summary: QI Detention - FY24-25

raw_content:
ST AT E OF FLORIDA
DEPART MENT OF JUVENILE JUST ICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Hillsborough West Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated )
3948 W. Martin Luther King Jr. Blvd
Tampa, Florida 33614
Review Date(s): February 18-21, 2025
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Florida Department of Juvenile Justice Residential Quality Improvement Report
Office of Program Accountability Page 1 of 58
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:
Crystal Blair-Gallon, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Belinda Alexander, Office of Education, Education Coordinator (Standard 2)
Jeremy Curvan Office of Accountability and Program Support, Regional Monitor (Standard 4)
Gustavo Mazorra, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Justin Terziu, Office of Accountability and Program Support, Regional Monitor (Standard 1)
Jennifer Tummino, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Qualia Turner, Pinellas Regional Juvenile Detention Center, Juvenile Justice Detention Officer
Supervisor (Standard 5)
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 2 of 58 (Revised July 2023)
Program Name: Hillsborough West Juvenile Detention Center MQI Program Code: 294
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Hillsborough County / Circuit 13 Number of Beds: 80
Review Date(s): February 18-21, 2025 Lead Reviewer Code: 215
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
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 58 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Right Interactions (RI) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 58 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 58 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Secure Observation* Satisfactory
3.12 Suicide Precaution Observation Logs * Satisfactory
3.13 Suicide Prevention Training * Satisfactory
3.14 Mental Health Crisis Intervention Services * Satisfactory
3.15 Emergency Care Plan * Satisfactory
3.16 Crisis Assessments * Satisfactory
3.17 Baker and Marchman Acts * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 58 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 58 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance and Reviews Satisfactory
5.06 Key Control Satisfactory
5.07 Vehicles and Maintenance Satisfactory
5.08 Inventory, Management, Youth Access, & Use of Tools Cleaning Items* Satisfactory
5.09 Inventory of and Access to all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.10 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.11 Confinement Under Twenty-Four Hours Satisfactory
5.12 Confinement Over Twenty-Four Hours Non-Applicable
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory
5.14 Escape Drills Satisfactory
5.15 Fire Drills Satisfactory
5.16 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 58 (Revised July 2023)
Program Overview
The Hillsborough West Regional Juvenile Detention Center is a state-owned detention facility,
operated by the Department, located in Tampa, Florida. The center serves youth in Hillsborough
County in Circuit 13. Male and female youth who are detained pending adjudication, disposition,
or placement in a residential commitment program are housed in the eighty-bed center. Youth
are provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Hillsborough County School Board. The center’s
management team includes the superintendent, one assistant superintendent, one
administrative assistant, eight juvenile justice detention officer supervisors (JJDOS), and thirty-
nine juvenile justice detention officers (JJDO). Mental health and healthcare services are
provided through the contracted provider, VitalCore Health Strategies. Mental health services
are provided by one psychiatrist, one licensed designated mental health clinician authority, one
licensed clinical social worker, two licensed mental health and substance abuse clinical staff,
and four pro re nata (PRN) 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 four registered nurses (RNs), one
medical doctor, one advanced practice registered nurse (APRN), and three PRN RN’s. The
medical clinic maintains nursing coverage Monday through Friday, from 6:30 a.m. to 8:00 p.m.,
and on weekends, from 7:00 a.m. to 8:00 p.m. Food services are provided by Department staff
and include menus, meal planning, meal schedules, special diets, nutritional analysis, daily
allowance, food preparation, health certifications, food product standards, sanitation, and
cleaning. Staff are responsible for the custody and control of youth in their care, providing youth
supervision twenty-four hours a day, seven days a week. The center has four living modules
which are divided by male and female. There are eighty security cameras at the center, of which
seventy-three were operational. During the tour, the facility was clean and maintained, with no
immediate maintenance issues observed. At the time of the annual compliance review, the
center had twenty-four vacancies, which included two assistant superintendents, one JJDOS,
ten JJDO Is, ten JJDO IIs, and one food service worker.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 58 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures addressing the requirement of sight and sound
supervision of volunteers, mentors, and interns who work with youth less than ten hours a
month. The center’s Annual Affidavit of Compliance with Level 2 Screening Standards was
completed and submitted on January 21, 2025, prior to the January 31st deadline. The affidavit
for the teachers was also submitted prior to the deadline; on January 27, 2025. Sixteen new
staff, one volunteer, two contracted staff, and one intern were hired since the last annual
compliance review. All twenty had a background screening completed prior to contact with youth
or confidential youth records, including a criminal history check. One staff required and obtained
an exemption prior to working with youth. Fifteen of the twenty staff were direct care applicants
and had a pre-employment assessment tool administered. The pre-employment assessment
passing scores were documented in each applicant’s record. Two contracted provider staff and
one intern staff were added to the Clearinghouse employee roster.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
Five staff were applicable and received a five-year rescreening/renewal completed not more
than twelve months prior and no later than ten days prior to each 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.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 58 (Revised July 2023)
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) outlining the guidelines of staff code of
conduct. The FOPs state any form of abuse, profanity, threats, harassment, intimidation, or
personal relationships with youth are prohibited for staff. If the code of conduct is violated, there
is a process in place for management to follow to address each violation. The superintendent
confirmed there have not been any incidents of staff violating the code of conduct since the last
annual compliance review. The superintendent indicated if a violation is suspected, an internal
investigation is conducted to determine if the violation is substantiated or unsubstantiated. If
substantiated, disciplinary actions are to occur, which include re-trainings. The Department’s
Central Communications Center (CCC) reports and incident reports did not document any staff
were in violation of the code of conduct during the annual compliance review period. Each of the
three reviewed staff, signed a code of conduct form during orientation. The center provided
commendations for three staff earning certificates of appreciation.
During youth interviews, each of the seven youth stated staff are respectful when talking to
them. Six youth indicated they have never had to call abuse hotline or have been stopped from
calling the abuse hotline. One youth stated yes to being stopped from being able to report
abuse to the abuse hotline. Six youth stated they have never heard staff use curse words when
speaking to youth. One youth stated yes to having heard staff use curse words once when
speaking to youth. Six youth stated they have never heard staff threaten youth and one youth
stated it was heard once. Six youth stated they feel safe at the center. One youth stated no to
feeling safe at the center because of being bullied by youth and fearing staff. The CCC was
contacted regarding the youth interviews. The CCC report number provided is 202500992. All
seven youth stated no to ever exchanging emails, telephone numbers or social media contact
information with staff.
During staff interviews, each of the seven staff were able to explain the process for allowing and
youth to call the Florida Abuse Hotline or CCC to report suspected abuse. Each staff stated they
would notify the supervisor and allow the youth to make the call. Six staff stated they have never
observed a co-worker using profanity when speaking to a youth, and one staff stated once. Five
staff stated working conditions have been good in the past year, and two staff stated working
conditions have been very good. All seven staff stated never having observed a co-worker use
threats, intimidation or humiliation when interacting with youth.
The superintendent interview indicated if an employee violates the code of conduct, law
enforcement and the CCC will be notified if necessary. Staff are expected to communicate and
interact with youth in a way which provides a role model of socially accepted behaviors. If there
is an allegation of abuse from a youth, the staff is immediately removed from contact with the
youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 58 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures (FOPs) outlining the process of contacting the
Department’s Central Communication Center (CCC). Since the last annual compliance review
the center had seventy-five reports made to the Department’s CCC during the annual
compliance review period. Seven CCC reports were reviewed and each incident was called into
the CCC within the required two-hour time frame. None of the seven reviewed reports were
logged in the logbook or shift report. During the annual compliance review period, there were no
additional incidents/grievances which should have been reported to the CCC.
The superintendent interview explained the incident reporting process to include reporting any
reportable allegations within the required time frame. Any allegations of physical, sexual, and
emotional abuse will be called in to the Florida Abuse Hotline.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
The center has facility operating procedures (FOPs) outlining the staff’s use of physical
intervention techniques. The center had a total of 227 Right Interactions (RI) reports during the
annual compliance review period. A RI report was completed for each use of countermoves. A
review of nine RI events were conducted. All nine included statements of all staff involved, and
all reports were completed by the end of each staff’s workday. None of the incidents resulted in
serious injury to youth or staff, or a youth alleging abuse. All nine reports were reviewed by a
supervisor or a RI instructor. All nine had post-RI interviews conducted with each youth by the
administrator/designee, as soon as possible, no longer than thirty minutes after the incident.
None of the RI reports documented the use of mechanical restraints, allegations of abuse, the
requirement of a RI medical review, or any injuries. The superintendent/designee reviewed all
nine RI reports within the required seventy-two hours. No additional RI incidents noted in
internal incidents, grievances, or logbooks which were not documented by a RI Report. The
center’s RI rate during the annual compliance review period was 13.8, which was above the
statewide detention PAR rate of 9.79.
The superintendent interview indicated mechanical restraints may only be used when necessary
to prevent harm to the youth or staff. The Department’s regional director or designee must be
notified if mechanical restraints are used. Mechanical restraints must be removed as soon as it
is safe to do so and should never be used as means for discipline. When a RI is conducted by
staff, an incident report and RI report is entered into the Department’s Juvenile Justice
Information System (JJIS). The superintendent /designee are required to conduct a post RI
review within seventy-two hours.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 58 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures (FOPs) outlining the training requirements for all
new staff. Seven pre-service training records were reviewed. All seven staff completed all pre-
service and certification requirements, as well as academy training within 180-days of hire. All
trainings were captured in the Department’s Learning Management System (SkillPro). All seven
staff received orientation completed within thirty days of hire.
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 (FOPs) outlining the annual training requirements
for staff. A review of seven in-service training records indicated all staff completed a minimum of
twenty-four hours of in-service trainings including mandatory topics specified in Florida
Administrative Code. Three of seven staff were supervisors and completed a minimum of eight
hours of supervisory training in the areas of coaching, leadership, and personal accountability.
All staff trainings were documented in the Department’s Learning Management System
(SkillPro). The center has a licensed nurse who provides in-service education on girls’
healthcare to all non-healthcare staff who supervise or provide treatment to girls. The in-service
training includes training on monitoring, observation, and emergency care of pregnant youth.
The center maintains an annual in-service training calendar, which is updated as changes
occur, and is approved by the highest-ranking official at the location, the assistant secretary of
detention, and the director for the Department’s Office of Talent, Leadership, and Culture.
The superintendent was interviewed and advised management trainings have been completed
in SkillPro such as trauma informed care, sexual harassment, and delivering constructive
criticism. Staff are required to attend juvenile detention certification training in two phases.
Phase one consists of 120 hours of computer and instructor lead training. Phase two consists of
120 hours and is conducted by staff development.
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
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 58 (Revised July 2023)
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has facility operating procedures outlining how grievances are processed.
Observations during the annual compliance review indicated youth have access to grievance
forms. The center did not have any grievances since the last annual compliance review. A
review of the Facility Management System (FMS) in the Department’s Juvenile Justice
Information System (JJIS) confirms the center did not have any grievances during the annual
compliance review period. An interview with the superintendent indicated each youth have the
right to grieve and there is an informal phase and a formal phase for grievances. The informal
phase is when the juvenile justice detention officer (JJDO) attempts to resolve the complaint
with the youth. The formal phase is when the youth submit a written grievance which results in a
response from the JJDO supervisor by the end of the shift if possible or within twenty-four
hours. Youth will be given a pencil and grievance form to complete. Seven youth were
interviewed, and each youth indicated they have never filed a grievance and are aware of the
process. Seven staff were interviewed, and all described the grievance process as a youth
completes the grievance form, giving the form to staff, and the staff give the form to the JJDO
supervisor.
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures which require all critical and special alerts for youth
to be listed in the Department’s Juvenile Justice Information System (JJIS). Supervisory staff
are to review the alert report daily and share alert information with staff during shift briefing.
Medical and mental health staff are required to review alerts to ensure each alert is correctly
tracked and managed. Seven youth records were reviewed for alerts. The seven youth had a
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 58 (Revised July 2023)
total of fifteen alerts. A review of alerts confirmed each alert was entered, updated, and/or
closed, as required. All alerts were documented in the logbook for each youth. The center
utilizes an alert report generated in JJIS as their internal alert system. All alerts entered in JJIS
are documented on the internal alert system once the alert is entered. All reviewed alerts
matched in JJIS and the internal alert system. All alerts were verified prior to being entered in
JJIS. The JJIS alert report is reviewed daily by supervisors and shared during shift briefing and
in the logbook. A review of shift briefing minutes and an observation of a shift briefing during the
annual compliance review week verified youth alerts are shared and reviewed with staff. Alerts
are updated as needed by mental health, medical, or supervisory staff. All alerts are reviewed
by the assistant superintendent or superintendent. There were no additional alerts found during
the annual compliance review week which should have been entered into the alert system. The
superintendent was interviewed and advised medical staff enters the alerts and an alert list is
given out each day during shift briefing. Seven staff were interviewed, and all stated they are
informed of alerts during shift briefing, by review of the logbook, alert forms in JJIS and alert
boards. Six staff stated they are informed of alerts during shift briefing, and one staff stated it
depends on the situation. Six staff stated they believe the process for communicating
information is very good, and one staff stated it is good.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center maintains all data information in the Department’s Juvenile Justice Information
System (JJIS) daily. Data collected includes Right Interactions (RI), incident reports,
confinements, the Department’s Central Communication Center (CCC) reports and vacancies.
Data is compiled by headquarters into a report card which is disseminated to the regional
directors and then is shared with the center’s administration on a weekly basis. The center’s
administration shares the information with supervisors and department heads monthly during
central region leadership meetings. The center shares information with stakeholders quarterly
during the community advisory board meetings. Agendas and meeting minutes are maintained
for reference. The collected data is used to improve the center’s processes by incorporating
policy changes, additional training, programming, scheduling, and hiring.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 58 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures (FOPs) which require the admission process to
address a review of required paperwork from law enforcement, an electronic, frisk, and strip
search of youth by an officer of the same gender, the allowance for youth being admitted to
make a telephone call to their parent/guardian, the provision of food for a youth in the event the
admission process is completed two or more hours before serving the next scheduled meal, and
for all youth to be screened to identify medical, mental health, and substance abuse needs.
Seven youth case management records were reviewed, and all contained a printed copy of the
Admission Wizard from the Department’s Juvenile Justice Information System (JJIS). Each of
the Admission Wizards contained an arrest affidavit or custody order, a completed Detention
Risk Assessment Instrument (DRAI), a completed Suicide Risk Screening Instrument (SRSI),
documentation of a completed full body and electronic search by an officer of the same gender,
documentation confirming each youth made a telephone call to their parent/guardian,
verification each youth was provided a meal during admission, and a medical, mental health,
and substance abuse screening. An admission was observed during the annual compliance
review week. The youth made a telephone call to his mother at 11:30 a.m., and was provided a
lunch meal at 11:50 a.m. All admission procedures were followed.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
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9. Youth rights.
10. PREA-related information
The center has facility operating procedures (FOPs) which governs the orientation process for
all youth being admitted. Seven youth case management records were reviewed, and each
contained documentation which verified each youth was provided with an orientation during
admission. Each youth signed an acknowledgement which confirmed all required topics were
discussed during orientation. A youth orientation was observed during the annual compliance
review. The youth was oriented on all required topics, to include Rules, grievance procedures,
visitation and telephone calls, access to medical and mental health, behavior expectations,
access to the Florida Abuse Hotline and the Department’s Central Communication Center
(CCC), behavior expectations, youth rights, and Prison Rape Elimination Act (PREA)
information, which included PREA guidelines and videotape. Seven youth were interviewed, and
all said they were oriented upon admission with regards to rules and regulations, daily schedule,
education, visitation schedule, abuse reporting, the behavior management system, youth rights,
medical care, mental health care, searches, telephone calls and mail, fire evacuation plan,
meals, and grievance procedures.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) requiring the classification of all youth
being admitted to provide the highest level of safety and security. Seven youth case
management records were reviewed, and all contained a printed copy of the Admission Wizard
from the Department’s Juvenile Justice Information System (JJIS). Each Admission Wizard
contained verification showing the classification for youth included a screening for mental
illness, intellectual and physical disabilities, history of violent behavior, gang affiliation, criminal
behavior, history of any sexual offenses to include sexual battery which may have been reduced
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to a minor offense, Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB),
medical issues, Suicide Risk Screening Instrument (SRSI), escape threat, security threat, and
history of human trafficking to ensure each youth is housed in a room which will provide the
highest level of safety and security. The classification process also included the following
additional factors in determining proper room assignment: youth’s age, sex, height, weight, and
level of aggressiveness. Youth were assigned to a room based on their classification, and
reclassified if changes in behavior or status were observed. Youth with a history of committing
sexual offenses or if they are a victim of a sexual offense are placed in a room alone. The
superintendent receives an email from the designated gang representative anytime a youth is
suspected or confirmed as to their involvement in a gang. The superintendent was interviewed
and said center staff look at the detention risk assessment, SRSI, VSAB, Community
Assessment Tool (CAT), past and current charges of the youth during the intake process to
assist with the classification and room assignment.
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has facility operating procedures (FOPs) which require the notification of the juvenile
probation officer (JPO) designated as the circuit gang liaison whenever a youth is admitted who
is suspected of possible gang involvement. Seven youth case management records were
reviewed, and one was applicable for youth gang involvement. The center provided two
additional applicable records for review. All three applicable records contained copies of emails
between the center’s gang representative and the JPO designated as the circuit gang
representative, which indicated suspicions of gang activity, and the basis for the suspicions.
Center staff included in the email copies of written statements which led to the suspicion of each
youth’s gang involvement. An informal interview was conducted with the center’s gang
representative to determine the process for sharing information with the JPO designated and
the circuit gang representative, which revealed the center’s gang representative sends an email
to the JPO designated as the circuit gang representative and the superintendent if a youth is
identified as being a gang member, involved, or suspected of gang activity.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has facility operating procedures (FOPs) which require they take possession of
youth property during admission. Staff must inventory all personal property in the youth’s
possession and record each surrendered item on the Property Receipt Form. The center must
safeguard youth’s personal property until it is returned to the youth and/or parent/guardian.
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Seven youth case management records were reviewed, and each record contained a Personal
Property Receipt Form. Six of the seven youth signed their property receipts, and one refused to
sign. This refusal was documented by a supervisor on the Personal Property Receipt Form. All
seven youth Personal Property Receipt Forms were signed by center staff, and all contained a
letter of acknowledgement regarding unclaimed property, which were signed by each youth.
Three of the seven youth had money and personal items of value, and these items were
secured in a clear, tamper-proof bag. The tamper-proof bag contained the date, youth name,
Department of Juvenile Justice identification number (DJJID), and a listing of items stored in the
bag for all three youth. The tamper-proof bag is then placed in a drop-safe, which is under video
surveillance. A review of the drop-safe confirmed the tamper-proof bags for all three youth were
secured as required. The drop-safe logbook included the date, time, DJJIDs, each of the three
youth’s names and printed name and initials of the officer who secured the property. The
valuable Property Receipt form was placed in each applicable youth record. Remaining
personal property for each youth was placed in an assigned bag, which was documented on the
Personal Property Receipt Form. A copy of the Personal Property Receipt Form was maintained
in the assigned bag of each youth. Property bags are stored in a secured room, inaccessible to
youth. During the annual compliance review week, a youth was admitted which allowed an
observation of the center receiving youth property. The youth gave all personal property to
intake staff. The intake staff logged the property on the Personal Property Receipt Form, put all
personal property in a bag, and secured the property in the property room, with a copy of the
Personal Property Receipt Form in the bag and in the youth’s active record. All youth personal
property is stored in a secured area and access is limited to designated staff. A review of
Department’s Central Communications Center (CCC) reports for the annual compliance review
period confirmed there were no incidents of youth property valued over $50.00. Seven youth
were interviewed, and all said their personal property was inventoried, and they each signed
and received a form stating the inventory of personal property stored was correct. This inventory
and storage were completed during admission. The superintendent was interviewed and
advised valuable property is stored in a safe which is in the intake office, under video
surveillance. Only supervisors and administration staff have access to the valuable property.
Clothing and non-valuable property is stored in a locker, under video surveillance as well, in
which all detention officers, supervisors, and administration have access to. If a youth does not
retrieve their property after thirty days, center staff send out a certified letter to the
parent/guardian, advising they have thirty days to retrieve the property. If they have not
retrieved the property after the additional thirty days, an inventory is done of the unclaimed
property and the unclaimed property is donated. If there is unclaimed money, the money is
totaled, a money order is made, and it is sent to the regional office.
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.
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The center has facility operating procedures (FOPs) requiring center staff to ensure appropriate
authorization before releasing youth from detention. Three closed youth case management
records were reviewed. All contained documentation which verified the on-duty supervisor
reviewed all paperwork related to release prior to releasing the youth. The supervisor initialed
confirmation of release paperwork received from the court being reviewed. The supervisor also
initialed the release paperwork verifying the identification of the youth prior to release, in
addition to the identification of the parent/guardian being verified prior to release. The center
maintains a copy of the parent/guardian identification in the closed record. None of the closed
records were youth who had an endangered person alert. Release documentation also
contained information of any future court dates, and this documentation was signed by the youth
and parent/guardian as well. The three closed records date of admission and release correlated
with the Department’s Juvenile Justice Information System (JJIS). During the annual
compliance review, a release was conducted. Observations confirmed center staff are following
release procedures.
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures (FOPs) requiring the retrieval and return of
personal property to the youth and/or their parent/guardian upon release from detention. Three
closed youth case management records were reviewed, and all contained documentation which
confirmed the youth and parent/guardian signed the receipt of property form upon release. All
three closed records also contained documentation which verified the youth was released to an
appropriate person, with a copy of their identification included. One of the three youth were
released with medication, and a receipt of medication was signed by the parent/guardian. All
three records contained documentation signed by the youth and parent/guardian showing they
were reminded of any health or welfare issues, to include medical, mental health, substance
abuse need, and any pending appointments. The center was able to provide an example of
property held over thirty days during the annual compliance review. The youth had not retrieved
their personal property within thirty days of discharge. Center staff mailed a certified letter to the
parent/guardian, advising the property would be disposed of if not picked up in the next thirty
days, in accordance with the center’s FOP. During the annual compliance review week, a
release was observed. Center staff designated to conduct the release verified the release court
order, checked to see if there were any open warrants, verified if the youth was taking any
medication, and checked to see if the youth had personal or valuable property stored. Staff then
contacted the youth's parent/guardian to set up a time for the release. When the
parent/guardian arrived, staff checked the parent/guardian identification card to verify they were
authorized to pick up the youth. Staff then completed the Release Wizard in the Department's
Juvenile Justice Information System (JJIS) and had the parent/guardian sign the release
paperwork, which included a receipt of property, medication, and any aftercare follow-up, such
as probation contacts. Once this was complete, staff had the youth escorted to the
intake/release area and had the youth sign for their property. The youth was then dressed out,
and personal and valuable property was verified and returned, with the youth signing
acknowledgment of receiving their personal and valuable property. The youth was then released
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to the parent/guardian. Center staff then updated the center census and updated release
information in JJIS. All release procedures were followed.
2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has facility operating procedures (FOPs) requiring detention reviews to be
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 center holds their detention
reviews each Thursday. An observation of a detention review was conducted during the annual
compliance review week. The observation confirmed the center conducts very thorough and
extensive detention reviews. Observation of the weekly detention review confirmed the
attendance virtually by probation staff and placement staff. In person attendance included
mental health, medical, education, and intake center staff. The review consisted of a census
review, a review and discussion on exceptional cases, courtesy holds, transfers, commitment
residential placement review, education update, medical update, mental health update, a review
of center alerts, and a detention review of all youth currently at the center. Valuable information
concerning youth at the center was shared by all staff in attendance. Detention review
documentation is then uploaded to the center's SharePoint system, in accordance with FOPs. A
review of the center's SharePoint system confirmed weekly detention reviews have been
conducted during the annual compliance review period. All required participants attended the
meetings. Center intake, medical, mental health, and education staff attended each meeting in
person. The juvenile probation officer (JPO), JPO supervisor, chief probation officer,
commitment manager, and diversion program staff attended each meeting virtually. The
superintendent was interviewed and said detention reviews are conducted every Thursday.
Information discussed during this meeting include court hearings, placements, youth behavior,
youth wellbeing, and youth status.
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
A center tour was conducted during the annual compliance review week. During this tour, youth
were observed in various classrooms and being escorted from one classroom to another. In all
instances, adequate staff were supervising youth, and all staff questioned were aware of the
number of youth they were supervising. The daily activity schedule was observed posted in the
dayrooms of all living areas. Activities on the daily activity schedule included wake up and
personal hygiene time, mealtimes, school hours, a minimum of twice a week visitation,
recreation and physical activities for a minimum of one hour each day, indoor activities which
promote education, problem solving, and life skills, groups, open program time, and bedtime.
Seven youth were interviewed, and all said the center has a daily activity schedule which is
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followed as written. Seven staff were interviewed, and all said the daily activity schedule is
followed as posted.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures (FOPs)to provide for educational access. The
center integrates education into the daily schedule in such a way to ensure the integrity of the
required minimum instruction time is distributed over a twelve-month period. A random sample
of three video and three logbook reviews showed youth are starting and ending school at the
appropriate times. In a review of the seven youth interviews, all youth indicated they attend
school Monday through Friday. Two youth indicated the center is preparing them for the high
school equivalency diploma (GED), high school, vocational school, employment and/or college
very well, four stated well, and one stated not well. Youth are enrolled in academic courses
through Hillsborough County Public Schools. Seven staff were interviewed and all seven stated
there is minimal interference of educational instruction. The Superintendent’s interview stated
there is minimal interference of educational instruction.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures (FOPs)to provide for career education. Career
educational services are provided through the Hillsborough County School district. The center
provides vocational competency development programs to all youth. Seven youth were
interviewed and five reported they are taking life skills, three have career choices, six are
enrolled in math, four are taking science and social studies, two are taking history, and seven
are taking reading.
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Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a designated mental health clinician authority (DMHCA) who is a licensed
mental health professional and is responsible for coordination and implementation of mental
health and substance abuse services. The DMHCA is on-site full-time for forty hours a week.
The DMHCA is a licensed mental health counselor with a clear and active license in the State of
Florida, with a license expiration date of March 31, 2027. There were no other DMHCAs used
during the scope of the annual compliance review period. The center has two staff designated
as back-up DMHCA, one licensed mental health counselor (LMHC) and one licensed clinical
social worker (LCSW). Both back-up DMHCA’s have a clear and active license which expire on
March 31, 2025. Copies of the DMHCA’s agreement and position description were reviewed.
The review of the sign-in logs and contract requirements confirmed the minimum of forty hours
weekly were met. An interview with the DMHCA was conducted. The DMHCA has worked at the
detention center for thirteen years and confirmed oversight of the mental health services
provided to youth and families. The DMHCA’s responsibilities include conducting assessments
for suicide risk (ASR), follow-up ASR’s, initial treatment plans, individualized treatment plans,
discharge summaries, responding to mental health referrals, providing supportive counseling
and brief supports, crisis support/interventions, treatment team and facilitation of mental health
groups. Additionally, the DMHCA communicates with juvenile probation officers (JPO) weekly
by providing Psychiatrist and treatment team information, as well as discharge diagnosis and
information. According to the DMHCA, communication is daily with the two full-time licensed
clinicians and meetings are held weekly, as needed. The DMHCA regularly communicates with
staff to make sure everyone is aware of daily responsibilities and to provide updates on youth.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center currently employs two full-time licensed mental health and substance abuse clinical
staff and four pro re nata (PRN) licensed mental health and substance abuse clinical staff in
addition to the designated mental health clinician authority (DMHCA). The clinical supervisor
ensures the licensed clinical staff working under their supervision are performing services they
are qualified to provide based on their education, training, and experience. The licensed mental
health professionals are all licensed under the appropriate Florida statutes chapter. Copies of
licenses were available on-site. All licensed mental health professionals and licensed qualified
professional’s licenses were reviewed with no noted issues.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The center has facility operating procedures to ensure mental health and substance abuse staff
have the appropriate qualifications. The designated mental health clinician authority (DMHCA)
must ensure clinical staff working under their supervision are performing services the staff are
qualified to provide based on education, training, and experience. The DMHCA interview
indicated the clinical supervisor assures the non-licensed clinical staff working under their
supervision are performing services they are qualified to provide based on education, training,
and experience. The center does not currently have any non-licensed mental health and
substance abuse clinical staff providing services. The center has one unpaid intern, hired on
January 28, 2025, who does not provide any services. An informal interview with the DMHCA
confirmed the center does not have any vacancies in mental health staff.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
Seven youth records were reviewed for mental health and substance abuse admission
screening. Each record contained screening documents completed upon the youth’s detention
intake. Each record indicated screening documents were reviewed by center staff upon receipt
of the youth. The suicide risk screening instrument (SRSI) was completed at intake. Both the
SRSI and the Massachusetts Youth Screening Instrument (MAYSI-2) were initiated within the
Department’s Juvenile Justice Information System (JJIS). In each record, documentation
reflected mental health staff completed the required sections of the SRSI, and the completed
entries included accurate referral selections in the screening results section. Five of seven
records indicated the youth had positive responses on the SRSI, each youth was placed on
suicide precaution and a mental health referral was completed which documented the youth’s
need for an Assessment of Suicide Risk (ASR). The SRSI screening in each record included a
yes response when youth had any open or closed suicide risk alerts within JJIS. All MAYSI-2
and SRSI screenings were completed by trained staff as verified in the Department’s Learning
Management System (SkillPro). In each record, the results of the MAYSI-2 and SRSI indicated
a need for further assessment. Five of the seven records were applicable for all negative
responses requiring an invalid marking. Based on the results of the MAYSI-2 assessment in
each record, the need for further assessment was required and the appropriate referrals were
made with notification to the superintendent. The MAYSI-2 assessment results in each of the
five applicable records indicated an elevated suicide risk subscale which prompted the youth to
be placed on suicide precautions and a referral for an ASR. The screener for each youth made
a referral to the mental health clinical staff for comprehensive substance abuse and mental
health (SAMH) assessment.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
Seven youth records were reviewed for mental health and/or substance abuse evaluations. Two
of the seven youth were applicable for mental health and/or substance abuse evaluations, while
the remaining five were not applicable; consequently, the center provided one additional youth
to meet the sample size of three. All three youth were identified at admission and referred to the
center provider for a mental health and substance abuse evaluation. One of the three
Comprehensive Mental Health and/or Substance Abuse Evaluations completed by the center
were classified as new and the remaining two were classified as updated. All three evaluations
were completed within thirty one days of admission. Treatment recommendations were
specified for each of the three youth records reviewed and corresponded with all diagnosed
mental health or substance related disorders. Each of the Comprehensive Mental
Health/Substance Abuse Evaluations consisted of the Substance Abuse and Mental Health
(SAMH) form documented within the Department’s Office of Health Services Electronic Medical
Record. In each record, the SAMH was completed by the contracted provider. An interview with
the designated mental health clinician authority (DMHCA) was conducted. The DMHCA
indicated the juvenile probation officer (JPO) is responsible for ensuring youth who are identified
through preliminary screening as in need of further mental health and/or substance abuse
assessment are referred for comprehensive assessment by the Office of Probation contracted
provider or Juvenile Assessment Center (JAC). The JPO is responsible for ensuring when the
comprehensive assessment of a detained youth is received, the information will be forwarded to
the detention center. If an assessment is not received, the DMHCA shall contact the JPO and
request the status of the assessment. The DMHCA is also responsible for ensuring a thorough
review of comprehensive assessments received and completion of comprehensive
assessments by day thirty-one if one has not been received. The DMHCA added, if while the
youth is in a detention center, exhibits behavior, or information is obtained, which indicates the
youth needs an in-depth mental health or substance abuse assessment, the DMHCA is
responsible for ensuring the youth receives an in-depth comprehensive assessment by day
thirty-one, unless a comprehensive evaluation is available.
3.06 Treatment and Discharge Planning [Contract Provider] Satisfactory Compliance
The superintendent and DMHCA or mental health and substance abuse clinical staff are
responsible for ensuring the development and review of an initial and/or individualized mental
health/substance abuse treatment plan for each youth receiving mental health/substance
abuse treatment in the center.
All youth who receive mental health and/or substance abuse treatment while in at the center
shall have a discharge summary completed documenting the focus and course of the youth's
treatment and recommendations for mental health and/or substance abuse services upon
youth's release from the center.
Seven youth records were reviewed for treatment and discharge planning. Five of seven youth
required a treatment plan, and two records were not applicable. All five records indicated the
mental health orientation was held within fourteen days of admission and each record indicated
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the youth required a treatment plan. Documentation revealed each youth’s initial treatment
plans were in place within seven days of the onset of treatment. Each initial treatment plan was
developed on the Department’s Initial Mental Health/Substance Abuse Treatment Plan form.
The initial treatment plan form in each record included the reason for referral of treatment and
the initial diagnosis. The initial treatment plan methods included counseling and frequency of
monitoring, and psychiatric services including psychotropic medication and frequency of
monitoring. Two of five youth were admitted to the center with psychotropic medication and in
each record the initial treatment plan included the medication the youth was admitted with in
order to compare with the initial treatment plan goals. One youth was prescribed medication
after admission and the remaining two youth were not prescribed any medication. The progress
notes in all five records validated each youth was receiving treatment services as stipulated on
the treatment plan. All five records indicated the initial treatment plan contained the signatures
of the youth, the mental health and substance abuse professionals’, treatment team members,
and the parent/guardian when possible. Three of the five records documented attempts to
contact the parent/guardian of each youth. Each youth was assigned to a mini treatment team
and the members were involved in the development of the initial treatment plan. Documentation
confirmed all five youth individualized treatment plans were developed by the youth’s thirty-first
day of admission. All five records indicated the individualized treatment plan contained a
diagnosis, symptoms which are treatment focused, treatment goals included mental health
services and substance abuse services, strength and or needs, and psychiatric services
including psychotropic medication and frequency of monitoring. Documentation in two of five
records supported psychotropic medications listed in the initial treatment plan matched the
psychotropic medication youth was prescribed at the time the treatment plan was developed.
The remaining youth was prescribed medication after the initial treatment plan; however, the
revised plan reflected the addition of prescribed medications. Records in each youth progress
note validated the youth was receiving treatment services as stipulated on their treatment plans.
Each individualized treatment plan was signed by the youth, mental health and substance
abuse professional, treatment team members, and parent/guardian when possible.
Documentation supports a copy of treatment plans were mailed to parents/guardians. Two of
the five records indicated the youth was applicable for treatment plan reviews. Both records
indicated treatment plan reviews were completed and documented on the Department’s
Individualized Mental Health and Substance Abuse Treatment Plan Review form every thirty
days. Additionally, both records required modifications on the review form which were clearly
identified. Documentation in each record reflected the individualized treatment plan review
forms were signed by the clinical staff, youth, licensed mental health professional, treatment
team members, and parent/guardian when available. Documentation revealed copies of each
plan were mailed to the parent/guardian. In each record, the treatment plan included treatment
and services provided by a licensed psychiatrist. None of the reviewed records indicated youth
had alleged being a victim of a Prison Rape Elimination Act (PREA) event. None of the
reviewed records indicated the youth were applicable for treatment and discharge summaries.
In each record, all documentation was maintained as required. In each record, all uploaded
additional information was completed within fourteen days, contained signature of the licensed
mental health professional, and provided the completion date of service. A mini treatment team
review was not observed during the annual compliance review week due to the timing, as the
review team was completing the entrance and facility tour while the meeting was taking place.
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3.07 Mental Health and Substance Abuse Treatment
Satisfactory Compliance
[Detention Staff/Contract Provider]
Mental health and substance abuse treatment planning in Department facilities focuses on
providing mental health and/or substance abuse interventions which will reduce or alleviate a
youth's symptoms of mental disorder and/or substance abuse impairment and enable youth
to function adequately in the juvenile justice setting.
Each youth determined to need mental health treatment, including treatment with
psychotropic medication, or substance abuse treatment while in at the center, must be
assigned to a mini-treatment team.
Seven youth records were reviewed for mental health and substance abuse treatment. Five of
seven youth records were applicable. All five records indicated the youth was assigned to a
mini-treatment team which consisted of a mental health clinical staff, one staff from a different
service area, youth, and parent when available. Each record indicated youth required mental
health treatment and received individual, group, or family therapy counseling according to
frequency required by the plan. Each plan included individual, group, and/or family therapy
prescribed at least weekly. Two of five youth records indicated the youth required substance
abuse treatment; however, both youth refused substance abuse treatment, which was
documented in their records. The remaining three youth did not require substance abuse
treatment. All five youth records contained a proper Authorization for Evaluation and Treatment
(AET). The proper consent for treatment was obtained through the signed Department forms for
each youth who required substance abuse treatment. Each record contained treatment notes
documented on the Department’s Counseling/Therapy Progress Note form. A video review of
groups on three days were conducted with a verified facilitator. The group durations were forty-
five minutes, fifty minutes and one hour, respectively. Mental health (MH) staff had adequate
access and confidential space to provide services. Reviewed records confirmed therapy was
limited to ten or fewer youth with mental health diagnosis for mental health groups. An informal
interview with the designated mental health clinician authority (DMHCA) revealed the center did
not have any substance abuse groups from the time of the last annual compliance review.
Seven youth were interviewed. Four of seven youth indicated they would rate the mental health
and substance abuse services they are receiving as very good and the remaining three rated
their services as good.
An interview with the DMHCA was conducted. The DMHCA stated the center provides
Assessment for Suicide Risk (ASR’s), Follow-up ASR’s, Initial Treatment Plans, Individualized
Treatment Plans, Discharge Summaries, supportive counseling/crisis counseling, brief supports,
treatment team, and also mental health groups are conducted (focusing in on anger
management, decision-making, and life skills). The DMHCA meets with the center’s
superintendent on a weekly basis and daily, as needed. The DMHCA indicated an Individualized
Mental Health/Substance Abuse Treatment Plan is required when a youth enters ongoing
mental health/substance abuse treatment (including treatment with psychotropic medication). A
comprehensive mental health and/or substance abuse evaluation must be completed by or
reviewed by the DMHCA, or other licensed mental health professional and the development of
the Individualized Mental Health/Substance Abuse Treatment Plan must be completed. The
Individualized Treatment Plan is recorded on the form developed by the Department. The
Individualized Treatment Plan is developed by the mini-treatment team for youth receiving
treatment and should the stay in detention exceed thirty days, the plan is completed by the
thirty-first day the youth is at the center. The mental health and/or substance abuse
interventions/strategies are documented on the treatment plan, as well as target dates for
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completion. The intervention/ strategies are based upon best practices and effective treatment
models appropriate to the individual characteristics and needs of the youth including psychiatric
services when applicable. A review of the Individualized Treatment Plan is conducted by the
mini-treatment team every thirty days. Any modifications/updates of the Individualized
Treatment Plan are recorded on the Individualized Treatment Plan Review. The mini-treatment
team includes at least one or more representatives from the Department’s operations staff,
mental health staff, medical staff (as needed), and information from psychiatric staff when a
youth is prescribed psychotropic medication. The DMHCA indicated a youth with a substance
dependence goal will have an Individualized Treatment Plan which includes a substance abuse
goal/treatment. Services are provided by the DMHCA and/or a licensed mental health staff as
needed for the youth, if they accept substance use information/services. Intervention/strategies
within the plan are based upon best practices and effective treatment models appropriate to the
individual characteristics and needs of the youth, including psychiatric services when applicable.
A review of the Individualized Treatment Plan is conducted by the mini-treatment team every
thirty days. Any modifications/updates of the Individualized Treatment Plan are recorded on the
Individualized Treatment Plan. Licensed mental health staff will provide any substance use
information/services as needed, keeping in mind detention is short term and not a treatment
facility. Therapist will provide individual counseling for mental health areas as indicated in the
plan.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has a psychiatrist who is board certified, with a license expiration date of January 31,
2026. The center does not utilize an advanced practice registered nurse (APRN). The back-up
psychiatrist is licensed under chapter 459 with a license expiration date of March 31, 2026. The
back-up psychiatrist maintains equal education to the psychiatrist. The center is not approved
for tele-psychiatry. An interview with the designated mental health clinician authority (DMHCA)
reported she meets with the psychiatrist to discuss youth receiving psychiatric services one time
a week and the psychiatrist is on call, as needed.
Seven youth records were reviewed for psychiatric services. Three of the seven were applicable
for psychiatric services. Two of the three youth were admitted to the center on psychotropic
medications and the remaining youth was referred for psychiatric services after admission. The
initial diagnostic interview for the two youth who were admitted to the center on psychotropic
medications were completed within fourteen days of admission. The remaining youth’s initial
diagnostic interview was completed within fourteen days of their referral, as required. All initial
diagnostic psychiatric interviews contained the reason for referral, history, mental status
examination, diagnosis, treatment recommendations, prescribed medications, and medication
name. Each record contained the explanation of the need of the psychotropic medication and
the frequency of the medication management. In each record, an in-depth psychiatric evaluation
was completed within thirty days of admission or referral for psychiatric services. The in-depth
psychiatric evaluation in each record included the reason and factors leading to the referral,
history, history of psychiatric illness, psychotropic medication management, mental health
treatment and or substance abuse treatment, mental status examination, identification of
individual, family and or environmental factors which may potentially account for, influence or
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amelioration of difficulties, diagnostic formulation, treatment recommendation and interventions,
prescribed medications and frequency of medication management. Each in-depth psychiatric
evaluation in each record further contained the explanation of the need for psychotropic
medications related to youth’s diagnosis, target symptoms, potential side effects, risk, and
benefits of taking medications. Each in depth psychiatric evaluation contained the most recent
applicable therapeutic serum levels and signature of the practitioner conducting the evaluation.
In each record, page three of the of the clinical psychotropic progress note (CPPN) was
completed and the CPPN was clearly identified. The required information when psychotropic
medications are prescribed, dispensed, or administered by the psychiatrist was present in each
record. Each record contained identifying data, diagnosis, target symptoms, evaluation and
description of effects of prescribed medication on target symptoms, medication name, dosage
and quantity, ordered dosage, frequency and route of administration, reasons for changes in
medications or dosages, side effects, youth’s adherence to medication regime, height, weight,
blood pressure, most recent serum drug levels or laboratory findings, whether telephone contact
with youth or guardian to discuss medication, signature of psychiatrist, and the date of
signature. In each record, the psychiatrist documented monitoring for Tardive Dyskinesia
monthly on the CPPN. Each record contained an appropriate Authority for Evaluation and
Treatment (AET) and parental notification and verbal consent for prescribed, discontinued,
significant dosage changes was documented on each CPPN form, page three. Each record also
contained written consent documented on the Acknowledgement of Receipt of CPPN form. One
of three youth required consent provisions of psychotropic medication while under the care of
the Department of Children and Families (DCF). The youth mental health record included a
consent for psychotropic medication for youth under the care of DCF. None of the youth were
responsible authorizing their health care and release of healthcare records due to being
eighteen years of age.
3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center maintains a written plan addressing suicide prevention. The center’s suicide
prevention plan includes the identification and assessment of youth at risk of suicide, staff
training, suicide precautions, levels of supervision, referral, communication, notification,
documentation, immediate staff response, and the review process. The center maintains an
established review process for every serious suicide attempt or serious self-inflicted injury
requiring hospitalization or medical treatment. The review process includes the circumstances
surrounding the event, center procedures relevant to the incident, all relevant training received
by involved staff, pertinent medical and mental health services involving the victim, possible
precipitating factors, and recommendation for policy change, training, physical plant, medical or
mental health services and operational procedures.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
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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).
Seven youth records were reviewed for suicide prevention services. Five of the seven records
were applicable for suicide prevention services and the remaining two youth records were not
applicable. In each applicable record, the youth was determined to be at risk during the
admission screening and a suicide risk assessment referral was completed. Observations
confirmed alerts were entered in the Department’s Juvenile Justice Information System (JJIS).
In each record, the Assessment of Suicide Risk (ASR) was completed on the required
Department form and was documented in real time. Each youth was placed on constant
supervision prior to the completion of the ASR. For each record, the suicide precaution
observation logs were completed entirely to include safe housing areas, required signatures,
and the qualified mental health professional was involved. Each record confirmed no youth was
released prior to receiving an ASR. In each record, consultation with the designated mental
health clinician authority (DMHCA) was documented, and the superintendent or designee was
notified immediately of suicide risk, the date and time the referral was made, as well as the time
the youth was placed on precautionary observation (PO). All five ASRs were completed within
twenty-four hours. A follow-up ASR was not required for any of the youth, as none were
determined to be in crisis. In each record, the date and time the youth were discontinued from
observation was documented, each youth was stepped down to standard supervision and all
documentation was in accordance with the center’s suicide prevention plan. All ASRs were
completed by a licensed mental health professional with the credentials of licensed mental
health counselors (LMHCs) or licensed clinical social workers (LCSW). All ARSs included the
results of the assessment including recommendations for supervision and follow-up. There was
evidence in the center’s logbook and ASR indicating staff was provided specific instructions for
each youth related to the ASR finding and precaution decisions. A review of JJIS determined all
alerts were entered and removed following the youth’s removal from PO. Logbook review
determined beginning and ending time of PO was documented for each youth. An interview with
the DMHCA was conducted. According to the DMHCA, the initial suicide screening process
begins at the Juvenile Assessment Center (JAC) with the administration of the Massachusetts
Youth Screening Instrument – 2 (MAYSI-2) to assess mental health and substance abuse
issues, and the Suicide Risk Screening Instrument (SRSI) to assist in identifying youth at-risk of
suicide. If the intake screener at the JAC determines the youth is a suicide risk, they place the
youth on suicide precautions, and the youth is maintained on a minimum of precautionary
observation/ constant supervision when entering the detention center. Intake screening
continues at the center with the juvenile justice detention officer (JJDO). The officer immediately
reviews all screening instruments and forms upon admission of a youth to the detention center.
The intake officer reviews the MAYSI-2 and the SRSI, and if an assessment is indicated by the
SRSI or PACT, or information obtained at intake suggests the youth is a potential suicide risk,
the youth is placed on suicide precautions and maintained on a minimum of precautionary
observation/constant supervision until an ASR is completed by a mental health professional.
The youth is also entered into JJIS as a suicide risk alert. The DMHCA indicated staff are
trained to use screening tools to identify youth entering the facility at risk of suicide. Staff are
also trained in verbal and behavioral warnings which suggest suicide risk. Both of the
aforementioned result in mental health referrals to assess a youth’s potential for suicide. The
direct care worker, either observing indications of suicide risk upon admission from screening
tools (e.g., MAYSI-2, SRSI, or record review) or observing warning signs, immediately notifies
the juvenile justice detention officer supervisor (JJDOS) who serves as the designee for the
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superintendent for the purpose of the youth’s potential suicide risk. The JJDOS places the youth
on precautionary observation/constant supervision and initiates suicide precautions. The JJDOS
places the youth on suicide alert in the JJIS (if an open alert is not already entered). A Report of
Suicide Precautions is completed. The JJDOS contacts the mental health professional by
ensuring a referral for an Assessment of Suicide Risk and intervention is made to the mental
health staff. The DMHCA indicated mental health is notified through the JJIS when an SRSI
indicates any issues, and the DMHCA is on call twenty-four hours a day, seven days a week.
The DMHCA added any youth exhibiting suicide risk behaviors or who is identified at intake as a
potential suicide risk is placed on suicide precautions, precautionary observation or secure
observation and maintained on a minimum of PO/constant supervision until an ASR is
conducted. Staff are notified in writing through a log entry, receiving a precautionary/secure
observation log form, verbally through shift briefing and relief of on-duty officer in the mod when
a youth is potentially suicidal. Prior to revising the supervision level of a youth, MH
communicates and talks things over with the supervisor on duty, either in the administration
area, in an office, or in the interview room. Information is then documented in ASR, in the mod
logbook and master control is informed of supervision level and time. If mental health is on duty
when a youth is potentially suicidal or has attempted suicide, mental health notifies the
parent/guardian by telephone, and the youth's juvenile probation officer (JPO) through email. If
mental health is not on duty, then the on duty JJDOS will notify the parent/guardian by
telephone and a mental health referral is submitted. If necessary, a report in the Department’s
Central Communications Center (CCC) will be completed, and email and telephone will be used
to notify the DMHCA, Superintendent, JPO and necessary guardians. In the last six months, the
center has had one youth attempt to hang themselves or put anything around their neck in an
apparent attempt to hurt themselves and this youth is no longer at the center.
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
Seven youth records were reviewed for secure observation. None of seven records were
applicable for secure observation. A request for additional records to meet the minimum
requirement was made. Two additional records were provided. According to the designated
mental health clinician authority (DMHCA) no additional records were applicable for secure
observation during the scope of the annual compliance review period. For the two applicable
records, each placement was authorized by the superintendent and DMHCA, the secure room
was designated, in writing, and the health status checklist was completed prior to placement in
secure observation. Both suicide precaution observation logs were completed entirely, an
appropriate Assessment of Suicide Risk (ASR) was completed within eight hours, and parental
and juvenile probation officer (JPO) notification was completed. Neither record indicated the
youth remained on secure observation beyond twenty-four hours. Mental health staff provided
supportive counseling services during secure observation status. The observation logs
documented supervision and each youth’s level was reduced only after the conference with the
superintendent/licensed mental health professional. The discontinuation of secure observation
and step-down to close supervision was documented in the center’s logbook and each youth’s
mental health record by mental health clinical staff.
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3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Seven youth records were reviewed for suicide precaution observation (PO) logs. Five of the
seven records included PO logs, and the remaining two records were not applicable. For each
record, the PO logs were maintained for the duration the youth was placed on suicide
precaution, which included the appropriate level of supervision, and the observation of each
youth’s behavior documented in real time, and did not exceed thirty minutes. Each PO log was
reviewed and signed by the shift supervisor and mental health clinical staff, and the PO logs
documented safe housing requirements in each record. Video footage was reviewed for three
youth and corresponding documentation confirmed proper supervision was maintained for the
duration each youth was on precautionary observation.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Fourteen staff training records were reviewed for suicide prevention training, seven for pre-
service and seven for in-service training. Documentation supports staff completion of suicide
prevention training. Training records indicated suicide drills were held no less than quarterly on
each shift. The center maintains six suicide response kits, including a knife-for-life, wire cutters,
and needle nose pliers, which were all observed during the annual compliance review week.
One kit is in master control, one kit is in medical and the remaining four kits are located within
the sub-control of each of the four modules. All suicide kits are co-located with the first-aid kits.
The center’s suicide trainings included mock drills for all staff who encounter youth, including
kitchen and maintenance staff. All mock mental health drills were in response to a suicide
attempt and/or incident of serious self-injury. No youth were used in drill simulation related to
mental health or substance abuse care. The center conducted semi-annual training on
emergency response procedures which included mock training in emergency response to a
suicide attempt or incident of serious self-inflicted injury. Staff who were not present during any
quarterly drill had the opportunity to review the drill scenario and procedures to understand the
process and receive necessary training to respond. Seven staff were interviewed. Six staff
indicated suicide response kits are located in sub control. Five staff indicated suicide response
kits are located in master control, and four staff indicated suicide response kits are located in
medical.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
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The center maintains a combined emergency services plan which allows the center to respond
to a youth in crisis in the least restrictive means possible to protect the safety of the youth and
others while maintaining control and safety. The center’s combined emergency services plan
includes a notification and alert system, means of referral, including self-referral,
communication, supervision, documentation, and review.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center maintains an emergency care plan which was approved on March 22, 2022, and
was last updated on March 22, 2022. One copy of the plan is in master control and one copy is
in each of the dormitory sub-controls. The emergency care plan is available to all staff. The plan
includes immediate staff response, notifications, communication, supervision, authorization to
transport for emergency mental health or substance abuse services, transport for emergency
mental health evaluation and treatment, transport for emergency substance abuse assessment
and treatment, documentation, training, and review.
3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
Seven youth records were reviewed for crisis assessment. None of the seven youth were
applicable for a crisis assessment. A request for three additional records was made. The
designated mental health clinician authority (DMHCA) reported there were no other applicable
records to review for a crisis assessment during the annual compliance review period.
3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Seven youth records were reviewed for Baker and Marchman Acts. None of the seven records
were applicable for Baker or Marchman Acts during the scope of the annual compliance review
period. A request for additional records was made. The designated mental health clinician
authority (DMHCA) reported there was only one youth for whom the center had to utilize a
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Baker Act during the annual compliance review period. A review of the record confirmed the
youth was placed on one-to-one supervision, and a suicide alert had already been opened while
pending transport. Youth supervision was documented on a suicide precautions observation log
until the youth’s authorized release. Documentation confirmed the youth was placed on suicide
precautions upon re-admission from Baker Act. The record contained a completed referral for a
mental status examination (MSE) which was completed by a licensed mental health
professional. The youth was maintained on a minimum of constant supervision until properly
transitioned to a lower level of supervision. Additionally, the youth’s supervision level was
maintained until an appropriate assessment was conducted and mental health staff conferred
with the licensed supervisor and superintendent or designee. The youth had a suicide alert
entered into the Department’s Juvenile Justice Information System (JJIS) and the
discontinuation of the alert and precaution was based upon an Assessment of Suicide Risk
(ASR).
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center maintains facility operating procedures requiring a contractual agreement with a
licensed physician to serve as the designated health authority (DHA). The center maintains a
contract with VitalCore Health Strategies, LLC which subcontracts with a licensed physician
(MD) to serve as the center’s DHA. The DHA holds an unrestricted, clear, and active license
which meets all requirements for independent and unsupervised practice in the State of Florida
and expires January 31, 2027. The center utilizes a part-time advanced practice registered
nurse (APRN) whose license expires July 31, 2026. The APRN and the DHA have a valid
Collaborative Practice Protocol (CPP) agreement in place. The DHA is contracted to be on-site
for at least four hours once a week, with a week defined as the seven-day period beginning on
Sunday and ending on Saturday; however, at no time are more than nine days to pass between
on-site visits. The DHA is on-call twenty-four hours a day, seven days a week. A review of the
center’s healthcare staff sign-in sheets since the last annual compliance review showed the
DHA was consistently on-site for the required four hours. When the DHA scheduled an
absence, a back-up licensed MD was designated by VitalCore Health Strategies, LLC to provide
clinical services.
An interview with the DHA revealed they are on-site at least once every nine days to provide
clinical services, and are available by telephone twenty-four hours a day, seven days a week.
The DHA’s responsibilities include communication with staff regarding youth medical needs,
availability for consultation by electronic means twenty-four hours a day, seven days a week for
acute medical concerns, emergency medicine, and coordination of off-site care.
The interviewed DHA reported the specific duty of the DHA is to perform Comprehensive
Physical Assessments (CPAs) and CPA updates, conduct periodic evaluations, sick calls, policy
and procedure development, medical evaluations, and advise nursing staff with urgent matters,
medication questions, medical condition questions, provide consultation to Department staff
when nursing staff are not available, follow-up on urgent and acute issues with detained youth.
The center has four full-time registered nurses (RNs) one of whom serves as a clinical nurse
manager, and three RN’s. All four nurses hold a clear and valid license.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center maintains facility operating procedures (FOPs) for all health-related procedures and
protocols. Reviewed documentation indicated the designated health authority (DHA) reviewed,
signed, and dated the FOPs, on November 12, 2024, the superintendent signed on November
14, 2024, and the psychiatrist signed on November 12, 2024. Reviewed documentation
validated the advanced practice registered nurse (APRN), clinical nurse manager, reviewed,
signed, and dated the FOP and treatment protocol cover page in August 2024. The additional
three registered nurses (RNs) signed and dated the FOP and treatment protocol cover page in
September 2024. VitalCore Health Strategies, LLC has an established comprehensive clinical
orientation for all newly employed healthcare staff, which includes the Department’s healthcare
policies and procedures. The orientation is provided by a RN.
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4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
The center maintains facility operating procedures requiring parents/guardians to be afforded
the right to give or withhold consent regarding the healthcare provided to youth. A review of
seven youth Individual Healthcare Records (IHCRs) found one youth had an AET form which
was not signed by the youth’s parent/guardian. The center completed an Affidavit of Diligent
Report which was in the youth’s IHCR; furthermore, there was a Limited Consent for Evaluation
and Treatment signed by the superintendent in the youth’s IHCR. Four reviewed youth had a
signed, valid Authority for Evaluation and Treatment (AET). Each AET was obtained prior to
providing medical services for each youth. Two reviewed youth were applicable for being under
the care and custody of the Department of Children and Families (DCF) whose
parents/guardians had their rights terminated. Consent was given for ordinary medical treatment
by executing the Limited Consent for Evaluation and Treatment for both youth. Both youth had a
current and valid court order authorizing all treatment procedures. None of the seven youth
records reviewed were out of the custody of the Department. An interview with the clinical nurse
manager indicated the policy nursing staff use to obtain a new or current AET upon each
youth’s admission into secure detention. The center will contact the parent or guardian as listed
on the youth Facesheet, requesting them to come to the facility and sign the new AET. The
center may include enlisting the assistance of the assigned juvenile probation officer (JPO) in
obtaining the parent/guardian signature. If the parent cannot be contacted, the facility
superintendent can sign a limited consent to perform necessary medical procedures. When a
youth reaches eighteen years of age, the youth will provide consent at the point of contact for
healthcare.
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
The center maintains facility operating procedures outlining requirements for parental/guardian
notification of significant changes in each youth’s condition and for obtaining written consent
from a parent/guardian when new medications and treatments are prescribed. A review of
seven youth Individual Healthcare Records (IHCRs) indicated none were applicable for any over
the-counter (OTC) medication beyond those covered by the Authority for Evaluation and
Treatment (AET). Three youth records were applicable for taking a psychotropic medication, for
whom staff witnessed all telephone call attempts and conversations to the parent/guardians
regarding psychotropic mediations for two youth records reviewed. The one remaining
applicable youth record indicated the youth was under the care and custody of the Department
of Children and Families (DCF); therefore, no parental notification was made. Six reviewed
youth records did not receive vaccinations or immunizations; however, one youth record
documented a tuberculosis test. All seven youth records reviewed found none were applicable
for new medication; therefore, parental notifications were not necessary. Three youth records
applicable for psychotropic medication did not require a new prescription, and the drug dosage
was not significantly changed or discontinued. Seven youth IHCRs were reviewed for
vaccination status, and each contained a vaccination record from Florida Shots, which was
reviewed by medical staff within thirty days of each youth’s admission. Six youth records
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documented no new vaccines were administered. One applicable youth record documented
parental consent on the Department’s Parental Notification of Health-Related Care
Vaccination/Immunizations (HS 022) prior to administering a tuberculosis test.
The clinical nurse manager was interviewed and described the center’s process for
documenting attempted parental/guardian notifications. A parent/guardian must submit a signed
exemption form stating their objection to immunizations. The form must comply with state laws
and facility policies, which may require notarization or specific language. Acceptable exemptions
generally fall under medical, religious, or philosophical grounds. The center will verify
compliance with state regulations to ensure the exemption aligns with the state's immunization
exemption laws. Some states require additional documentation, such as a physician's statement
for medical exemptions. In order to maintain proper records, the center will document the
exemption in the youth's medical file and electronic health records, if applicable, clearly indicate
the reason for the exemption and the date the exemption was granted, include any additional
required forms or supporting documents, communicate with healthcare staff, inform medical
personnel, facility administrators, and relevant staff about the exemption, ensure the youth's
records reflect special precautions in case of an outbreak, review and update periodically and
ensure compliance with any new regulations or facility policies, implement outbreak procedures
if an outbreak of a vaccine-preventable disease occurs and follow facility policies for quarantine
or exclusion of exempted individuals to prevent the spread of illness.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
The center maintains facility operating procedures requiring each youth, at the time of
admission, to receive a Facility Entry Physical Health Screening utilizing the Department’s
Medical and Mental Health Admission Screening form in the Department’s Juvenile Justice
Information System (JJIS) Admission Wizard. A review of seven youth Individual Healthcare
Records (IHCRs) found each had a Medical and Mental Health Admission Screening form
completed on the date of admission. Each reviewed form was completed on the date of
admission by a registered nurse (RN), and each indicated the screening was reviewed by a
licensed medical staff within twenty-four hours. Each youth screening form was completed in
JJIS, as required. The center reported there were no youth applicable for a change in physical
custody since the last annual compliance review.
An interview with the clinical nurse manager confirmed a youth is seen by a nurse no later than
twenty-four hours after admission. There are several methods used to determine when new
youth enter the center. If medical staff are on-site and hear several radio transmissions
discussing a new youth being picked up and transported to the facility. When the youth arrive to
the center, intake staff call medical staff to go to intake to clear the youth. When medical staff
arrive in the morning, they are informed about all the intakes throughout the night by looking at
the alphabetical list of youth and determining who is new and hasn't been seen yet. Medical
staff also get all the new intake packets either delivered to medical, or the packets are placed in
the nursing bin in intake. Direct care staff completes the admission screening. If the admission
screening is completed by direct care staff, the nurse documents a review of the form in the
Chronological Progress Note. When there is a change in physical custody since the youth's
admission, a new Health Related History is completed.
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4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center maintains facility operating procedures requiring all youth to be oriented to the
process of general healthcare delivery services at the center. A review of seven youth Individual
Healthcare Records (IHCRs) indicated each youth received a general healthcare orientation on
their day of admission to the center. Each record contained a completed Department Health
Education Record form documenting each youth’s orientation to the center’s healthcare services
within twenty-four hours of admission to the center. The center’s facility operating procedures
(FOPs) included topics addressing access to medical care, sick call, instances which constitute
an emergency and when to notify staff, the medication process and side-effect monitoring, the
right to refuse care and how refusals are documented, what to do in the case of a sexual assault
or attempted sexual assault, the non-disciplinary role of the healthcare providers, and a review
of the list of healthcare contacts to ensure accuracy.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
The center maintains facility operating procedures which require notification to the designated
health authority (DHA) of all youth admitted with chronic health conditions or youth in need of
emergency care. A review of seven Individual Healthcare Records (IHCRs) indicated five youth
were applicable for a known or suspected chronic condition upon admission. All seven records
reviewed documented the DHA was notified of each youth’s admission within twelve hours;
however, no later than noon the day following admission, as it is the center’s practice to notify
the DHA of all newly admitted youth. Documentation of the notification was listed in each
youth’s Chronological Progress Note. Three of the five applicable youth records were for youth
having been admitted while taking psychotropic medication and the psychiatrist was notified of
each youth’s admission.
An interview with the clinical nurse manager indicated the DHA is notified immediately when a
youth is admitted and identified with an emergency or chronic condition. When the DHA is
notified by the nursing staff, it is to be documented in the IHCR on the Chronological Progress
Note. It is the center’s practice to notify the DHA of all new admissions regardless of medical
condition and the notification is documented in the Chronological Admission Progress Note.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
The center maintains facility operating procedures requiring completion or review and updating
of the Department’s standard Health-Related History form (HRH). The center utilizes and
completes the standard Department HRH form for all youth admitted into the center’s physical
custody. A review of seven youth Individual Healthcare Records (IHCRs) found seven contained
a new HRH form. Reviewed documentation indicated each HRH form was reviewed by the
advanced practice registered nurse (APRN). The applicable HRH forms were completed prior to
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or at the same time as the Comprehensive Physical Assessment (CPA) for each youth and
reflected the most current admission, as evidenced by signature and date. Each applicable HRH
form was completed by a licensed nurse within seven days of the youth’s admission to the
center.
An interview with the clinical nurse manager confirmed an HRH is completed within seven
calendar days of each youth’s admission by direct care staff or nurses.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
The center maintains facility operating procedures requiring a Comprehensive Physical
Assessment (CPA) to be completed or updated for all youth admitted to the center to determine
the health and wellbeing of each youth. A review of seven Individual Healthcare Records
(IHCRs) was completed. All seven records contained a current CPA on file at the time of
admission. Each CPA was completed or reviewed within seven days of the youth’s admission
and signed by the designated health authority (DHA) or the advanced practice registered nurse
(APRN). Five of seven youth CPAs were completed in full to include the Medical Grade, Tanner
stage, cardiovascular, body mass index, visual acuity field, and most recent Tuberculosis (TB)
Skin Test (TST). One youth record reviewed had all sections of the CPA completed at the
center except for two sections which the youth refused. A refusal form was documented in the
IHCR of the youth refusal. One youth record reviewed had all sections of the CPA completed at
the center except for four sections which was noted by the APRN or DHA as not being clinically
indicated. Seven reviewed youth records had a current CPA with no changes in the youth’s
medical conditions. All seven youth’s current CPA confirmed each youth was examined and
signed off by the physician or advanced practice registered nurse (APRN). None of the
reviewed youth records were applicable for a focused evaluation. All sections of the CPA were
marked with an “O” or an “X” for each youth. The Department’s Problem List was updated in
each reviewed instance, as required. The center’s policy and procedures for tuberculosis control
and screening requires the routine screening of all youth for latent and active TB and outlines
environmental controls in the case of a youth with suspected active TB. Each of the seven
reviewed youth records documented a TST was completed within the last year and each were
documented on the CPA and the Infectious and Communicable Disease (ICD) form and each
matched. Each youth’s TB screening was completed within seventy-two hours, with the
exception of one, which was completed one day late. None of the reviewed youth required
further evaluation prior to entering general population. An informal interview with the clinical
nurse manager indicated the DHA or designee completes a new CPA if a youth medical grade
is one and is completed every two years thereafter if a medical grade one. If the medical grade
is two through five, a CPA is completed every year. Nursing staff indicated TB screenings are
provided to youth within seventy-two hours of arrival to the center. Gynecological examinations
are not routinely completed for female youth.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
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Office of Accountability and Program Support Page 39 of 58 (Revised July 2023)
The center maintains facility operating procedures requiring all youth to be evaluated and
treated for sexually transmitted infections (STIs), if necessary. All sexually active youth are
clinically screened and evaluated for STIs. After the screening, youth are referred to the
designated health authority (DHA) or advanced practice registered nurse (APRN) to determine if
further testing is indicated. A review of seven Individual Healthcare Records (IHCRs) indicated
each youth was clinically screened and evaluated for STIs. Five youth records indicated no
further evaluation was required. Two youth records included a referral and ordered testing which
was documented on the STI form. Both youth records reflected testing, screening results,
clinical evaluations, and diagnosis and were documented on the Infectious Communicable
Diseases (ICD) form, excluding human immunodeficiency virus (HIV) results and each were
filed in the lab section of the IHCR. STI screenings, evaluations, and referrals are documented
and maintained in each youth’s IHCR. There were no youth applicable for being out of the
Department’s custody for thirty days or more needing a rescreening since the last annual
compliance review. All seven reviewed records validated each youth was offered counseling
and testing for human immunodeficiency virus (HIV). Five youth IHCRs confirmed the youth did
not consent to the HIV test. One youth record documented a consent form signed by the youth
for an STI test, not an HIV test. One youth record documented a consent form signed by the
youth for an HIV test. The youth received an HIV test on November 4, 2024, at Marion Regional
Juvenile Detention Center and on January 22, 2025, at Orange Regional Juvenile Detention
Center. The sealed envelope marked “CONFIDENTIAL” had not been signed off by the DHA
before the youth was transferred and was still at the previous center; however, the youth’s IHCR
had alternative proof of the test results in the form of a test result card. There was
documentation of pre-test/post-test counseling in the IHCR for both applicable youth records.
The confidentiality for each youth was protected and the HIV status or STI diagnosis was not
placed in the center’s internal alert system.
Seven youth were interviewed and asked if they can ask for an HIV/AIDS tests, and all seven-
youth confirmed yes. An informal interview with the clinical nurse manager indicated youth are
required to read and sign a HIV form to indicate whether they consent or not to being tested for
HIV. If the youth consents, they are added to the HIV testing log. The APRN performs the
testing and documentation. Documentation of pre/post-test counseling is recorded on the IHCR.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
The center maintains facility operating procedures regarding the sick call process and requests.
The center conducts sick calls seven days a week where a healthcare professional responds to
youth medical illnesses or injuries of a non-emergent nature. Postings on the medical clinic door
indicated sick call takes place daily at the center from 8:30 a.m. to 10:30 a.m. When there is not
a licensed nurse on site, the center has procedures whereby the shift supervisor reviews all sick
call requests as soon as possible and within four hours after the request is made. A review of
seven Individual Healthcare Records (IHCRs) indicated two were applicable for a sick call;
therefore, one additional applicable record was requested for review and was provided. There
were no instances of a youth presenting with a similar sick call complaint three or more times
within a two-week period. Sick calls were conducted by a licensed nurse either immediately or
within twenty-four hours of the sick call request submission, which was completed by the
medical staff on behalf of the youth. Three reviewed youth records confirmed staff were made
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aware of the sick call complaint and the youth were seen by medical staff. A review of the three
youth records confirmed the Sick Call Request forms were filled in the youth’s Individual
HealthCare Record (IHCR). The Sick Call Request forms and progress notes were documented
in accordance with Florida Administrative Code. All three records confirmed the youth’s sick call
was documented on the Sick Call Index, and the dates listed on the Sick Call Index
corresponded with each completed Sick Call form located in the IHCR. The center has
approved treatment protocols for both registered nurses (RN) and licensed practical nurse
(LPN) level staff. Only RN’s conduct sick call, as the center does not utilize LPN’s.
Observation of a sick call was observed in medical after a youth was involved in a physical
altercation with three other youth in the classroom. The youth was immediately seen by two
registered nurses (RN). The youth provided consent for the annual compliance review team
member to observe the sick call. The youth was escorted to the medical clinic by a juvenile
detention officer (JDO). The RN properly identified themselves, the youth was seen in a private
area which contained an examination table and curtain for privacy. The youth was examined by
the RN for a bloody nose, and the examination took place behind a curtain for privacy. The JDO
stood by the door until the examination was completed.
Seven staff were interviewed, and all indicated nursing staff review sick call requests and
conducts sick calls. Two of the interviewed staff stated they will escort the youth to medical for a
sick call. Seven youth were interviewed and asked how quickly they can be seen once you
make a sick call request. Four youth stated immediately, one youth stated within one day, and
two youth stated within two days. Seven youth were interviewed and four stated the nurse
conducts sick call, and four stated staff can also conduct sick call. An informal interview with the
clinical nurse manager confirmed sick call is conducted by a registered nurse within twenty-four
hours of the request and documented on the Sick Call Referral Log; however, it is the center's
practice to provide episodic medical care to each youth as quickly as possible rather than
waiting for youth to submit a sick call request through the electronic system. All sick calls are
conducted in the medical clinic to ensure the youth’s privacy. The center maintains treatment
protocols appropriate to the level of the provider conducting sick call, which were approved by
the designated health authority (DHA). Youth notify staff of medical complaints by completing a
sick call request. Staff then input each sick call request in the Department’s Juvenile Justice
Information System (JJIS). Nursing staff pull sick call lists twice a day, and have twenty-four
hours to see each youth. Youth are assessed and vital signs, treatment, education, and follow-
up plans are completed. The nurse advised the DHA will conduct sick call if it is scheduled when
the DHA is on-site. The nurse advised sick call is conducted daily from 8:00 a.m. to 10:30 a.m.,
or more frequently if needed in the clinic. Any youth who present with similar sick call complaints
three or more times within a two-week period are referred to the DHA and added to a list to be
seen by the provider.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
The center maintains facility operating procedures detailing a comprehensive process for the
provision of episodic care, first-aid treatment, and emergency care. The center utilizes an
Episodic Care Log to document episodic care and first-aid treatment. A review of seven youth
Individual Healthcare Records (IHCRs) showed three youth were applicable for episodic or
emergency care. A review of three youth records confirmed each youth received episodic care
or first-aid by a licensed healthcare staff and was documented either in the problem-oriented
(SOAP elements; subjective, objective, assessment, and plan) or standard narrative charting,
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Office of Accountability and Program Support Page 41 of 58 (Revised July 2023)
and the findings of the healthcare staff rendering care were included for each youth. One of the
three applicable instances of episodic care indicated no referral to offsite care was needed,
while two documented the treatment rendered. Each reviewed instance documented the
education/instruction provided to the youth, and an entry in the Episodic Care Log was
completed. All three reviewed instances of episodic care required follow-up. One of the three
applicable youth was placed on the alert list. A parental notification was made and documented
in the IHCR for two applicable youth, one youth was not applicable. All three youth received a
follow up evaluation from a licensed healthcare staff the next time a licensed staff was on site or
sooner if warranted.
The center maintains two automated external defibrillators (AEDs). The center’s AEDs are
maintained in wall-mounted AED boxes in the medical clinic and the other is located in module
B1. The AED procedures are stored with the AED in the medical office and on module B1. Each
AED provides audible instructions when utilized. Nursing staff check the AED batteries and
pads each month to ensure each AED is operational and the checks are documented. A review
of the center’s AED tracking sheets since the last annual compliance review period documented
the center’s practice. The AEDs were self-tested in front of the annual compliance reviewer to
ensure they were operational. The batteries in the center’s AEDs do not have expiration dates;
however, each AED has an LED indicator which is lit green when the unit is fully functional and
able to rescue. Both observed AEDs displayed green LED indicator lights during the week of the
annual compliance review. The center’s AED pads expire March 28, 2026. Nursing staff check
the AED batteries and pads each month to ensure each AED is operational and the checks are
documented. A review of the center’s AED tracking sheets since the last annual compliance
review period documented the center’s practice. The AEDs were self-tested in front of the
annual compliance reviewer to ensure they were operational. The batteries in the center’s AEDs
do not have expiration dates; however, each AED has an LED indicator which is lit green when
the unit is fully functional and able to rescue. Both observed AEDs displayed green LED
indicator lights during the week of the annual compliance review. The center’s AED pads expire
March 28, 2026.
Reviewed documentation and an interview with the clinical nursing manager indicated the AED
batteries were last installed on August 19, 2022, and the pads were last changed on October 1,
2024. AED maintenance was last conducted by an outside medical equipment company on
October 31, 2023. The center maintains a total of fourteen first-aid kits which are located on
each of the three living modules, intake, teacher’s office, the kitchen, master control, and in the
medical clinic. Seven first-aid kits for use in the transport vehicles are stored within the intake
office. The center’s first-aid kits are sealed with breakaway tabs. When a first-aid kit seal is
broken, the kit is inspected and restocked. An informal interview with the clinical nurse manager
indicated nursing staff check the kits at least monthly. A review of the first-aid kit checklist since
the last annual compliance review confirms the center checks the first-aid kits monthly. Three
randomly selected sealed first-aid kits were checked and found to contain all items approved by
the DHA, as required. A review of seven pre-service and seven in-service staff training records
found each was trained and held current certifications in cardiopulmonary resuscitation (CPR),
first-aid, and AED. All non-healthcare staff and nursing staff are required to maintain
certifications. A review of emergency drills since the last annual compliance review supported
drills were conducted monthly on each shift through January 2025. Mock use of CPR was
demonstrated as part of drills on each shift since the last annual compliance review. Emergency
drills are held for each shift, at a minimum on a quarterly basis; however, the center is
conducting drills monthly on each shift.
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Observations confirmed emergency contact telephone numbers were posted out of the view of
youth in the medical clinic. Only licensed healthcare and trained non-healthcare supervisory
staff can administer the epinephrine auto injector for youth requiring administration. A review of
seven in-service and seven pre-service training records supported each staff received the
required training on the center’s Emergency Care Plan and the designated supervisory staff
received training on epinephrine auto injector. Reviewed documentation supported the DHA, the
advanced practice registered nurse (APRN), and all nursing staff maintained current
certifications in CPR and AED. The center’s licensed clinical nursing manager provided
instruction to the supervisors trained and approved for medication administration on how and
when to use Narcan.
Seven staff were interviewed, and each indicated they can call 9-1-1 if needed. Seven youth
were interviewed, and three rated the medical care at the center as very good, four rated it as
good.
4.13 Off-Site Care/Referrals [Contract Provider] Satisfactory Compliance
The center shall provide for timely referrals and coordination of medical services to an off-site
healthcare provider (emergent and non-emergent), and document such services, as required
by the Department.
The center has facility operating procedures to provide for referrals and coordination of medical
services to ensure youth have timely access to off-site care services. A review of seven youth
Individual Healthcare Records (IHCRs) found two of the youth were applicable for off-site care;
therefore, one additional applicable record was selected for review. The center maintained
documentation in all three applicable records of notification made to the designated health
authority (DHA) and each record had a completed Summary of Off-Site Care form and
discharge paperwork for each instance of off-site care which was documented in the Episodic
Care Log. Parental/guardian notification efforts were also documented for two applicable youth.
The third applicable reviewed youth was under the care and custody of the Department of
Children and Families (DCF); therefore, a parental notification was not applicable. The DHA or
advanced practice registered nurse (APRN) reviewed and initialed the off-site findings,
instructions, and information for each instance of off-site care. Two of the three applicable
records indicated follow-up testing, referral, or an appointment was necessary, and each referral
was entered on the center’s referral tracking log. The two youth records applicable for required
follow-up care documented the youth received appropriate and timely follow-up care, as
needed.
An interview with the clinical nursing manager indicated the center documents follow-up testing,
referrals, and appointments in a calendar and sends e-mail communication to staff. The
Summary of Off-Site Care form is utilized if a youth is sent off-site for follow-up testing, referrals,
or additional appointments requested by the provider. A review of the center’s Off-Site Care Log
indicated each youth medical transport was documented.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
The center maintains facility operating procedures (FOPs) to ensure youth identified with
chronic conditions receive regularly scheduled evaluations and necessary follow-up care. A
review of seven youth Individual Healthcare Records (IHCRs) found two youth were applicable
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for a chronic condition; therefore, one additional applicable record was selected for review.
None of the reviewed youth records were applicable for a communicable disease. Four youth
were applicable for taking prescribed medication on an on-going basis. None of the reviewed
youth were undergoing treatment for a physical health condition. Three youth were classified
with a medical grade between two and four. None of the youth identified as being pregnant. Five
youth were placed on the chronic conditions list. One youth was applicable to receive periodic
evaluations at least every ninety days, the remaining youth had not been at center for ninety
days. A review of progress notes confirmed the periodic evaluations were competed as
required. There were no youth applicable for taking antituberculosis medication. The
Department’s Problem List was updated for each youth, in accordance with Florida
Administrative Code.
An interview with the designated health authority (DHA) and the clinical nurse manager
indicated the center maintains a chronic conditions binder and all youth who have chronic
conditions receive regularly scheduled evaluations every ninety days which are documented in
Focused Evaluation Progress Notes. There was no indication of lapses in care or missed
periodic evaluations in the reviewed records.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
The center maintains facility operating procedures (FOPs) requiring all medication and
pharmaceutical products to be procured, dispensed, administered, and stored safely,
accurately, and in accordance with state, federal, and industry standards. The center’s practice
is for nursing staff to verify each medication has a current, valid order, and are given according
to a current prescription or practitioner’s order. A Medication Receipt, Transfer, and/or
Disposition form is used to document medication received in the original packaging from a
licensed pharmacy with a current, legible, patient-specific label affixed. All medication is
delivered to the center in sealed blister packs.
A review of seven youth Individual Healthcare Records (IHCRs) showed there were four youth
taking medication upon admission. A review of the four applicable records indicated the
designated health authority (DHA), and when applicable, the psychiatrist was contacted to
obtain an order to resume the specified medication prescribed prior to admission. Each
medication had a current, valid order, and was administered pursuant to the current
prescription. Each reviewed record validated a prescription verification was completed and
documented in the Chronological Progress Notes of the related IHCR. There were no youth
applicable for over the counter (OTC) medications not listed on the Authority for Evaluation and
Treatment (AET) form. When current medications were continued, discontinued, or changed,
the reviewed records indicated the DHA placed an order on the practitioner order form, as
required.
The center utilizes the standard Department Medication Administration Record (MAR) for each
youth receiving either prescription medications on a routine basis or OTC medications. The
center maintains a written policy and procedures to ensure the usage of the MAR by licensed
healthcare staff and non-licensed staff. Seven youth records were reviewed and six were
applicable for having MARs documenting administered medications. One youth record reviewed
confirmed the youth has not been issued any medication. There was no youth record applicable
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Office of Accountability and Program Support Page 44 of 58 (Revised July 2023)
for trained non-healthcare staff assisting in the delivery of medications when licensed healthcare
staff were not on-site. There were no undocumented explanations for lapses or errors in
medication administration. The healthcare staff documented side effect monitoring for each
medication administration on the MAR for each applicable youth record reviewed. A review of
the standardized MAR form for each applicable youth, showed the form included the youth’s
name, Department identification number (DJJID), date of birth, youth allergies, precautions,
Medical Grade, medical alerts, and a current picture of the youth. Each youth and staff
electronically initialed each medication entry, without exception. There were no applicable
records for youth requiring parenteral medication. There were no refusals documented on the
MARs. The center did not have any standing, pro-re-nata (PRN), or emergency treatment
orders for psychotropic medication. Three of the seven reviewed records confirmed youth were
on psychotropic medication and a review of progress notes validated the DHA, and the
psychiatrist were both notified at the time of all three youth admissions. The psychiatrist
conducted an initial diagnostic psychiatric interview within fourteen days of each youth's
admission, as required. Youth prescribed psychotropic medication upon admission to the center
are to be seen at least every thirty-days by the psychiatrist for medication management. Three
youth were applicable for requiring medication monitoring and only one had been at the center
for more than thirty days, while the other two had been in the center for only eleven days. The
one applicable youth did receive a medication monitoring review every thirty days as required.
Observations of a medication pass were conducted during the week of the annual compliance
review. Medication delivery was the sole responsibility of the nurse at the time of administration.
The youth was escorted to the medication administration area by a juvenile detention officer
(JDO). The youth approached the nurse administering medication individually, and the nurse
provider properly identified herself. The nurse did verify the youth alert status and allergy status.
The same nurse prepared and administered each medication. The nurse did observe the youth
to make sure the medication was swallowed. The nurse and youth both electronically initialed
the MAR.
An interview with the clinical nursing manager indicated the center has a process for verifying
each youth’s medication regimen once admitted to the center. Additionally, the center has non-
healthcare supervisory staff who are trained by medical staff to provide medication to youth;
however, non-healthcare supervisory staff are rarely used. The clinical nurse manager last
conducted the training of non-healthcare supervisory staff on April 8, 2024. An interview with the
clinical nurse manager indicated the center utilizes a chemical pharmaceutical drug disposal
system to dispose of expired medication in the presence of a consultant pharmacist. An
interview with seven staff regarding medication administration was conducted, and all seven
staff stated they do not give medication to youth. Seven youth were interviewed, and five youth
indicated the nurse gives them their medication while two youth indicated 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 maintains facility operating procedures regarding the requirements for the storage
and inventory of medications and sharps ensuring all medication is inaccessible to youth at the
center. Observations of the medication cart showed it was clean and organized, with stock items
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separate from youth specific medications. An observation of the medication cart found all
medications were stored in the locked cart which is kept in the locked medical clinic. All non-
controlled medications were stored in the secure, locked medication cart. Narcotics and other
controlled medications are securely stored and double locked within the medication cart.
Observations found all medications were securely stored in the medical clinic which is
inaccessible to youth. The center had no medication requiring refrigeration during the week of
the annual compliance review; however, the center has a refrigerator which is used only for
medication, if needed. Perpetual inventories with running balances are maintained on all
controlled substances with a shift-to-shift inventory conducted by the nurses and documented
on the youth’s individualized Controlled Medication Inventory Record as required. There were
no oral medications stored with injectable or topical medications. Non-healthcare staff are
trained in the delivery and oversight of medication self-administration and may perform these
duties. The training was delivered by the clinical nurse manager.
A review of three OTC medications was conducted, each of which validated the related
inventory was accurate. Syringes and sharps are counted through a perpetual inventory and are
verified weekly. Observations of a count were conducted with nursing staff. A review of three
sharps verified all three matched the count on the perpetual inventory. A review of three
controlled medications was conducted, each of which validated the related inventory was
accurate.
During an interview, the clinical nurse manager stated controlled medications are disposed of by
nursing staff and the pharmacy consultant. Non-controlled medications are disposed of by
nursing staff. The clinical nurse manager indicated the controlled medications are stored in a
locked compartment in the locked medication cart. The center maintains a contract with a
pharmacist who visits the center monthly to review the medication cart, medication cabinet,
medication refrigerator, sharps, and the Medication Administration Records, destroy medication,
ensure everything is labeled correctly, and ensure licenses are up to date. The center has an
innovative and best practice inventory process by which all inventory items are labeled with an
alpha numeric code. Weekly counts are conducted and documented in a “double blind” method
by documenting the count on pages separate from the inventory forms. This allows for counts to
be documented without the healthcare staff able to view the count log during the count. This
avoids any preconceived expectation on counts.
4.17 Infection Control – Exposure Control and Education
Satisfactory Compliance
[Contract Provider]
The center shall have implemented infection control procedures including prevention,
containment, treatment, and reporting requirements related to infectious diseases, as per
OSHA federal regulations and the Centers for Disease Control and Prevention guidelines.
The comprehensive education plan shall include pre-service and in-service training for all
staff. Education for youth infection control shall also be provided at the time of intake and
subsequently when the need is identified.
The center maintains facility operating procedures requiring proper procedures to be followed to
prevent the spread of infectious diseases or illnesses and provide staff with the knowledge of
appropriate prevention, containment, treatment, and reporting requirements of infectious
diseases. A review of seven youth Individual Healthcare Records (IHCRs) was conducted.
Reviewed documentation indicated each youth received infection control training within seven
days of admission. The infection control training included hand-washing techniques,
universal/standard precautions, prevention/transmission of communicable diseases,
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vaccinations, and the Centers for Disease Control and Prevention (CDC) guidelines for infection
control. A review of the center’s Exposure Control/Infection Control Plan showed the plan was
written in accordance with Occupational Safety and Health Administration (OSHA) guidelines to
include risk assessment and methods of compliance. The plan addressed common childhood
infectious diseases, self-limiting, episodic contagious illnesses, viral and bacterial infectious
diseases, tuberculosis, Hepatitis A, B, and C, human immunodeficiency virus (HIV), bloodborne
pathogens, other outbreaks and epidemics, and outbreaks of pediculosis. In addition, the plan
addressed Methicillin Resistant Staphylococcus Aureus (MRSA) and other antibiotic-resistant
micro-organisms, foodborne illnesses, bioterrorism agents, chemical exposures in the
workplace, and protocols for needlestick post-exposure intervention and treatment. The center
ensures Hepatitis B immunizations are available for staff and staff have access to protective
equipment as needed.
A review of seven pre-service and seven in-service staff training records confirmed each staff
completed Exposure Control Plan/Infection Control Plan training. An interview with the clinical
nursing manager indicated youth are provided with infection control training upon admission,
and nursing staff are responsible for the provision of staff training on the center’s Exposure
Control Plan.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has not had any pregnant youth throughout the annual compliance review period;
therefore, this indicator is rated non-applicable.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another. Youth are in sight of
at least one juvenile justice detention officer (JJDO) at all times (with the exception of
sleeping hours or time secured in rooms). Officers are responsible for the care of youth at all
times. At no time shall another youth be allowed to exercise control over or provide discipline
or care of any type to another youth. When a youth leaves the group or program area of the
center for any reason, all staff assigned to supervise the youth are informed. Master control
authorizes all movement of youth prior to the actual movement, and no movement occurs
until cleared by master control. Staff moves youth from one area of the center to another in
accordance with Florida Administrative Code.
The center has facility operating procedures (FOPs) to ensure youth are actively supervised by
staff. During the annual compliance review week, youth supervision was observed each day.
Center staff were adhering to the daily activity schedule. Observations were made during the
annual compliance review week and a tour of the center was completed on the first day of the
annual compliance review. Observations found youth were attending class as scheduled with
fourteen youth in portable two, each classroom had two assigned staff and one teacher
facilitating class. Throughout the week of the annual compliance review week various
observations of the chemical shed the youth living modules, the dining hall, and hallways
throughout the center. Each area was observed to have no youth present. Additional
observations found youth were observed to be in the classrooms actively participating in
education and recreation, observed to be in the day room of each living module watching
television, and in portables one and two engaging in education materials. Lunch line movement
was observed with module B2 moving to the dining hall. On another occasion during the week
of the annual compliance review classroom three had fifteen youth and two staff with one
teacher. Classroom one had eight youth and one staff with one teacher. Classroom two had ten
youth and two staff with one teacher. All teachers were actively facilitating class and youth were
engaging. Staff maintained continuous sight supervision of all youth in their assigned area. Staff
were observed supervising youth by controlling line movements, positioning themselves
appropriately, and giving clear directions to youth. The center staff were interacting
appropriately with youth. All movements were authorized by master control prior to the youth
being moved. Tracking daily census is completed by conducting head counts throughout the
shift and documenting in the logbook. Seven staff were interviewed, and each stated there were
enough staff to provide adequate supervision.
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.
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Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC). The use of drugs to control the
behavior of youth is prohibited. This does not preclude the proper administration of
medication as prescribed by a licensed physician.
The center maintains a facility operating procedures (FOPs) requiring a uniform behavior
management system (BMS) which provides rewards, privileges, and consequences for
behavior. The center has a system of rewards, privileges, and consequences for all
inappropriate behavior. During a tour of the center, postings were observed of the BMS in the
living areas. A review of the facility operating procedures on the BMS ensured compliance with
components outlined in the center’s FOPs. A review of youth point cards confirmed youth are
receiving their rewards and are being held accountable for their actions daily. The center
prohibits the use of group punishment and there were no instances of inappropriate use of
restrictions or group punishment displayed. During the week of the annual compliance review,
daily activities were observed to determine implementation of the BMS.
Seven staff were interviewed and each had knowledge of the level system. Three staff stated
the BMS is posted throughout the center. Three staff stated the BMS is included in the youth
handbook and orientation process. All seven staff indicated the center provides rewards to
youth as part of the BMS in the form of additional snacks, telephone calls, and outdoor time. Six
staff stated they believe the center’s behavior management system is effective and one staff
stated it is not effective. One staff stated it is not perfect as it could be better. All seven staff
stated they speak with youth to discuss the consequences being imposed and youth are given
the opportunity to explain their behavior. All seven staff stated they speak with youth about
alternative acceptable behaviors and all staff indicated supervisors provide feedback to staff
regarding the implementation of the BMS during staff meetings or shift briefings. Seven staff
stated they receive daily feedback on the implementation of the behavior management system.
Two staff stated they receive weekly feedback on the implementation of the behavior
management system. Four staff stated points can be taken away as a consequence. Six staff
stated levels can be taken away as a consequence. One staff stated nothing can be taken away
as a consequence. All seven staff they had never seen a co-worker take meals, snacks,
clothing, education or medical care from a youth because they were acting out. All seven staff
stated they had never observed any staff encouraging youth to beat up another youth. Seven
youth were interviewed and two rated the center’s BMS as very poor. One youth rated the
center’s BMS as poor. Three youth rated the center’s BMS as fair. One youth rated the center’s
BMS as good. The seven youth were asked to explain the difference between each level and
how to move from level to level. Four youth stated good behavior allows you to move from level
to level. Two youth stated the BMS is not good at all. One youth stated they don’t know. One
youth stated if you get in trouble, your level is then restarted. Six youth stated they are rewarded
with extra snacks, games, telephone calls, and movies. One youth stated they did not know. All
youth stated staff use rewards the same. All seven youth stated they had never been allowed to
punish other youth. Three youth stated they had been locked in their room for fighting or bad
behavior and each stated the door was shut and locked. Four youth stated they had never been
locked in their room for punishment. Two youth stated the consequences received are fair, while
one stated they are not. Four youth stated they never received consequences. Two youth stated
when consequences were given, points and levels were taken away. One youth stated when
consequences were given, school was taken away. Four youth stated they never received any
consequences. When each of the youth were asked if handcuffs or leg irons are used on out of
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control youth, two stated no and five stated they have never witnessed this. The superintendent
stated during an interview the Department’s approved BMS is used to increase or decrease the
youth’s level by following the rules of the facility.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction. Staff conduct observations in a manner ensuring the safety and
security of each youth and documents each check in real time, manually or electronically.
Documentation must include the actual time of each visual observation and initials of the staff
conducting the check; preprinted times are not acceptable. There shall be no obstructions
(e.g., clothing, memos, pictures) over windows and areas where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures addressing ten-minute checks. An electronic wand
system is utilized to document these checks. The facility is equipped with eighty cameras, of
which seventy-three were operational at the time of the annual compliance review week. Video
recordings are stored for a period of thirty days. A review of the documentation and video
surveillance was conducted for three randomly selected dates during the thirty days prior to the
annual compliance review week, across three shifts, and on four different youth living modules.
Ten-minute checks were conducted within the center’s FOPs. In addition, wand report
observation logs of ten-minute checks were reviewed for one thirty-minute increments from
each shift, each month, from November 2024 to the present. Due to the Department-wide
system outages during the annual compliance review period, the center was unable to provide
documentation of ten-minute check logs prior to November 2024. There was a weekly review of
management oversight which was documented in SharePoint. A review of SharePoint with the
superintendent confirmed weekly reviews were being conducted.
Seven staff were interviewed, and all seven responded room checks are conducted every ten-
minutes when youth are in their room sleeping. The superintendent was interviewed and stated
ten-minute checks are done when youth are secured behind the door, usually for sleep
purposes and are recorded with an electronic wand.
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.
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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 to ensure staff always know the exact number and
location of all youth under their supervision. During the annual compliance review week staff
were observed conducting counts before and after every movement. Counts were also
observed being conducted when youth transitioned to and from the dining hall for meals. An
interview of seven staff indicated counts are conducted at the beginning and end of each shift.
Five staff stated counts are conducted before and after each meal. All seven staff stated if the
count is not correct, youth movement is stopped, and supervisors are notified. Seven staff were
asked when emergency counts are conducted And all seven stated when a youth is believed to
be missing. Six stated when visibility is hindered and after a major incident. A logbook review
from April 2024 through January 2025 reflects youth census, counts, and tracking were
documented at the beginning of each shift, following any emergency such as power outages,
and evacuations due to emergency drills. All months reviewed reflect youth census, counts, and
tracking were also documented prior to and following routine group movement, population
changes, random head counts each shift and youth movements.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) for logbook maintenance. The center has
separate logbooks for master control, each living module, visitors, and vehicles. A review of
eleven logbooks from April 2024 to January 2025 found they were bound with numbered pages.
Thirty-four days in the master control logbook and three days each month in each living module
logbook were reviewed. The master control logbooks and living module logbooks contained the
date documented at the top of page. All entries included the times of events in a.m./p.m. and not
military time with the name of staff, youth, brief description of events, and the initials of staff
making the entries. All entries impacting the safety and security of the center, including
medical/special needs and mental health alerts were highlighted. The master control logbook
contained emergency situations, and incidents including the use of protective action
response/right interactions (PAR/RI); however, the calls made to the Florida Abuse Hotline and
the Department’s Central Communications Center (CCC) related to the incidents were not
documented in the master control logbook. All errors were struck through with a single line and
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“void” was written after the error followed by the staff’s initials. All contingency of operations
(COOP) drills, monthly fire drills, monthly medical drills and monthly mental health suicide drills
were documented as required. Counts for the beginning of shifts, end of shifts, emergency
situations, group movement, admission, and releases, when law enforcement is on-site,
searches to include frisk and electronic, and youth placed in confinement with start and end
times were all documented in the master control logbook. Youth placed on precautionary
observation, or secure observation were documented in the logbooks as well with the date, and
time initiated and ended. The juvenile justice detention officer supervisor (JJDOS) reviewed the
master control logbook when accepting responsibility for the center and reviewed the living area
logbooks daily. The juvenile justice detention officers (JJDOs) reviewed the logbook entries from
the previous shift when accepting responsibility for the living area. Each logbook review
designated the name and position of the review and the date and time the review was
completed. An interview with the superintendent indicated management’s role regarding
logbooks is to review and sign logbooks weekly.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures (FOPs) regarding key control, issuance of keys to
staff, inventory and tracking, key restrictions, storage, missing or lost keys, and reporting and
replacement of damaged keys. A review of key inventory confirmed the key rings on the
inventory matched the actual key rings in use and included emergency keys. Staff keys are
secured in master control and are issued to staff during shift change. All keys are stored on a
tamper resistant key ring which inhibits the removal of keys and is color coded specific to the
position to which the keys are assigned. Emergency keys which provide egress through exterior
doors are stored in the foyer near master control which all staff can access. The master key
inventory included the ring number, number of keys on each ring, capability of each key, and to
whom the key ring was issued. All facility keys were maintained on a tamper-resistant key ring
and correctly color coded according to policy. The issuance of keys and key ring’s number was
documented on each shift report and included the date and time of issuance, the name of staff,
and the time the key ring was returned. Based on observation during the annual compliance
review week, staff carried their facility issued keys on them at all times, did not allow youth to
handle keys, and did not remove keys from the facility without approval of the superintendent.
The key box was not easily accessible when locked and could not be opened without a key.
Since the last annual compliance review there were no incidents reported to the Department’s
Central Communications Center (CCC) or Program Monitoring and Management (PMM)
deficiencies related to key control. An informal interview with the master control operator
indicated when visitors enter the facility, they provide their personal keys and then the master
control operator gives a chip with a number on it. A sampling of three staff key rings were
observed and compared to the inventory and key log. There were no discrepancies identified.
Seven staff were interviewed. All seven interviewed staff were able to explain the key control
process. The superintendent was interviewed and stated permanent keys are issued to staff and
a key issued receipt is signed by each staff.
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5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains facility operating procedures (FOPs) for transportation, operation, and
maintenance of each vehicle used to transport youth. The center has a total of seven vans, and
three of which are used to transport youth. An annual inspection was completed by a certified
mechanic on all three vans and documentation was provided to confirm the inspections.
Documentation reviewed confirms monthly inspections were completed by the center’s
maintenance mechanic or staff and included checking the vehicles water coolant, lights, oil,
emergency equipment, brakes, horn, interior, exterior, and cleanliness of the vehicle.
Inspections are also conducted on the tires, battery, windshield, wipers, windows, mirrors, and
damages. A physical inspection of the three applicable vehicles was conducted, each vehicle
contained the appropriate number of seatbelts, a seatbelt cutter, window punch, fire
extinguisher, and first-aid kit. Each vehicle had an assigned logbook for transport
documentation which included acknowledgement the vehicle was checked, destination, number
of youth and staff names, name of the officer riding in the back of the van, time transport began,
and time transport ended. There was one transport during the time of the annual compliance
review week for observation. The van logbook documented acknowledgement the vehicle was
checked, destination, number of youth, staff names, name of officer riding in the back of the
van, and the time the transport began and ended. Seven random vehicles from the center were
checked, during the week of the annual compliance review, to ensure vehicles were locked
when not in use, and all vehicles were secured. Seven youth were interviewed, all stated they
felt staff are driving safely when transporting youth. In addition, all stated they have never seen
anyone place contraband in transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center maintains facility operating procedures (FOPs) ensuring all tools and equipment
related to maintenance and the kitchen are properly maintained, stored, and inventoried. The
FOP prohibits youth from having access to any tools, including kitchen, and/or medical
equipment. According to the centers FOP youth are allowed to use cleaning items such as
mops, brooms, and other common household items when completing general cleaning under
staff supervision. Observations confirmed maintenance tools and kitchen sharps are secured
when they are not in use. A review of the monthly inventory sheets since the last annual
compliance review confirmed there were no missing maintenance or kitchen tools. All tools
listed on the kitchen’s inventory were present. The kitchen also maintained a continuous
inventory of tools upon use and return. An informal interview with maintenance staff confirmed
service vendors are always accompanied by designated center staff while in the secure area of
the center. A review of the monthly inventory sheets during the annual compliance review period
confirmed there were no missing maintenance or kitchen tools. A review of the inventory used to
document the issuance and return of maintenance tools found no discrepancies. An informal
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interview with maintenance and kitchen staff determined they understood the process when
there are missing or damaged tools. A sampling of ten maintenance tools revealed all tools
were secured, marked for easy identification, inventoried accurately, and signed by the
superintendent. Seven interviewed staff were able to explain the center’s practice for damaged
and missing tools. All seven staff indicated all movement is stopped if a tool is missing and the
major, supervisor, and maintenance staff are then notified. All seven staff stated mops and
brooms are tools in which youth are allowed to use. The superintendent interview indicated the
maintenance mechanic, major, and captains have access to tools. An informal interview with the
captain indicated youth may use cleaning items. Seven youth interviews were conducted and
six stated they can use mops and brooms, and one youth indicated they have never used a tool.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center maintains facility operating procedures (FOPs) ensuring the proper use, storage,
disposal, and inventory of chemicals including poisonous, flammable, and toxic materials. The
FOP also ensures limited access to flammable, toxic, caustic, and poisonous items. Only
authorized personnel are permitted access and use of flammable, toxic, caustic, and poisonous
items. Youth are not permitted to use or handle hazardous chemicals. No toxic materials were
observed at the center in any place accessible to youth during the week of annual compliance
review. Observations of G1 living module utility room, G1 living module supply room, and
kitchen utility room did confirm inventories of all flammables, toxic, caustic, and poisonous items
during the annual compliance review week as well as Safety Data Sheet (SDS) sheets in a
binder. Inventories had an accurate count of the chemicals present. A SDS binder was in the G1
utility room, G1 storage room, in both the Bravo utility rooms and kitchen. Maintenance secures
chemicals in a chemical shed located outside of the center. Flammable items are maintained in
a locked cabinet within the chemical shed. A sample of five items in the chemical shed were
selected randomly for review and each had an SDS and an accurate inventory of the selected
five chemicals. Seven youth were interviewed and all seven stated they do not handle
chemicals or have access to chemicals. Seven staff were interviewed. All seven staff stated
youth are not allowed to clean with substance which are toxic, flammable, or poisonous.
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5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center maintains facility operating procedures (FOPs) ensuring proper disposal of
hazardous items and toxic materials in accordance with Occupational Safety and Health
Administration (OSHA) guidelines. There were no chemical spills or disposal of flammable,
toxic, caustic, or poisonous items during the annual compliance review period. Kitchen staff
indicated grease is used for cooking and is disposed of by an outside contractor. An informal
interview with the maintenance mechanic indicated all hazardous materials are disposed
appropriately.
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center maintains facility operating procedures to address requirements for behavioral
confinements for less than twenty-four hours. The center had 1409 confinements lasting less
than twenty-four hours since the last annual compliance review. The center documents
confinements in the facility management system (FMS). Fifteen confinements were reviewed.
Documentation indicated all youth rights were afforded in each instance including three meals a
day, access to mental healthcare as requested, daily shower, clean clothing, bedding and
education materials. All youth were afforded the right to grieve a confinement placement. A
review of FMS indicated the supervisor approved all confinements, staff only placed one youth
in a room, and the room was searched, and the search was documented in FMS. All reviewed
documentation of confinement logs indicated each youth in confinement was supervised by
staff. The first hour, five-minute checks were conducted for all fifteen confinements, then every
ten minutes thereafter, the reason of confinement was explained to each youth, and the
supervisor on duty conducted reviews within one hour of each youth being placed in
confinement. All reports were completed by the staff before the end of their shift. Supervisors
conducted additional reviews with each youth at the required minimum of three hours, and the
youth were continually counseled by the supervisors and staff. Consideration was made to
remove the youth from confinement as soon as the youth was able to safely rejoin the
population and there was no threat to safety. This information was documented in FMS.
Superintendent reviews were completed within the required forty-eight-hour time frame. During
the tour of the center some scratching was observed on the youth room windows in the living
modules. The superintendent was interviewed and stated confinements are put in the
Department’s Juvenile Justice Information System (JJIS), and then supervisors approve the
confinements. Regional detention management review the use of confinements, lockdowns, and
restraints monthly. Seven staff interview results were reviewed. All seven staff explained the
center’s step by step process for placing youth in confinement. All interviewed staff stated
confinement reports are completed, and confinement rooms are searched. Six stated youth
checks are completed every ten minutes. Six staff stated youth receive education materials
while in confinement and one staff stated youth don’t receive educational materials.
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5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinements over twenty-four hours during the annual compliance
review period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains facility operating procedures (FOPs) establishing a procedure for
conducting drills to address the Continuity of Operations Plan (COOP). Quarterly hurricane drills
were conducted since January 2024 to June 2024. The reviewed documentation of the drills
contained the type of drill, date, and time of the drill, who participated and what actions they
took, a brief scenario and findings and recommendations from the observers. The
superintendent interview indicated the comprehensive safety/emergency program is the COOP
Plan. The center conducted at least two drills during the year including severe weather, major
disturbances, hostage situations, chemical spills, flooding or threats/acts, with at least one drill
being completed prior to hurricane season which starts June 1st.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures (FOPs) to address escape drills and escape
prevention. A review of drill documentation since the last annual compliance review confirmed
quarterly drills were conducted on each shift as required and documented in the center’s
logbook. Seven in-service training records and seven pre-service training records were
reviewed, and each staff completed training in security and escape prevention annually. Seven
staff were interviewed, and all seven confirmed completing escape drills annually. A review of
the master control logbook confirmed documentation of each drill completed.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 56 of 58 (Revised July 2023)
The center has a disaster plan, fire prevention plan, and evacuation plan addressing fire
prevention and safety in the center. The center conducted monthly fire drills on each shift, as
required. All thirty one fire drills were documented in the logbook. Fire evacuation plans were
posted throughout the center. Each posting identified the primary and secondary exit routes and
locations of fire extinguishers, along with first-aid kits. All fire extinguishers had a completed
annual inspection, as required. Seven interviewed staff all stated fire drills take place at least
monthly. Seven youth were interviewed, and all youth stated they had been instructed on what
to do in case of a fire.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) in place for searches and to ensure
contraband is prevented from entering the secure area of the center. The policy includes
procedures for electronic, frisk, strip, room, and staff/visitor searches. An admission was not
able to be observed during the annual compliance review week. During the annual compliance
review week an observation of a youth search was completed upon returning from a transport
where the youth was searched with no findings. There was no strip searches conducted since
the last annual compliance review outside of admissions. Searches of staff and visitors prior to
entering the secure area were observed. All observed people entering the center were
electronically searched, all bags, cases, jacket pockets, and other items were searched, and all
prohibited items were secured prior to the person entering the center. Staff were observed
wearing gloves for all searches of visitors and staff entering the center. Documentation of room
searches for the past eleven months was found in the module logbook and master control
logbooks. Searches were also documented electronically in the facility management system
(FMS). Through a review of documentation, it was confirmed rooms were searched prior to
placing a new youth in a room and all rooms were searched for contraband on each awake shift.
A sample of shift reports since the last annual compliance review was reviewed and it was
determined room searches are completed daily on each shift. There were one instances of
contraband being found at the center during the annual compliance review period, and it was
reported to the Department’s Central Communications Center (CCC) within the required time
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 58 (Revised July 2023)
frame and an incident report was completed. The center did not document all required CCC
information in the logbook. The center’s visitors log contains a contraband attestation statement
and requires all visitors entering to complete a separate contraband attestation form. A review of
fifty-seven staff personnel records found all fifty-seven staff had a signed contraband attestation
form. A review of twenty newly hired staff personnel records found all had the signed
contraband attestation form. The superintendent interview reported youth are searched when
they enter the facility, come from recreation, court, and appointments. The center’s procedures
if a youth or staff is found with contraband is to secure the contraband, call law enforcement,
and notify the CCC. Contraband is secured, local law enforcement is contacted, and a report is
made to the CCC. Based on the outcome of the investigation from law enforcement, staff and
youth can be charged and corrective action will be completed.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 58 of 58 (Revised July 2023)

report_type: QI Detention