summary: QI Detention - FY23-24 - 9 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Volusia Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
3840 Old Deland Road
Daytona Beach, Florida 32124
Review Date(s): April 31, 2024 - May 3, 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:
Heather Molinario, Office of Accountability and Program Support, Lead Reviewer (Standards 1,
3, and 4)
Teresa Andersen, Office of Accountability and Program Support, Deputy Regional Supervisor
(Standards 3 and 4)
Crystal Blair-Gallon, Office of Accountability and Program Support, Regional Monitor (Standards
3 and 4)
Jeremy Curvan, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Cindy Jones, Office of Education Services, Deputy Director of Education (Standard 2)
Tamara Mahl-Adkins, Office of Accountability and Program Support, Regional Monitor
(Standard 5)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Interviews and
Video Observation)
Angenette Williams, Office of Detention Services, Regional Training Coordinator, (Standard 2)
Program Name: Volusia Regional Juvenile Detention Center MQI Program Code: 139
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Volusia County / Circuit 7 Number of Beds: 50
Review Date(s): April 31, 2024- May 3, 2024 Lead Reviewer Code: 197
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
This program has received an overall program compliance rating of Failed, a follow-up review of the program shall be conducted within six (6) months of publication of
the program report.
Limited Ratings Failed Ratings
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions 2.10 Educational Access*
2.09 Daily Activity Schedule 5.08 Vehicles and Maintenance
3.12 Suicide Prevention Training * 5.09 Tool Inventory and Management
5.03 Ten-Minute Checks* 5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items
5.16 Continuity of Operations Planning (COOP) Drills
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 55 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Non-Applicable
1.05 Protective Action Response (PAR) Non-Applicable
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 55 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Non-Applicable
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 Limited
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Limited
2.10 Educational Access* Failed
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).
Overall Rating Summary for Standard 2
This standard has received a standard-level rating of Failed, a follow-up review of the program shall be conducted
within six (6) months of publication of the program report.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 55 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Non-Applicable
3.05 MH/SA Assessment/Evaluation Non-Applicable
3.06 MH/SA Treatment Non-Applicable
3.07 Treatment and Discharge Planning Non-Applicable
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Limited
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 55 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Non-Applicable
4.04 Parental Notification/Consent Non-Applicable
4.05 Healthcare Admission Screening & Rescreening Form Non-Applicable
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Non-Applicable
4.08 Health-Related History Non-Applicable
4.09 Comprehensive Physical Assessment/TB Screening Non-Applicable
4.10 Sexually Transmitted Infection Screening & HIV Screening Non-Applicable
4.11 Sick Call Process Non-Applicable
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Non-Applicable
4.14 Chronic Conditions/Periodic Evaluations Non-Applicable
4.15 Medication Management Non-Applicable
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Non-Applicable
* 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 55 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Limited
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Satisfactory
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Failed
5.09 Tool Inventory and Management Failed
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Failed
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Non-Applicable
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Limited
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 55 (Revised July 2023)
Program Overview
The Volusia Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Daytona Beach, Florida. The center serves youth in Flagler, Putnam,
St. Johns, and Volusia counties in Circuit 7. Male and female youth who are detained pending
adjudication, disposition, or placement in a residential commitment program are housed in the
fifty-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 Volusia County School Board.
The center’s management team includes the superintendent, two assistant superintendents,
one administrative assistant, eight juvenile justice detention officer (JJDO) supervisors, twenty-
six JJDO IIs, and twenty-two JJDO Is. Mental health and healthcare services are provided
through the contracted provider, VitalCore Health Strategies, LLC. Mental health services are
provided by one designated mental health clinician authority (DMHCA) and four licensed mental
health and substance abuse clinical staff. The center does not have any non-licensed mental
health and substance abuse clinical staff. Clinical services provided by the center include
mental health and substance abuse evaluations, mental health treatment planning, individual,
group, and family therapy, mental health crisis intervention services, on-site psychiatric
services, and availability for substance abuse services for youth with co-occurring disorders.
Medical services are provided by one designated health authority (DHA), one advanced practice
registered nurse (APRN), five registered nurses (RN), and one psychiatrist. The medical clinic
maintains nursing coverage seven days a week, between ten and twelve hours each day. Food
services are provided by Department staff and include menus, meal planning, meal schedules,
special diets, nutritional analysis, daily allowance, food preparation, health certifications, food
product standards, sanitation, and cleaning. Staff are responsible for the custody and control of
youth in their care, providing youth supervision twenty-four hours a day, seven days a week.
The center has four living modules which are divided by male and female youth. There are
seventy-two security cameras at the center, of which seventy-two were operational. The center
was observed to need new interior paint throughout, new ceiling tiles throughout, new window
blinds in the multipurpose rooms, repair/replacement of several interior secure doors,
replacement of dormitory door windows, appropriate length shower curtains, renovated youth
showers, and repair/replacement of several exterior windows and/or window framing. The
modules, multipurpose rooms, and sub control rooms were observed to be highly unorganized
and lacked evidence of daily maintenance and cleaning as food, garbage, and clothing debris
were observed throughout the modules. Youth dormitory rooms were in disarray and contained
food and other debris. A deficiency for cleanliness was issued as a result. At the time of the
annual compliance review, the center had fifteen vacancies, which included five JJDOIIs and
ten JJDOIs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 55 (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) to ensure all Department staff, contracted
providers, volunteers, mentors, and interns with access to youth and youth records have an
initial background screening with a determination of “Eligible” prior to contact with youth or
confidential youth records. Each background screening included a criminal history report review.
The center’s FOP also ensures an Affidavit of Compliance with Level 2 Screening Standards is
completed annually as required. During the annual compliance review period the center did not
have any volunteers, mentors, or interns applicable for screenings; however, the center’s policy
does have directives for a background screened staff to be in sight of any non-screened
persons who may be within the center irregularly as outlined by Florida Administrative Code.
The center completed and submitted the current Annual Affidavit of Compliance with Level 2
Screening Standards, on the required form, on January 30, 2024, prior to the required deadline.
The local school board, on behalf of the center’s educational staff, completed and submitted the
current Annual Affidavit of Compliance with Level 2 Screening Standards, on the required form,
on January 26, 2024, prior to the required deadline. Eighteen initial background screenings for
newly hired staff were reviewed. All eighteen staff records contained a completed background
screening with an “Eligible” determination prior to the staff having any contact with youth or
youth records, documentation of a criminal history report review, and a pre-employment
assessment tool. Sixteen of eighteen reviewed staff records contained a pre-employment
assessment tool with a passing score; the remaining two records contained non-passing scores
on the assessment tool; however, they both included documentation of the required interview
and score adjustment for employment eligibility. The center had six contracted medical and
mental health staff hired during the annual compliance review period. All six contracted staff
records contained a completed background screening with an “Eligible” determination prior to
the staff having any contact with youth or youth records, documentation of a criminal history
report review, and each was added to the center’s Clearinghouse employee roster as required.
None of the eighteen reviewed staff or six contracted staff were applicable for a screening due
to being hired from another provider. Due Department-wide system outages, the Department’s
Juvenile Justice Information System (JJIS) was unable to be accessed and breaks in service
were not able to be reviewed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 55 (Revised July 2023)
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures to ensure all Department staff, contracted
providers, volunteers, mentors, and interns with access to youth and youth records have a
rescreening every five years. The center had six applicable staff eligible for a five-year
screening within the annual compliance review period. All six reviewed staff records contained
documentation to confirm the center completed and submitted the rescreen within the required
timeframe, not more than twelve months and at least ten days prior to the staff’s five-year
anniversary date.
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures (FOPs) to ensure all staff adhere to a code of
conduct prohibiting any form of abuse, profanity, threats, harassment, intimidation, “horseplay,”
or personal relationships with youth. The code of conduct also outlines the staff’s requirement to
maintain confidentiality for all youth. Three staff records with applicable violations of the code of
conduct were reviewed. Two of three staff records contained the original signed code of conduct
form; the remaining record was unavailable as the staff has since separated from the center,
and the staff record is maintained electronically, and physically off-site. Due to Department-wide
system outages the electronic record was not available. A copy from the physical record was
requested, but not received. Two of three reviewed violations were due to the staff’s refusal to
complete a mandatory shift hold over; the remaining incident was for missing ten-minute
checks. Two of three violations resulted in disciplinary actions through an oral/verbal reprimand;
the remaining violation resulted in disciplinary action through a notice of investigation. Three
staff records were reviewed for documentation of commendations received during the annual
compliance review period. All three commendations resulted in the staff being promoted within
the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 55 (Revised July 2023)
Nine youth interviews were conducted. Four of nine reported they had never been stopped from
reporting abuse to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC); the remaining five youth confirmed they had never asked or needed to report
abuse. Seven of nine interviewed youth reported staff are respectful when speaking with youth;
the remaining two reported staff are sometimes not respectful; however, staff are respectful
most of the time. The center’s superintendent and assistant superintendent stated youth may
perceive consequences of undesirable behavior as disrespect. Three of nine interviewed youth
reported they had never heard staff use curse words when speaking with youth; five of nine
youth indicated this occurs occasionally; and the remaining youth reported staff use curse words
often. The center’s superintendent and assistant superintendent stated they have not heard staff
using profanity toward the youth. Seven of nine youth stated they had not heard staff threaten a
youth; one of nine reported hearing this occur once; and the remaining youth stated staff threats
are heard often; however, no examples or additional information was provided. The center’s
superintendent and assistant superintendent stated each reported incident is reviewed and
handled appropriately; they confirmed one incident included a Department of Children and
Families investigation which was closed as unfounded. All nine interviewed youth reported they
felt safe at the center; one youth provided an additional statement regarding feeling unsafe only
with youth who tend to fight often. All nine interviewed youth reported they have never
exchanged emails, telephone numbers, or social media contact information with staff.
Nine staff were interviewed regarding the abuse reporting process and six staff included
notification to the supervisor; one staff specified notification to the superintendent; one staff
confirmed a staff can call if needed; and all nine staff confirmed youth are allowed to call upon
request. Seven of nine interviewed staff reported they have not heard staff using profanity when
speaking with youth; one staff reported this to occur occasionally; and the remaining staff
reported this occurs often. One staff stated youth made staff use profane language when youth
were acting up and the other staff stated they had observed a couple coworkers using profanity;
however, the staff are no longer employed at the center. Eight of nine staff confirmed they have
not witnessed a staff threatening a youth; the remaining staff reported to have observed a staff
threatening a youth once; however, stated the staff is no longer employed at the center. Four of
nine staff reported the working conditions to be good; three of nine reported them to be fair; one
of nine reported conditions were poor; and the remaining staff reported very poor working
conditions. The center’s superintendent and assistant superintendent provided staff shortage
and youth overpopulation as the primary reasons reported to them by staff for undesirable
working conditions.
The superintendent confirmed the center has FOPs which are required to be followed. All
physical abuse and threats are strictly prohibited, and all abuse allegations and incidents are
reported to the Florida Abuse Hotline and the CCC, as well as to local law enforcement. An
investigation is conducted, and if required upon completion, staff may receive disciplinary
action, up to and including dismissal.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 55 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The superintendent stated incidents are reported to the Florida Abuse Hotline and local law
enforcement in a timely manner. The Department’s Central Communications Center (CCC) is
called within the required two hours of initial knowledge with all known and required information,
including youth Department identification numbers, information about the incident, and those
involved. The administration team notifies regional staff within the required time frame.
1.05 Protective Action Response (PAR) Non-Applicable
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
Nine interviewed staff reported they try to talk with youth, utilizing verbal de-escalation, prior to
employing the use of any restraints. The superintendent reported all physical and mechanical
restraints are inventoried daily and the facility operating procedures (FOPs) are followed. The
superintendent confirmed the center’s administrative team reviews all Protective Action
Response Right Interactions model Reports, along with video review, to ensure the FOPs and
Department policy are followed, and to ensure no excessive use of force is utilized.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures (FOPs) to ensure all newly hired staff receive the
required trainings within the first 180 days of employment. Nine staff records were reviewed for
pre-service training and certification requirements. Four of nine reviewed staff records contained
documentation each completed a new staff orientation within the first thirty days, Phase One,
and Phase Two (the academy) of the detention training, and became certified within the
required 180 days of hire. Two of nine reviewed staff records contained documentation each
completed a new staff orientation within the first thirty days and completed Phase One of
training while waiting to attend the academy; these staff are still within their first 180 days of
hire. The remaining three reviewed staff records, within the first 180 days of hire, contained
documentation each completed a new staff orientation within the first thirty days and are
working to complete Phase One. All staff had the required trainings prior to contact with youth
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 55 (Revised July 2023)
and youth records. The center did not have any returning/rehired staff this annual compliance
review period.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic training records were not available for review, and the center’s staff training files were
utilized for this annual compliance review.
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
The center has facility operating procedures to ensure all staff receive the required annual
trainings. Nine staff records were reviewed for in-service training, and all nine records contained
documentation of current cardiopulmonary resuscitation (CPR), first-aid, and automated
external defibrillator (AED) certifications; protective action response (PAR)/Right Interactions
(RI) refresher training; and four hours of required in-person suicide awareness and prevention
training. All nine reviewed staff records contained documentation, evidenced by sign-in sheets,
each staff attended the required trainings for the emergency care plan, infection control, the
exposure control plan, escape prevention, and the fire prevention plan/disaster procedures. An
informal interview with the nurse on-site confirmed a registered nurse provides the annual girl’s
healthcare in-service training to all non-healthcare staff, and confirmed the training does include
the monitoring, observation, and emergency care of pregnant youth. The center’s annual in-
service training list included all required information and was approved by the Department’s
regional director on November 17, 2023, prior to the required deadline. The center maintains an
annual training calendar which is updated as changes occur.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic training records were not available for review, and the center’s staff training files were
utilized for this annual compliance review.
The superintendent confirmed receiving trainings through the Department’s Learning
Management System (SkillPro), as well as in-person trainings which included PAR/RI refresher
training and leadership training at headquarters. The superintendent requires their supervision
level staff to complete dos and don’ts of interviewing and customer service.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 55 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures to ensure youth have an established process in
place to file a grievance when a youth’s rights have gone unprotected or have been violated.
The center employs an electronic grievance system.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic records were not available for review.
Two of nine interviewed youth were able to describe what a grievance is and how filing a
grievance works; the remaining seven interviewed youth stated they did not know, were not told,
or had forgotten what a grievance is. The superintendent and assistant superintendent were
able to confirm all youth receive an orientation and handbook at admission into the center, and
grievance information is provided to them. Seven of nine interviewed youth stated they had
never filed or needed to address a grievance; one youth reported the grievance process to
good; and the remaining youth stated it is fair.
Nine staff were interviewed and each staff was able to explain how a youth would file or make a
grievance and how the process works.
The superintendent confirmed the center’s grievance procedures and process, including the
required timeframes and the staff’s responsibilities in the process. The center maintains a
record of filed grievances for a period of three years.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 55 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures to ensure all staff are informed and maintain
current information regarding youth alerts for the safety of youth, staff, and the center. The
center utilizes the Department’s Juvenile Justice Information System (JJIS) to enter, update,
and maintain a current list of youth alerts for youth within the center. Alerts are reviewed at each
shift briefing, which was confirmed by observation of a shift briefing and a review of shift briefing
reports.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic records were not available for review. In order to maintain safety and security during
the outages the center created and maintains an in-house document, a daily email, with all
known and new alerts for each youth in the center.
Nine staff were interviewed about the center’s alert system. Seven staff confirmed youth alerts
are reviewed at shift briefing; four staff reported alert information can be reviewed in the
logbooks; three staff indicated the center has an alert form; two staff stated JJIS is a location to
see youth alerts; three staff confirmed the center utilizes an alert board for staff review; and one
staff stated an email is a location to see youth alerts. Staff were also asked how administrative
staff relay information about issues within the center. Seven staff confirmed this information is
presented at shift briefing; one staff stated issues are noted within the logbooks; and one staff
stated issues are relayed through emails. Four of nine staff reported these systems as good;
two staff stated the processes were very good; and the remaining staff rated these as fair.
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Office of Accountability and Program Support Page 16 of 55 (Revised July 2023)
The superintendent confirmed the center’s process starts with ensuring the Admission Wizard is
completed accurately at a youth’s admission to the center. Alerts are reviewed by intake staff,
supervisors, administration, and dietary staff to ensure all applicable alerts are maintained. The
superintendent confirmed youth alerts are presented at shift briefing; shift supervisors have a
current alert list in their possession for reference and to make updates as needed; youth alerts
are noted in the logbooks; and alerts are communicated between staff at shift change.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center has facility operating procedures to ensure they collect, update, and maintain data
trend analysis. The data is utilized to make decisions regarding the center and youth. The
center provides their information for state data; and the center also utilizes the state data in
decision-making processes when applicable. The center’s administration participates in the
weekly statewide headquarters/director’s call where center-specific and state data is shared and
discussed and in the monthly superintendent conference calls which also review this
information. The superintendent holds a captain’s weekly meeting with the assistant
superintendents to relay information from the other calls and meetings as well as to discuss
center-specific and youth issues; the center holds a monthly supervisors meeting to relay and
address in-house data and issues; and staff are provided pertinent information at the daily shift
briefings. The superintendent also participates in a bi-monthly meeting with providers and the
Department’s regional staff and attends the quarterly circuit meetings where data trends are
discussed. Community-based meetings, such as Community Advisory Board and the
Department of Children and Families administration, are utilized for the superintendent to share
current data trends with the stakeholders. A review of shift briefing reports, Detention Review
notes, agendas and minutes, and emails was conducted and confirmed the center’s data trend
analysis collection, maintenance, and distribution processes. The center utilizes a data
collection and analysis computer system to compile and maintain their data.
Due to Department-wide system outages at the time of the annual compliance review, the
electronic records were not available for review.
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Office of Accountability and Program Support Page 17 of 55 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Non-Applicable
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has facility operating procedures ensuring all program orientation protocols are
followed with each youth being admitted. A review of nine youth case management records was
conducted. Each record had documentation to indicate the youth was provided an orientation
within twenty-four of admission and each signed an orientation acknowledgement form. Each
reviewed youth record documented the orientation was explained to the youth verbally and in
writing by staff. The orientation brochure covered all required information, to include Prison
Rape Elimination Act (PREA) related information. An admission was not observed during the
annual compliance review week; however, an informal interview was held with a staff who was
able to give the steps of an admission which includes the PREA video. The staff stated the
PREA video has not been played at admission due to a broken video player, which has not
been replaced.
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Office of Accountability and Program Support Page 18 of 55 (Revised July 2023)
Five of nine interviewed youth confirmed the center’s rules, regulations, daily schedule,
education services, visitation, abuse reporting, and behavior management system were
reviewed with them at admission; the remaining four youth stated these topics were not
reviewed. The superintendent and assistant superintendent stated each youth signs off on these
items at orientation/admission, which was confirmed by a review of youth case management
records.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) for the classification of youth being
admitted to the center to ensure safety and security. The center’s FOPs listed all required
elements. Nine youth case management records were reviewed. Each record had classification
documentation with information concerning the youth’s history and status and were used to
determine youth room assignment. The classification included gender, height, weight, age, level
of aggression, mental illness, intellectual disability, physical disabilities, history of violent
behavior, gang affiliation, criminal history, history of sexual offense, Vulnerability to Victimization
and Sexually Aggressive Behavior (VSAB) screening results, medical, suicide risks, and escape
and security risks. Youth with a history of committing sexual offenses or youth identified as a
victim of a sexual offense are not to be placed in a room with any other youth. The nine
reviewed records documented youth were assigned to a room based on their classification and
reclassification if any changes in behavior or status were observed. Two of nine were placed on
single room only (SRO) due to history of sexual offense; the remaining seven youth were not
applicable.
The superintendent interview confirmed the center’s procedures for room assignments and
alerts, if applicable.
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Office of Accountability and Program Support Page 19 of 55 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures to ensure gang information is shared with the
circuit’s gang representative. Nine youth case management records were reviewed. None of the
nine reviewed records indicated gang activity. An additional three records were requested for
review; however, the center was not able to identify any applicable youth due to Department-
wide system outages. An informal interview was conducted with the superintendent regarding
youth gang association and confirmed the gang representative for the circuit. The
superintendent stated when a youth is identified as a gang associate at screening the Juvenile
Assessment Center (JAC) will notify the center, or the circuit gang representative will notify the
center.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures to ensure the proper handling and security of youth
property, to include valuable property items. The staff completing the admission process collects
each youth’s property and documents each item on the personal property receipt form. Any
valuable items, including money, cellular telephones, and or jewelry is placed in a clear tamper
proof bag. The tamper proof bag is marked with the date, youth’s name, and Department
Identification number (DJJID). The list of items is written on the bag and the bag is placed in a
secured drop box. The staff securing the property will record the property in the center’s drop
safe logbook. The property safe is only accessible by limited staff including the superintendent,
assistant superintendents, and supervisors. The drop safe is maintained under camera
surveillance. Other property items from youth, including clothing and shoes, are placed in
garment bag which is marked with the date, youth’s name, DJJID, and a list of included items.
The property bag is then placed in a secured property room located in the intake processing
area. Nine youth case management records were reviewed. Eight of nine records had the youth
signature on the property form. All property documents had the staff signature on the form.
Seven of nine records included a letter of acknowledgement regarding unclaimed property,
signed by the youth. The remaining two did not. Three of nine reviewed youth records indicated
youth had valuable property. The property was placed in a clear tamper proof bag and placed in
a locked cabinet for each. The property logbook was reviewed, and each youth’s name was
logged; however, neither the DJJIDs nor the time of entry were logged. An observation of the
center receiving youth personal property was not completed, as there was no admission during
the annual compliance review week.
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Office of Accountability and Program Support Page 20 of 55 (Revised July 2023)
Seven of nine interviewed youth stated staff checked their personal property at admission and
they signed a form stating the personal property was correct; the remaining two youth did not
remember signing a form for their property.
The superintendent was interviewed and confirmed the center’s procedures to secure and store
youth property, the disposal of unclaimed property, and who has access to youth property.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center has facility operating procedures to address youth releases from the center. The
staff and the supervisor completing the release shall verify the court authorization prior to
releasing each youth. The supervisor must ensure all release documents are complete and
ensure there are no holds, court orders, or any other legal reason not to release a youth from
the center. A copy of each parent/guardian photo identification card is made and placed in each
youth’s record prior to release. None of nine reviewed youth records from the sample were
applicable for release. Three additional closed youth case management records were requested
for review. All three closed records contained the completed release wizard to include the
youth’s name, any open youth alerts at time of release, and any medication if applicable. Two of
three closed records had all required signatures on each release form; the remaining record
was missing the supervisor’s signature on the forms. An informal interview was conducted with
the supervisor and confirmed all release paperwork is reviewed prior to a youth being released.
The supervisor also confirmed the court order is printed and reviewed prior to initiating a
release. All three reviewed records had a copy of photo identification of the adult whom the
youth was released to. None of the reviewed youth had endangered person alerts. Due to
Department-wide outages, the Department’s Juvenile Justice Information System (JJIS) could
not be reviewed to determine if the dates of admission and release documented in each case
file correlated with the dates in JJIS. A release was not observed during the annual compliance
review week as the team was not notified when a release was taking place. Two of three youth
records contained documentation of future court dates and notification to the youth and
parent/guardian of the future court date; the remaining record was not applicable.
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Office of Accountability and Program Support Page 21 of 55 (Revised July 2023)
2.07 Release of Youth Personal Property, Medication, Aftercare
Limited Compliance
Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures to ensure there is documentation of each youth’s
property being transferred upon release. Each youth’s personal property receipt form is required
to have the signatures of the youth, the staff completing the release, and the youth’s
parent/guardian confirming the property was reviewed and returned, matching what was logged
in at admission. The center has procedures to ensure prescribed medications, along with
medical instructions, are sent with each released youth. Three closed youth case management
records were reviewed, and all three records were missing the receipt of returned property. All
three released youth records had no medication to be released. Each reviewed record
contained a copy of the photo identification of the person who picked up the youth. The center
did not have any examples of property held for more than thirty days during the annual
compliance review period. An observation of the release process was not completed, as the
team was not notified when a release was taking place.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures to ensure the center conducts a weekly Detention
Review meeting for proper management of youth placed in a secure detention and appropriate
sharing of information between all involved and/or assigned staff. The superintendent or
designee coordinates each weekly Detention Review meeting. A Detention Review meeting was
observed during the annual compliance review week. A review of secure detention logs and
meeting documentation confirmed all required participants attended each meeting, either in
person, virtual conferencing, or by telephone.
The superintendent interview confirmed the weekly Detention Review meetings were held and
the required information was discussed regarding each youth in secure detention.
2.09 Daily Activity Schedule Limited 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) to ensure a daily activity schedule is posted
and followed each day. Observations made during the annual compliance review week showed
the center was not following the posted daily schedule. Youth were not observed to be in the
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scheduled location or engaged in the scheduled activity during two days of the annual
compliance review week. Scheduled bathroom breaks, meal break, and movement to physical
education were also observed. The center regularly provided youth with daily hygiene, meals,
visitation, physical activity and recreation, and indoor activities.
All nine interviewed youth stated the center does not have nor do they follow a daily schedule;
however, observations found a daily schedule was posted on each living module. The
superintendent and assistant superintendent stated the schedule is posted and followed barring
any safety or security issues or unscheduled events. Nine interviewed staff indicated the center
follows the daily activity schedule.
2.10 Educational Access (Critical) Failed 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 ensure educational access for youth. The
Volusia County School District provides the educational services and approves the 250-day
calendar, which incorporates up to ten days of teacher planning and/or training. The center’s
daily bell schedule meets the required twenty-five hours of instruction weekly. All youth have an
opportunity to earn course credit upon completion.
All nine interviewed staff, as well as the superintendent, responded there was minimal
interference to the daily school schedule; however, the youth responded differently, with only
one of the nine indicating they go to school Monday through Friday. The other eight youth said
they do not and indicated they have been locked down and there has not been enough staff to
take them to school.
The lead teacher confirmed school has been taking place on the living modules, as there is not
enough staff to be able to bring youth to the classrooms. When asked about how well they are
being trained for their next educational or employment placement, four youth responded with
very well, two said well, and three said not well with a comment they had only been to school
two times in the past two weeks.
A review of four randomly selected master control and two B1 module logbook entries indicated
youth are not following the daily school schedule. The biggest loss of time is getting the youth to
the classrooms first thing in the morning and additional time needed for the mid-morning break.
For the past several weeks, the school schedule has been disrupted due to the increase of
youth and the lack of staff needed to move youth to the classrooms. Video review of three days
reflected the school schedule was not being followed and there was less than two hours of
school for two days; and there was no movement of youth to school on the remaining day.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
An interview with the lead teacher confirmed the center provides career education
programming. The program meets the requirements of a Type 1 program which incorporates
communication, interpersonal, and decision-making skills, as well as life skills and activities
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through career-related instruction in class. Nine interviewed youth stated they are enrolled in a
combination of the academic courses.
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Office of Accountability and Program Support Page 24 of 55 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a licensed mental health counselor (LMHC) who has a clear and active license
which expires March 31, 2025. The LMHC became the designated mental health clinician
authority (DMHCA) March 2024. Starting December 2023 through March 2024, a licensed
mental health therapist (LMHT) was the acting DMHCA, who has a clear and active license,
which expires March 31, 2025. Prior to December 2023, another LMHC was the DMHCA, who
had a clear and active license, which expires March 31, 2025. A back-up DMHCA is not
required by contract; however, the center’s LMHT is the back-up when needed. A review of the
DMHCA sign-in and sign-out logs, confirmed the DMHCA was on-site a minimum of forty hours
a week since the start of the contract June 12, 2023. The DMHCA was interviewed and
described the role of the DMHCA and the process and implementation of mental health and
substance abuse services at the facility. The DMHCA described the communication between
the DMHCA and clinical staff as occurring daily.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department has a contract with VitalCore Health Strategies, LLC, who provides all mental
health and substance abuse services for all applicable youth at the center. The clinical
supervisor ensures the licensed clinical staff working under their supervision are performing
services they are qualified to provide based on education, training, and experience. All licensed
staff working at the center are licensed mental health and qualified professionals licensed under
the appropriate Florida Statutes chapter. All the licensed mental health staff’s licenses were
reviewed and confirmed to be clear and active, all expiring March 31, 2025. A total of five staff
provided mental health and substance abuse services at the center since the start of the
contract in June 2024, three licensed mental health counselors and two licensed clinical social
workers.
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Office of Accountability and Program Support Page 25 of 55 (Revised July 2023)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department has a contract with VitalCore Health Strategies, LLC, who provides all mental
health and substance abuse services for all applicable youth at the center. A review of the
contract found non-licensed clinical staff are not required. At the time of the annual compliance
review, the center did not have any non-licensed staff.
3.04 Mental Health and Substance Abuse Admission Screening
Non-Applicable
[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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
3.05 Mental Health and Substance Abuse Evaluation [Detention
Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The designated mental health clinician authority (DMHCA) was interviewed and described the
process for completing the youth’s initial screening and obtaining the comprehensive mental
health and/or substance abuse assessment.
3.06 Treatment and Discharge Planning [Contract Provider] Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
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Office of Accountability and Program Support Page 26 of 55 (Revised July 2023)
The designated mental health clinician authority (DMHCA) was interviewed and stated all
mental health and substance abuse services are reviewed at a minimum of once a week at the
management meeting. The DMHCA explained the initial treatment plan is developed within
seven days of the psychiatrist meeting with the youth and the individual treatment plan is
developed by the youth’s thirty-first day at the center. The review of individualized treatment
plans, individualized substance abuse treatment plans, and/or integrated mental
health/substance abuse treatment plans are conducted every thirty days while the youth are in
secure detention.
3.07 Mental Health and Substance Abuse Treatment [Detention
Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
Nine youth were interviewed and two youth stated mental health and substance abuse services
at the center are very good, two stated good, one stated fair, and one stated very poor; three
youth were not receiving mental health/substance abuse services. The designated mental
health clinician authority (DMHCA) was interviewed and stated youth who are receiving services
are seen by mental health and substance abuse staff at least weekly.
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.
Psychiatric services at the center are provided by a physician licensed pursuant to Florida
Statute, who is a board-certified psychiatrist. The psychiatrist’s license expires January 31,
2025. The center has a back-up psychiatrist, who has an equal licensure and who’s license
expires January 31, 2026. According to the provider’s contract, approved tele-psychiatry shall
be classified as on-site, where appropriate, to meet the needs of the youth. The designated
mental health clinician authority (DMHCA) was interviewed and stated psychiatric, mental
health, and substance abuse services are provided at the center, at a minimum weekly for all
applicable youth.
Due to Department-wide system outages at the time of the annual compliance review, youth
records were unable to be reviewed.
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Office of Accountability and Program Support Page 27 of 55 (Revised July 2023)
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a suicide prevention plan which is signed and reviewed by the designated
mental health clinician authority (DMHCA) annually and contains all required elements. Included
in the suicide prevention plan is an established review process for every serious suicide attempt
or serious self-inflicted injury and a mortality review for a completed suicide. This
multidisciplinary review included all required elements.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
The center has facility operating procedures (FOPs) for suicide precautions which include
supervision, observation, monitoring, and housing for youth identified as a potential suicide risk
through screening, collateral information, and staff observations. Each identified youth must be
placed on precautionary observation (PO) or secure observation (SO) with constant supervision
and have an Assessment of Suicide Risk (ASR) completed by a licensed mental health
professional. None of the nine reviewed youth mental health records were applicable for this
indicator. One additional youth record was requested, as the youth had three separate
instances of suicide observations and assessments. One of three incidents of PO was initiated
due to staff observation of at-risk or concerning behaviors; the remaining two incidents of PO
were after a youth returned to the center after a Baker Act. Each PO was started immediately or
upon readmission to the center from a Baker Act, and each had a suicide risk assessment
referral made as required. Due to Department-wide system outages at the time of the annual
compliance review, the Department’s Juvenile Justice Information System (JJIS) alerts were not
able to be confirmed or reviewed. All three ASRs were completed on the required Department
form within twenty-four hours. In two of three incidents, the youth was placed on constant
supervision while awaiting the ASR; the remaining incident occurred when the youth was on
standard supervision and the designated mental health clinician authority (DMHCA) was on-site
during the incident. Each of the three reviewed PO logs were completed in their entirety to
include safe housing and required signatures. All three ASRs occurred while the youth was in
the custody of the center. Documentation of the staff’s consultation with the DMHCA and the
immediate notification of the superintendent or designee was located on all three referrals. One
of three incidents required a Follow-Up ASR to be completed prior to removing the youth from
PO, and the Follow-Up ASR contained the documentation of the conference held by the
superintendent and licensed mental health professional. The two remaining incidents were not
applicable for a Follow-Up ASR as the youth was Baker Acted in both incidents. A licensed
mental health professional completed each of the reviewed ASRs which included the
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assessment results and supervision recommendations. All three incidents were in the
appropriate logbook with beginning and ending times, as well as when each youth was taken
off-site for the Baker Acts and the youth’s return to the center. One of three incidents resulted in
the youth being placed in SO under the superintendent and DMHCA’s authorization and a
secure room assignment was made; the remaining two incidents were not applicable. Prior to
placement in SO a health status checklist form was completed and during the SO a supervision
log was completed in its entirety, including observations made of the youth’s behavior. The
youth was in SO for less than eight hours; therefore, a new ASR was not required, and the
youth was Baker Acted from SO. Supportive counseling was not initiated due to the short SO
period prior to being Baker Acted.
Three of nine interviewed youth confirmed they had been under suicide watch and staff always
watch the youth; the remaining six youth were not applicable. Nine staff were interviewed and
seven identified the task of notifying the mental health authority, six staff identified the task of
searching the youth and their room for sharp objects, six staff confirmed they place the youth on
constant sight and sound supervision, five staff identified the task of documenting the constant
supervision, and one staff noted they are to document it in the logbook and inform the master
control when a youth expressed suicidal thoughts. The superintendent interview confirmed
youth placed in SO have a staff placed at their door window, in direct sight of the youth at all
times, and documentation of the SO is completed on the required supervision log.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
The center has facility operating procedures (FOPs) to ensure all youth on suicide precautions
have constant supervision from an assigned staff who documents observations of the youth’s
behavior at a minimum of every thirty minutes. None of the nine reviewed youth mental health
records were applicable for this indicator. One additional youth mental health record was
requested, as they had three separate suicide observations and assessments. All three
incidents had a corresponding Suicide Precaution Observation Log maintained during the
duration of the suicide precaution supervision, and each log was observed to have
documentation for the appropriate level of supervision and behavior observations made every
thirty minutes. All three logs included documentation of notification to the superintendent or
designee and mental health clinical staff when warning signs were observed; signatures from
each applicable shift supervisor and mental health clinical staff; and safe housing requirements
identified. Three video observations, each a minimum of thirty minutes, were conducted and
verified the documented supervision matched the video observation.
3.12 Suicide Prevention Training [Detention Staff] (Critical) Limited Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
The center has facility operating procedures (FOPs) to ensure all direct care staff receive
annual training on suicide prevention, to include risk factors, behavioral observations, and
implementation of suicide precautions. A review of eighteen direct care staff training records
including nine pre-service and nine in-service records, was completed. All reviewed staff training
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records contained documentation of four hours of in-person suicide prevention training. Due to
Department-wide system outages at the time of the annual compliance review, a review of the
Department’s Learning Management System (SkillPro) for the required two-hour course was not
able to be completed. The center provided documentation of suicide drills held monthly,
exceeding the quarterly requirement, on each shift throughout the annual compliance review
period. The center has four suicide kits containing the required items and each is co-located
with a first-aid kit. The kits are in master control and each of the three sub control rooms. The
center had two shifts from May 2023 through December 2023 and held a total of sixteen suicide
prevention drills, eight on each shift, during this time. Three of sixteen drills contained all the
required elements, to include proper contacts made, life saving measure utilized within the drill
narrative, the supervisor recommendations, as well as all required signatures. The remaining
thirteen drills were all missing at least one, and up to four, required elements. The center has
had three shifts since January 2024 through the remainder of the annual compliance review
period. Four of twelve drills contained all the required elements, to include proper contacts
made, life saving measure utilized within the drill narrative and the supervisor
recommendations, as well as all required signatures; the remaining eight drills were all missing
at least one, and up to three, required elements. In the review of the first six-month period forty-
two of forty-eight staff, and in the second six-month period thirty-seven of thirty-eight staff
participated in at least one drill as evidenced by the drill sign-in sheets. There were five staff on
the roster of thirty-eight, with no documentation to support they participated in a required annual
drill utilizing cardiopulmonary resuscitation (CPR). Staff who are not present for mock drills can
review the drill scenario report.
Nine staff were interviewed and asked about the location of the suicide kits in the center. Five
staff reported one is in master control, seven staff reported there is a kit in each sub control, and
six staff reported there is a kit in medical. An informal interview with the center’s administration
confirmed there are the same items in the nurse’s “go bag”; however, it is not a suicide kit for
staff to access, and a review of the location of each kit would be conducted at shift briefings.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has facility operating procedures (FOPs) to ensure the least restrictive
means/response to protect the safety of youth and others while maintaining control is utilized for
youth in crisis. A review of the center’s combined emergency services plan was conducted and
confirmed the combined plan contains all the required elements, to include notification and alert
systems, communication and documentation, supervision, and incident review.
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3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center has facility operating procedures (FOPs) to ensure youth determined to be in
imminent danger to themselves or others due to mental health or substance abuse issues
receive emergency care services in accordance with the center’s emergency care plan. A
review of the center’s combined emergency care plan and crisis intervention plan was
conducted and confirmed the combined plan contains all the required elements, to include
immediate staff response, notifications and communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transport for Baker Act and
Marchman Act, documentation, training, and review procedures. The center’s combined plan
was approved on April 8, 2024, and last updated on March 15, 2022. All staff have access to the
approved plan. The plan is in the superintendent’s office, medical, and mental health office, as
well as online for staff to access and review.
3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The center has facility operating procedures (FOPs) to ensure youth demonstrating acute
psychological distress receive a detailed evaluation conducted by a licensed mental health
professional, or under the supervision of a licensed mental health professional, to determine the
level and severity of risk. A Crisis Assessment is only utilized when the presenting acute
psychological distress is not related to suicide risk factors. None of the nine reviewed youth
mental health records received these services. The center has not had any youth in need of a
Crisis Assessment during the annual compliance review period.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center has facility operating procedures (FOPs) to ensure youth believed to be an imminent
danger to themselves or others due to mental health or substance abuse issues receive
emergency services through Baker or Marchman Act procedures. None of the nine reviewed
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youth mental health records were applicable for these services. Additional records were
requested, and one youth record was applicable and provided for review. The youth record had
two separate Baker Act incidents applicable for the annual compliance review period. The youth
was placed on precautionary observation upon re-admission to the center, a mental health
referral was completed for a Mental Status Examination (MSE), and the MSE was completed by
a licensed mental health professional after each Baker Act incident. One of two incidents had
documentation of the youth being maintained on constant supervision until properly transitioned
to a lower level of supervision, after an appropriate assessment was conducted by a licensed
mental health professional; the remaining incident the youth was sent out again under a Baker
Act.
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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’s designated health authority (DHA) is a board-certified physician, with an
unrestricted license and a specialty in family practice. The DHA’s license expires January 31,
2026. The center has an advanced practice registered nurse (APRN) with a collaborative
practice protocol in place. A review of sign-in and out logs during the annual compliance review
period confirmed the DHA was on-site weekly since the last annual compliance review. The
center has a backup DHA with equal licensure, expiring January 31, 2025. The backup DHA
was utilized three separate dates during the annual compliance review period. The center
utilizes tele-medicine, has corresponding facility operating procedures, and maintains a
Telehealth Log, documenting the provider's name, date, time-in, time-out, youth's name, the
Department’s Identification number, chief complaint, and treatment order. The DHA was
interviewed and indicated they are on-site weekly and described their role as conducting
periodic evaluations, conducting sick call, focused physicals, Comprehensive Physical
Assessments (CPAs), and episodic evaluations. The DHA further stated they develop and
review protocols, policies, and procedure documents and act in collaboration with the medical
staff in a decision-making role. While on-site the DHA reviews the list of youth, orders, and other
medical information with staff and is available by telephone when not on-site. A folder is
reviewed weekly for any off-site visits or evaluations for all applicable youth. All youth receive a
medical visit from the DHA upon return from an emergency room or any additional off-site
evaluations. All pertinent or urgent issues with youth are addressed when the DHA is on-site or
through telephone communication with the DHA. When the DHA is not available, the clinical
manager arranges for the backup DHA to cover.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center has facility operating procedures (FOPs) and treatment protocols which were
reviewed and signed by the designated health authority (DHA) on February 19, 2024. The
signature line for the superintendent’s review and signature was inadvertently left off the FOPs,
according to the Department’s Office of Health Services; therefore, the medical FOPs were not
reviewed and signed by the center’s superintendent. This is being rectified and will be updated
in the near future. The psychiatrist reviewed and signed the psychiatric FOPs on February 16,
2024. Nursing staff reviewed, signed, and dated the cover page for the medical FOP's and
treatment protocols; all were reviewed and signed in the month of February 2024. There were
no policy changes or updates since the staff review in February 2024. In addition, the center
maintains health related procedures and treatment protocols. There was one healthcare staff
hired since the last annual compliance review, who received a comprehensive clinical
orientation, provided by a registered nurse, to the Department’s healthcare policies and
procedures.
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4.03 Authority for Evaluation and Treatment [Detention
Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated when a new psychotropic medication is
prescribed, discontinued, or the dosage is significantly changed, parental/guardian verbal
consent is documented on the Clinical Psychotropic Progress Note (CPPN) on page 3. Written
consent is documented on the Acknowledgment of Receipt of CPPN form. Any verbal
notification (in person or by telephone) is documented on a written Parental Notification/Consent
form, showing attempts to obtain the signed parent/guardian consent. The center obtains each
youth’s immunization records through Florida Shots upon admission. In the event the
parent/guardian is requesting exemption from immunizations, the parent/guardian must present
a certified documentation of exemption. It is reviewed by nursing staff and the designated health
authority and uploaded in the youth’s medical chart.
4.04 Parental Notification/Consent [Contract Provider] Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated parental/guardian notifications should be made
to inform parents/guardians of significant changes in each youth’s condition and obtain consent
when new medications are ordered, medications are stopped, youth are sent off-site for
treatment, whether scheduled or emergency, and treatments are prescribed. These notifications
are first done verbally and followed with a letter. The nurse contacts the parent/guardian by
telephone as soon as the change occurs. Then a letter is sent out explaining the medication
(given or started) or treatment rendered.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening entered Non-Applicable
into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated each newly admitted youth is seen by medical
staff the day of admission. If nursing staff are not on-site when the youth is admitted, the youth
is seen the following morning when medical staff return. Direct care staff or master control notify
medical of each newly admitted youth. In the event direct care staff complete the admission
screening the nurse signs on the third page of the screening form confirming a review of the
screening packet. When there is a change in a youth’s physical custody, upon return, the youth
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is accessed for any changes in their medical condition. Vital signs are also obtained, and the
health-related history 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 addressing youth orientation to healthcare services
in the facility. The procedures address access to medical care, sick call, what constitutes an
emergency and when to notify staff, the medication process to include side effect monitoring,
the refusal process and how to document it, what to do in the case of a sexual assault or
attempted sexual assault, the non-disciplinary role of healthcare providers, and the review of the
list of healthcare contacts to ensure accuracy. A review of youth healthcare records was unable
to be completed at the time of the annual compliance review. The center utilizes the
Department’s Health Education form to document the orientation process for all newly admitted
youth.
4.07 Designated Health Authority/Designee Admission
Non-Applicable
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated nursing staff are required to
contact the designated health authority by telephone for all youth admitted with serious or
chronic conditions, which is documented on the center’s intake log as well as on the youth’s
admission form.
4.08 Health-Related History [Contract Provider] Non-Applicable
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated nursing staff are responsible for
completing the Health-Related History form, which is completed within seven days of each
youth’s admission. The designated health authority (DHA) completes the Comprehensive
Physical Assessment (CPA) within seven days of each youth’s admission. A new CPA is
needed every two years if the youth is a Medical Grade 1; however, if a youth’s Medical Grade
changes from a 1, a new CPA is created.
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4.09 Comprehensive Physical Assessment/TB Screening
Non-Applicable
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated the designated health authority
(DHA) completes the Comprehensive Physical Assessment (CPA) within seven days of each
youth’s admission. A new CPA is needed every two years if youth is a Medical Grade 1;
however, if a youth’s Medical Grade changes from a 1, a new CPA is created. Tuberculosis (TB)
screenings shall be completed for each youth within seventy-two hours of admission if one is
not documented in the youth’s Individual Healthcare Record (IHCR) within the past year. Youth
are given a purified protein derivative (PPD) test one time a year and results are documented on
the CPA, Infectious Disease Form, and the TB tracking log. Gynecological exams are not
routinely completed for female youth, only if needed.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Non-Applicable
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated each youth’s Sexually Transmitted
Infectious Disease form (STID) is reviewed by the designated health authority (DHA) and if
testing is ordered, with the youth's consent, a urine sample is requested from the youth and sent
to the lab for testing. If the screening indicates a need for further evaluation, the DHA or
advanced practice registered nurse (APRN) shall provide orders for specific testing, which is
completed within seven days. The orders are noted, followed up on, and documented. All
sexually transmitted infection screenings, evaluations, referrals, and testing are documented on
the STID form, as well as in a progress note which is in the youth’s Individual Healthcare
Record (IHCR). If a youth is out of the center’s/Department’s custody for more than thirty days
and/or symptoms are present, the nurse reviews and completes the STID form with the youth.
The form is then reviewed by the DHA and if testing is ordered, with youth's consent, a urine
sample is sent to the lab. Youth are required to read and sign a Human Immunodeficiency Virus
(HIV) form to indicate whether they consent or not to being tested for HIV. If the youth consents,
they are added to the HIV testing log. Currently the APRN is performing the testing and
documentation. Documentation of pre/post-test counseling is documented on the Individual
Health Education Record. In addition, a log is kept of youth requesting to be tested. HIV results
are given verbally to the youth. The DHA meets with youth individually, does HIV pre-counseling
and testing, then the youth is later brought back to go over results and post-counseling.
Documentation of pre/post-test counseling is documented in the youth’s Individual Health
Education Record.
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4.11 Sick Call Process [Detention Staff/Contract Provider] Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and indicated the center’s designated health
authority (DHA) approved all treatment protocols. Youth who are in restricted
housing/confinement are assessed and evaluated for medical complaints or distress every
twenty-four hours which is documented in an episodic note. Any distress noted, when medical is
not on-site, direct care staff will contact the DHA. The center’s sick call hours are daily from 8:00
a.m. to 10:00 a.m. and as needed. Youth presenting with similar sick call complaints three or
more times within a two-week period are referred to the DHA or advanced practice registered
nurse (APRN). Youth notify direct care staff of a medical complaint, at which time staff enter a
sick call. Medical staff pull sick call twice a day. Medical staff have twenty-four hours to see the
youth; however, youth are often seen sooner. Youth are assessed and treatment, education,
and follow-up plans are completed. A licensed practical nurse (LPN) or registered nurse (RN)
complete all the sick calls. When a LPN completes sick call, the RN reviews the sick call within
twenty-four hours. The DHA conducts sick call when on-site. All sick calls are conducted in
medical. Nine youth were interviewed and three stated youth are seen within one day of
submitting a sick call, three stated within two days, and three stated more than three days. Eight
staff stated the nurse conducts sick call, while one stated the doctor conducts sick call. Nine
staff were interviewed and eight stated the nurse reviews sick calls and one stated the doctor
reviews sick calls. All nine stated the nurse conducts 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 maintains first-aid kits and ensures all are fully stocked with designated health
authority (DHA) approved items. The registered nurse conducts monthly checks of each first-aid
kit. All items are checked and if expired, are replaced. Reviewed documentation confirmed kits
were monitored by a registered nurse monthly since the last annual compliance review. The
first-aid kits are located in medical, master control, the youth modules, the center’s kitchen,
breakroom, intake, and one in each classroom. There are seven first-aid kits for the center’s
vehicles. A review of three first-aid kits confirmed all contained the DHA-approved items. One
first-aid kit was located in a center van. The center has two automated external defibrillators
(AEDs); one is located in medical, and one is located in the sub-control between two youth
modules. The AED instructions are located with each AED. Nursing staff check each AED
weekly and document on a weekly documentation checklist. The weekly checklist was reviewed
and confirmed weekly checks were completed since the last annual compliance review. An
outside agency inspected the AEDs on November 10, 2023, confirming each were operational.
Each AED was checked during the week of the annual compliance review confirming both were
operational. The batteries and pads, for each AED, were installed February 11, 2023. The pads
for each expire March 28, 2025. A review of the center’s documentation of required emergency
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drills was conducted. The center held twenty-eight emergency drills during the annual
compliance review period, once a month on each shift. One of twenty-eight reviewed
emergency drills was missing a required element in the narrative and supervisor review
documentation; the remaining twenty-seven documented drills had all required staff response
elements within the narrative or was mentioned within the supervisor’s review of the drill. The
center conducted announced and unannounced emergency drills to simulate an episodic care
event which included first-aid and/or administration of cardiopulmonary resuscitation (CPR)
techniques and the initiation of emergency procedures for a life-threatening event. A list of
emergency numbers is posted and accessible to staff and not accessible to youth. Authorized
direct care staff were trained on the administration of the epinephrine auto-injector by the
registered nurse on February 23, 2024. Nine pre-service and nine in-service staff training
records were reviewed. All eighteen staff completed the training requirements regarding
episodic, first-aid, and emergency care. The center has a policy detailing the process of the use
of Narcan. The center maintains Narcan in medical in a locked medication cart, where juvenile
justice detention officer supervisors, the assistant superintendents, the superintendent, and
nursing staff have access. Each staff who has access was trained on the proper use of Narcan
on February 23, 2023. The center’s process for inventory for Narcan is the same as all other
prescription medications. The center’s nurse was interviewed and indicated the center maintains
first-aid kits throughout the center and for the center’s transport vehicles. Episodic care by
licensed staff is documented in the Department’s Electronic Medical Record (EMR) in an
Episodic Care Progress Note and covers all elements of a Subjective, Objective, Assessment
and Plan (SOAP) note. Direct care staff episodic care is documented on the Report of On-Site
Care by Non-Healthcare Staff form. Episodic care provided by direct care staff is followed up on
by an evaluation by medical staff when they return to the center. The center tracks youth who
go off-site for emergency care, by documenting it on the Off-site Care Log which is entered into
the EMR. The nurse confirmed the center had AEDs and medical staff tracks them weekly. Drills
are completed monthly on each shift, according to the nurse. Nine staff were interviewed and
indicated they are able to call 9-1-1 if they feel it is necessary. Nine youth were interviewed and
three rated the medical care as fair, five rated it good, and one rated it very good.
4.13 Off-Site Care/Referrals [Contract Provider] Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated youth who are sent off-site for first-aid or
emergency care is logged in the Department’s Electronic Medical Record. Medical staff review
all hospital orders with the designated health authority (DHA). The DHA then gives orders to
follow in the center. The DHA reviews all findings, instructions, and follow-up information from
off-site care next time they are on-site. All follow-up, referrals, and appointments are notated on
the calendar and sent to medical staff through email. The Summary of Off-Site Care form is
utilized to track follow-up as well.
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4.14 Chronic Conditions/Periodic Evaluations [Contract
Non-Applicable
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and stated alerts are entered into the Department’s Juvenile
Justice Information System (JJIS) and the designated health authority (DHA) sees each youth
who has a chronic condition. The DHA was interviewed and stated youth with chronic conditions
are seen every three months, although often they are seen more frequently if warranted or
necessary. The nursing manager tracks periodic evaluations based on the recommendation at
the time of the medical evaluation following intake.
4.15 Medication Management [Contract Provider] Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s nurse was interviewed and indicated when youth arrive with medication upon
admittance a medication receipt is filled out and the nurse reviews the medication to ensure it is
from a licensed pharmacy, with a current, patient-specific label intact on the original medication
container in order to accept it. Medications shall have a current, valid order and are given as
ordered on current prescription or Practitioner Order form. The designated health authority
(DHA) or psychiatrist are contacted to obtain all orders to resume the specified medication each
youth is prescribed prior to admission. Supervisors are trained by the registered nurse to
administer medications and the staff approved list is located in the front of the medication book
in medical. The nurse stated medication pass is at 8:00 a.m., 5:00 p.m., and 7:00 p.m. daily.
Gynecological exams are not routinely completed, only if medical attention is needed. Youth
medications are procured; ten percent through a community pharmacy and ninety percent
through a vendor. The center utilizes a psychiatrist, who is on-site to provide individual therapy
and medication management. Nine staff were interviewed and two stated they administer
medication to youth and seven stated they did not. Nine youth were interviewed and five stated
the nurse provides their medication and four stated they do not take medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The center utilizes a perpetual inventory, in descending count, for all sharps. During the annual
compliance review week an observation of all sharps confirmed all were secured in medical, in a
locked cabinet. All medications were in medical, in a locked medication cart, inaccessible to
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youth. Medical was clean and organized, with all medications in the locked medication cart. All
youth medications were separated. All controlled medications were stored in a separate locked
box, in the locked medication cart, and each had a perpetual inventory with a shift-to-shift count
documented. All injectable and topical medications are kept separate from oral medications.
The center has a refrigerator in medical, which is only used for medications. The controlled
medication inventories confirmed medical staff use each youth's Controlled Medication
Inventory Record to document a shift-to-shift count of the medications. All non-healthcare staff
who provide medication to youth were trained in the delivery and oversight of medication self-
administration on February 23, 2024. The training was provided by the center’s registered
nurse. During the week of the annual compliance review, the inventory for three controlled
medications, three over-the-counter medications, and three sharps were reviewed, and all
counts matched the ending inventory. The nurse stated in the event there is a discrepancy in
medication inventories, nursing staff review all Medication Administration Records (MARs) and
inquire with each nurse. This process, often times resolves the discrepancy; however, if not, the
regional manager is contacted and depending on the medication the process moving forward
will be decided. Controlled substances are disposed of through the pharmacist who goes on-site
to the center. All medications are destroyed in the same fashion, with both nursing staff and the
pharmacist disposing of them with the liquid chemical destroyer. The center’s nurse was
interviewed and stated medication inventories are completed weekly and/or perpetually,
depending on the medication. Controlled medications are locked in a compartment in a locked
medication cart. The nurse stated the center has a contract with a local pharmacist who is on-
site monthly and reviews the medication cart, medication cabinets, medication refrigerator,
destroys medications, ensures everything is labeled appropriately, and reviews MARs and
sharps. The pharmacist also ensures licenses are up-to-date. The center maintains a copy of
the pharmacist license on-site.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center maintains an exposure control plan in accordance with Occupational Safety and
Health Administration (OSHA) standards. The exposure control plan includes all required
elements. It includes prevention, containment, treatment, and reporting requirements related to
infectious diseases, according to OSHA and the Centers for Disease Control and Prevention
(CDC) guidelines. The center has a process for needle stick post-exposure evaluations. Staff
are provided with a Hepatitis B Vaccination Program form to accept or deny the vaccine. All staff
have access to personal protective equipment. The center had no instances in which infectious
diseases and sexually transmitted infections (STIs) were reported to the local health
department, any instances in which incidents reported to the local health department were
reported to the Department’s Central Communications Center (CCC), any instances where
there were three or more cases of any reportable infectious diseases which needed to be
reported to the local health department and/or CDC, or any instances involving the quarantining
or hospitalization of at least ten percent of the total population of youth or staff. Nine pre-service
and nine in-service staff training records were reviewed, which confirmed biomedical
waste/exposure control plan training was completed on February 23, 2024 by the center’s
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registered nurse. The center’s nurse was interviewed and stated the center’s exposure control
plan is available to staff and is located in the exposure control plan policy binder. The nurse
stated the center’s nurse manager provides infection control training for all staff and for youth
upon admission. The center routinely uses the county health department for youth
immunizations, Human Immunodeficiency Virus treatment, dental care, and prenatal care.
4.18 Prenatal Care/Education [Contract Provider] Non-Applicable
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
The center’s registered nurse was interviewed and stated pregnant youth who are admitted to
the center are placed on a pregnancy diet, monitored monthly or as needed, provided health
education on pregnancy, provided prenatal vitamins, and any pregnancy-related orders are
provided by the designated health authority (DHA). All female youth are tested for pregnancy
upon admission if they verbally consent, at which time the DHA orders the testing. The nurse
manager provides non-licensed healthcare staff education on girls’ healthcare. Nine youth were
interviewed and all stated they needed no prenatal, obstetrical, or gynecological services while
at the center.
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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) regarding active supervision of youth.
During the annual compliance review week, observations confirmed youth were actively
supervised during all daily activities such as school, recreation, medication pass, admission
process, transportation, mental health sessions, precautionary observation, and meals.
Observations confirmed positive interactions between staff and youth, youth were in sight of at
least one juvenile justice detention officer and accounted for at all times. All movement was
reported to and approved by the master control operator.
A random review of the center’s logbooks for the annual compliance review period found youth
counts were being consistently conducted. The center keeps track of the daily census through
counts being conducted randomly throughout the day, census being tracked in shift meetings,
module logbooks, master control logbook, the Department's Juvenile Justice Information
System (JJIS), and on a white board in master control.
Six of nine interviewed staff indicated they felt there was not enough staff to provide for the
proper and safe supervision of youth; however, the remaining three staff stated there was
adequate staffing.
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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) in place providing a system of rewards and
privileges for positive behavior, and consequences for inappropriate behavior to encourage
youth to meet the center’s expectations utilizing a behavior management system (BMS).
Observations during the annual compliance review week indicated the center has postings of
the BMS in all modules clearly specifying appropriate and inappropriate behaviors, rules, norms,
and expectations. A review of point cards confirmed positive rewards and consequences are
given in accordance with the BMS and there were no instances of inappropriate use of
restrictions or group punishment. An interview with the superintendent confirmed the center
follows the BMS as detailed in the FOPs.
Two of nine interviewed youth rated the center’s BMS as very poor, two rated it as poor, four
rated it as fair, and one youth stated it was good. Eight of the nine youth were able to explain
the difference in levels and the types of rewards provided. The remaining one youth was unable
to explain the BMS because they stated it was never explained to them. All youth reported they
receive rewards for good behavior; however, the rewards are not consistently provided. Each
youth reported youth are not allowed to punish other youth in the center. Eight of nine youth
reported they have been sent to their room for punishment, and one youth stated they have not.
Seven of the eight youth reported when they were sent to their room the door was shut and
locked for the purpose of confinement. Five youth reported the consequences they received
were fair, one stated they were not fair and the remaining three said they never received
consequences. All youth stated they lost points and levels as a form of punishment, and none
had ever witnessed youth being handcuffed or having leg irons when being out-of-control.
All nine interviewed staff explained the center’s BMS to include a point system, where the BMS
is located throughout the center, and all confirmed it is included in the youth handbook and
youth orientation. Each staff provided the types of rewards such as snacks, dinners, movie
nights, and haircuts. Seven staff reported things cannot be taken away from youth as a
punishment and the remaining two indicated things can be taken. All staff reported points and
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levels can be taken away for punishment and all confirmed they have never seen a coworker
take meals, snacks, clothing, education, or medical care from a youth for acting out. Eight staff
reported the BMS is effective, and one said it needs improvement. All nine staff reported
speaking with youth to discuss consequences being imposed and allowing youth an opportunity
to explain their behavior. Each staff reported supervisors speak with them regarding how to
implement the BMS and areas of improvement, as well as receiving daily feedback, when
needed. All staff reported they have never observed another staff encourage a youth to beat up
another youth.
5.03 Ten-Minute Checks (Critical) Limited Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has seventy-two cameras with a recording capacity of thirty days. All cameras were
working during the annual compliance review week. The center utilizes a wand system for ten-
minute checks, which can be retrieved from an online system. During the annual compliance
review week the online system was not accessible to review ten-minute check documents.
Video observations of six different dates, for at least thirty minutes each, including a random
sampling of the three modules, indicated ten-minute checks were not conducted as required on
two days. One of the two days had forty-two minutes between checks and the other day had
thirty-two minutes between checks. Three days of confinement checks were reviewed. Two of
the days had two checks conducted late. One check was conducted twenty-two minutes late
and another was thirty-six minutes late. All other checks were conducted as required by staff
looking into each youth room to ensure youth safety and using the wand to record the date and
time of the check. A review of weekly management oversight reports for the annual compliance
review period indicated they were conducted as required.
All nine interviewed staff indicated room checks are conducted every ten minutes when a youth
is placed in their room for sleeping or non-punishment reasons.
The superintendent interview indicated staff will ensure ten-minute checks are conducted on the
modules and are encouraged to begin checks on an eight-minute mark. All staff shall utilize the
wand to conduct ten-minute checks.
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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 stating staff must always know the exact number
and location of all youth under their supervision. A review of logbooks for one day a month for
the annual compliance review period indicated counts were conducted at the beginning and end
of each shift, prior to and following routine group movement, anytime a population change
occurred, randomly at least once each shift, and following any emergency. Head counts and
youth movements were also captured in the logbook. Observations during the annual
compliance review week confirmed counts were being conducted as required.
Nine interviewed staff reported counts are conducted at the beginning and end of each shift, as
well as before and after school and meals. Eight of nine staff stated emergency counts are
conducted when a youth is believed to be missing, when visibility is hindered such as during an
electrical outage, and after a major disturbance. The remaining one staff reported an emergency
count is conducted every time there is an alert code called, also when counts are not correct, all
activities are stopped, and a recount is completed.
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5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has facility operating procedures (FOPs) outlining the use of logbooks to maintain a
chronological record of events, incidents, and activities. The center has separate logbooks for
master control, each module, visitor sign-in, and vehicles. A review of logbooks for three days a
month for the annual compliance review period indicated logbooks were bound with numbered
pages, the date was documented at the top of the page, all entries included the times of the
events with the name of the staff and youth involved, a brief description of the events, and the
initials of the staff making the entries. All errors were struck through with a single line and “void”
written after the error followed by the staff’s initials. The center staff did not highlight all entries
impacting the safety and security of the center, nor did a juvenile justice detention officer (JJDO)
supervisor and/or lead officer record comments regarding the corrected errors. The logbooks
included JJDO supervisors reviewing the master control logbook when accepting responsibility
for the center, and reviewing the living area logbooks daily. The JJDOs reviewed the logbook
entries from the previous shift when accepting responsibility for the living area. The name and
position of the reviewer was documented, as well as the date and time each review was
completed. The center does not utilize an electronic logbook. One of the master control
logbooks was found to be falling apart and had a tattered spine. The review of the master
control logbooks confirmed they included emergency situations, incidents, population counts at
the beginning and end of each shift and throughout shifts as count changes, mental health and
medical alerts, group movements, admissions, releases, presence of law enforcement, name of
youth placed in confinement including the time confinement began and the time confinement
ended, name of youth placed on precautionary/secure observation, including the time
precautionary/secure observation began and the time precautionary/secure observation was
discontinued, and youth counts following emergency situations. The logbook documentation did
not include all fire and escape drills.
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5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
A review of logbooks for three full days each month during the annual compliance review period
confirmed the superintendent and/or the assistant superintendent review all logbooks on a
weekly basis and provide recommendations as needed. The review also confirmed the juvenile
justice detention officer supervisors (JJDOSs) review the module logbooks upon assuming the
responsibility of the center. The JJDOSs maintain the module living logbook daily and review
the logbooks at each shift change. The superintendent, assistant superintendent, or the staff in
charge of center toured the youth living areas at least once during each shift and documented
their visit in each area’s logbook. The superintendent was interviewed and stated management
reviews and signs the logbook every day.
5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys.
All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of
keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch.
The key(s) on these rings shall provide egress through facility exterior doors providing access
to evacuation areas.
A key inventory shall be maintained by the Superintendent or designee at all times.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center has facility operating procedures (FOPs) addressing key control, including key
assignment and usage, inventory, daily tracking and reconciliation of keys, secure storage of
keys not in use, procedures addressing missing or lost keys, and reporting and replacement of
damaged keys. The FOPs specified the key inventory shall include the ring number, the number
of keys on each ring, the capability of each key, and to whom the key ring is issued, as well as
the key ring hub system to be color-coded with officer keys are blue, supervisor keys are yellow,
administration keys are black, white for medical and mental health, green for food service,
education is brown, and the emergency keys have a red hub.
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During the annual compliance review week, center staff did not have access to the computer
system which maintains the current key inventory or the Department’s Central Communications
Center (CCC) reports; therefore, the key inventory and CCCs were not reviewed.
Observations of the key storage area indicated the center has a large see-through key box
maintained on the wall in master control, which maintains all keys, other than the emergency
egress keys. The emergency keys are maintained in a small box in locked sub control rooms
and during an emergency the window of the box is broken to retrieve the keys. During the first
and second day of the annual compliance review week the master control room was unlocked
and the door was open, as well as the key storage box being unlocked and open. The last two
days of the ACR week the key storage box was locked and only accessible when the master
control operator unlocked the box. Observations of the distribution and the collection of keys
during the annual compliance review week indicated staff will enter the center, provide master
control their personal keys, and in return get center keys. Observations included restricted keys,
like education and medical, who have key numbers assigned to them. The staff receiving the
center key entered their name, the key number, and the date and time in the sign-in and out log,
and when leaving entered the date and time when the key was returned. The master control
operator placed the staff’s personal key in the secure key storage box on the hook with the
same number as the center key which was provided. The review team provided their personal
keys to master control, which were placed on the counter in front of the key storage box until the
team retrieved them at the end of each day. All center keys observed had a tamper-resistant
ring. Observations during the annual compliance review week indicated staff who were issued
keys carried them on their person at all times, did not allow youth to handle facility keys, and did
not remove the keys from the facility or the facility grounds without authorization from the
superintendent. Five key rings were observed, and all had the correct color key hub on the key
ring, according to the FOP. Three of the five staff were questioned, and one was able to indicate
the function of each key on the key ring, the remaining two did not know the function of one of
the keys each. A review of shift reports indicated each documented the issuance of keys and
key ring numbers.
The informal interview with the master control operator indicated the process for restricted key
usage is for the individuals, like medical, mental health, or education to only get the keys
assigned to the specified areas, and no other staff are allowed to use those keys.
All nine interviewed staff indicated the medical and mental health record keys are restricted,
seven stated the case management record keys are restricted, six said the kitchen keys are
restricted, and two said the youth property area keys are also restricted. All nine staff indicated
the center’s key control process includes staff keys being given to master control upon entry,
personal keys are securely stored, and youth do not have access to keys. Eight staff stated the
program keys are assigned to staff and they will notify master control of missing keys, as well as
search youth for missing keys. Seven stated the facility is searched for missing keys, and six
staff also said daily tracking of the keys and a key log are part of the key control process, five
said visitor personal keys are given to master control upon entry, and three mentioned a chit or
token is provided to visitors. Two also mentioned a key is replaced when damaged as part of
the key control process.
The superintendent interview indicated permanent keys are issued to the administration team.
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5.08 Vehicles and Maintenance Failed 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.
A review of documentation for six youth transportation vehicles indicated two annual inspections
could not be confirmed. The remaining four vehicles had an annual inspection completed, two
on April 2, 2024, and one each on April 9, 2024, and April 16, 2024.
The center was unable to provide the monthly visual transport vehicle checks for the annual
compliance review period, other than February to April 2024, due to an online system error. A
review of the two monthly visual checks indicated each included the water coolant, lights, oil,
emergency equipment, brakes, horn, interior/exterior, cleanliness, tires, battery, windshield and
wipers, windows, mirrors, and damage.
Observations of the six youth transportation vehicles indicated they all had the appropriate
number of seatbelts and a current fire extinguisher. Each vehicle had debris like empty water
bottles, old food containers, and jumper cables strewn in the area where the transporter and
passenger sit. The center maintains first-aid kits by the master control room for youth
transportation. Each of the locked first-aid kits contained the designated health authority
approved contents, a window punch, and a knife-for-life, which is utilized as a seatbelt cutter.
A review of twelve van logbook entries on various dates and times indicated nine were missing
the acknowledgement the vehicle was checked. All twelve had the destination, number of youth,
staff names, the time transport began, and the time the transport ended.
An observation of a transport indicated the transport staff inspected the vehicle for contraband,
ensured it was documented in the vehicle logbook, ensured the vehicle had sufficient gasoline
to reach the destination, maintained copies of current transportation procedures in the vehicle,
verified the seatbelts were securely anchored, tested the security screen to ensure it was
secure, and confirmed the vehicle folder contained the vehicle logs, vehicle and mechanical
restraint keys, gas credit card, and vehicle registration. The transport staff also ensured a
cellular telephone was assigned to the vehicle, charged, and turned on prior to departure,
ensured the vehicle was secured at all times, the youth was searched prior to being placed in
the vehicle, and youth and staff wore seatbelts. Seven Department vehicles and five other
vehicles parked in the center parking lot were checked. One of the Department vehicles was
unlocked, and all other vehicles were locked.
Eight of nine interviewed youth indicated they feel staff are driving safely when transporting
youth. The remaining one youth said no, and stated staff drive over the speed limit. Eight youth
said they had never seen anyone place contraband in a transport vehicle. One said yes and
specified having seen one of the youth’s parents/guardians bring contraband in. Staff
confiscated the contraband, and the parent/guardian is no longer allowed to visit. It should be
noted this incident was called into the Department’s Central Communications Center (CCC).
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5.09 Tool Inventory and Management Failed Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center has facility operating procedures (FOPs) addressing maintenance and kitchen tool
inventories. The center’s FOP requires kitchen knives to be inventoried daily in the morning,
mid-day, and evening, and all other kitchen utensils weekly. Inspections of the kitchen indicated
six of the eight knives were in the locked knife box and two were being used. Kitchen staff had
to search for the knives in use and found them after two minutes. The remaining kitchen tools
were hung on a peg board in the kitchen and maintained in a locked drawer. The requirement is
for kitchen tools to be maintained on a shadow board. The tool room, which is located in the
maintenance shed outside of the facility, is inaccessible to youth and locked. A review of the
kitchen knife sign-in and out log for the annual compliance review period indicated forty-nine
entries were missing either a count of the knives, the signature of the person counting, or the
time of the count. The kitchen tool and maintenance tool sign-in and out logs for the annual
compliance review period could not be reviewed, due to no logs being completed. The
maintenance tools had a sign-in and out log for the annual compliance review week, which
coordinated with the inventory. The kitchen tool inventory are stored on an online system which
could not be accessed during the annual compliance review week.
A total of ten kitchen and maintenance tools were observed as secure and correctly noted on
the inventory. One of the kitchen tools did not have any markings. The remaining nine tools from
the maintenance shed were all marked for easy identification. None of the inventories were
signed by the superintendent.
An informal interview with the superintendent indicated service vendors are escorted while they
are in the secure area of the center and must sign in and out. The superintendent interview
indicated the administration team and maintenance staff have access to facility tools.
An informal interview with the maintenance staff indicated when there is a missing or damaged
tool administration will be notified, it will be noted it on the inventory, and a note is placed on the
spot for where the tool would be located.
Nine interviewed staff indicated the center's practice for damaged or missing tools is to contact
master control and then conduct a search for the tool.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center has facility operating procedures in place which prohibit youth from using cleaning
products, medical equipment, and accessing any tools. The policy outlines youth may use items
such as mops, brooms, and buckets under direct supervision of staff. Observations during the
annual compliance review week included a youth using a broom under direct staff supervision.
Nine interviewed staff reported youth are allowed to use mops, and brooms, as well as scrub
brushes under supervision. Nine youth were interviewed, and they all concurred they only use
mops and brooms. Each youth indicated they do not clean with bleach, laundry soap, window,
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or toilet cleaners; however, a staff member may spray the chemical and just have the youth
wipe it off.
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous
Failed Compliance
Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center staff did not provide the center’s Safety Plan; therefore, it could not be reviewed.
A review of documentation during the annual compliance review period determined the center
does not maintain an up-to-date inventory of all flammables, toxic, caustic, and poisonous items.
Observations during the annual compliance review week indicated the kitchen had flammable,
toxic, caustic, and poisonous items under the sinks, next to the sinks, under an office table, as
well as in the kitchen shed, and none had any Safety Data Sheets (SDSs) or current
inventories. A locked sub control room between two modules also had three cleaning items, two
of which the bottles had no lids, and there were no SDSs or inventories maintained. Two locked
janitorial closets in the center hallway were observed, each with flammable, toxic, caustic, and
poisonous bottles and spray cans, some of which had no lids, and none had any SDSs or
inventories; the inventories were from more than one year ago. A review of five flammable,
toxic, caustic, and poisonous items in the maintenance shed indicated all counts were noted
correctly on a current inventory and none had any SDSs.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center has facility operating procedures indicating flammable, toxic, caustic, poisonous
fluids, and other dangerous substances may only be drawn or acquired by authorized personnel
and youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Observations were conducted during the annual compliance
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review week and found all chemicals were securely stored in locations inaccessible to youth and
only authorized staff have access.
Nine youth were interviewed and stated they do not have access to flammable, toxic, caustic,
and poisonous items. Nine interviewed staff reported youth are not allowed to clean with
substances which are toxic, flammable, or poisonous.
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) in place outlining the disposal of all
flammable, toxic, caustic and poisonous items. The FOP states the maintenance mechanic or
other trained staff shall be responsible for disposing of hazardous items and toxic materials in
accordance with the Occupational Safety and Health Administration standards.
The superintendent reported there have been no chemical spills or disposal of any flammable,
toxic, caustic, and poisonous items since the last annual compliance review, all chemicals are
utilized until they are empty, and they have not used grease for approximately two years.
The program utilizes a local vendor to dispose of flammable, toxic, caustic, or poisonous
materials when applicable.
5.14 Confinement Under Twenty-Four Hours Non-Applicable
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.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
During an interview, the superintendent indicted the use and appropriateness of confinements
are tracked through supervisor and administrator reviews. The superintendent indicated
management reviews are conducted daily to ensure accuracy and compliance to policy. Nine
staff were interviewed, and each was able to explain the center’s process for placing youth in
confinement. Each staff indicated the confinement room is searched prior to placing a youth.
Seven staff also indicated a confinement report is completed and ten-minute checks are
conducted and documented. Four staff indicated five-minute checks are conducted for the first
hour. Eight interviewed staff indicated youth placed in temporary confinement are provided
education materials. The remaining staff stated they are not.
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Office of Accountability and Program Support Page 52 of 55 (Revised July 2023)
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
Due to Department-wide system outages at the time of the annual compliance review, this
indicator could not be reviewed and is rated non-applicable.
During an interview, the superintendent indicted the use and appropriateness of confinements is
tracked through supervisor and administrator reviews. The superintendent indicated
management reviews are conducted daily to ensure accuracy and compliance to policy.
5.16 Continuity of Operations Planning (COOP) Drills Limited Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has facility operating procedures (FOPs) in place which include a Continuity of
Operations Plan (COOP). The plan indicates COOP drills shall be conducted and documented,
at a minimum, twice a year, with one drill being completed prior to the hurricane season. A
review of drill documentation for the past year found one of two required COOP drills was not
completed. The one completed COOP drill was a hurricane drill, which was completed on April
30, 2024, prior to June 1, as required. The drill was documented on an emergency drill report
form and included all required information.
Eight of nine interviewed staff stated they participated in drills including major disturbances,
bomb threats, chemical spills, escape, and fire. One staff reported they were a new hire and did
not participate in any drills. One staff confirmed during daily debriefings they will talk about drill
scenarios. An interview was conducted with the superintendent and confirmed the center utilizes
a shelter, impact team, and FOP as part of their comprehensive safety program.
5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures (FOPs) and a Continuity of Operations Plan which
both include the required Department elements regarding an escape prevention plan. A review
of escape drills for the annual compliance review period indicated they were completed
quarterly, as required. The center conducted more than the required drills for a total of nine
drills, with three of them being documented in the logbook. A review of seven in-service training
records indicated all staff had received the required escape prevention training annually. Five of
nine interviewed staff indicated they have participated in an escape drill. One staff stated they
have not participated in an escape drill due to being a new staff. The remaining three staff
stated they participated in other drills in the last year.
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5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a fire prevention plan which was approved by the local fire official. Each of the
center’s thirty-one fire extinguishers were inspected annually, as required. A review of
documentation for the annual compliance review period found the center conducted fire drills
monthly on each shift, with the exception of one drill on second shift in July 2023 and one drill
on first shift in January 2024. The center was running on two shifts from May 2023 through
December 2023. They began running on three shifts in January 2024, through the remainder of
the annual compliance review period. A total of thirty drills were reviewed and each drill was
documented on a Department form which included all required elements. Twenty-four drills were
documented in the logbook and six were not.
Eight of nine interviewed staff reported fire drills take place at least monthly. The remaining one
staff stated they do not.
Three of nine interviewed youth reported they were instructed on what to do in case of a fire.
The remaining six reported they were not.
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures addressing search and contraband procedures. A
review of logbooks indicated frisk searches are conducted prior to admission, and during
admission, as well as strip searches being conducted during the admission process. Frisk
searches are also completed when deemed appropriate by the shift supervisor, when there is
reasonable suspicion the youth is harboring contraband, and during facility-wide initiatives to
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Office of Accountability and Program Support Page 54 of 55 (Revised July 2023)
reduce the introduction of contraband. Searches are documented in the logbook, as well as in
reports in the Department’s Juvenile Justice Information System (JJIS). During the annual
compliance review week JJIS was not operational; therefore, strip searches, room searches,
and the Department’s Central Communications Center (CCC) documentation could not be
reviewed. A review of documentation indicated the center had six occasions which
compromised the safety or security of the center during the annual compliance review period,
wherein contraband items were found during searches. Two of the six incidents documented
confiscation of contraband in the logbook, the remaining four did not. All six instances were
called into the CCC, law enforcement was contacted, and the regional director or designee was
notified.
Observations during the annual compliance review week indicated youth were searched prior to
transport with staff wearing gloves, electronic searches were conducted on all persons entering
the facility, as well as all bags, cases, jacket pockets, and other items being searched. All
personal keys, personal cellular telephones, and other contraband items were prohibited from
entering the secure area.
The superintendent interview indicated the center’s contraband procedure is once a youth
arrives at the facility a law enforcement officer will remove all restraints, staff will ask the youth if
they are in possession of contraband, and they will perform a pat down and strip search of the
youth. Law enforcement will leave if no contraband is found, otherwise a report is generated in
JJIS.
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Office of Accountability and Program Support Page 55 of 55 (Revised July 2023)

report_type: QI Detention

rule: Indicator 2.07

rating: Limited Compliance

rule: Indicator 2.09

excerpt: Daily Activity Schedule

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Failed Compliance

rule: Indicator 3.12

rule: Indicator 5.03

excerpt: Ten-Minute Checks (Critical)

rule: Indicator 5.08

excerpt: Vehicles and Maintenance

rule: Indicator 5.09

excerpt: Tool Inventory and Management

rule: Indicator 5.11

rule: Indicator 5.16