facility_name: Pinellas 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
Pinellas Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated )
5255 140th Avenue North
Clearwater, Florida 33760
Review Date(s): December 17-20, 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:
Jeremy Curvan, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Marvin Bliss, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Kara Brown, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standard 1)
Cheryl Francis, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Evan Hald, Office of Educational Services, Education Coordinator (Standard 2)
Amanda Nelson, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Luis Rodriguez, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Sandra Thompson, Office of Accountability and Program Support, Regional Monitor (Co-lead,
Interviews, Video Review)
Program Name: Pinellas Regional Juvenile Detention Center MQI Program Code: 364
Provider Name: Department of Juvenile Justice Contract Number: NA
Location: Pinellas County / Circuit 6 Number of Beds: 95
Review Date(s): December 17-20, 2024. Lead Reviewer Code: 213
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
4.14 Chronic Conditions/Periodic Evaluations 5.03 Ten-Minute Checks*
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 53 (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 53 (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* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 53 (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 53 (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 Limited
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 53 (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* Failed
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 Satisfactory
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 53 (Revised July 2023)
Program Overview
The Pinellas Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Clearwater, Florida. The center serves youth in Pinellas counties in
Circuit 6. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the ninety-five-bed center. Youth
are provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Pinellas County School Board. The center’s
management team includes the superintendent, two assistant superintendents, one
administrative assistant, nine juvenile justice detention officer (JJDO) supervisors, and sixty-five
JJDOs. Mental health and healthcare services are provided through the contracted provider,
Vital Core Health Strategies, LLC. Mental health services are provided by ten staff; one
designated mental health clinician authority (DMHCA), one back-up DMHCA, one full-time
licensed mental health staff, five pro re nata (PRN) licensed mental health staff, one travel
licensed mental health staff, and one non-licensed mental health staff. Clinical services provided
by the center include mental health and substance abuse evaluations, mental health treatment
planning, individual, group, and family therapy, mental health crisis intervention services, on-site
psychiatric services, and availability for substance abuse services for youth with co-occurring
disorders. Medical services are provided by two designated health authority (DHA) positions,
one serves as a back-up, one advanced practice registered nurse (APRN), two registered
nurses (RNs), one licensed practical nurse (LPN), and one medical records clerk. The medical
clinic maintains nursing coverage Monday through Friday, from 7:00 a.m. until 7:00 p.m., and
Saturday and Sunday, from 7:00 a.m. through 5:00 p.m. Food services are provided by
Department staff and include menus, meal planning, meal schedules, special diets, nutritional
analysis, daily allowance, food preparation, health certifications, food product standards,
sanitation, and cleaning. Staff are responsible for the custody and control of youth in their care,
providing youth supervision twenty-four hours a day, seven days a week. The center has five
living modules which are divided by male and female. At the time of the annual compliance
review, one of the modules was out of service and had no youth assigned. There are 106
security cameras at the center, of which 106 were operational. During the tour, the facility was
found to be generally clean and with no major maintenance or security issues. The grass was
mowed and well-manicured. At the time of the annual compliance review, the center had
seventeen vacancies, which included one assistant superintendent, five JJDOIs, and eleven
JJDOIIs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 53 (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 (FOPs) for volunteers, mentors, and interns who
work with youth less than ten hours a month requiring sight and sound supervision. All
volunteers, and mentors must complete an application for service which requires them to sign a
code of ethics, Prison Rape Elimination Act document (PREA), and background screening. The
center submitted their Annual Affidavit of Compliance with Level 2 Screening Standards on
January 31, 2024. The school board submitted their annual Affidavit of Compliance with Level 2
Screening Standards also on January 8, 2024. A total of eighteen staff, and four contracted staff
were reviewed for initial background screening requirements. Reviewed personnel records for
twenty-two staff indicated each staff had a completed background screening and documented
criminal history report review prior to their hire date in the Department’s Background Screening
Unit (BSU). Each staff reviewed was rated as eligible for hire with no exceptions. Sixteen of the
twenty-two total staff were applicable for the pre-employment assessment tool. Two of the staff
were hired as administrative assistants and twelve volunteers were not applicable for taking the
assessment. Three were contracted staff hired as nursing staff and one was hired as mental
health staff, therefore, they were not applicable for taking this assessment. Thirteen applicable
staff had evidence of the passing assessment score in their personnel records. Three applicable
staff did not have a passing assessment score, and two of the three staff completed the
remedial training for the pre-employment screening tool. One staff did not have a copy of the
completed remedial training; however, the center did have evidence it was submitted. The
contracted provider, Vital Core Health Strategies, LLC, did add the contracted staff to the
Clearinghouse employee roster for all four records reviewed.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center had a total of three staff applicable for five-year rescreening requirements. All three
staff personnel records which were reviewed had a completed rescreening. The re-screenings
were completed within the twelve-month requirement, and none of the three personnel records
were submitted late.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 53 (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.
Eight reviewed staff records were applicable for violations of the staff code of conduct, and two
reviewed staff records reviewed were applicable for commendations. Each staff personnel
record was reviewed and contained evidence which confirmed management took action with
each staff for allegations and/or findings in direct violation of the center’s code of conduct. All
eight staff had evidence of staff signing the code of conduct form. Two staff reprimands resulted
in retraining, three staff were terminated, one staff was unable to operate a state vehicle, one
staff received a substantiated use of force, and one staff received a written reprimand. Two
different staff records were reviewed which contained commendations and/or awards during the
annual compliance review period. One staff received the Department’s Food Service Director of
the Year award. The other staff received the Food Service Worker of the Year award. The
center’s superintendent was interviewed and stated if there is an allegation of abuse, the staff is
removed from youth contact and the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC) is contacted. Based on the outcome of the investigation,
corrective action will be taken. Nine staff were interviewed, and all stated youth are allowed to
make a call to the Florida Abuse Hotline or the CCC. Nine staff stated they allow the youth to
make the call and they notify the supervisor, six stated staff can make the call, and four staff
stated they notify the superintendent. When asked if they have heard a staff use profanity when
speaking with youth, six staff stated never, and three staff stated occasionally. When asked to
clarify, the staff stated it’s a stressful job, and they have unfortunately witnessed it on occasion.
When asked if they have heard staff use threats or intimidation when interacting with youth,
eight staff stated never, and one staff stated once. The staff did not want to elaborate on the
statement. This information was shared with the superintendent. Nine staff were asked about
working conditions at the center in the past year, four staff stated they were fair, three staff
stated the conditions were good, and two staff stated they were very good. Nine youth were
interviewed, and each youth confirmed they have never been stopped from reporting abuse to
the Florida Abuse Hotline since they have been at the center. All nine interviewed youth
confirmed staff are respectful when talking with all youth at the center. Seven youth stated they
have never heard staff use curse words when speaking with them or other youth; however, two
youth stated they occasionally hear staff use curse words when speaking with youth. Nine youth
said they have never heard a staff threaten any youth at the center. Eight youth said they do
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 53 (Revised July 2023)
feel safe at the center; however, one youth said they did not feel safe because it’s jail. Nine
youth said they have never exchanged emails, telephone numbers or social media contact
information with staff.
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center had a total of 119 incidents reported to the Department’s Central Communications
Center (CCC) for the annual compliance review period, twelve of which were reviewed. All
twelve reports were documented as reported to the CCC within the two-hour required time
frame. All twelve reports were documented in the center’s master control logbook. The center’s
superintendent was interviewed and explained the center’s incident reporting process. The
superintendent said all CCC reportable incidents are reported to the regional director and CCC
within two hours of gaining knowledge of the incident.
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 had 274 documented Right Interaction (RI) incidents reported during the annual
compliance review period. Nine RI incidents were reviewed for reporting and documenting
requirements. Six of the reports were completed by the end of the staff’s workday. Three of the
reports were not completed by the end of the staff’s workday. The center stated the incidents
occurred during Department-wide system outages and no staff had access to any computer
systems/emails. No Department’s Juvenile Justice Information System (JJIS) number would
have been generated. The incident happened prior to the staff being off for their three-day
rotation. Paper reports were completed upon their return to work. All nine reports included
statements from each staff involved. None of the incidents had evidence there were injuries to
either the youth or staff involved. None of the reports had evidence the youth made allegations
to the Florida Abuse Hotline. All nine reports were reviewed by a supervisor or RI certified
supervisor. None of the youth required a medical review. None of the incidents involved
mechanical restraints. All nine incidents had documentation the post-RI interview was
conducted within the thirty-minute time frame from the time of the incident. All nine RI incidents
had evidence the superintendent/designee reviewed the report within seventy-two hours from
the date/time of the incident. The center’s RI rate during the previous quarter was 15.86, which
was above the statewide detention RI rate of 9.79. Nine interviewed staff stated the staff try to
talk to the youth prior to using physical restraints. One staff elaborated and explained putting
hands on a youth is the last resort. The superintendent was interviewed and stated the physical
and mechanical restraints are tracked by utilizing the mechanical restraint log and JJIS/Florida
Model Jail Standards (FMJS). The superintendent explained the process for monitoring RI
incidents and use of force which are documented in JJIS, supervisory and administrative
reviews which include reviewing the RI report, and Closed-Circuit television (CCTV) to ensure
compliance.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 53 (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.
Nine staff training records were reviewed for pre-service training requirements. Eight of the nine
staff records confirmed pre-service training and certification requirements were completed within
180 days of hire. One staff record was two days over the 180 days of hire requirement. Eight of
the staff completed a new staff orientation within thirty days of hire, and one staff record was not
applicable. Eight of the nine reviewed staff completed Phase Two training at the Department’s
Academy, which consisted of 120 hours of training for each staff. One of the nine staff was not
applicable. One staff reviewed was a rehire and completed trainings including active shooter
preparedness, cardiopulmonary resuscitation (CPR), first-aid, and the automated external
defibrillator (AED), human trafficking intervention, Information Security Awareness, mental
health and substance abuse, Prison Rape Elimination Act (PREA), Right Interactions update,
professionalism, interpersonal communication, ethics, sexual harassment, suicide awareness
and prevention, and trauma responsive practices. All trainings were documented within the
Department’s Learning Management System (SkillPro) for all nine staff.
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.
Nine staff training records were reviewed for annual in-service training requirements. Six of the
reviewed staff were juvenile justice detention officers (JJDOs), and three of the staff were JJDO
supervisors. All nine staff exceeded the required number of hours for in-service training and
completed between sixty-two and seventy-seven hours. All nine staff received training in Right
Interactions (RI), as well as cardiopulmonary resuscitation (CPR), first-aid, and automated
external defibrillator (AED) training. All nine staff received the required hours for suicide
prevention annual training. All nine staff had active shooter, human trafficking training,
emergency care plan, infection control training, exposure control plan, and escape prevention
and fire prevention plan/disaster procedures. All three supervisory staff received an additional
eleven hours of supervisory specific training. All trainings were documented in the Department’s
Learning Management System (SkillPro). The center has a licensed nurse who provided in-
service education on girls’ healthcare annually to all non-healthcare staff involved in the
supervision or treatment of girls. The center does maintain an annual in-service training
calendar, which is updated as changes occur. The center provides the annual in-service training
calendar which was approved by the superintendent, and the assistant secretary of detention
which was evident by a signature. The calendar did not have a signature from the director of the
Department’s Office of Talent, Leadership, and Culture. The superintendent was interviewed
and elaborated about the management training they received which consisted of pre-service
and leadership training, and training with corrections in previous leadership roles.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 53 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
A review of grievances for the annual compliance review period found a total of zero grievances
completed by youth. Grievance forms are available for youth access and are maintained on
each mod in the staff drawer. Nine staff were interviewed, and all summarized the grievance
process. Nine youth were interviewed concerning the center’s grievance process, and four of
the nine have never filed a grievance. One youth reported the grievance process was fair, and
the other four youth rated the process good. Five of the nine youth summarized the grievance
process. Two youth were unsure of the process. Two youth stated youth write it down and hand
it to staff. The center’s superintendent was interviewed regarding the grievance process and
stated the youth are given the opportunity to submit a grievance. The officer submits the
grievance in the Departments Juvenile Justice Information System (JJIS) if they are unable to
resolve the issue. If the youth is not satisfied with the outcome, it will be sent to the sergeant for
appeal. If the youth is still not satisfied it will be appealed to the administration. The
superintendent explained the grievance forms are uploaded into JJIS/Facility Management
System (FMS) and the grievance remains in JJIS.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 53 (Revised July 2023)
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.
Nine youth were selected for a review of alerts entered by the center. A total of thirty-five alerts
were entered for the nine youth selected. All thirty-five alerts had evidenced the alert was
entered and/or closed on the date required. The Department’s Juvenile Justice Information
System (JJIS) alert reports were not reviewed daily by supervisors and administrators; however,
the center stated the supervisors review the reports during daily debriefs. There was no
documentation of administration reviewing the JJIS alerts daily. Information regarding youth
alerts being shared with all staff occurs during shift briefing which is held in the training room
with supervisors and floor staff. The supervisors hand out the alert sheet and talk with staff
about recent events at the center and staff assignments. The center’s shift briefing minutes
were reviewed for identification of youth with alerts. A shift briefing was observed in the training
room with supervisors and floor staff. The superintendent was interviewed regarding the
center’s medical alert process and stated the admitting officer will bring it to the attention of the
medical staff if the youth have any alerts. Medical will then confirm with the parent/guardian.
Nine staff were interviewed regarding how they are informed of alerts, and all stated it was
written in the logbook and on alert forms, and eight staff stated they are informed during shift
briefings. One staff elaborated and explained staff are informed during debriefing and given the
alert on paper. Nine staff were asked how management informs staff about issues within the
center and five staff stated logbooks, nine staff stated staff debriefings, one staff stated alerts,
five staff stated meetings, one staff stated they may be pulled aside, and one staff stated all
issues with the youth are debriefed for the previous twelve hours. Nine staff were interviewed
and asked how effective they believe this process is for communicating information. Five staff
stated very good, three staff stated good, and one staff stated fair.
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 utilizes information gathered from various reports found in the Department’s Juvenile
Justice Information System (JJIS) and the information is disseminated. The center shares the
information either in person, or by email on a quarterly basis with stakeholders. Furthermore,
the information is disseminated during the superintendent’s monthly meetings, education
meeting, mental health and medical meeting, safety meeting, youth focus group, and treatment
team. The center’s management team reviews the reports and any trends noticed are discussed
during these management meetings. Monthly meetings are held with administration and center
staff during which specific topics are discussed. The meeting is open for staff to discuss issues
and ask questions. Documentation of monthly meetings was provided for the annual compliance
review period and found data trend analysis topics were discussed. The superintendent
provided documentation of the data reviewed which included Right Interactions model (RI),
behavior management reports, and all staff reports.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 53 (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 (FOPs) in place to ensure proper screening,
evaluation, and documentation of each youth, ensuring all youth are admitted into the center in
accordance with Florida Administrative Code. A review of nine Admission Wizard forms from the
Department’s Juvenile Justice Information System (JJIS) found documentation of a Detention
Risk Assessment Instrument (DRAI), Suicide Risk Screening Instrument (SRSI), and an arrest
affidavit or order to retain the youth in custody. Reviewed documentation confirmed all nine
youth had a full body visual search and/or electronic search. Each youth record documented all
nine youth received a telephone call and were evaluated for medical, mental health, and
substance abuse needs upon admission. An observation of a youth admission process was able
to be completed during the annual compliance review week. The youth was offered a meal and
a telephone call to their parent/guardian during the admission process. All procedures were
followed during the admission process.
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
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The center has facility operating procedures (FOPs) to ensure each youth admitted into the
center is informed of the center rules and regulations, grievance procedures, visitation,
telephone calls, expectations for behavior, related consequences for failing to meet behavior
expectations, and youth rights within twenty-four hours of admission. Nine youth case
management records were reviewed, and each included an orientation packet which was
completed within twenty-four hours of admission. All nine reviewed case management records
had documentation to validate the orientation was explained verbally and in writing by the
juvenile justice detention officer (JJDO). Each of the nine orientation packets included
information on rules and regulations, youth rights, dress code, personal hygiene, visitation,
telephone calls, education, daily schedule, mental health, grievance procedures, access to
medical, mental health and substance abuse services, access to the Florida Abuse Hotline,
access to the Department’s Central Communications Center (CCC), the behavior expectations,
the behavior-related consequences, and Prison Rape Elimination Act (PREA) related
information. Each of the nine reviewed case management records had an orientation
acknowledgement form and handbook cover page signed by the youth. Nine youth were
interviewed regarding the orientation process and all reported they had been provided
information regarding the center’s rules and regulations, daily schedule, education services,
visitation, abuse reporting, and behavior management system. An observation of a youth
admission process was able to be completed during the week of the annual compliance review
and the observation found the staff to verbally explain the admission forms to the youth while
the youth read along. The staff and youth then signed the forms. Observations also found the
orientation videotape including the PREA guidelines were playing in the youth seating area.
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.
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The center has facility operating procedures (FOPs) ensuring all youth admitted into the center
are classified to ensure the highest level of safety and security. The center’s policy listed all the
required elements, including human trafficking information. All youth are given a room
assignment based upon their classification and may be reclassified if there are any changes in
the status or behavior. The center reviews several factors prior to placing the youth into a room
inclusive of height, weight, age, gender, level of aggression, mental illness, developmental
disabilities, physical disabilities, history of violence, gang affiliation, criminal history, history of
sexual offenses, vulnerability to victimization, suicide risk identified or suspected, medical, and
security and escape risk. Youth with a history of committing sexual offenses, who were a victim
of a sexual offense and/or abuse, or youth determined to be physically or sexually aggressive
are not to be placed in a room with any other youth. Additionally, the policy requires a review of
the Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) results documented
by the staff when making a youth’s room assignment. All room assignments are documented in
the Department’s Juvenile Justice Information System (JJIS). All youth requiring a single room
shall have an alert entered in JJIS. Nine youth case management records were reviewed for
classification. Each reviewed record contained a copy of the JJIS Admission Wizard
documentation, which included the classification results and the screening for VSAB. Each
reviewed youth case management record contained the VSAB form and the Suicide Risk
Screening Instrument (SRSI). All nine records contained a classification form which identified
the module or room classification of where the youth was placed. None of the nine youth had a
history of sexual offenses including sexual battery charges which were reduced to a lesser
offense or a history of human trafficking. None of the nine youth records required a
reclassification. An interview with the superintendent confirmed the admitting officer is to follow
the classification process as outlined in the FOP and is informed of how to identify youth with a
gang alert of a history of gang activity by email.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures (FOPs) in place to ensure all information regarding
suspected youth gang affiliation is shared with the circuit gang representative. The center’s
admission juvenile justice detention officer supervisor (JJDOS) has been designated to serve as
the gang representative for the center and is responsible to correspond with the chief probation
officer (CPO) regarding all suspected gang activity. The center is required to enter the
suspected gang affiliation alert into the Department’s Juvenile Justice Information System (JJIS)
if there is a youth suspected to have gang affiliation. Staff are notified of all updates and alerts
during shift briefings and on the daily alert sheet. An informal interview with the designated gang
representative confirmed the center’s practice. Nine youth case management records were
reviewed in which three of the records were applicable for gang affiliation. All three applicable
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Office of Accountability and Program Support Page 18 of 53 (Revised July 2023)
youth had a referral for suspected gang involvement shared by email with the CPO designated
as the circuit gang representative indicating suspicions of gang activity such as youth flashing
gang signs, gang tattoos, gang-related drawings, or related activity.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures (FOPs) in place ensuring the proper safe handling
and security of personal property, including valuables, which are collected and secured at the
time of a youth’s admission. All youth personal and valuable property are inventoried in the
Department’s Juvenile Justice Information System (JJIS), maintained securely, and returned to
the youth or the parent/guardian in a timely manner upon the youth’s release. Personal items,
such as clothing and shoes, are placed in a mesh bag and secured in the center’s inventory
locker room. Valuable items are listed and placed in a clear tamper-proof property bag,
identified with the youth’s name and Department identification number (DJJID), then secured in
the property cabinet located in the admission office which is under video surveillance and only
accessible by designated staff. Valuable items are secured in the drop safe located in the
admission office. The center maintains a drop safe logbook to document the time, youth’s name,
name of the juvenile justice detention officer (JJDO) securing the property, and the JJDOs
initials. Nine youth case management records were reviewed, and each contained
documentation of a letter of acknowledgement of unclaimed property signed by the youth and
staff. Each record contained Property Receipt forms documenting the assigned locker for
personal items. An observation of all nine personal property bags was conducted and each
contained an inventory form. Two of the nine reviewed youth case management records were
applicable for having a Property Receipt form and each of the two contained a Property Receipt
form for valuable items. An admission was able to be observed during the annual compliance
review week; however, none of the youth being admitted had valuable property to be secured.
The drop safe bound logbook contained all required elements for the applicable three reviewed
youth closed records. The three applicable youth with valuable items had the items stored in a
clear tamper-proof bag and securely stored in the drop safe. A review of the Department’s
Central Communications Center (CCC) reports since the last annual compliance review found
no incidents regarding youth property. All nine interviewed youth reported staff check their
property inventory and each youth who signed the inventory was correct. The superintendent
interview confirmed the center’s property storage practice.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
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by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has facility operating procedures (FOPs) in place to ensure all releases from the
center occur promptly and accurately. Three closed youth case management records were
reviewed. The on-duty juvenile justice detention officer supervisor (JJDOS) verified each youth’s
release by reviewing the court order and signing the secure detention release form. Each of the
closed youth records had the appropriate documentation including a copy of photo identification
of the person taking custody, youth and parent/guardian notifications for any future court dates,
and a review of any pending or historic child abuse investigations related to trafficking, charges
of child abuse, drug trafficking, or prostitution. All parties signed all required release forms for
each of the three applicable youth records reviewed. None of the released youth had an alert
reflecting an endangered person. The release date in the Department’s Juvenile Justice
Information System (JJIS) corresponded with the youth’s correct release date in each reviewed
record. A youth release was able to be observed during the annual compliance review week and
the staff conducting the release followed the FOPs 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 (FOPs) in place to ensure all youth personal
property is released to the youth or the youth’s parent/guardian. The parent/guardian, youth,
and staff must sign a receipt acknowledging all property was returned upon the youth’s release.
A review of three closed youth case management records revealed each youth record contained
the required information with all required signatures of receipt of youth’s personal property.
Each record contained identifying documentation verifying each youth was released to an
appropriate person. One of the three closed records was applicable for the youth and person
the youth was being released to being reminded of any health or welfare issues, including
medical, mental health, and/or substance abuse needs, and any pending appointments as
required. One of the three youth records was applicable for a receipt of medications to be
signed by the person receiving the youth and the document was signed as required. The center
did not have any inventory of unclaimed property held more than thirty days during the annual
compliance review period.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures (FOPs) ensuring detention reviews are
conducted weekly for youth securely detained, placed on home detention, or placed on
electronic monitoring to ensure proper management of youth and the sharing of information.
Detention reviews are conducted on a weekly basis to address the status of each youth. The
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center’s admission juvenile justice detention officer supervisor (JJDOS) has been appointed to
coordinate the weekly detention reviews. The superintendent reported detention reviews are
conducted every Wednesday at 1:00 p.m. for Circuit 6 and 2:00 p.m. for Circuit 10. Detention
reviews are completed by video conferencing. Updates are provided regarding the youth’s next
court date, behavior while in detention, residential placement status, and release status.
Reviewed documentation found the reviews were conducted with the center’s staff including
medical, education, mental health, commitment, and representatives from probation. All staff
attended by video conferencing and the video conferencing attendance logs were being
maintained for each meeting. Attendees from outside the center participated virtually utilizing
video conferencing. An interview with the superintendent confirmed detention reviews are
conducted weekly by video conference.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has facility operating procedures (FOPs) addressing the daily activity schedule. The
center’s daily activity schedule includes daily expectations in accordance with the behavior
management system (BMS), education, mealtimes, visitation, indoor and outdoor recreation,
shift changes, bedtimes, groups, and open center time. The center provides and maintains
weekday, weekend, and holiday schedules. Observations during the annual compliance review
week revealed schedules are posted throughout the center along with a monthly activity
calendar. Visitations are held twice a week for youth. During the morning and early afternoon
hours, youth are participating in education. Reviewed documentation reflected activities
included behavior management incentive parties, and a variety of recreational activities. A
review of the center’s logbook and observations confirmed the center adheres to the daily
activity schedule. Nine youth were interviewed, and each youth reported the center has a daily
schedule which is followed. Nine staff were interviewed, and all reported the daily schedule is
followed unless circumstances do not permit.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to provide educational access. The center provides
education services through the Pinellas County School District. A review of the daily school
schedule revealed the center provides six fifty-minute class periods daily, fulfilling the weekly
requirement of twenty-five hours of instructional time. The school schedule was also reviewed
and coincides with the provided facility daily activity schedule. A review of twelve randomly
chosen dates, one a month from January through December 2024, demonstrated the daily class
schedule was adhered to, and classes were facilitated as they were scheduled. A review of
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video from three random dates on December 4, 2024, December 11, 2024, and December 18,
2024, also confirmed the adherence to the daily school schedule. Nine youth were interviewed,
with eight reporting they attend school Monday through Friday, and one indicating sometimes
they don’t have enough staff and they sometimes do not have school all day. Seven youth felt
the school was preparing them very well regarding preparation towards high school equivalency
diploma (GED), high school, vocational school, employment, and/or college, while two stated
they felt the school was preparing them well. Nine staff were interviewed, and all felt there was
minimal interference in educational services. The interview with the superintendent also
reported there is minimal interference with educational services.
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 students,
offering a Type 1 program which includes communication, interpersonal, and decision-making
skills. The center currently employs career education software to provide diverse career learning
opportunities. Nine youth were interviewed, and all reported they were taking core classes such
as math, science, history, reading, social studies, career choices, and Life Skills.
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Office of Accountability and Program Support Page 22 of 53 (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 detention center.
The DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the detention center and
shall promote consistent and effective services and allow the superintendent and staff a
specific source of expertise and referral.
The center has facility operating procedures which provide for a single licensed mental health
professional working as the designated mental health clinician authority (DMHCA) who is
responsible for the coordination and implementation of mental health and substance abuse
services at the center. During the annual compliance review period, the center employed two
DMHCAs. The current DMHCA began providing services at the center in August 2024. Both
DMHCAs are licensed mental health counselors and have clear and active licenses which
expire on March 31, 2025. The center has two staff, a licensed clinical social worker (LCSW)
and a licensed mental health counselor (LMHC), both designated as back-up to the DMHCA.
Both back-up DMHCA staff have clear and active licenses which expire on March 31, 2025. A
review of sign-in sheets and the position description confirmed the DMHCA is on-site at
minimum of forty hours weekly. An interview with the DMHCA confirmed the DMHCA is
responsible for coordination, implementation, and oversight of mental health and substance
abuse services at the center. The DMHCA provides weekly supervision for non-licensed clinical
staff.
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 facility operating procedures to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The center contracts with a
provider to employ one designated mental health clinician authority (DMHCA) and one
additional licensed mental health and substance abuse clinical staff. The center currently has a
DMHCA and two additional licensed clinical staff. The center has two staff, a licensed clinical
social worker (LCSW) and a licensed mental health counselor (LMHC). Both licensed clinical
staff have clear and active licenses which expire on March 31, 2025. The provider also employs
pro re nata (PRN) clinical staff to provide services as needed. Ten licensed clinical staff
provided PRN services at the center during the annual compliance review period. The center
also employed two full-time licensed clinical staff during the annual compliance review period,
who are no longer employed at the center. Each of these additional twelve clinical staff who
provided services during the annual compliance review period have a clear and active license
which expire on March 31, 2025.
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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 to ensure mental health and substance abuse
services are provided by staff with the appropriate qualifications. The designated mental health
clinician authority (DMHCA) must ensure clinical staff working under their supervision are
performing services the staff are qualified to provide based on education, training, and
experience. The center had two non-licensed master’s-level clinical staff during the annual
compliance review period. Both staff are/were registered clinical social work interns. Only one of
the non-licensed clinical staff members is still employed at the center. The center is not required
to provide a specific amount of non-licensed clinical staff hours as stipulated in the provider’s
contract. A review of documentation confirmed each non-licensed mental health clinical staff
working under the direct supervision of the DMHCA received a minimum of one hour a week of
on-site, face-to-face direct supervision, by a licensed mental health professional, for the purpose
of overseeing and directing the mental health services provided in the center during the annual
compliance review period. The center does not have Chapter 397 license; therefore, all
substance abuse services are provided by licensed clinical staff. A review of substance abuse
group sign-in logs and nine youth mental health and substance abuse records confirmed this
practice. Documentation confirmed both non-licensed clinical staff have completed twenty hours
of training and supervised experience in assessing suicide risk, mental health crisis intervention,
and emergency mental health services. The training included administration of five
Assessments of Suicide Risk (ASRs) conducted on-site in the physical presence of a licensed
mental health professional.
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 which address mental health and substance abuse
needs of youth which 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 center reviews all screening documentation
completed by the probation/juvenile assessment center staff to include the Massachusetts
Youth Screening Instrument, Second Version (MAYSI-2) in the Department’s Juvenile Justice
Information System (JJIS) and the Suicide Risk Screening Instrument (SRSI). Nine youth
mental health and substance abuse records were reviewed. Each youth had a completed
MAYSI-2 and SRSI entered into JJIS. Nursing and mental health clinical staff completed the
required section of the SRSI for each youth. Seven of the nine reviewed youth had at least one
positive response on the SRSI and included a “yes” response for previous suicide alerts. All
seven applicable youth were placed on suicide precautions and a mental health referral was
submitted. All screening assessments were completed by trained staff. All nine reviewed youth
were applicable for requiring further assessment due to responses on MAYSI-2 and/or SRSI.
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Office of Accountability and Program Support Page 24 of 53 (Revised July 2023)
Five of the nine reviewed youth were applicable for all negative responses on the MAYSI-2;
therefore, the assessment was marked as invalid, and youth were referred to mental health
clinical staff. Each youth record contained a mental health referral and notification to the
superintendent/designee. During the annual compliance review period, the center had a minor
deficiency for a late SRSI. This deficiency was closed on October 25, 2024.
3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
The center has facility operating procedures to ensure youth identified by screenings, staff
observations, or behaviors post-admission and are in need of further evaluation will be referred
for a combined mental health and substance abuse comprehensive evaluation by the thirty-first
day after admission. Nine youth mental health and substance abuse records were reviewed.
Four of the nine reviewed youth were applicable for having been in the center for at least thirty-
one days and requiring a comprehensive evaluation. Each of the four youth received an
evaluation within thirty-one days of admission. The center did not receive an evaluation from the
juvenile probation officer for any of the reviewed youth. Each applicable youth’s evaluation
included treatment recommendations made which corresponded to all diagnosed mental health
or substance-related disorders. All evaluations were completed in the Department’s Office of
Health Services Electronic Medical Record. No comprehensive assessments were completed
by a community provider. An interview with the designated mental health clinician authority
confirmed this practice.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
The provider’s contract requires the superintendent and designated mental health clinician
authority (DMHCA), or mental health/substance abuse clinical staff, to ensure the development
and review of an initial and/or individualized treatment plan for each youth receiving mental
health/substance abuse treatment in the center. Nine youth mental health and substance abuse
records were reviewed. One youth was applicable for requiring a mental health orientation and
received an orientation within fourteen days. Four out of nine youth required treatment within
seven days of admission; therefore, a mental health orientation was not required. Three out of
the four applicable youth requiring treatment received an initial treatment plan within seven days
of initiation of treatment as required. One of the four applicable youth requiring treatment
refused treatment, so an initial treatment plan was not required. The remaining four youth did
not require a mental health orientation due to having been at the center less than fourteen days.
Three youth records had an initial treatment plan in place within seven days of initiation of
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Office of Accountability and Program Support Page 25 of 53 (Revised July 2023)
treatment which was developed on the Department’s Initial Mental Health/Substance Abuse
Treatment Plan form. Two youth records were missing the required elements of the frequency
for their counseling, and one youth’s initial plan did not include the names and dosages of the
youth’s psychotropic medications. All three initial treatment plans were completed and signed by
a licensed clinical staff member. Each initial treatment plan was developed and signed by the
youth and members of the mini treatment team. Four of the nine reviewed youth were applicable
for an individualized treatment plan (ITP). The youth who originally refused treatment decided to
engage in treatment by their thirty-first day at the center. The remaining five youth were not
applicable for an ITP as they had not been at the center at least thirty-one days. All four
applicable youth’s ITPs were completed prior to their thirty-first day at the center. Each ITP
identified a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, treatment-focused symptoms, treatment goals, and strengths/needs. Three of the
four records were applicable for psychiatric services or pharmacological interventions and two of
the three ITPs matched medications listed on the initial treatment plan. The remaining
applicable youth did not have medications listed on their initial treatment plan. All ITPs were
signed by the youth, mental health professional, treatment team members, and the
parent/guardian, when applicable. Two of the four youth were applicable for an ITP review
completed every thirty days by the treatment team. The ITP reviews for both youth were signed
by all treatment team members and the youth; however, one of the two youth had missing
signature dates for the youth and one treatment team on their ITP reviews. The ITP reviews
were completed every thirty days for both youth, except one month for one youth was one day
late. No youth were applicable for having been an alleged victim of a Prison Rape Elimination
Act (PREA) incident. One of the two youth applicable for ITP reviews was applicable for
psychiatric services, which were documented as required. A review for progress notes
confirmed each youth was receiving treatment services as designated on their ITPs. None of the
nine reviewed youth were applicable for a Mental Health/Substance Abuse Treatment
Discharge Summary. Three additional records were requested for a minimum sample of three.
Each youth had a discharge summary which was completed on the Department’s Mental
Health/Substance Treatment Discharge Summary form upon each youth’s transition/discharge
and a copy was provided to the youth, parent/guardian, and juvenile probation officer. Each
discharge summary was completed on the day of service in the Department’s Office of Health
Services Electronic Medical Record, signed by licensed clinical staff, and all additional
documentation was uploaded within fourteen days as required. A mini-treatment team was not
observed during the week of the annual compliance review due to none being held. An interview
with the DMHCA confirmed the provider’s practice. During the annual compliance review period,
the center had a minor deficiency for late treatment plans and missing treatment refusal forms
and progress notes. This deficiency was closed on October 25, 2024.
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.
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The center has facility operating procedures which ensure mental health/substance abuse
interventions are provided to applicable youth to reduce or alleviate symptoms of mental
health/substance abuse issues. Nine mental health and substance abuse records were
reviewed and four were applicable for receiving treatment services, one youth refused services,
and the five remaining youth were not applicable. Each applicable reviewed record contained
the properly executed consents for mental health and/or substance abuse treatment services
and each youth was assigned to a mini-treatment team as required. Each applicable record
contained documentation of the youth receiving mental health treatment in the form of
individual, group, and/or family counseling as outlined in the treatment plan, at least a minimum
of once a week. An interview with the designated mental health clinician authority (DMHCA)
confirmed mental health services are provided to youth at the center and a treatment team is
initiated to offer services to each youth. The DMHCA confirmed mini treatment team meetings
are conducted every thirty days. Reviewed progress notes validated youth were receiving
treatment services as stipulated on their treatment plan. None of the youth required substance
abuse treatment. One youth did have a signed consent for substance abuse treatment services;
however, the youth refused substance abuse services. All nine individual youth mental health
records contained the proper Authority for Evaluation and Treatment (AET) consent form, and
each contained treatment notes documented on the required Department form with all required
elements. A review of three separate samples of video was conducted and observations
showed each mental health group was conducted, as required. A review of group sign-in sheets
and logbooks validated groups were conducted. Each group had the appropriate number of
youth in the group, not exceeding the maximum number allowed. Observations and a review of
documentation indicated groups were held from twenty to twenty-five minutes and the times
noted on the sign-in sheets matched the video review. The mental health staff at the center
provide groups a minimum of one time each week when there are enough youth receiving
treatment. In an informal interview with the DMHCA, it was stated if the center has a higher
capacity of youth requiring treatment services, mental health staff will provide more than one
group a week, depending on the need. Additionally, in the event there are only a few youth,
mental health clinical staff will meet with youth individually. Nine youth were interviewed, and
five youth rated the center’s mental health and substance abuse services as good, and the
remaining four youth stated they were not receiving mental health or substance abuse services.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center maintains facility operating procedures which outline the required psychiatric
services to be available to youth. Psychiatric services include psychiatric evaluation,
consultation, and medication management. Psychiatric services are provided to youth
determined in need of services, as indicated by symptoms of mental disorder or substance-
related disorder, or to youth who are treated with psychotropic medication after their admission
to the center. The center maintains a contract with the provider to provide psychiatric services
for applicable youth in the center. The contract provides a part-time psychiatrist who is
contracted to provide services for a minimum of two hours each week. The psychiatrist’s license
was clear and active with an expiration date of January 31, 2026. The back-up psychiatrist is a
licensed osteopathic physician who holds a clear and active license with an expiration date of
March 31, 2026. The center does not provide tele-psychiatry services. A review of nine youth
mental health and substance abuse records found three youth were applicable for entering the
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center on psychotropic medication. Each of the three reviewed individual youth mental health
records contained documentation of a psychiatric referral and interview completed within
fourteen days of admission. All three youth had an initial psychiatric interview which included the
reason for referral, the youth’s history, a Mental Status Examination, the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis, treatment
recommendations, applicable prescribed medication, explanation of the need for psychotropic
medication, and the frequency of the medication. Each youth record documented the psychiatric
evaluation was completed within thirty days of the youth’s referral/admission. All three youth
were applicable for the prescription of medications and each psychiatric interview documented
the most recent applicable therapeutic serum drug levels, signature of the practitioner, page
three of the Clinical Psychotropic Progress Note (CPPN), target symptoms of each medication,
evaluations and description of effect of prescribed medication on target symptoms, normal
dosage range, ordered dosage, frequency and route of administration, side effects, adherence
to medication regime, and whether there was telephone contact with the parent/guardian to
discuss medication. Each youth’s evaluation was documented on the Department’s CPPN and
completed within the required time frame. All three youth records contained a current Authority
for Evaluation and Treatment (AET) form. None of the reviewed youth were applicable for the
monitoring of Tardive Dyskinesia. None of the reviewed youth were applicable for receiving tele-
psychiatry. An interview with the designated mental health clinician authority
(DMHCA)confirmed they meet with the psychiatrist on a weekly basis to discuss youth receiving
mental health and psychiatric services and the psychiatrist is on-call twenty-four hours a day.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a suicide prevention plan to safely screen, refer, assess, monitor, and
protect youth with elevated risk of suicide in the least restrictive means possible. The center has
a suicide prevention plan including 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. The center’s review process for
suicide attempts and mortality review includes circumstances surrounding the event, facility
procedures relevant to the incident, all relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations. The suicide prevention plan is reviewed annually by the designated mental
health clinician authority (DMHCA) and superintendent.
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).
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The center maintains facility operating procedures (FOPs) to address supervising, observing,
monitoring, and housing youth identified through screenings, documentation, and observation
as being at risk for suicide, and protect youth with elevated risk of suicide in the least restrictive
means possible. A review of nine youth mental health and substance abuse records showed no
youth were applicable for having been placed on precautionary observation (PO) except for at
the time of admission until an Assessment of Suicide Risk (ASR) was completed a half hour
later; therefore, three additional records were requested for a minimum sample of three. Each
youth began on constant supervision and after the completion of the ASR, all three youth were
continued on constant supervision. Each youth’s ASR was completed within twenty-four hours,
as required. Two of the three reviewed youth required a Follow-Up ASR, which was completed
prior to each youth being removed from PO. The remaining youth was released to their
parent/guardian on PO and the parent/guardian was notified. Each youth was removed from PO
after being evaluated by the licensed clinical staff and notification was made to the
superintendent. All reviewed forms were completed by a licensed clinical staff and contained all
required elements. Each applicable record contained a completed mental health referral, PO
log, ASR, and the Department’s Juvenile Justice Information System (JJIS) alert. Each
applicable JJIS suicide alert was observed to be open and closed appropriately. A review of all
three youth’s Suicide Precaution Observation Logs confirmed each was completed in their
entirety to include documented safe housing areas and all required signatures. A review of the
center’s logbooks revealed the start and end time of each youth’s precaution period was
documented in the logbook. An interview with designated mental health clinician authority
(DMHCA) confirmed the center is following their suicide prevention plan. During the annual
compliance review period, the center had a minor deficiency for incorrect step-down procedures
and notifications. This deficiency was closed on October 25, 2024.
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 (FOPs) to ensure youth placed on suicide
precautions may be maintained on secure observation (SO) when less restrictive means are not
effective. Nine youth mental health and substance abuse records were reviewed. None of the
youth were applicable for having been placed on SO; therefore, three additional records were
requested for a minimum sample of three youth on SO. Each youth’s placement on SO was
approved by the designated mental health clinician authority (DMHCA) and superintendent.
Each youth had secure housing designated in writing, had a Health Status Checklist form
completed, and had Suicide Precautions Observation Logs completed in their entirety. All three
youth had a new Assessment of Suicide Risk (ASR) completed within eight hours of placement
and each parent/guardian and juvenile probation officer (JPO) were notified of each youth’s
potential suicide risk as indicated on the ASR. None of the reviewed youth were maintained on
SO beyond twenty-four hours. All three youth received supportive services from mental health
clinical staff while on SO placement. Each youth’s supervision level was lowered only after a
conference with the DMHCA and superintendent. A review of the center logbooks confirmed
discontinuation and step-down from SO placement for each youth was documented in the
logbooks; however, the initial placement of youth on SO was only documented for one of the
three reviewed youth. Observation of video surveillance footage on two dates and
corresponding documentation of two youth on precautionary observation (PO) confirmed each
youth was placed on constant supervision and proper supervision was maintained throughout
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the youth’s placement on PO. Only two dates were applicable for youth placed on PO for the
last thirty days of video surveillance.
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 maintains a suicide prevention plan to address precautionary observation (PO) and
the process to safely screen, refer, assess, monitor, and protect youth with elevated suicide risk
in the least restrictive means possible. A review of nine youth mental health records showed
none were applicable for having been placed on suicide precautions; therefore, three additional
records were requested for a minimum sample of three. Each youth had a Suicide Precaution
Observation Log maintained. Each of the three applicable records contained Suicide Precaution
Observation Logs completed, on the required Department form, and for the duration of the
youth’s PO. The appropriate level of supervision was maintained, and checks were documented
in real time, at a minimum of every thirty-minutes as required, for each youth. One reviewed
youth was applicable for having warning signs documented on the logs. All logs were signed by
the shift supervisor and reviewed by the mental health clinical staff. Each log documented safe
housing requirements. During the annual compliance review period, the center received a minor
deficiency for missing information on logs. This deficiency was closed on September 15, 2024.
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.
The center maintains a suicide prevention plan to safely screen, refer, assess, monitor, and
protect youth with elevated risk of suicide in the least restrictive means possible. The plan
requires all staff who work with youth to receive six hours of annual training on suicide
prevention and implementation of suicide precautions. Suicide prevention trainings are
completed and documented in the Department’s Learning Management System (SkillPro). Nine
pre-service and nine in-service staff training records were reviewed. In an informal interview, the
superintendent indicated the center was operating with two, twelve-hour shifts starting in June
2024. The reviewed documentation of “mock” suicide drills conducted since the last annual
compliance review, showed the center had completed all drills on each shift at least monthly, as
required by policy. Staff who are not present during a drill had the opportunity to review each
drill scenario, procedures, and critique in an effort to understand the process and receive the
necessary training to respond to an incident of a suicide attempt or incident of serious self-
inflicted injury. All drills were simulated, and no youth were utilized in mock suicide drills.
Documentation confirmed drills included the use of cardiopulmonary resuscitation at minimum of
semi-annually. The center maintains four complete suicide response kits which are located on
each youth module in the staff bathroom and are co-located with the first-aid kits. An interview
with nine staff was conducted and all indicated the suicide response kits were located in the
staff bathrooms, youth modules, and seven staff indicated they were located in medical. Nine
staff were interviewed concerning staff response to a youth expressing suicidal ideation; eight of
nine staff stated they would notify mental health and would place youth on sight and sound,
seven out of nine staff stated they would document supervision, and six out of nine staff stated
they would search the room and youth for sharp objects. One staff stated they would talk to the
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youth to see if they had an immediate need and one staff stated they would talk to youth and if
warranted, the youth would sleep outside of their room on sight and sound. Video cameras
record the past thirty-days only. An observation of video review was conducted for two mental
health drills. Video camera review confirmed all drills were simulated and were in response to a
suicide attempt and/or an incident of serious self-injury.
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 written combined crisis intervention and emergency services plan which
details the response procedures for youth in crisis. The plan includes a notification and an alert
system, means of referral, youth self-referral, communication, supervision, documentation, and
review.
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 a written combined crisis intervention and emergency services plan which
details mental health and substance abuse emergency procedures for youth who are believed
to be an imminent danger to themselves or others because of mental illness or substance abuse
impairment. The plan was last updated and approved on September 5, 2024. The center’s plan
includes procedures for immediate staff response, notifications, communication, supervision,
authorization to transport for emergency Baker Acts or Marchman Acts, documentation, training,
and review. Copies of the plan are located in the superintendent’s office, in the mental health
and medical offices, and the briefing room, and are accessible to all staff.
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.
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The center has facility operating procedures (FOPs) to address Crisis Assessments and
stipulating the response procedures for youth in crisis. Staff response is to be in the least
restrictive means possible to protect the safety of youth and others while maintaining control
and safety of the center. Any youth presenting with acute and extreme emotional or
psychological distress is to receive a Crisis Assessment to evaluate the severity of their distress
and symptoms, level of risk to self or others, and recommendations for treatment and follow-up
care. Nine youth mental health and substance abuse records were reviewed, and none were
applicable for having required a Crisis Assessment. Three additional records were requested for
a minimum sample. A review of the three records for Crisis Assessments was conducted. A
review of documentation showed each assessment was completed the same day the youth was
determined to be in crisis and was documented on the Department’s Crisis Assessment form.
The assessments included the reason for assessment, a Mental Status Examination, a
determination of the youth’s danger to self/others, initial clinical impressions, supervision and
treatment recommendations, recommendations for follow-up, and notification to the
parent/guardian. None of the reviewed assessments indicated a potential safety or security risk;
therefore, a mental health alert was not warranted. Each of the three reviewed assessments
confirmed they were completed by a licensed mental health staff. Each of the reviewed
assessments were related to an allegation of a Prison Rape Elimination Act (PREA) event;
therefore, each youth was offered ongoing mental health treatment services, as required. An
examination of Assessments of Suicide Risk (ASRs), logbooks, and the Department’s Central
Communications Center (CCC) incidents did not reveal any events where a Crisis Assessment
should have been completed and was not.
3.17 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 (FOPs) to address mental health and substance
abuse emergency procedures for youth believed to be an imminent danger to themselves or
others because of mental illness or substance abuse impairment. Nine youth mental health and
substance abuse records were reviewed. None were applicable for having required Baker or
Marchman Act procedures. Three additional records were requested for a minimum sample.
Two of the three reviewed youth had a suicide risk alert opened in the Department’s Juvenile
Justice Information System (JJIS) while pending transport. The remaining youth already had an
open suicide risk alert. All three youth were placed on one-to-one supervision and supervision
was documented on the Precautionary Observation Log until the youth’s authorized release.
Each youth was placed on suicide precautions upon re-admission from their Baker Act and was
referred to mental health for a Mental Status Examination (MSE). A MSE was completed by a
licensed mental health clinical staff member for each youth. Each youth was maintained on
constant supervision until properly transitioned to a lower level of supervision as a result of an
appropriate assessment completed by a licensed mental health staff and a conference with the
superintendent/designee. Two of the three reviewed youth had their suicide risk alert
discontinued in JJIS based on an Assessment of Suicide Risk (ASR). The remaining youth
remained on suicide precautions. Two of the three reviewed youth were applicable for requiring
a Crisis Assessment prior to discontinuation of a mental health alert and were maintained on
constant supervision until a Crisis Assessment could be completed. The remaining youth did not
have an open mental health alert.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains 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 pediatrics, and the 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 July 31, 2026. The APRN has a Collaborative Practice
Protocol in place with the DHA, which was signed on May 15, 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 days during the annual compliance
review period. The back-up DHA is an 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 reported
being on-site one day each week, communicating with medical and center 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 by telephone with 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 May 15, 2024, and the superintendent and psychiatrist
on May 15, 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, as well as an annual review of medical policies, procedures, and
protocols conducted by all required individuals. The psychiatrist reviewed and developed the
FOPs, or other protocols related to psychiatric services and psychotropic medication
management. The healthcare personnel hired since the last annual compliance review received
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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 nine reviewed Individual Healthcare Records (IHCRs) had a valid Department Authority for
Evaluation and Treatment (AET) form with the word “COPY” stamped on the form filed in each
youth’s IHCR. 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 and one of the nine youth was 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 (JPO) 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.
Four of nine reviewed Individual Healthcare Records (IHCRs) were applicable for
parental/guardian notification/consent. All four applicable IHCRs had documentation of
parental/guardian notification for over-the-counter (OTC) medications beyond those covered by
the Authority for Evaluation and Treatment (AET) and consent was provided by the
parent/guardian. In all four IHCRs, written notifications were sent utilizing the Department’s
Parental Notification of Health-Related Care: General or Parental Notification of Health-Related
Care: Medications forms or the Department’s Acknowledgment of Receipt of the Clinical
Psychotropic Progress Note (CPPN). Three of the youth were taking psychotropic medications
at the time of admission. In the three IHCRs, the staff witnessed all telephone call attempts and
conversations for psychotropic medications. The remaining 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. None of the youth required vaccinations and one
youth was in the care of the Department of Children and Families (DCF). Two of the four 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 notices sent regardless of telephone
notifications. In all nine IHCRs, vaccines were verified within thirty days of each youth’s
admission. The nursing interview indicated parental/guardian notification should be made to
inform the parent/guardian of significant changes in the youth's condition and obtain consent
when new medications are ordered, medications are stopped, a youth is sent off-site for
treatment, and treatments are prescribed. These notifications are first done verbally and
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
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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 the website Florida
SHOTS upon a youth’s admission. If a parent/guardian presents certified documentation of
exemption, it is reviewed by nursing staff and the DHA, and is 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 nine 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 (JJDOS) on the date of admission. In all nine, a nurse reviewed the screening
form within twenty-four hours. All nine records documented the designated health authority
(DHA) notification, as required. None of nine IHCRs were applicable for a re-screening;
therefore, three 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 re-screenings were completed by a JJDO or
JJDOS on the date of admission and a nurse reviewed the re-screening forms 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. The JJDOS and/or
master control shall 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 JJDOS, 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 (HRH) 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 (FOPs) covering 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 a review of the list of
healthcare contacts to ensure accuracy. In all nine 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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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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed, and there was a referral
documented to the designated health authority (DHA) for all youth. Eight of the nine youth were
admitted 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
nine 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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed, and each included a Health-
Related History (HRH) form completed within seven days of admission by a licensed healthcare
staff on the Department’s form. The nine applicable HRHs were completed prior to the
Comprehensive Physical Assessment (CPA), as evidenced by signature and date, and the
designated health authority (DHA) reviewed the HRH as indicated by a check mark on the CPA.
The nursing interview indicated the HRH is completed by a nurse 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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for completion of a
Comprehensive Physical Assessment (CPA) and tuberculosis skin test (TST). Each of the youth
had documentation completed on the Department’s CPA form. All youth had a CPA completed
within seven calendar days of admission. Each CPA documented the youth’s Medical Grade.
The nine applicable youth CPAs were reviewed and completed by the designated health
authority (DHA)/advanced practice registered nurse (APRN), and all were marked with “O” and
“X” and missing no elements. In all nine IHCRs, the Department’s Problem List was updated, as
required. One of the nine youth refused a part of the exam and no refusal form was found;
however, the DHA/APRN deferred the exam due to each youth not showing any indicators
needing the specific section of the exam. All nine applicable IHCRs contained a TST completed
within the last year with the results having been documented on the Infectious Communicable
Disease (ICD) and the CPA forms. All nine of the applicable youth received a tuberculosis (TB)
screening within seventy-two hours of admission with no further evaluation required. 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.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Nine youth were clinically screened and evaluated for sexually transmitted infections (STIs).
Four of nine 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. The
four IHCRs 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.
Two of the four youth consented to a gynecological exam or were sexually active. None of the
youth were out of the Department’s physical custody. All nine applicable IHCRs had evidence
each youth was offered counseling and testing for HIV. Two of the nine youth consented to
testing. The two 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 center’s internal alert system. All nine
youth interviews indicated they can ask for an HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center has facility operating procedures including a sick call process for youth to receive
regular medical care while in room restriction/confinement. Only two of the nine youth Individual
Healthcare Records (IHCRs) had a sick call event; one extra record was requested. Three of
the sick call events reviewed were documented on the Sick Call Referral Log. 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 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 the 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 on each module. The center has approved treatment protocols for both
the 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 one sick call event while the annual compliance review
team was on-site, which was observed. The medical provider identified themselves and stated
why the youth was there. The youth was seen in a private area where no other youth was
present to hear or see the examination. The examination table was utilized, and an officer was
present and positioned opposite of the privacy curtain. 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
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treatment, education, and make follow-up plans. If a 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/APRN 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.
Nine youth were interviewed, and it was noted seven youth stated they never placed a sick call
before, two youth stated the nurse conducts sick calls, and one youth stated the doctor
conducts sick calls. Nine staff were interviewed and each stated the nurse conducts the sick
call. Three of the nine staff also stated the doctor conducts the sick call.
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 including ensuring the contents of first-aid kits are
maintained and stored to prevent expiration or deterioration and shall have a comprehensive
process for the provision of episodic care and first-aid care. The first-aid kits are maintained with
a break away closure and are inventoried and stocked monthly by the nurses. Only two of nine
reviewed Individual Healthcare Records (IHCRs) were applicable for episodic or first-aid care;
therefore, one extra record was requested. All three records showed 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) format. All episodic care events were documented in the Episodic Care Log. The center
has nineteen first-aid kits. One each located in master control, each of the five modules, kitchen,
intake, the clinic, and administration. Nine more are used for transportation and are maintained
in master control. Three of the first-aid kits were observed to be fully stocked with the
designated health authority (DHA) 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 three automated external defibrillators (AEDs), one in master control, one in the
clinic, and one on the B4 module 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 4, 2024, and the documentation for the AED checks
indicated the nurses conducted monthly checks for the annual compliance review period.
Observations of three AEDs indicated they were functioning appropriately during the annual
compliance review week. Each of the three AED batteries expire on August 19, 2026, and the
pads on September 28, 2024. The batteries were changed on August 19, 2022. A review of the
emergency medical drills since the last annual compliance review 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 one medical drill indicated the drill was visible on camera and was simulated. The list
of emergency numbers was posted in the clinic accessible to staff and inaccessible to youth. A
review of documentation indicated select authorized direct care staff were trained on the
administration of the epinephrine auto-injector by a RN. A review of nine in-service and nine
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pre-service staff 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 format 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 nine staff
interviews indicated they can call 9-1-1 if needed. Nine youth were interviewed, and five youth
indicated they do not require medical services, three youth stated medical care is good, and one
youth stated medical care is 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 nine Individual Healthcare Records (IHCRs) indicated none of the youth required
off-site care. Three more examples were requested. The center was able to provide three youth
with off-site care events. The three applicable youth required off-site care, and for two events
there was a Department Summary of Off-Site Care Consultation Report form filed in each IHCR
and the remaining youth did not have an Off-Site Care Consultation Report form. All three
events were documented on the Episodic Care Log. 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. All 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. Only one youth required a follow-up appointment which was
tracked, and timely follow-up care was received. 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 binder in the medical clinic 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.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Limited Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Eight of the nine reviewed Individual Healthcare Records (IHCRs) were applicable for chronic
conditions. In all eight 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. Five youth
were taking prescribed medication on an on-going basis, and two of the five youth were
undergoing treatment for a physical health condition. Two of the eight youth had been at the
center long enough to receive a periodic evaluation within a ninety-day period. One youth did
not receive a periodic evaluation and one youth received a periodic evaluation five days beyond
the ninety-day requirement. Progress notes were reviewed, and documentation was completed
for the one youth. For the two youth in the center long enough for the periodic evaluation, one
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youth evaluation was conducted prior to renewing a prescription medication which expired, and
one youth did not have documentation of a periodic evaluation being conducted. 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. Nine Individual
Healthcare Records (IHCRs) were reviewed, and six IHCRs indicated the youth were taking
medication at the time of admission. All six youth medications were verified prior to being
admitted into the center and documented on the chronological progress notes and the
Department’s Medication Receipt Transfer Disposition form. In the six applicable IHCRs, the
designated health authority (DHA) and, when applicable, the psychiatrist were contacted to
obtain the order to resume the specified medications. In all six records, all medications had a
current, valid order and were administered pursuant to a current prescription. The DHA placed
an order on a Practitioner Order Form for any current medications which were continued,
discontinued, changed, or new ones ordered. In all six records, 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, and none of the youth had any
refusals or received parenteral medication. In all six IHCRs, the MARs included youth name,
Department Identification Number (DJJID), date of birth, youth allergies, precautions, Medical
Grade, and medical alerts. All MARs documented weekly side effect monitoring by the nursing
staff; a nurse initialed each medication administration entry, as well as youth. The MAR book
and the electronic MARs include a current picture of each youth. Three of the six youth entered
the center on psychotropic medications and the psychiatrist conducted an initial diagnostic
psychiatric interview within fourteen days. Only one of three youth had been at the center long
enough to receive a medication monitoring/review and received it within thirty days as required.
The center did not have any standing orders, emergency treatment orders, or pro re nata (PRN)
orders for psychotropic medications. During the annual compliance review week an observation
of a medication administration for one youth was conducted. This youth was 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 the youth allergies and alert status, retrieving each medication
individually from the medication cart and administering it. After the medication administration,
the youth was asked to cough and move their tongue to ensure the medication was swallowed;
both the nurse and JJDO verified this process. The youth and nurse initialed the MAR. A review
of documentation indicated the center had designated staff trained by a registered nurse (RN) 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 8:00 p.m. Nine staff were interviewed, and all of the staff interviews indicated
they do not provide medication to youth. Five of nine youth interviews indicated they do not take
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medication, three youth indicated the nurse administers medication, and one youth indicated the
doctor administers the medication. Expired medications shall be quarantined for destruction in
an area separate from where non-expired medications are maintained and shall be clearly
marked as the disposal area.
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 which include 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 injectable,
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 did not contain any medication at the time of
the annual compliance review. All medication and sharp storage areas are inaccessible to youth
and only accessible to staff with a key. Observations of medication and sharp inventories were
conducted during the annual compliance review week. This consisted of a nurse counting three
controlled medications, three OTC medications, and three sharps. The results indicated one
OTC medication was off by one and was updated in front of the monitor. A review of
documentation indicated non-healthcare staff received training in the delivery and oversight of
medication self-administration by a RN. The nursing interview indicated 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 (MARs), sharps, and licenses, as well as destroys medication.
Controlled substances are kept in a locked compartment in the locked medication cart.
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,
control, and education. A review of nine Individual Healthcare Records (IHCRs) indicated eight
of the nine youth received infection control training within seven days of admission and one did
not. All nine youth received hand-washing techniques, universal/standard precautions, and
prevention/transmission of communicable diseases. Only eight of the nine youth received
training on vaccinations, and one did not. All nine youth received training in the Center for
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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, C, and 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 needed to be
reported to the Department’s Central Communications Center (CCC), 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 staff 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 center’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] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has facility operating procedures (FOPs) which require access to prenatal care for all
pregnant youth. In addition, the FOPs also require health education to be provided to both youth
and staff. Nine youth Individual Healthcare Records (IHCRs) were reviewed, and none were
applicable for prenatal care/education. The center was able to provide IHCRs for two pregnant
youth who were at the center during the annual compliance review period. A review of the two
applicable IHCRs revealed each youth received prenatal care immediately upon determination
of pregnancy and continued until discharge. Each youth was placed on the Department’s
Juvenile Justice Information System (JJIS) alert system for vital nutrition, health awareness, and
sleeping arrangements. Neither of the youth complained of issues related to pregnancy while
they were at the center. Reviewed IHCRs revealed each youth received education related to
pregnancy including alcohol and drug use, smoking, nutrition, sexually transmitted diseases,
contraception, prenatal care, birthing process, postpartum care, basic baby care, child
development, and parenting skills. All required topics were documented on the Health Education
Record. Each youth received nutritious food in quantities appropriate for a pregnant youth.
Nursing staff provided routine monitoring of nutritional and weight status for each youth while at
the center. A review of nine in-service and nine pre-service staff training records confirmed all
non-healthcare staff involved in the supervision or treatment of youth have received training on
youth prenatal healthcare. This training included observation and monitoring of emergency care
needs and symptoms of possible miscarriage. The center’s nursing protocols include treatment
plans for pregnant youth. The nurse was interviewed and advised if a youth is pregnant upon
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admission, the youth is educated on pregnancy issues by the nursing manager, given a special
diet, started on pregnancy vitamins, and scheduled for prenatal appointments. All female youth
are given a pregnancy test upon admission if the youth consents. Nine youth were interviewed,
and one said they received prenatal, obstetrical, or gynecological services when needed at the
center. The remaining eight youth said they did not need these services.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures (FOPs) to ensure active supervision of youth by
staff. Daily observations were conducted during the annual compliance review week confirming
staff were providing and maintaining active youth supervision during each activity observed.
Staff were observed supervising youth by controlling line movements, positioning themselves
appropriately, and giving clear directions to youth. The annual compliance review team
observed several youth activities including school, recreation, meals, line movements, and
positive interactions with youth. The master control staff authorized all youth movement prior to
youth being moved. A review of the center’s logbooks during the annual compliance review
period revealed youth counts were consistently conducted. Documentation was properly noted
in the module and master control logbooks. Three full days of group video were observed and
confirmed group start and end times followed the group schedule as required. Nine staff were
interviewed. Six staff stated there were enough staff to provide adequate supervision and three
staff stated there are not enough staff to provide for the safety and security of youth and staff.
5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations. Each center shall implement and maintain a behavior
management system to meet the needs of the youth and the center. The system shall include
rewards for positive behavior and consequences for inappropriate behavior. The behavioral
norms and expectations for youth shall be posted in all living areas and shall clearly specify
appropriate and inappropriate behaviors. The system restricts certain types of penalties on
youth who demonstrate negative behaviors. Group punishment shall not be used. However,
corrective action taken with a group of youth is appropriate when the behavior of a group
jeopardizes safety or security, and this should not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) detailing the behavior management system
(BMS). A tour of the facility during the annual compliance review week found the center has
BMS postings in all modules, the intake/release area, and in the dining room area which clearly
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specified appropriate and inappropriate behaviors, rules, norms, and expectations. The BMS
includes a level system where youth are given the opportunity to earn points by meeting
required expectations. Youth can move up or down the level system depending on their
behavior. A review of completed point cards and logbook entries during the annual compliance
review period supported the center utilized the BMS in compliance with the components outlined
in the center’s FOPs including daily observations. The center prohibits the use of group
punishment and there were no instances of inappropriate use of restrictions or group
punishment displayed. Nine staff were interviewed. All nine staff had knowledge of the point
system. Seven of nine staff had knowledge of the level system. Eight of nine staff stated the
BMS is posted throughout the center. Eight of nine stated the BMS is included in the youth
handbook and orientation process. All nine staff stated youth receive canteen and extra
telephone calls as a reward. Eight staff stated they believe the center’s BMS is effective. One
staff stated they do not believe the center's BMS is effective. All nine staff reported they speak
with youth to discuss the consequences being imposed, the youth are given an opportunity to
explain their behavior, and youth are talked to about alternative acceptable behaviors. Six of
seven staff stated supervisors provide feedback regarding the implementing the BMS with
youth. One staff stated supervisors do not provide feedback and one staff stated the supervisors
can do better. Five staff stated they receive feedback on the implementation of the BMS as
needed. Two of nine staff stated feedback on the implementation of the BMS occurs
daily/weekly, and one staff stated they have never received feedback on the implementation of
the BMS. All nine staff stated levels and/or points can be taken away as a consequence and
they never seen a staff take meals, snacks, clothing, education, or medical care from a youth.
None of the staff have ever observed any staff encouraging youth to beat up another youth. An
interview with nine youth was conducted. Six youth stated the BMS was good, and three youth
stated the BMS was fair. All nine youth were able to explain the difference between each level
and provided examples of rewards received. Nine youth stated all staff reward the same. All
nine youth stated youth are not allowed to punish other youth. Four youth stated they have been
sent to their room for punishment. Eight youth stated when they received consequences the
consequences were fair and only points or levels were taken away. One youth stated they have
never received consequences. All youth interviewed stated they did not witness handcuffs or leg
irons being used on out-of-control youth to prevent them from hurting themselves or others. The
superintendent was interviewed and stated a standardized BMS is used.
5.03 Ten-Minute Checks (Critical) Failed Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures requiring visual ten-minute checks to be
conducted on youth during sleep time or other times such as during an illness or room
restriction. The center has a total of 106 cameras, and all were operational during the week of
the annual compliance review. The cameras retain video recording for thirty days. An electronic
wand system is used in the center to document and collect data of the visual ten-minute checks
Florida Department of Juvenile Justice Detention Annual Compliance Report
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conducted. 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
wand documentation and video coverage was conducted for three different modules for ten-
minute checks. One module observation was noted where staff failed to complete and
document ten-minute checks within the required time frame. Staff missed the checks by three to
twenty-one minutes. There were five separate ten-minute check observations whereby staff
documented their ten-minute check and the observed video review showed the ten-minute
check was not conducted. The annual compliance review team reported the incidents to the
Department’s Central Communications Center. The assistant superintendent reported facility
administration provides management oversight by conducting weekly reviews of ten-minute
checks to ensure fidelity. Nine staff were interviewed and stated room checks are conducted
every ten minutes when youth are 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. When youth are secured in their room for shift change, showers, or
bedtime, the wand is utilized. If youth are on confinement, a visual observation report (VOR) is
utilized. Checks are required every ten minutes unless they are on close supervision which
requires five-minute checks.
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 outlining the census, counts, and tracking of all
youth. A review of logbooks for one full day from each month throughout the annual compliance
review period confirmed counts were conducted and documented at the start of the shift, mid-
day during the shift, end of each shift, prior to and following routine group movements, when a
population change occurs, at least once during each shift, following any emergency, and
randomly on each shift. If the count is not cleared by master control staff, then a physical head
count is conducted again until the count is cleared. Observations of headcounts were conducted
during the annual compliance review week, and no issues were noted. Nine staff were
interviewed and stated counts are conducted at the beginning and end of each shift and after
every youth movement. Each staff also confirmed emergency counts are conducted when a
youth is believed to be missing, when visibility is hindered, and after a major disturbance.
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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 outlining the requirement of a chronological record
of events, incidents, and activities in logbooks maintained at master control and in each living
area. The center maintains separate logbooks in master control, each living area, for visitors,
and for each vehicle. A review of logbooks for one full day for each month during the annual
compliance review period revealed the logbooks were bound with numbered pages, the dates
were documented on the top of each page, all entries included the times of the events in a.m. or
p.m. with the name of the staff and youth involved, all entries impacting the safety and security
of the center were highlighted, and all errors were struck through with a single line and initialed
by the staff. The master control logbook included all required entries including emergency
situations, incidents, drills, counts, movement, admissions and releases, confinements, and
precautionary observations. Supervisors reviewed the master control logbook when accepting
responsibility for the center as well as reviewed living area logbooks daily. The staff reviewed
logbook entries from the previous shift when accepting responsibility for the living area. A review
of logbook entries for one full day from each month during the annual compliance review period
for educational interference was conducted. The logbook entries, compared to the activity
schedule, documented minimal interference with educational instruction; however, there were
inconsistencies of start and end times of educational instruction. The superintendent indicated in
an interview supervisors are required to review logbooks at a minimum two times each shift and
the administrative staff are required to review logbooks once a week. When reviewing logbooks,
they must ensure no scribbling or write overs.
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.
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The center has facility operating procedures describing the center’s process for key control, key
assignment and usage, key restriction, inventory, tracking, storage, missing or lost keys, and
reporting and replacement of damaged keys. The center has an inventory of all keys which
includes all required information to include a tamper-resistant key ring and color coding specific
to the position to which the keys are assigned. An inventory of staff keys was maintained by the
shift supervisor. Missing or damaged keys are immediately reported to a supervisor and
documented. If a key was reported missing, all movement would cease, searches would be
conducted throughout the facility, and youth would be searched, to include their assigned
rooms/living areas. If the key was still missing it would be reported to administration and the
Department’s Central Communications Center (CCC) within the required time frame. During the
annual compliance review week, an observation revealed keys are kept in master control in a
secured box not easily accessible while locked. Observations of the issuance of keys was
conducted. Staff who received the keys always kept them on their person, did not allow youth to
handle the keys, and did not remove the keys from the facility or the facility grounds. The center
did not have any key incidents during this annual compliance review period. Five key rings were
observed and compared to the key inventory and the keys matched the key inventory and the
key log. Three informal interviews were conducted with staff and each staff knew the number of
keys and function for each key on their key ring. An informal interview with the master control
staff revealed only medical and mental health staff have access to keys with access to
confidential youth records. Nine staff were interviewed and were able to articulate the center’s
key control process. All nine staff indicated the restricted keys include keys to medical, mental
health, case management, the kitchen, and the youth property area. An interview with the
superintendent revealed the administrators have permanent keys which are securely kept in the
office of the superintendent and are documented and inventoried on the key inventory log.
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 for transportation, operation, and
maintenance of each vehicle used to transport youth. The center has a total of eight vehicles
used to transport youth. Reviewed documentation validated each of the eight vehicles had an
annual vehicle inspection and the center’s assistant superintendent conducted weekly and
monthly visual checks of all transport vehicles which included all required elements. Typically,
the center’s maintenance personnel are responsible for this duty; however, the position is
vacant. All eight vehicles have the appropriate number of seatbelts, a seatbelt cutter, a window
punch, updated fire extinguishers, and a first-aid kit with approved items by the designated
health authority (DHA). The vehicle logbooks indicated each vehicle was searched for
contraband prior to use and again upon return, number of youth transported, and the destination
with date and time for each transport. An observation of a transport was conducted during the
week of the annual compliance review and the transporting staff were observed following all
required transportation procedures prior to transport. Eight center vehicle checks were
conducted, and each was found to be securely locked when not in use. Nine youth were
interviewed and stated they have not seen any contraband in the vehicles.
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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 ensuring all tools and equipment related to
maintenance and the kitchen are properly maintained, stored, and inventoried. The policy also
prohibits youth from having access to any tools, including kitchen, and/or medical equipment.
According to the center’s policy youth are allowed to use cleaning items such as mops, brooms,
and other common household items when completing general cleaning under staff supervision.
An observation of youth utilizing cleaning tools was unable to be conducted during the annual
compliance review week. 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. An
itemized inventory of kitchen tools is also maintained. All items, including knives, are inventoried
daily upon kitchen staff reporting for duty. The kitchen knives and other hazardous kitchen
sharps are stored in a locked cabinet. An informal interview with the assistant superintendent
indicated all service vendors are identified prior to entering the secure area of the center and
are always accompanied by staff. Youth are removed from the area being serviced and are not
allowed to re-enter the area until it has been searched and cleared by center staff. The vendor
checks for all their tools to ensure they leave with the tools they entered with into the center,
which is confirmed by center staff. A review of the inventory used to document the issuance and
return of maintenance tools found no discrepancies. An informal interview with the assistant
superintendent and dietary staff determined they understood the process when there are
missing or damaged tools. Ten tools within the facility were sampled to include six maintenance
tools and four kitchen tools confirming the inventory was correct, tools were secured, and no
discrepancies were found. Nine interviewed staff were able to explain the center’s practice for
damaged and missing tools and the tools youth are allowed to use. Six of nine youth stated they
can use brooms and mops while cleaning and three youth stated they do not use any tools. The
assistant superintendent interview indicated youth may have access to mops and brooms under
direct supervision.
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
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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 ensuring the proper use, storage, disposal,
and inventory of chemicals including poisonous, flammable, and toxic materials. The policy also
ensures limited access to flammable, toxic, caustic, and poisonous items. Only authorized staff
are permitted access to and use of flammable, toxic, caustic, and poisonous items. Youth at no
time are 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 the annual compliance review.
Reviewed documentation during the annual compliance review period revealed the center
maintained an inventory of all flammables, toxic, caustic, and poisonous items. Nine youth were
interviewed and all stated they do not handle chemicals or have access to chemicals. Nine staff
were interviewed, and all staff stated youth are not allowed to clean with substances which are
toxic, flammable, or poisonous. Five chemical samples were selected. Each chemical had a
corresponding safety data sheet and accurate inventories.
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 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. Dietary staff indicated grease is
used for cooking and is disposed in grease traps and an outside contractor comes monthly to
drain. An informal interview with the assistant superintendent indicated all hazardous materials
are disposed appropriately.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures addressing the procedures for the use of
behavioral confinement as an immediate, short term response strategy during volatile situations
in which a youth’s sudden or unforeseen onset of behavior imminently and substantially
threatens the physical safety of others or self. The center had 394 instances of confinement
under twenty-four hours during the annual compliance review period. A random selection of
fifteen were reviewed. There was evidence of each of the fifteen youth were given the
opportunity to grieve a confinement placement. There was documentation of each youth
receiving three meals a day plus school, evening snack, and access to mental health care as
requested/needed. Twelve youth were applicable for a shower and there was documentation of
the youth being offered a shower. Fourteen youth were applicable and offered clean clothing,
and twelve youth were applicable for mattress/bedding based on the time and duration of
confinement and this was provided. Thirteen youth were applicable for requiring education
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materials during education hours and were provided them. Prior to placing each youth in
confinement, the supervisor approved each confinement and staff placed only one youth in the
confinement room. The center does not have separate confinement rooms and youth are
confined in their own room. There was documentation of the confinement rooms being searched
and entered into the Department’s Facility Management System (FMS). A tour of the center and
youth rooms found windows and cameras were free of obstructions/scratches, so the youth may
be visually observed. Each of the youth placed in confinement supervision were documented
using the Visual Observation Report (VOR) Log at a minimum every five minutes for the first
hour in confinement and every ten minutes thereafter. There was evidence of the reason for
confinement and it was explained to each youth. The supervisor conducted an initial review with
the youth within one hour of the incident for each of the fifteen reviewed confinements. The full
confinement report was completed for each of the fifteen reviewed confinements before the end
of the shift. The supervisor conducted additional reviews with the youth at a minimum of every
three hours and documented the reviews in FMS for all fifteen reviewed confinement reports.
There was evidence of the supervisors continually counseling the youth and considered
removing the youth from confinement as soon the youth was able to safely rejoin the population
and there was no threat to safety. The superintendent or designee reviewed all confinement
reports within forty-eight hours, excluding weekends and holidays and determined whether each
confinement was appropriate or inappropriate. The center had no pregnant youth placed in
confinement during the annual compliance review period. The superintendent revealed the use
and appropriateness of confinement is tracked in the Department’s Juvenile Justice Information
System (JJIS)/FMS and is completed by administration and the regional operations team to
ensure compliance. The superintendent stated regional detention management review the use
of confinement, lockdown, and restraints monthly. Nine staff were interviewed. All staff were
able to explain the center's step by step process for placing youth in confinement. Each staff
stated youth placed in confinement are provided educational materials.
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.
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 maintains facility operating procedures establishing procedures for conducting drills to
address the Continuity of Operations Plan (COOP). Three drills were conducted during the
annual compliance review period. 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 the
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COOP is the center’s comprehensive safety and emergency plan. An informal interview with the
superintendent described the process for the relocation and continued operations of a facility
during an emergency or disaster. The center’s emergency plan describes how to respond to
emergency situations including fire and fire prevention/evacuation, severe weather, major
disturbances, pandemics, bomb threats, taking of hostages, chemical spills, flooding, or
terrorism threats or acts.
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 to address escape drills and escape
prevention. The procedures require the center to conduct escape drills at least quarterly. Each
of the required drills during the annual compliance period were conducted as required. The
documentation of the drills included scenarios as well as the dates and times of the drills. The
drill documentation form included the signatures of the supervisory staff and the staff completing
the drill. Recommendations and critiques of the drills were included in each report. A review of
logbooks revealed each escape drill was documented in the logbook, as required. Nine in-
service training records and nine pre-service training records were reviewed, and each staff
completed training in security and escape prevention annually. Nine 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. A review of drill documentation found fire drills were
conducted monthly on each as required. All fire extinguishers had a completed annual
inspection, as required. Nine staff were interviewed and all confirmed fire drills take place at
least monthly. Nine youth were interviewed. Seven youth stated they have been instructed on
what to do in case of a fire. Two youth stated they have not been instructed on what to do in
case of a fire.
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
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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 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. A youth departing on transport was
observed during the annual compliance review week. Two juvenile justice detention officers
(JJDOs) of the same gender were in the process of a frisk search of an individual youth while
wearing gloves. Staff inspected the secure vehicle prior to the youth entering the vehicle and
informed master control of the movement and destination. There were no strip searches
conducted during the annual compliance review week. Searches of staff and visitors prior to
entering the secure area were observed during the annual compliance review week. There was
one instance a staff member was not electronically searched; all bags, cases, jacket pockets,
and other items were searched, and all prohibited items were secured prior to the staff member
entering the center. Documentation of room searches for the annual compliance review period
was found in the 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 was one instance of contraband being found at the center during the
annual compliance review period and reported to the Department’s Central Communications
Center (CCC) within the required time frame and an incident report was completed. The center
documented all required information and responded in accordance with the center’s procedures.
The center’s visitors log does not contain a contraband attestation statement which requires all
visitors entering to complete a separate contraband attestation form. A review of nine staff
personnel records found all staff had a signed contraband attestation form. A review of eighteen
newly hired staff personnel records found all newly hired staff had the signed contraband
attestation form. The superintendent interview revealed the center’s procedures for searching
youth include a frisk search and strip search and are conducted at the time of admission, off-site
transports, or when there is suspicion of contraband. Random frisk searches are conducted
following movement throughout the facility. The superintendent stated if a youth or staff is found
with contraband, the handling of it would depend on what the contraband is based off of the
Florida Statue. The contraband will be confiscated, local law enforcement will be contacted, and
the CCC will be contacted.
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rule: Indicator 4.14

rating: Failed Compliance