening Unit on January 26, 2024.
Similarly, the Pasco County School Board submitted its Annual Affidavit of Compliance with
Level Two Screening Standards on January 29, 2024.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures which outline the five-year background rescreening
process. A background rescreening is required for all Department staff, contracted staff,
volunteers, mentors, and interns every five years from the initial date of employment. A review
of the center’s staff, volunteer, and contracted staff rosters indicated the center had five staff
eligible for a five-year rescreening since the last annual compliance review. A rescreening was
completed every five years from the staff’s hire date for all five staff, and a rescreening was
submitted at least ten business days prior to the five-year anniversary for each. There were no
additional staff applicable for the five-year rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 52 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures ensuring all staff adhere to a code of conduct. Five
staff personnel records, each of which received a code of conduct violation in the last year, were
reviewed. Each staff record included a code of conduct form signed upon hire. Reviewed
documentation indicated management responded to each code of conduct violation. Four of the
staff received an oral reprimand, and one staff received a written reprimand. The center
provided a list of three staff who received commendations since the last annual compliance
review. Each staff received employee of the month submissions. Six of the seven interviewed
youth stated they have never been denied a call to the Florida Abuse Hotline, as they have
never had to report abuse. One youth stated they have not been denied a call. All seven youth
stated staff are respectful when speaking with them and other youth. Two youth indicated they
have never heard staff use curse words while speaking with them or other youth. Two youth
stated they have heard staff curse once and two youth stated they have heard staff curse
occasionally. One youth stated often. All seven youth stated they have never heard staff
threaten them or other youth. Each youth stated they feel safe at the center. All seven youth
stated they have never exchanged contact information or social media contact information with
staff. Seven staff were interviewed and all seven were able to explain the process for allowing
youth and staff to call the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC), if age eighteen or older, to report suspected abuse. All seven staff stated they
would notify a supervisor and a supervisor could make the call. Five staff indicated the youth are
allowed to make a call to report abuse. Four staff indicated they would notify the superintendent.
Six staff indicated staff are allowed to make the call. Three staff indicated they have never
observed a co-worker using profanity when speaking to youth. Three staff indicated they have
observed a co-worker using profanity once when speaking to youth. One staff indicated they
have observed a co-worker using profanity occasionally when speaking to youth. All seven staff
stated they have never observed a co-worker using threats, intimidation, or humiliation when
interacting with youth. During an interview, the superintendent stated the code of conduct
prohibits abuse, profanity, threats, harassment, or personal relationships with the youth. When
staff are in violation of the staff code of conduct corrective action is taken. Some cases require
the Florida Abuse Hotline and CCC to be contacted. The staff is also placed on no youth
contact.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 52 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures ensuring the Department’s Central
Communications Center (CCC) is notified within two hours of an incident, or within two hours of
becoming aware of an incident, whenever a reportable incident occurs. The center had 100
CCC incidents since the last annual compliance review. Ten incidents were reviewed, and they
were all reported within two hours of the center becoming aware of the incident. All ten incidents
were documented in the center’s logbook. One incident was a medication error, one was a
youth behavior incident, one was a Right Interactions restraint incident, two were a program
disruption, two were a complaint against staff, two were mental health substance abuse
incidents, and one was a contraband incident. A review of internal incidents and grievances
found no additional incidents which should have been reported to the CCC. During an interview,
the superintendent stated reportable incidents are called into the Florida Abuse Hotline and
CCC within two hours of the supervisory/administration staff gaining knowledge. Staff are
mandated reporters and when they have knowledge of an incident or abuse allegation they
must call the Florida Abuse Hotline, complete an incident report, inform the regional director,
and call the CCC within two hours. If the allegation is against a facility staff member, the
individual should be removed from youth contact pending the investigation.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures regarding the use of physical intervention
techniques in accordance with Florida Administrative Code. Anytime staff use a physical
intervention technique, a Right Interactions (RI) incident report is completed and filed in
accordance with Florida Administrative Code. The center had a total of 107 RI incidents
reported since the last annual compliance review. Nine RI incidents were reviewed. All nine RI
Reports were completed by the end of the staff’s workday. All nine of the RI Reports included
statements from all staff involved. None of the reviewed RIs resulted in serious injury to the
youth or staff involved or required a call to the Florida Abuse Hotline. Each reviewed RI Report
was reviewed by a supervisor and a RI instructor or RI certified supervisor. A post-RI interview
was conducted with the youth within thirty minutes of the incident for all nine incident records
reviewed. One of the reviewed incidents required a medical review which was completed. The
youth was no longer at the center; therefore, documentation in the youth’s record was unable to
be verified. All nine RI Reports were reviewed by the superintendent or designee within seventy-
two hours. Seven interviewed staff indicated they try to talk with youth prior to using RI or
mechanical restraints. During an interview, the superintendent stated RI Reports are completed
in the Department’s Facility Management System (FMS) anytime staff are required to use RI
intervention outside of routine transports or searches.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 52 (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.
The center has facility operating procedures (FOPs) ensuring staff are trained in accordance
with Florida Administrative Code. Detention staff are required to complete pre-service
certification requirements within 180 days of hire. Seven staff training records were reviewed for
pre-service training. Four of the seven staff completed all pre-service and certification
requirements, including Academy training, within 180 days of hire. Three of the staff were still
within 180 days of hire. Each staff completed all essential skills trainings required prior to being
in the presence of youth, including Child Abuse: Recognition, Reporting, and Prevention,
cardiopulmonary resuscitation (CPR), first-aid, and automated external defibrillator (AED),
emergency procedures, FOP, Prison Rape Elimination Act (PREA), professionalism,
interpersonal communication, and ethics to include standards of conduct, Right Interactions,
and suicide awareness and prevention. Five of the seven reviewed staff trainings were
documented in the Department’s Learning Management System (SkillPro). Two of the seven
staff were not documented due to Department-wide system outages. During the Department’s
system outage, the center’s pre-service training was done through PowerPoint. Training
agendas were provided to the annual compliance review team as well as a training checklist
indicating all required pre-service trainings were completed. The checklist was provided to the
Department’s Office of Talent, Leadership, and Culture (TLC) to enter into SkillPro. New staff
orientation was completed within thirty days of hire for each staff. Four of the seven reviewed
staff completed the Department’s Academy Training; two were still within 180 days of hire and
one was a rehire.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures in place to ensure all center staff receive twenty-
four hours of in-service training, including mandatory topics specified in Florida Administrative
Code, each calendar year. Seven staff training records were reviewed for in-service training.
All seven completed a minimum of twenty-four hours of in-service training in 2023; they
completed between forty and seventy-five hours of training. One staff did not complete two
hours of suicide awareness and prevention training. All supervisors completed an additional
eight hours of training. The review indicated all trainings completed were entered into the
Department’s Learning Management System (SkillPro). A licensed nurse provided in-service
education on girls’ healthcare to all non-healthcare staff involved in the supervision or treatment
of girls, including monitoring, observation, and emergency care of pregnant youth. The center
maintains an annual in-service training calendar, which is updated as changes occur, and
approved by the highest ranking official at the location, the assistant secretary of detention, and
the director of the Department’s Office of Talent, Leadership, and Culture. During an interview,
the superintendent reported receiving leadership training, in-service training assigned in
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 52 (Revised July 2023)
SkillPro, leadership development, professional development, Information Security Awareness,
sexual harassment, and mandatory leadership training.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures for managing grievances. Grievance forms are
accessible to youth on each living module. Once a form is completed, the grievance is entered
into the Department’s Facility Management System (FMS) on the youth's behalf. Since the last
annual compliance review, the center has received thirteen grievances. Seven grievance
records were reviewed, all of which were addressed and resolved on the same day they were
submitted with no need for an appeal phase. Responses to grievances were provided within the
designated time frames. Seven youth were interviewed, and none reported filing a grievance
form. Seven staff members were also interviewed and demonstrated a clear understanding of
the grievance process, confirming a youth can complete a grievance form, which is then
forwarded through the chain of command. The superintendent verified the grievance process,
noting if a youth requests a grievance form, a juvenile justice detention officer will provide one
for completion unless it pertains to a Prison Rape Elimination Act (PREA) grievance, in which
case it must be submitted through the Department’s Juvenile Justice Information System (JJIS).
Staff, supervisors, and administrators are required to review the grievance process with the
youth at different stages, providing an opportunity for appeal. All phases are signed by involved
individuals and uploaded into FMS.
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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 52 (Revised July 2023)
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures in place to ensure critical and special alerts are
documented in the Department’s Juvenile Justice Information System (JJIS). Seven youth
records were reviewed for alerts, and a logbook review confirmed applicable alerts were
documented; however, in five of the seven records, the "no strenuous activity" alerts were not
updated or closed as required in JJIS. The center’s assistant superintendent stated these alerts
are not entered by detention staff during admission. These alerts are only closed after youth are
evaluated by medical staff, and direct care staff cannot close these alerts, only medical
personnel can do so. Due to Department-wide system outages, the medical department gained
full access to JJIS during the week of the annual compliance review to remove the "no
strenuous activity" alerts and has begun to do so. Medical regional staff also assisted with
updating alerts and training new staff. All alerts were updated before the end of the annual
compliance review week. A review of five shift briefing documents confirmed alerts were
reviewed with staff. The center’s superintendent noted alerts are entered by detention officers,
probation officers, mental health professionals, and medical staff based on assessments,
observations, and/or information provided by the youth or their parents/guardians. Alerts are
reviewed during each shift briefing, and dining hall staff receive a copy for dietary needs or
allergies. Additionally, alerts are reviewed weekly by facility administrators, medical, and mental
health staff for accuracy.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center’s superintendent reported regional leadership meetings are held quarterly, during
which information is shared and discussed. Report cards are also sent out by detention
headquarters on a quarterly basis. The detention regional operations team distributes monthly
reports on Right Interactions (RI) confinements, incidents, and CCCs to administration, which
are then discussed with staff during supervisory meetings and shift briefings. The
superintendent also noted information is shared with providers and stakeholders on a quarterly
basis during department head meetings and advisory board meetings.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 52 (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, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures to ensure each youth admission is conducted as
required. A review of seven youth case management records confirmed each Admission Wizard
was completed, including a review of the arresting affidavit, Detention Risk Assessment
Instrument (DRAI), and Suicide Risk Screening Instrument (SRSI). The admission
documentation included a full-body search by a staff of the same gender, a youth telephone call,
a youth meal, and medical, mental health, and substance abuse screenings. An admission was
observed during the annual compliance review week. The observation included the youth being
provided a brown bag meal obtained from the site kitchen staff, and telephone calls with the
parent/guardian and staff, as well as the youth and parent/guardian. All procedures were
followed during the admission observation.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures to ensure each youth admitted is provided a
complete orientation. All seven reviewed case management records had documentation of an
orientation held within twenty-four hours of admission; the center completes the orientation
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during the intake process. Each reviewed record had a copy of the signed orientation
acknowledgment form. An observation of an orientation was completed during the annual
compliance review week. The youth was instructed to watch the required Prison Rape
Elimination Act (PREA) orientation videotape, which was observed to include all required
elements, while the staff was completing the intake/admission documentation. Another staff was
then observed sitting with the youth and reviewing each page and topic of the center’s youth
handbook. The center’s youth handbook contains all of the required orientation elements. All
seven interviewed youth confirmed a staff at the center reviewed the rules and regulations, daily
schedule, education services, visitation procedures, abuse reporting, and behavior management
system at admission.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures to ensure each youth admitted to the center is
provided the highest level of safety and security and utilizes a classification system which
considers all of the required elements. Seven youth case management records were reviewed
for the classification process and documentation. Each reviewed record included a review of the
youth history and status at admission, and consideration of mental illness, intellectual
disabilities, physical disabilities, history of violent behavior, gang affiliation, criminal behavior,
history of sexual offenses, level of vulnerability to victimization and sexually aggressive
behavior, medical needs, identified or suspected suicide risk, escape risk, security risk, and
history of human trafficking. The classification process included all required elements prior to
making a room assignment. The superintendent remains informed of how to identify and
address local youth gangs through updates from the circuit gang liaison. The superintendent ‘s
interview confirmed the center utilizes the information in the Department’s Admission Wizard
and the results of each youth’s most current Vulnerability to Victimization and Sexually
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Aggressive Behavior (VSAB) and Suicide Risk Screening Instrument (SRSI) when making
classification decisions.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures to ensure communication with the circuit gang
representative regarding any suspected gang activity. Two of the seven reviewed youth case
management records were applicable; an additional record was requested to meet the three-
record minimum requirement. All three applicable records each contained the email notification
to the circuit gang representative about suspected gang activity; none of three were applicable
for including pictures or copies of gang activity. An informal interview with the center’s staff gang
representative was conducted. The staff is the intake juvenile justice detention officer supervisor
for the center, and confirmed information is shared with the circuit gang representative through
emails and direct conversation.
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 to ensure proper inventory and storage of youth
property is maintained. All seven reviewed youth case management records contained a
property receipt form signed by both the youth and staff inventorying the property, and an
acknowledgement letter regarding unclaimed property signed by the youth; none of the youth
refused to sign the receipt or acknowledgement. Each youth is assigned a locker within the
intake area where their non-valuable items are stored with a copy of the property receipt form.
Three of seven youth property lockers were observed, all of the inventoried items and a copy of
the property receipt were found. Four of seven reviewed records also had valuable items
included on their property receipt form; the remaining three were not applicable. All four
applicable valuable property bags were observed to be stored within the drop safe and had all of
the required information written on the tamperproof clear bag, or on a visible property receipt
inside of the bag. Each property bag was documented in the drop safe bound logbook with all
required information to include the date, time, youth’s name, Department identification number,
and the name and initials of the staff submitting the property. A copy of the property receipt
form, including valuable property if applicable, is also maintained in each youth record. An
observation of the center receiving property was observed. The received youth property was
stored in a secure area with limited access to designated staff. The center’s drop safe is in
master control and under video surveillance. The center did not have any applicable Central
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Office of Accountability and Program Support Page 18 of 52 (Revised July 2023)
Communications Center (CCC) reports during the annual compliance review period regarding
incidents of youth property valued over fifty dollars.
All seven interviewed youth confirmed their property was checked by staff at arrival, and each
had signed the property receipt form. The superintendent interview confirmed the center
secures each youth’s property within an assigned locker, and valuables are placed in the drop
safe, upon admission. All youth property access is limited to designated staff. The intake
supervisor is responsible for sending notice of abandon property on a quarterly basis. Property
would be considered abandon after thirty days of being unclaimed. Unclaimed property is
donated to a local non-profit organization and unclaimed currency is sent to headquarters in the
form of a money order.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures to ensure all youth are released properly. Three
closed youth records were reviewed. All three reviewed records contained documentation of the
on-duty supervisor’s review of all release paperwork, to include the court release paperwork.
Upon release, the youth’s identity and the parent/guardian or responsible adult receiving the
youth were verified. Two of three records contained a copy of the identification for the receiving
adult; the remaining youth was released to another state staff for transportation, not requiring a
copy of identification. None of the reviewed records were applicable for endangered person
alert, nor the procedures necessary for youth with endangered person alerts. Each youth and
receiving adult were provided any pending court dates and all required release paperwork
signatures were located. Each record had admission and release dates which correlated to the
dates in the Department’s Juvenile Justice Information System. An observation of a release was
made during the annual compliance review week, and the release was observed to be
conducted as required.
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 to ensure the proper release and transfer of youth
property, medications, and aftercare instructions. Three closed youth records were reviewed.
Each reviewed record contained a signed property receipt, verification documentation of the
receiving adult, signed medication receipt, and communication of aftercare instructions, to
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include pending appointments and health/welfare issues. The center had one applicable
example of property held for more than thirty days during the annual compliance review period.
The example was a youth who left money, in the amount of forty-nine cents, at the facility, and it
was documented the parent/guardian collected the property. The documentation was observed
to be in accordance with the facility operating procedures. An observation of a release was
conducted during the annual compliance review week, which confirmed the processes were in
accordance with the center’s facility operating procedures.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures to ensure a weekly review of all youth on detention
status are reviewed and appropriate information is shared. The weekly detention review was
observed during the annual compliance review week. All required parties were observed to be in
attendance, and the detention youth were reviewed in alphabetical order by type of detention
status. All parties participated in sharing and reviewing release dates, court dates, updated
commitment status information, courtesy holds, active pick-up orders, and youth who had been
seen by mental health staff. A review of past weekly detention review documentation from the
annual compliance review period was conducted and found all required participants were in
attendance by telephone, virtual conferencing, or in person. The superintendent’s interview
confirmed all required participants, information reviewed, and meeting location and times for the
weekly detention reviews.
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 to ensure the posted daily activity schedule is
followed. Throughout the annual compliance review week, the youth were observed within the
classrooms, on breaks, during mealtimes, and medication pass; all observed activities occurred
according to the posted daily activity schedule. The posted daily activity schedule contained all
activities which are required to be provided to youth throughout the week. All seven youth
interviews and all seven staff interviews confirmed the center follows the posted daily activity
schedule.
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2.10 Educational Access (Critical) Limited Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has an activity schedule which reflects the education schedule and times, which
coincides with the daily activity schedule times. A review of three randomly selected days of
video footage and the logbook indicated education classes were not facilitated as scheduled,
with youth not attending school one day due to the staff shortage at the center, and two days
showing inconsistencies with getting youth to and from class as scheduled throughout the day
with classes ending fifteen to twenty-seven minutes early. A review of one randomly selected
day from each month throughout the annual compliance review period for start and stop times
confirmed inconsistencies in youth transitioning to and from classes at the correct time. Youth
interviews confirmed youth attend school Monday through Friday, while staff and superintendent
interviews confirmed minimal interference in education.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has established facility operating procedures to deliver career education to youth,
offering a Type 1 program which includes communication, interpersonal, and decision-making
skills. The facility employs the career education software Naviance, to provide diverse career
learning opportunities. All seven interviewed youth confirmed participating in various courses
while enrolled at the facility, which incorporate career education offerings.
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Office of Accountability and Program Support Page 21 of 52 (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, LLC to provide mental health
services at the center. The center has a 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 clinical social worker (LCSW), who 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, LLC to employ licensed clinical staff
qualified to provide mental health and substance abuse services based off their education,
training, and experience. The center has four licensed mental health counselors (LMHCs) and
two licensed clinical social workers (LCSWs) working under the direction of the designated
mental health clinician authority (DMHCA), who is also a LCSW. Both LMHCs and the LCSWs
have clear and active licenses in the State of Florida with expiration dates of March 31, 2025.
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has facility operating procedures (FOPs) regarding non-licensed mental health and
substance abuse clinical staff. The FOP includes requirements for direct supervision, education,
and training. The center reported not having non-licensed mental health and substance abuse
clinical staff since the last annual compliance review.
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Office of Accountability and Program Support Page 22 of 52 (Revised July 2023)
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
The center has facility operating procedures to ensure the mental health and substance abuse
needs of youth are identified through a comprehensive screening process in which referrals are
made when youth are identified with mental health and/or substance abuse needs or are
identified as a possible suicide risk in accordance with Florida Administrative Code.
Seven youth record were reviewed, which confirmed upon their admission, a juvenile justice
detention officer (JJDO) reviewed the screening documents. The Suicide Risk Screening
Instrument (SRSI) and the Massachusetts Youth Screening Instrument, Second Version
(MAYSI-2) were completed in the Department’s Juvenile Justice Information System (JJIS), for
all seven youth. None of the screenings were invalid. A review of seven mental health and
substance abuse records found each youth had a mental health, substance abuse, and suicide
risk screening utilizing the SRSI and the MAYSI-2 completed during the admission process by
trained staff. Six of the seven SRSIs had completed entries which included a summary and
recommendations in the screening results section, one was not filled out in its entirety. Six of
seven youth had yes responses on the SRSI form. The applicable youth were placed on suicide
precautions and a mental health referral was completed documenting a need for an Assessment
of Suicide Risk (ASR). The results of the SRSI and/or MAYSI-2 indicated the need for further
assessment for each youth and referrals were made and the superintendent was made aware.
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 regarding mental health and substance abuse
evaluations. None of the seven selected youth mental health records 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 and referred 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,
and recommendations which corresponded with the youth’s diagnosed mental health or
substance abuse disorders. Each Comprehensive Mental Health/Substance Abuse Evaluation
included all required elements consistent with the Department’s form.
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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
need services and any youth who is in the center for more than thirty days. None of the seven
reviewed youth mental health records were applicable for treatment plans; therefore, the center
provided an additional three youth records. Three mental health and substance abuse records
reviewed were applicable for treatment and discharge planning. All three youth were assigned
to a mini-treatment team and a treatment team meeting was observed during the week of the
annual compliance review. The three youth were participants, along with education, mental
health, and physician staff. Education, behavior, goals, and medication were all discussed
during the meeting. Each of the three youth received the mental health orientation within
fourteen days of admission. The three youth records documented an initial treatment plan was
completed on the Department’s Initial Mental Health/Substance Abuse Treatment Plan form
within seven days of the initiation of treatment. Each of the initial treatment plans documented
the reason for the referral, initial Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis, treatment methods, initial treatment goals, applicable psychiatric
services, and, if applicable, medication received at admission. All three plans were completed
and signed by the designated mental health clinician authority (DMHCA). Each plan was signed
by treatment team members involved in the development of the initial treatment plan, youth, and
parent/guardian when possible. All three records contained an individualized treatment plan
developed within thirty days of admission. Each of the three individualized treatment plans
documented the DSM-5 diagnosis, symptoms which were the focus of treatment, strengths,
needs, and applicable psychiatric services to include the youth’s prescribed psychotropic
medication, dosage, and the frequency of monitoring rates. A review of the progress notes in all
three records indicated each youth was receiving treatment services as stipulated on the
treatment plan. In all three records the individualized treatment plan was signed by the youth,
mental health/substance abuse clinical staff, treatment team members, and when available, the
parent/guardian. Each applicable record contained treatment plan reviews completed at thirty-
day intervals after the development of the individualized treatment plan on the Department’s
Individualized Mental Health/Substance Abuse Treatment Plan Review form. All modifications
documented on the review form were clearly identified. All treatment plan reviews were dated
and signed by each youth, clinical staff, licensed mental health professional, applicable
treatment team members, and, when possible, the parent/guardian. The three closed mental
health and substance abuse records were reviewed, and all contained a discharge plan
documented on the Department’s Mental Health/Substance Abuse Treatment Discharge
Summary form. The Mental Health/Substance Abuse Treatment Discharge Summary form was
signed by all required parties on the date of completion. Each form was uploaded in the
Electronic Health Record. Documentation supported a copy of the plan was provided to each
youth, when available the parent/guardian, and the assigned juvenile probation officer as
required.
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Office of Accountability and Program Support Page 24 of 52 (Revised July 2023)
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. None of the seven reviewed youth mental health records were applicable; therefore,
the center provided an additional three youth records for review. Each of the applicable youth
required mental health and substance abuse treatment and were assigned to a mini-treatment
team. The mini-treatment team consisted of mental health clinical staff, staff from a different
service area, youth, and the parent/guardian when possible. Two of the three youth received
mental health and substance abuse individual, group, or family counseling according to the
frequency required by their individual plan. Each plan had individual, group, and/or family
therapy prescribed weekly. One of the three youth refused services, which was documented by
a signed refusal form for services; however, the clinical staff continued to offer services weekly.
Each of the three youth had a signed Authority for Evaluation and Treatment (AET). The two
applicable youth had a proper consent for substance abuse treatment, and substance abuse
treatment records release on the Department forms. The two applicable youth had treatment
notes documented on the Department’s Counseling/Therapy Progress Notes form. The center
held life skills groups during the annual compliance review period. A review of tracking log,
video footage, and logbooks confirmed groups were being held according to the schedule.
Mental health staff has adequate access to youth and confidential space to provide treatment
services. A review of records and collateral documentation confirmed mental health and
substance abuse groups did not exceed the maximum number of youth for each. Five of the
seven interviewed youth reported services are good, one reported very good, and one youth
reported not receiving services. During the interview with the designated mental health clinician
authority (DMHCA), it was confirmed mini-treatment teams are held every thirty days to review
Individual Mental Health and Substance Abuse Plans with treatment team members.
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, LLC to provide mental health
services, including the provision of a psychiatrist to provide psychiatric services to youth at the
center. The VitalCore Health Strategies, LLC contract includes tele-psychiatry services;
however, this service was not utilized since the last annual compliance review. 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 31, 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, 2026. The center does not have a
psychiatric advanced practice registered nurse. The designated mental health clinician authority
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(DMHCA) indicated services such as counseling, treatment team, and treatment services are
provided to youth. None of the seven reviewed youth mental health records were applicable;
therefore, the center provided three additional youth records. Each of the applicable youth
entered the center on psychotropic medication or were referred for a psychiatric interview, and
each received an initial diagnostic interview within fourteen days of the youth’s admission to the
center. Each youth’s Initial Diagnostic Psychiatric Interview included all the required elements.
Each of the applicable youth had a psychiatric evaluation completed within thirty days of their
admission/referral and included all required elements. The form was clearly identified as a
psychiatric evaluation. The psychiatric evaluation was signed by the psychiatrist. Each
applicable youth record had a signed Authority for Evaluation and Treatment (AET). One of the
three applicable records confirmed a medication modification, and the parent/guardian gave
verbal consent for psychotropic medication which was documented on the Clinical Psychotropic
Progress Note (CPPN). The CPPN was filled out in entirety for each applicable youth. None of
the applicable youth were under the supervision of the Department of Children and Families or
eighteen years of age.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a Suicide Prevention Plan, detailing suicide prevention procedures. The plan
included identification and assessment of youth at risk of suicide, staff training, suicide
precautions, levels of supervision, referral, communication, notification, documentation,
immediate staff response, and review process which included all required elements.
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. Six of the seven reviewed youth mental health
records were determined to be at risk during admission. Each youth was placed on
precautionary observation (PO), the staff entered an alert in the Department’s Juvenile Justice
Information System (JJIS), and a referral was submitted. Four of the six PO logs were not filled
out entirely, the logs did not have documentation of safe housing designation. The clinical staff
were involved in the process for each youth. The superintendent and clinical staff were notified
and consulted of placement for each youth on the mental health/substance abuse referral
summary. 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
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was on PO. None of the youth were released while on PO. An Assessment of Suicide Risk
(ASR) was completed for each of the six applicable youth. Each of the applicable ASRs were
documented on the Department’s form which included all required elements. Each of the ASRs
were completed within twenty-four hours of the youth being placed on PO. Four of the six
applicable ASRs had a follow-up, prior to removal of youth from PO, the remaining did not
require a Follow-Up ASR. Each ASR 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 designated mental health clinician authority (DMHCA) and the superintendent were
consulted in regard to each youth being placed on and stepped down from PO. Each ASR was
administered by the licensed mental health clinician. The DMHCA reported a revision to a
youth’s supervision level is documented in the ASR, the Department’s Electronic Medical
Record (EMR), and logbook. Each of the seven interviewed staff reported when a youth
expresses suicide ideations, they are to notify mental health staff, the supervisor, search the
youth and room, and place the youth on constant sight and sound supervision. Each of the
seven interviewed youth reported not being placed on PO while at the center.
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
The center has facility operating procedures to govern the use of secure observation. None of
the seven reviewed youth mental health records were applicable; therefore, three additional
records, which were applicable, were requested and reviewed. One record was authorized by
the superintendent and designated mental health clinician authority (DMHCA). The remaining
two records were secure observations (SOs) which occurred during the evening shift, when the
superintendent and DMHCA were not on-site; therefore, the supervisor on-site initially
authorized the SO placements. All three records contained documentation of the secure room
designated in writing, a completed Health Status Checklist prior to the SO placement, and a
completed Suicide Precautions Observation log. One of three records had an Assessment of
Suicide Risk (ASR) completed within eight hours of placement; the remaining two records were
placed in SO during the evening shift and contained ASRs completed the following morning.
Each reviewed record contained documentation of parental and juvenile probation officer (JPO)
notification regarding the youth’s potential suicide risk as indicated by the completed ASRs.
None of the three reviewed records had youth who remained on SO over twenty-four hours; nor
did any of the records require supportive counseling services. Each reviewed SO log had
documentation of supervision. The reviewed logbook and each youth’s mental health record
documentation confirmed the supervision level for each youth was reduced after a conference
was held with the superintendent and DMHCA. SO was stepped down to precautionary
observation (PO) as required.
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Office of Accountability and Program Support Page 27 of 52 (Revised July 2023)
3.12 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 for youth placed on suicide precautions. Seven
youth mental health records were reviewed for the completion of Suicide Precaution
Observation Logs. Six of the seven reviewed youth had been placed on precautionary
observation (PO) and were applicable for the completion of Suicide Precaution Observation
Logs. Each youth had the Department’s Suicide Precaution Observation Logs completed for the
duration of their placement. The appropriate level of supervision and observations of each
youth’s behavior were 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. None of the youth displayed any warning signs while on PO. Two of the six
youth with Suicide Precaution Observation Logs had documentation of safe housing
requirements; the remaining four youth did not have documentation of safe housing. A review
video, during the week of the annual compliance review, of three youth placed on PO was
conducted. Each review revealed each youth was being supervised according to the logs.
3.13 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.
Seven in-service and seven pre-service staff were confirmed to have completed the required
suicide prevention training. The center conducted suicide drills quarterly on each shift. The
center has a total of four suicide response kits located on each of the two modules, medical,
and master control. Each suicide kit was co-located with first-aid kits. Mock mental health drills
in response to a suicide attempt and/or incident of serious self-injury were simulated. No youth
were used in drill simulations. The center provided semi-annual training on emergency response
procedures which include “mock” training in emergency response to a suicide attempt or
incident of serious self-inflicted injury. An informal interview with the center’s trainer confirmed
staff who do not participate in drills are able to review drills during shift briefings. Each of the
seven interviewed staff indicated the suicide kits are located inside of master control, medical,
the supervisor’s office, modules, and intake.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a combined Emergency Services Plan, detailing crisis intervention procedures.
The plan included, notification and alert system, means of referral, communication, supervision,
documentation, and review.
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Office of Accountability and Program Support Page 28 of 52 (Revised July 2023)
3.15 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 regarding the process for emergency mental health
and substance abuse services. The center’s Emergency Care Plan was signed August 22,
2024, by the superintendent and is accessible to all staff in the center’s computer system. The
plan included 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.
3.16 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 regarding the process for Crisis Assessments.
None of the seven reviewed youth mental health records were applicable; therefore, the center
provided an additional three applicable youth. Each of the youth had a Crisis Assessment when
determined to be in crisis by either direct care staff or clinical staff. Each of the Crisis
Assessments included all required elements. The staff entered a mental health alert into the
Department’s Juvenile Justice Information System (JJIS) when placed on precautionary
observation. Each Crisis Assessment was conducted by a licensed clinical staff within twenty-
four hours. Each of the youth were an alleged victim in a Prison Rape elimination Act (PREA)
event and were offered ongoing mental health treatment services; however, each refused
services.
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Office of Accountability and Program Support Page 29 of 52 (Revised July 2023)
3.17 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 regarding the process for Baker and Marchman
Acts. None of the seven reviewed youth mental health records were applicable; therefore, the
center provided an additional two applicable youth. The center was not able to provide a third
because the youth record was transferred with the remaining youth to the applicable residential
program. A suicide risk alert was opened while the youth was pending off-site transport for each
applicable youth. Each youth was placed on one-to-one supervision. Supervision was
documented on a Suicide Precaution Observation Log until each youth was released. Upon
each youth’s return to the center, the youth was placed on precautionary observation and an
Assessment of Suicide Risk was completed by licensed clinical staff. Each youth’s supervision
level was maintained until appropriate assessment was conducted and the licensed clinical staff
conferred with superintendent or designee. The appropriate suicide and mental health alerts
were entered and closed in both the center’s logbook and the Department’s Juvenile Justice
Information System (JJIS). A mental health referral was completed for a Mental Status
Examination (MSE) for each youth. Each of the two MSEs were completed by a licensed mental
health professional. Each youth was maintained on minimum of constant supervision until
properly transitioned to a lowered level of supervision. Each youth’s supervision level was
maintained until an appropriate assessment was conducted and the licensed clinical staff
conferred with the superintendent or designee. The discontinuation of the suicide risk
alert/mental health alert and precautions was based upon each youth’s ASR.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 30 of 52 (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 detailing the tele-medicine process, including sign-
in and sign-out logs for the practitioner. The center maintains a contract with VitalCore Health
Strategies, LLC (VitalCore), who maintains an agreement with a medical doctor (MD). The
center has a MD holding an unrestricted license and meeting all requirements for independent
and unsupervised practice in the State of Florida to serve as the designated health authority
(DHA). The DHA’s specialty training is in internal medicine, and their license expires on January
31, 2025. The center utilizes an advanced practice registered nurse (APRN), who holds an
unrestricted license in the State of Florida, with an expiration date of April 30, 2025. The APRN
has a Collaborative Practice Protocol in place with the DHA, which was signed on May 18,
2024, and copies are maintained on-site. The APRN provides the clinical services on-site, and
the DHA performs the administrative duties. The center does not utilize a physician assistant. A
review of the center’s DHA sign-in logs for the annual compliance review period found the DHA
was on-site once a week, as contractually required. The center has a back-up DHA through
their contract with VitalCore; however, the back-up DHA was only used for two weeks during the
annual compliance review period. The back-up DHA is a MD who holds an unrestricted license
which expires on January 31, 2025, and meets all requirements for independent and
unsupervised practice in the State of Florida. The back-up DHA’s specialty training is in
pediatrics. The center did not utilize tele-medicine during the annual compliance review period.
An interview with the DHA confirmed the DHA completes Comprehensive Physical
Assessments, focused medical reviews, periodic evaluations, as well as sick calls if requested,
during the weekly site visits. The DHA reports being on-site one day each week, communicating
with medical and program staff through telephone, in person, and email communication, and
being available twenty-four hours, seven days a week. The DHA also reported all off-site care
medical findings, instructions, and information are communicated telephonically by nursing staff,
and reviewed and signed by the DHA during the next on-site visit. The DHA interview stated all
communication with nursing staff is documented in the Electronic Medical Record. Additionally,
the DHA indicated in the event of a scheduled leave of absence, the back-up DHA provides
coverage.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center has facility operating procedures (FOPs) for all health-related procedures and
treatment protocols utilized at the center. The designated health authority (DHA) and
superintendent signed and dated all respective treatment protocols, policies, and procedures,
and conducted an annual review of all treatment protocols as required. This was demonstrated
by the signature and date of the DHA on July 24, 2024, and the superintendent and psychiatrist
on August 22, 2024. The nursing staff signed and dated a review of all nursing protocols. Any
new policies or changes in policies made during the year were reviewed, signed, and dated by
each nurse on a signature page. An annual review of medical policies, procedures, and
protocols was conducted by all required individuals. The psychiatrist reviewed and developed
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Office of Accountability and Program Support Page 31 of 52 (Revised July 2023)
the FOPs, or other protocols related to psychiatric services and psychotropic medication
management. The healthcare personnel hired since the last annual compliance review received
a comprehensive clinical orientation to the Department’s healthcare policies and procedures,
given by a registered nurse. The treatment protocols or standing procedures were approved,
written, and authorized by the DHA.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
All seven reviewed Individual Healthcare Records (IHCRs) had a valid Department Authority for
Evaluation and Treatment (AET) form with the word “COPY” stamped on the form. Each AET
was signed by a parent/guardian and a Department representative. All AETs were obtained
prior to each youth receiving medical services, and none of the youth were eighteen years old or
in the care of the Department of Children and Families (DCF).
The nursing interview indicated an AET is required prior to providing medical services and has
to be signed by the parent/guardian and a Department representative. The nurses will contact
the juvenile probation officer to assist with getting an AET signed, as well as sending an AET to
court to get it signed by the parent/guardian. If a youth is in the care of DCF, then the case
worker is contacted to get a limited AET. An eighteen year old youth can provide verbal consent
to receive medical services and can sign/initial for treatment or medications rendered.
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.
Three of seven reviewed Individual Healthcare Records (IHCRs) were applicable for
parental/guardian notification/consent. One of the three applicable IHCRs had documentation of
parental/guardian notification for over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment and consent was provided by the parent/guardian;
the remaining two did not require OTC medications. In all three IHCRs, written notifications were
sent utilizing the Department’s Parental Notification of Health-Related Care: General, Parental
Notification of Health-Related Care: Medications forms, or the Department’s Acknowledgment of
Receipt of the Clinical Psychotropic Progress Note (CPPN). Two of the youth were taking
psychotropic medications at the time of admission. In the two IHCRs, the staff witnessed all
telephone call attempts and conversations for psychotropic medications. One youth had a new
psychotropic medication prescribed and the parent/guardian verbal consent for psychotropic
medication was documented on page three of the Department’s CPPN and the IHCR showed
an attempt to obtain the written parent/guardian consent. Two of the three youth had a new
medication ordered and there was documentation of attempted contact to the parent/guardian in
the progress notes, as well as written parental/guardian notices sent regardless of telephone
notifications. None of the youth required vaccinations or were in the care of the Department of
Children and Families. Seven reviewed IHCRs confirmed vaccines were verified within thirty
days of each youth’s admission. The nursing interview indicated notification should be made to
inform the parent/guardian of significant changes in the youth's condition, to obtain consent
when new medications are ordered, medications are stopped, the youth is sent off-site for
treatment, and treatments are prescribed. These notifications are first done verbally and
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Office of Accountability and Program Support Page 32 of 52 (Revised July 2023)
followed up with a letter. In case of psychotropic medications, the CPPN is utilized. If a youth's
illness or injury requires emergency medical services or is life threatening, 9-1-1 is called as well
as the designated health authority (DHA). The nurse further stated the center does not provide
vaccinations on-site; however, will obtain immunization records from FLSHOTS upon a youth’s
admission. If a parent/guardian presents certified documentation of exemption, it is reviewed by
nursing staff and the DHA, and uploaded in the Electronic Medical Record.
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.
All seven reviewed Individual Healthcare Records (IHCRs) had a Department Medical and
Mental Health Admission Screening Form completed by a juvenile justice detention officer
(JJDO) or JJDO supervisor on the date of admission. In all seven records a nurse reviewed the
screening form within twenty-four hours. Five of seven records documented the designated
health authority notification, as required. One of seven IHCRs were applicable for a rescreening;
therefore, two more examples were requested. In all three applicable IHCRs, there was a
change in physical custody and the center completed a healthcare admission rescreening each
time a change in custody occurred. All three rescreenings were completed by a juvenile justice
detention officer (JJDO) or JJDO supervisor on the date of admission and a nurse reviewed the
rescreening form within twenty-four hours. None of the youth received a qualitative urine
pregnancy screening test. The nursing interview indicated each youth is first seen by a nurse on
the day of admission, unless nursing staff have left for the day, then the youth is seen the
following morning. JJDO supervisors and/or master control will notify the medical staff of all
newly admitted youth, as well as receiving the Department’s Medical and Mental Health
Admission Screening form/admission packet in the clinic mailbox. The admission screening is
usually conducted by the JJDO supervisor, and a nurse will conduct a review and document it
on page three of the form. When there is a change in physical custody since the youth's
admission, the youth is assessed for any changes in medical condition, vital signs are obtained,
and the Department’s Health-Related History form is reviewed with the youth.
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 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 to ensure accuracy. In all seven reviewed Individual Healthcare Records (IHCRs),
each youth received a general healthcare orientation, and all topics were documented on the
Department’s Health Education Record form.
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Office of Accountability and Program Support Page 33 of 52 (Revised July 2023)
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.
In all seven reviewed Individual Healthcare Records (IHCRs) there was a referral documented
to the designated health authority (DHA) for youth with known or suspected chronic conditions
and mental health issues. None of the youth were identified as requiring emergency care upon
admission. The DHA was notified within twelve hours or no later than noon the day following of
each youth’s admission. Three of the seven youth were taking psychotropic medication upon
admission, and the psychiatrist was notified.
The nursing interview indicated a nurse contacts the DHA telephonically as soon as a youth with
a chronic condition is seen in the clinic, and this is documented on the intake log as well as the
admission chronological 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 and six included a Health-
Related History (HRH) form completed within seven days of admission by a licensed healthcare
staff on the Department’s form. The remaining youth was not applicable having transferred from
another detention center. The six applicable HRHs were completed prior to the Comprehensive
Physical Assessment (CPA), as evidenced by signature and date, and the designated health
authority reviewed the HRH as indicated by a check mark on the CPA. The nursing interview
indicated the HRH is completed by the nurses within seven days of admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center has facility operating procedures addressing when any part of the Comprehensive
Physical Assessment (CPA) is not conducted or refused by the youth, as well as Tuberculosis
(TB) screening. In six of seven reviewed Individual Healthcare Records (IHCRs), the CPA was
documented on the Department form noting each youth’s Medical Grade, and confirmed each
was completed within seven days of admission. The remaining one youth was not applicable
due to being a transfer from another detention center. The six applicable youth received a new
CPA completed by the designated health authority (DHA)/advanced practice registered nurse
(APRN) and all were marked with “O” and “X”. Five of the six had no missing elements, the one
remaining youth was missing elements which should have been documented on the CPA. In all
six IHCRs the Department’s Problem List was updated, as required. None of the youth refused
any part of the exam; however, the DHA/APRN deferred a portion of the exam due to each
youth not showing any indicators needing the deferred portion. All six applicable 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 six of
the applicable youth received a TB screening within seventy-two hours of admission with no
further evaluation required.
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Office of Accountability and Program Support Page 34 of 52 (Revised July 2023)
The nurse interview indicated the CPA must be completed within seven days of admission. TB
screenings are completed within seventy-two hours of admission if one is not documented in the
youth’s IHCR within the past year. The results are documented on the CPA, ICD form, and the
TB tracking log. The center does not conduct routine gynecological exams.
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.
Six of seven youth were clinically screened and evaluated for sexually transmitted infections
(STIs). The remaining youth was transferred between detention centers and did not require a
new STI or human immunodeficiency virus (HIV) screening. Two of six youth required further
evaluation and the designated health authority/advanced practice registered nurse reviewed the
STI screening tool and noted a referral on the form. In one of two Individual Healthcare Records
(IHCRs), the youth declined testing. The remaining IHCR documented testing and screening
results on the Department’s Infectious Communicable Diseases (ICD) form and the testing was
filed in the lab section of the IHCR. None of the youth consented to a gynecological exam or
were sexually active nor were any out of the Department’s physical custody. All six applicable
IHCRs had evidence each youth was offered counseling and testing for HIV. Three of the youth
consented to testing. One youth was placed on the HIV testing log and the pre-test counseling
was documented in the IHCR. The two remaining youth received the testing, the pre and post-
test counseling was documented in each IHCR, and the test results were placed in a sealed
envelope marked confidential with a practitioner having reviewed the results. Both youth’s
confidentiality was protected by not including the HIV status or any other STI diagnosis on the
program’s internal alert system. All seven youth interviews indicated they can ask for a HIV test.
The nursing interview indicated the designated health authority reviews the STI screening tool
and if testing is ordered, they will request consent from the youth to get a urine sample to send
to the laboratory within seven days. The STI screenings, evaluations, referrals, and testing are
documented in the IHCR on the ICD form, as well as in a progress note. If a youth has been out
of the Department's physical custody for more than thirty days and/or symptoms present, a
nurse will conduct a STI screening, and the same process as mentioned before is utilized. All
youth are required to read and sign the HIV form to indicate consent or refusal for a HIV test. If
a youth consents, they are added to the HIV testing log and the pre/post-test counseling is
documented on the Individual Health Education Record. A youth’s HIV testing results are given
verbally to the youth, as well as documented on the ICD form.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures including a process for youth to receive regular
medical care while in room restriction/confinement. In three of seven reviewed Individual
Healthcare Records (IHCRs), each youth had a sick call event; two youth had two events and
one youth had one event. Three of the five sick call events were not documented on the Sick
Call Referral Log, the remaining two were noted. None of the youth presented with similar sick
call complaints three or more times within a two-week period. In all three IHCRs, each youth
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Office of Accountability and Program Support Page 35 of 52 (Revised July 2023)
and registered nurse (RN) completed the Department’s Sick Call Request form, and they were
filed in each IHCR in reverse chronological order. All Department Sick Call Request forms were
documented in accordance with Florida Administrative Code and all Sick Call Requests were
documented on the Department Sick Call Index. A review of the daily schedule, observations of
the posted schedule, and nurse interview indicated sick call is conducted daily, pursuant to
contract requirements. Sick call hours were posted next to the clinic door, as well as each
module. The center has approved treatment protocols for both RN and licensed practical nurse
(LPN) level staff. Only licensed nurses conduct sick call; however, the center does have
procedures in place whereby a supervisor will review all sick call requests as soon as possible
and within four hours after a request is submitted if there are no licensed nurses on-site. The
center had no sick call event while the annual compliance review team was on-site; therefore,
observations of a sick call could not be conducted. The nursing interview indicated youth will
notify the floor staff of a medical complaint and the staff will place the sick call in the electronic
system. The nurses check the system twice a day, and a RN or LPN will see a youth within
twenty-four hours, usually sooner, and will assess the youth, take vital signs, complete
treatment, education, and make follow-up plans. If an LPN conducts sick call, a RN will review
the sick call within twenty-four hours, or if no RN is available the designated health authority
(DHA) can be contacted and will review the sick call with the LPN. If the DHA is on-site they will
also conduct sick call. Sick calls are conducted in the clinic. A youth presenting with similar sick
call complaints three or more times within a two-week period are referred to the DHA/advanced
practice registered nurse and added to the list to be seen. Youth in restricted
housing/confinement are assessed and evaluated for medical complaints or distress every
twenty-four hours and this is documented on an episodic progress note. If any distress is noted
while medical staff are not on-site, the DHA is contacted. The nursing interview also stated the
center has DHA approved treatment protocols.
Five of seven youth interviews indicated a nurse conducts sick call, two stating they had not
needed sick call. Five youth indicated they can be seen immediately when they request a sick
call, two indicated they never needed to request sick call. All seven staff interviews stated the
nurse reviews sick call, two also stated supervisors and two said staff. All seven said the nurse
conducts sick call, one also said staff.
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 ensuring the contents of first-aid kits are
maintained and stored to prevent expiration or deterioration. The first-aid kits are inventoried,
maintained with a break away closure, and stocked monthly by the nurses. In five of seven
reviewed Individual Healthcare Records (IHCRs), there was an indication each youth required
on-site first-aid or episodic care. All episodic care events were conducted by a registered nurse
(RN) and documented in subjective, objective, assessment, and plan (SOAP) charting. All
episodic care events were documented in the Episodic Care Log. The center has seventeen
first-aid kits, located in master control, each of the three modules, kitchen, intake, clinic, teacher
lounge, and mental health. Eight more are used for transportation and are maintained in master
control. Three of the first-aid kits were observed fully stocked with designated health authority
approved contents. A review of the first-aid kit checks for the annual compliance review period
indicated they had been inventoried monthly, as required. The center has two automated
external defibrillators (AEDs), one in master control and one in the clinic with the procedures
maintained with each AED. The AEDs are checked annually by an outside provider and monthly
by on-site nurses. The outside provider conducted the annual review on October 25, 2023, and
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Office of Accountability and Program Support Page 36 of 52 (Revised July 2023)
the documentation for the AED checks indicated the nurses conducted monthly checks for the
annual compliance review period. Observations of both AEDs indicated they were functioning
appropriately during the annual compliance review week. The AED batteries expire in August
2026 and the pads on November 28, 2024. The batteries were changed on August 19, 2022. A
review of the emergency medical drills for the annual compliance review period indicated the
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. Announced and
unannounced medical drills were conducted at least quarterly on each shift. The center made
an effort to ensure staff have the opportunity to participate in at least one emergency drill
annually. A review of video footage for two medical drills indicated one of the drills was not
visible on camera, the other was observed to be simulated. The list of emergency numbers was
posted in the clinic accessible to staff and inaccessible to youth. A review of documentation
indicated direct care staff were trained on the administration of the epinephrine auto-injector by
a RN on May 29, 2024. A review of seven in-service and seven pre-service training records
indicated they all received training regarding episodic, first-aid, and emergency care. The center
has a process in place regarding the use, access, and inventory of Narcan. Narcan is stored in
the locked medication cart in the clinic and is inventoried perpetually and monthly. The staff with
access to Narcan have been trained on when and how to use it. The nursing interview verified
the location of the first-aid kits. If a nurse conducts episodic care, it will be documented on an
episodic care note in SOAP charting in the Electronic Medical Record. If a non-healthcare staff
conducts episodic care, it is documented on the Department form and a nurse will have to do a
follow-up evaluation when back on-site. Any youth who is sent off-site for emergency care is
tracked on the Off-Site Care Log. All seven staff interviews indicated they can call 9-1-1 if
needed. Three of seven youth interviews stated they would rate the medical care at the center
as very good, three said good, and one said fair.
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.
A review of seven Individual Healthcare Records (IHCRs) indicated none of the youth required
off-site care. Three more examples were requested. The center was able to provide two youth,
one with two off-site care events. The two applicable youth both required off-site care and for all
three events there was a Department Summary of Off-Site Care Consultation Report form filed
in each IHCR. Two of the three events were documented on the Episodic Care Log, the
remaining one was missing. In all three IHCRs the parental/guardian notification efforts were
documented, the designated health authority (DHA) reviewed and signed all off-site care
findings, instructions, and information. Two of three were applicable and had the discharge and
other applicable documents filed in each IHCR, as well as the DHA being notified of an
emergency event. Two of the three required a follow-up appointment which was tracked, and
both received timely follow-up care. The nursing interview indicated youth who are sent off-site
for first-aid or emergency care are tracked on the Off-Site Care Log. When a youth returns to
the center the off-site care findings are placed in a folder for the DHA to review and initial. The
DHA will then provide orders to follow on-site. The nurses track follow-up appointments in a
calendar and send email communication to the center staff.
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Office of Accountability and Program Support Page 37 of 52 (Revised July 2023)
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Two of the seven reviewed Individual Healthcare Records (IHCRs) were applicable for chronic
conditions; therefore, one additional IHCR was requested. In all three applicable IHCRs, each
youth had a chronic condition, which was documented on the Department’s Medical/Mental
Health Screening form. Each youth was entered on the Chronic Conditions Roster and had a
Medical Grade of two to five. None were pregnant, took antituberculosis medication, nor had
any communicable diseases. Two youth were taking prescribed medication on an on-going
basis, as well as undergoing treatment for physical health condition. The three youth had not
been at the center long enough to receive periodic evaluations every ninety days and the staff
indicated they did not have any applicable youth for the annual compliance review period. In
one youth’s IHCR, the Department’s Problem List was updated. The designated health authority
(DHA) interview indicated periodic evaluations are completed every thirty to ninety days
depending on the nature of the condition. The DHA will communicate this information to the
nursing staff, and they will track and add the youth to the chronic list as appropriate. The nurse
interview indicated youth with chronic conditions are noted in the chronic condition binder, alerts
are entered, and the DHA is notified to see the youth.
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 including medication disposal. Six of seven
Individual Healthcare Records (IHCRs) were applicable. Three of the six youth were taking
medication at admission and the medication was verified prior to being admitted into the center
and documented in the chronological progress note and the Department’s Medication Receipt
Transfer Disposition form. In the three applicable IHCRs, the designated health authority (DHA)
and, when applicable, the psychiatrist were contacted to obtain the order to resume the
specified medications. In four of the six records, all medications had a current, valid order and
were administered pursuant to a current prescription. In those four records the DHA placed an
order on a Practitioner Order form for any current medications which were continued,
discontinued, changed, or new ones ordered. One youth was in restricted housing and the
nursing staff completed daily visits, other required services, and documentation, and the youth
received all prescribed medications, as ordered and on time. One of the six youth received over-
the-counter (OTC) medications not listed on the Authority for Evaluation and Treatment (AET)
form which were administered according to approved protocols or practitioner’s order. In all six
the Department Medication Administration Record (MAR) was used to document all medication
and treatment, including start and stop dates. None of the medication administration was
conducted by non-healthcare staff, there were no lapses or errors in medication administration,
none of the youth had any refusals or received parenteral medication. In all six IHCRs, the
MARs included youth name, Department identification number, date of birth, youth allergies,
precautions, Medical Grade, and medical alerts. All MARs documented weekly side effect
monitoring by the nursing staff. A nurse and the youth initialed each medication administration
entry. The MAR book and the electronic MARs include a current picture of each youth. Two of
the six youth entered the center on psychotropic medications and the psychiatrist conducted an
initial diagnostic psychiatric interview within fourteen days. None of the youth had been at the
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Office of Accountability and Program Support Page 38 of 52 (Revised July 2023)
center long enough to receive a medication monitoring/review. The center did not have any
standing orders, emergency treatment orders, or pro re nata orders for psychotropic
medications. During the annual compliance review week, an observation of medication
administration for three youth was conducted. All three youth were individually escorted to the
clinic by a juvenile justice detention officer (JJDO). The nurse identified themself and stated why
the youth was in the clinic, making the medication delivery their sole responsibility. The nurse
verified each youth’s allergy and alert status, retrieving each medication individually from the
medication cart and administering it. After the medication administration each youth was asked
to cough and move their tongue to ensure the medication was swallowed; both the nurse and
JJDO verified this process. Each of the youth and the nurse initialed the MAR. A review of
documentation indicated the center had designated staff trained by a registered nurse in
medication administration, which was confirmed by the nursing interview. The nursing interview
indicated when a youth arrives with medication, the medication is verified, and the DHA or
psychiatrist is contacted to obtain an order to resume the medication. The center utilizes
Department MARs and medication administration is scheduled daily for 8:00 a.m., 12:00 p.m.,
5:00 p.m., and 7:00 p.m. Five of seven staff interviews indicated they do not provide medication
to youth, two stated they do. Five of seven youth interviews indicated the nurse provides
medication and two stated 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 including the reporting criteria regarding inventory
discrepancies and a process for the disposal and destruction of expired and/or discontinued
medications. Observations during the annual compliance review week included the storage of
sharps and over-the-counter (OTC) stock medications. The center had them located in locked
cabinets in the clinic utilizing weekly and perpetual inventories, keeping sharps and OTC
medications separated. The medication cart was observed to be clean, organized keeping
youth-specific medications separated from all other medications, as well as keeping injectables,
topicals, and liquids divided. All controlled substances were maintained in a separate lock box
within the locked medication cart utilizing a perpetual inventory with a shift-to-shift count
documented on the Department’s Individualized Controlled Medication Inventory Record. The
clinic had a medication specific refrigerator which contained tuberculosis testing serum and
insulin. All medication and sharp storage areas are inaccessible to youth and only accessible to
staff with a key. Observation, during the ACR week, of a nurse counting three controlled
medications, three OTC medications and three sharps indicated the count matched the ending
inventory number. A review of documentation indicated non-healthcare staff received training in
the delivery and oversight of medication self-administration by a registered nurse. The nursing
interview indicated any controlled medications are disposed between nurses and the pharmacy
consultant, and other medications are disposed between nurses. The pharmacist is on-site
monthly, reviews the medication cart, medication storage area, ensures everything is labeled
appropriately, reviews Medication Administration Records, sharps, and licenses, and destroys
medication. Controlled substances are kept in a locked compartment in the locked medication
cart.
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Office of Accountability and Program Support Page 39 of 52 (Revised July 2023)
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center has facility operating procedures detailing the needle stick post-exposure evaluation.
A review of seven Individual Healthcare Records (IHCRs) indicated all youth received infection
control training within seven days of admission, including hand-washing techniques,
universal/standard precautions, prevention/transmission of communicable diseases,
vaccinations, and Center for Disease Control and Prevention (CDC) guidelines for infection
control. The center’s Exposure Control Plan was written in accordance with the Occupational
Safety and Health Administration (OSHA) and includes risk assessment and methods of
compliance requirements. The center’s infection control procedures entail prevention,
containment, treatment, and reporting requirements related to infectious diseases, according to
OSHA and the CDC guidelines. The procedures include common, infectious diseases of
childhood, self-limiting, episodic contagious illnesses, viral or bacterial infectious diseases,
tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus, infectious diseases caused
by bloodborne pathogens, other outbreaks or epidemics caused by any other infectious agent,
outbreaks of pediculosis and/or scabies, Methicillin-Resistant Staphylococcus Aureus and other
antibiotic-resistant micro-organisms, foodborne illnesses, bio-terrorist agents, and chemical
exposures in the workplace. The center makes Hepatitis B immunization available for staff, and
staff have access to protective equipment. The nurses indicated any cases of sexually
transmitted diseases for which youth are tested are automatically reported to the local health
department, as required. The center did not have any instances in which incidents reported to
the local health department or the Department’s Central Communications Center, nor three or
more cases of any reportable infectious diseases for which the local health department and/or
CDC had to be notified. The center did not have any youth and/or staff who had experienced a
facility/occupational exposure since the last annual compliance review. A review of seven pre-
service and seven in-service training records indicated all staff completed training on the
center’s specific Exposure Control Plan. The nursing interview indicated the Exposure Control
Plan is available to the nurses located in a binder in the clinic. The infection control training for
staff is conducted by the nurse manager and youth receive the training upon admission. The
nurse manager also trains the staff on the program’s Exposure Control Plan. The local county
health department is utilized to conduct immunizations, dental care, and prenatal care.
4.18 Prenatal Care/Education [Contract Provider] Non-Applicable
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 not had any pregnant youth throughout the annual compliance review period;
therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 40 of 52 (Revised July 2023)
Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures (FOPs) to ensure active supervision of youth by
staff. During the annual compliance review week, youth supervision was observed each day.
Center staff adhered to the daily activity schedule. Observations, during the annual compliance
review week, were made during the center tour. Youth were observed attending class as
scheduled, six youth in classroom A, eleven youth in classroom B, and eleven youth in
classroom C. Each classroom had two staff assigned and one teacher facilitating the class.
Each day during the remainder of the annual compliance review week, observations were
completed which confirmed youth were actively being supervised by the appropriate number of
staff. Three full days of education and group video were observed. Positive interactions between
staff and youth were observed during all three days. Staff maintained continuous sight
supervision of all youth in their assigned area. Staff were observed supervising youth by
controlling line movements, positioning themselves appropriately, and giving clear directions to
youth. The center staff were interacting appropriately with youth. All movements were
authorized by master control prior to the youth being moved. A review of the center’s logbooks
during the annual compliance review period confirmed all movements were logged and counts
were conducted consistently. Tracking daily census is completed by conducting head counts
throughout the shift and documenting in the logbook. Seven staff were interviewed; each stated
there were enough staff to provide adequate supervision, four stated they could use more staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 41 of 52 (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 requiring a uniform behavior management
system (BMS) providing rewards, privileges, and consequences for behavior. The center has a
system of rewards, privileges, and consequences for all inappropriate behavior. During a tour of
the center, postings of the BMS were observed in the living areas. A review of the facility
operating procedures on the BMS confirmed compliance with the components outlined in the
center’s policies and procedures. A review of point cards was conducted, confirming youth
receive their rewards and are being held accountable for their actions daily. The center prohibits
the use of group punishment and there were no instances of inappropriate use of restrictions or
group punishment displayed. Seven staff were interviewed. All seven staff demonstrated
knowledge of the point system. Six of seven staff had knowledge of the level system. Six of
seven staff stated the BMS is posted throughout the center and indicated the BMS is included in
the youth handbook and orientation process. One staff stated youth earn points daily with
positive behavior. Youth can also lose points for fighting and flooding. One staff stated when
youth arrive at the center, they are given a pamphlet stating the rules. During the daily
expectation meeting, youth are reminded of the rules and how to earn points. Points can be
earned by conducting hygiene, going to school, and positive behavior. Extra privileges are
provided to youth with higher levels. Points are deducted if youth cause disruptions to the
program. Three of seven staff stated when youth arrive, they are placed at a level two. Youth
receive points daily with good behavior. All seven staff stated when a youth reaches level three,
they are provided canteen, extra telephone calls, and extra leisure time. Youth are also able to
receive meals from their family on Sunday, and an extra snack on Friday. Six of seven staff
stated the BMS is effective. One stated the old BMS was more effective, because a youth did
not get their level back once it was lost. Six of seven staff stated they speak with youth to
discuss the consequences being imposed. All seven staff stated youth are given an opportunity
to explain their behavior. All seven staff stated youth are spoken to about alternative acceptable
behaviors and youth are allowed to explain their behavior. All seven staff stated they are
provided feedback from the supervisors by communicating with staff verbally, documenting in
the logbook, and shift briefings on how staff are implementing the BMS with youth. Six of seven
staff stated they receive feedback on the implementation of the BMS daily or as needed. Two
staff stated feedback on the implementation of the BMS occurs weekly. All stated levels can be
taken away as a consequence of inappropriate behavior. Six staff stated they have never seen
another staff take meals, snacks, clothing, education, or medical from a youth. One staff
indicated they had; however, provided no additional information. None of the staff ever heard
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Office of Accountability and Program Support Page 42 of 52 (Revised July 2023)
another staff encourage a youth to beat up another youth. Seven youth were asked to rate the
BMS. Five youth stated the BMS was good. One youth stated the BMS was fair. One youth
stated the BMS was very good, and every youth starts on level two. One of seven youth stated if
they misbehave, points and levels are lost. One youth stated if their level is high, they get
additional snacks, telephone calls, and parents/guardians are allowed to bring in food for them.
One youth stated if they do good then their level goes up each day. All seven youth stated all
staff reward the same. All youth stated youth are not allowed to punish other youth. Six youth
stated they are only locked in their room for showers, sleeping, and confinement. One youth
stated never being locked in a room. The superintendent stated during an interview the center
utilizes a point system. The point system includes incentives for level two and level three in
addition to each youth’s basic rights.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures (FOPs) requiring ten-minute checks to be
conducted when youth are in their rooms. The center has sixty-five surveillance cameras, and
all sixty-five were operational during the week of the annual compliance review. The center can
store video recordings for up to thirty days. An electronic wand system is used in the center to
document and collect data of the ten-minute visual checks. Staff tap an electronic wand on the
check point sensors on the outside of each youth’s assigned sleeping room door and the data is
downloaded as wand reports. A review of twelve samples of video over three different days and
their corresponding wand reports, including samples from each living module, revealed staff
conducted ten-minute checks as required. Staff were observed, during video observation from
three samples of thirty-minute increments from each shift, looking into the windows of each
sleeping room before tapping the wand to the check point sensor. The center operates with two
shifts from 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. Seven staff were interviewed, and
all staff stated room checks are conducted every ten minutes when placed in their room for
sleeping or non-punishment reasons. The superintendent interview indicated ten-minute checks
are conducted for all youth utilizing the Guard 1 Wand System, which staff were trained to use.
Checks are conducted while youth are secured in their room for showers, shift change, or
bedtime. While in confinement ten-minute checks are documented on a confinement visual
observation log. If a youth is on close watch checks are conducted every five-minutes on a
close watch form. If the youth are on secure observation (SO), the SO log is completed in thirty-
minute intervals along with the confinement visual observation reports (VOR) every ten minutes.
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Office of Accountability and Program Support Page 43 of 52 (Revised July 2023)
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures ensuring staff always know the exact number and
location of all youth under their supervision. During the annual compliance review week, staff
were observed conducting counts before and after every movement. Counts were also
observed during youth transitions to and from the dining hall for meals. All seven interviewed
staff stated counts are conducted at the beginning of each shift. Six of seven staff stated counts
are conducted at the end of the shift and before and after each meal. One staff responded if the
count is not correct, a physical head count is then conducted. One staff stated if the head count
is still not correct then it is placed in the logbook and the administrator is called. One staff stated
if the count is not correct, then all youth movement will be stopped. Seven staff were asked
when emergency counts are conducted and six stated when a youth is believed to be missing
and when visibility is hindered; seven stated after a major incident; five stated after a code is
called. Logbooks documenting youth census, counts, and tracking were reviewed from October
2023 through August 2024. All months reflected youth census, counts, and tracking were
documented at the beginning of each shift, following any emergency such as power outages,
and evacuations due to emergency drills. All reviewed months reflected youth census, counts,
and tracking were also documented prior to and following routine group movement, population
changes, and random head counts each shift.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 44 of 52 (Revised July 2023)
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) for logbook maintenance. The center has
separate logbooks for master control, each living module, visitors, and vehicles. A review of
eleven logbooks from September 2023 to the week of the annual compliance review found they
were bound with numbered pages. One logbook’s cover had fallen off. Thirty-four days in the
master control logbook and three days each month in each living module logbook were
reviewed. The master control logbooks and living module logbooks contained the date
documented at the top of page. All entries included the times of events in a.m./p.m. with the
name of staff, youth, brief description of events, and the initials of staff making the entries. All
entries impacting the safety and security of the center, including medical/special needs and
mental health alerts, were highlighted. Six out of thirty-four days reviewed in the master control
logbook had errors which were not struck through with a single line with “void” written after the
error followed by staff initials. The master control logbook contained emergency situations,
including the use of Right Interactions (RI) and calls to the Department’s Central
Communications Center (CCC) and Florida Abuse Hotline; however, some of the CCC calls
were missing. All Continuity of Operations Plan (COOP) drills, monthly fire drills, monthly
medical drills, and monthly mental health suicide drills were documented as required. There was
documentation of the center receiving medications from parents/guardians which was dropped
off at the center and medical and mental health alerts. Logbooks also included documentation
for counts for the beginning of shifts, end of shifts, emergency situations, group movement,
admission, releases, when law enforcement is on-site, searches to include frisk and electronic,
and youth placed in confinement with start and end times. Youth placed on precautionary
observation or secure observation were documented in the logbook as well with the date and
time initiated and ended. A review of the logbooks indicated education was conducted as
scheduled except for June 10, 2024, where Bravo was ten to twenty minutes late to class;
August 5, 2024, where Bravo was ten minutes late for period three, and on June 7, 2024 the
youth were let out early from period three. The juvenile justice detention officer supervisor
(JJDOS) reviewed the master control logbook when accepting responsibility for the center and
reviewed the living area logbooks daily. The juvenile justice detention officers (JJDOs) reviewed
the logbook entries from the previous shift when accepting responsibility for the living area.
Each logbook review designated the name and position of who reviewed and the date and time
the review was completed. The master control logbook included emergency situations,
incidents, all drills, documentation of receipt of medical/mental health alerts, population counts
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Office of Accountability and Program Support Page 45 of 52 (Revised July 2023)
at the beginning and end of each shift, population counts throughout shifts as counts changed,
youth counts following emergency situations, youth group movement, admissions and releases,
presence of law enforcement, names of youth placed in confinement with the time confinement
began and the time confinement ended, and name of youth placed on precautionary/secure
observation along with the time initiated and time ended.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures describing the center’s key control, issuance of
keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys, and reporting
and replacement of damaged keys. Missing or lost keys must be documented, and the
supervisor must be notified immediately; a Department’s Central Communications Center (CCC)
report is generated if any key is not found or located. An incident report is completed if any key
is damaged, and the key is replaced by the superintendent. An inventory of keys was
conducted, and all keys on the inventory matched the actual key rings in use. Keys are stored in
master control and the administration hallway. An observation of staff, during shift breaks,
displayed staff turning in their personal keys to receive facility keys. All keys were maintained on
a tamper-resistant ring. Emergency keys which provide egress through exterior doors are stored
in master control and the module sub-control rooms which staff can access. The master key
inventory included the ring number, number of keys on each ring, the capability of each key, and
to whom the key ring was issued. All key rings were numbered and indicated on the ring. The
facility keys were placed on color coordinated hubs and all colors matched the correct keys as
required. Each time a key was issued to staff it was documented in the shift report. Based on
observation, staff always carried keys on their person, and did not allow youth to handle facility
keys at any time. The key boxes in master control and in the administration hallway were not
easily accessible while locked. There were no incidents reported to the CCC relating to key
control concerns. A review of five key rings was conducted, and all key rings had the
appropriate number of keys on the ring as reflected in the inventory. Three staff were informally
interviewed, and they were able to accurately describe each function of the keys they
possessed. An informal interview was conducted with master control and the operator was able
to explain the process for restricting key usage. Seven staff were interviewed, and all seven
were able to fairly explain the key control process and which of the center’s keys are restricted.
The superintendent was interviewed and stated permanent keys are issued to administration
and the center has signed documentation of who each key is assigned to.
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Office of Accountability and Program Support Page 46 of 52 (Revised July 2023)
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains facility operating procedures (FOPs) for transportation, operation, and
maintenance of each vehicle used to transport youth. The center has a total of eight vans used
to transport youth. An annual inspection was completed by a certified mechanic on all eight
vans; documentation was provided to confirm the inspections. Documentation was reviewed
confirming monthly inspections were completed by the center’s maintenance mechanic or staff,
and included checking the vehicle’s water coolant, lights, oil, emergency equipment, brakes,
horn, interior, exterior, and cleanliness of the vehicle. One vehicle was out for service and the
other seven vehicles were current with the required oil changes. Inspections are also conducted
on the tires, battery, windshield, wipers, windows, mirrors, and for any damages. A physical
inspection of all the vehicles was conducted; each vehicle contained the appropriate number of
seatbelts, a seatbelt cutter, window punch, fire extinguisher, and first-aid kit. Each vehicle had
an assigned logbook for transport documentation which included acknowledgement the vehicle
was checked, destination, number of youth and staff names, name of the officer riding in the
back of the van, time transport began, and time transport ended. There were no transports
scheduled during the time of the annual compliance review for observation. Seven vehicles from
the center were checked to ensure vehicles were locked when not in use, all vehicles were
secured. Seven youth were interviewed, all stated they felt staff are driving safely when
transporting youth. In addition, all stated they have never seen anyone place contraband in
transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains facility operating procedures (FOPs) ensuring all tools and equipment
related to maintenance and the kitchen are properly maintained, stored, and inventoried. The
FOP also prohibits youth from having access to any tools, including kitchen and/or medical
equipment. According to the center’s FOP, youth are allowed to use cleaning items such as
mops, brooms, and other common household items when completing general cleaning under
staff supervision. Observations confirmed maintenance tools and kitchen sharps are secured
when they are not in use. A review of the monthly inventory sheets since the last annual
compliance review confirmed there were no missing maintenance or kitchen tools. All tools
listed on the kitchen’s inventory were present. The kitchen also maintained a continuous
inventory of tools upon use and return. An informal interview with the maintenance staff
confirmed service vendors are always accompanied by designated center staff while in the
secure area of the center. A review of the monthly inventory sheets during the annual
compliance review period confirmed there were no missing maintenance or kitchen tools. A
review of the inventory used to document the issuance and return of maintenance tools found
no discrepancies. An informal interview with maintenance and kitchen staff determined they
understood the process when there are missing or damaged tools. A sampling of ten
maintenance tools revealed all tools were secured, marked for easy identification, inventoried
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Office of Accountability and Program Support Page 47 of 52 (Revised July 2023)
accurately, and signed by the superintendent. During the center tour, it was observed a room in
Bravo three had a mop, broom, dustpan, and Class B tools. The room was marked with a sign
stating no youth in the room. The FOP does not state this room can be used to store Class B
tools. The tools were removed immediately. Seven interviewed staff were able to explain the
center’s practice for damaged and missing tools. The superintendent interview indicated the
maintenance mechanic, major, and captains have access to tools. An informal interview with the
captain indicated youth may use cleaning items such as mops, brooms, buckets, and other
common household items under direct supervision. Six youth stated they can use mops and
brooms and one indicated they have never used a tool. Six of seven youth stated they use tools
while cleaning, community service, and always use them under staff supervision. One youth
stated they have never used tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center maintains facility operating procedures (FOPs) ensuring the proper use, storage,
disposal, and inventory of chemicals including flammable, toxic, caustic, and poisonous
materials. The FOP also ensures limited access to flammable, toxic, caustic, and poisonous
items. Only authorized personnel are permitted access and use flammable, toxic, caustic, and
poisonous items. Youth are not permitted to use or handle hazardous chemicals. No toxic
materials were observed at the center in any place accessible to youth during the week of
annual compliance review. Observations of Bravo living module found room B3 to have laundry
soap with no Safety Data Sheets (SDSs) secured behind a locked door with a stop sign stating
no youth allowed. The FOP does not allow this. The laundry soap was removed. Observations
of G1 living module utility room, G1 living module supply room, and kitchen utility room
confirmed they did have inventories of all flammables, toxic, caustic, and poisonous items
during the annual compliance review week as well as SDSs in a binder. Inventories had an
accurate count of the chemicals present. A SDS binder was in the G1 utility room, G1 storage
room, in both the Bravo utility rooms, and kitchen. Maintenance secures chemicals in a
chemical shed located outside of the center. Flammable items are maintained in a locked
flammable cabinet within the chemical shed. Five items in the chemical shed were selected
randomly for review, and each had a SDS and accurate inventory of the selected five chemicals.
Seven youth were interviewed and all stated they do not handle chemicals or have access to
chemicals. One youth responded staff will spray the chemical and youth are able to wipe the
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Office of Accountability and Program Support Page 48 of 52 (Revised July 2023)
area. Seven staff were interviewed, and all stated youth are allowed to clean with chemicals
after staff spray them.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center maintains facility operating procedures (FOPs) ensuring the proper disposal of
hazardous items and toxic materials in accordance with Occupational Safety and Health
Administration (OSHA) guidelines. There were no chemical spills or disposal of flammable,
toxic, caustic, or poisonous items during the annual compliance review period. Kitchen staff
indicated grease is used for cooking and is disposed of by an outside contractor. An informal
interview with the maintenance mechanic indicated all hazardous materials are disposed
appropriately.
5.11 Confinement Under Twenty-Four Hours Failed 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 to govern the use of confinement for youth. Fifteen
incidents of confinement under twenty-four hours were reviewed for this annual compliance
review period. Fourteen of fifteen confinement records documented youth received scheduled
meals; the remaining record did not have documentation of one meal. Fourteen of fifteen
records were not applicable for requested/needed access to mental health care; the remaining
record did not indicate mental health care was offered to the youth. Eight of fifteen confinements
were during regularly scheduled daily showers; the remaining seven records were not during
this time. Four of eight records applicable for showers confirmed the youth were
provided/offered their daily shower; the remaining four did not have documentation to confirm
showers were offered/given. All fifteen records contained documentation the youth had clean
clothing and a mattress/bedding while in confinement. Nine of fifteen confinement records were
during the hours of educational instruction; the remaining six were during non-school hours or
on a weekend. Four of nine records contained documentation of educational materials being
provided to the youth; the remaining five did not have notations regarding educational material
access. Twelve of fifteen records confirmed the youth’s right to grieve a confinement placement;
the remaining three did not have any documentation this was reviewed. All fifteen records did
contain a supervisor approval prior to each confinement, and each youth was alone in a
confinement room. Eleven of fifteen records noted the room was searched prior to the youth
being placed; one of fifteen had a note the room was searched after the youth was placed in;
the remaining three records did not have any documentation confirming the room was searched
prior to placement. Eleven of fifteen records had fully completed Visual Observation Reports
(VORs) for the entire confinement, to include five-minute checks for the first hour and behavior
codes for observations made of youth; one record did not have any behavior codes; one record
did not have a VOR to review; and the remaining two records had one late five-minute check
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Office of Accountability and Program Support Page 49 of 52 (Revised July 2023)
each. None of the fifteen records were applicable for observed physical injury; therefore, they
did not need referrals. Ten of fifteen records contained documentation the reason for
confinement was explained to the youth; the remaining five records did not have this
documentation. Nine of fifteen records had a documented initial supervisor review within the first
hour of the confinement; one record had the initial review thirty minutes late; one initial review
was forty-eight minutes late; one initial review was ninety-four minutes late; one initial review
was 116 minutes late; one record did not have times documented for the initial review; and the
remaining record did not have an initial review documented. Twelve of fifteen records had the
full report completed by the end of the shift as required; the remaining three reports were not
completed by the end of shift. Twelve of fifteen records reviewed contained a supervisor review
at least every three hours during the confinement period; one record had one three-hour review
twenty-minutes late; and the remaining two records did not have three-hour supervisor reviews
noted. Ten of fifteen confinement records had documentation of staff continually counseling
youth and considered removing youth from confinement; the remaining five records did not have
these actions notated. None of the fifteen confinements interfered with scheduled visitation.
Eleven of fifteen confinement reports were reviewed within the required forty-eight hours by the
superintendent or designee; one report was reviewed fifteen days late; one report was reviewed
five days late; and the remaining two reports did not have a documented final review by the
superintendent or designee. The program did not have any pregnant youth in confinement
during the annual compliance review period. One of two confinement rooms was difficult to see
in due to lighting, although there were no scratches in the window. The captain was asked about
it and indicated they will open the door to observe youth if they are unable to see. The
remaining confinement room did not have any visual obstructions. The superintendent’s
interview confirmed the center ensures the appropriate use of confinements are tracked and
reviewed monthly with the regional chief, and regional management is alerted to each
confinement and Right Interaction incident from the Facility Management System within the
Department’s Juvenile Justice Information System (JJIS). These are reviewed bi-weekly with
regional staff and the superintendent. All seven interviewed staff confirmed education materials
are provided when a youth is in confinement during scheduled educational access times. Each
staff was able to explain the step-by-step process of placing a youth in confinement, to include
completing the confinement report, five and ten-minute checks, and searching the confinement
room.
5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 50 of 52 (Revised July 2023)
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains facility operating procedures (FOPs) establishing a procedure for
conducting drills to address the Continuity of Operations Plan (COOP). Quarterly hurricane drills
were conducted from November 2023 to August 2024. The documentation of the drills
contained the type of drill, date, and time of the drill, who participated and what actions they
took, a brief scenario and findings, and recommendations from the observers. The
superintendent interview indicated staff are trained in safety and security during Phase One
training annually. Seven staff were interviewed, and six staff stated they participated in weather
drills, two stated they participated in major disturbance drills, two stated they participated in a
bomb threat drill, three stated they participated in a flooding drill, one stated they participated in
a terrorism drill, and all seven staff stated they participated in an escape drill and fire drill. Three
of seven stated they have participated in a medical drill.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures (FOPs) to address escape drills and escape
prevention. Quarterly drills were conducted on each shift, as required, and documented in the
center’s logbook. Seven in-service training records and seven pre-service training records were
reviewed, and each staff completed training in security and escape prevention annually. Seven
staff were interviewed, and all confirmed completing escape drills annually.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a disaster plan, fire prevention plan, and evacuation plan addressing fire
prevention and safety in the center. The center conducted monthly fire drills on each shift, as
required. All thirty-one fire drills were documented in the logbook. Fire evacuation plans were
posted throughout the center. Each posting identified the primary and secondary exit routes and
locations of fire extinguishers, along with first-aid kits. All fire extinguishers had undergone a
completed annual inspection, as required. Seven interviewed staff stated fire drills take place at
least monthly. Seven youth were interviewed, and four indicated they did not know what to do in
case of a fire drill. The remaining three youth stated they had been instructed on what to do in
case of a fire.
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Office of Accountability and Program Support Page 51 of 52 (Revised July 2023)
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) in place for searches and to ensure
contraband is prevented from entering the secure area of the center. The policy includes
procedures for electronic, frisk, strip, room, and staff/visitor searches. An admission was not
able to be observed during the annual compliance review week. Youth returning from a
transport were not able to be observed during the annual compliance review week. There were
no strip searches conducted since the last annual compliance review aside from those
conducted upon admission. Searches of staff and visitors prior to entering the secure area were
observed. All observed people entering the center were electronically searched, all bags, cases,
jacket pockets, and other items were searched, and all prohibited items were secured prior to
the person entering the center. Staff were observed wearing gloves for each search.
Documentation of room searches for the past eleven months was found in module and master
control logbooks. A sample of shift reports since the last annual compliance review was
reviewed, and it was determined room searches are completed daily on each shift. There were
six instances of contraband being found at the center during the annual compliance review
period, all were reported to the Department’s Central Communications Center (CCC) within the
required time frame, and an incident report was completed for each incident. The center
documented all required information and responded in accordance with the center’s FOP. The
center’s visitors log contains a contraband attestation statement and requires all visitors
entering the center to complete a separate contraband attestation form. A review of seven staff
personnel records found all seven staff had a signed contraband attestation form. A review of
fourteen newly hired staff personnel records found ten had the signed contraband attestation
form, four did not. The superintendent interview indicated youth are searched when they leave
the center, transition from one area to another, during large movements, and in dining hall.
Contraband is secured, local law enforcement is contacted, and a report is made to the CCC.
Based on the outcome of the investigation from law enforcement, staff and youth can be
charged and corrective action will be completed.
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Office of Accountability and Program Support Page 52 of 52 (Revised July 2023)

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance

rule: Indicator 5.11

excerpt: Confinement Under Twenty-Four Hours

rating: Failed Compliance