state: FL

summary: QI Detention - FY23-24 - 6 findings

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Escambia Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
1800 Saint Mary Avenue
Pensacola, Florida 32501
Review Date(s): August 8 - 11, 2023
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Jessica Gibson, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Janise Best, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Lea Herring, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Interviews)
Ken Phillips, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Stephanie Solano, Office of Accountability and Program Support, Regional Monitor (Standard 5)
Brittany Thomas, Rite of Passage, Florida Regional Medical Coordinator (Standard 4)
Program Name: Escambia Regional Juvenile Detention Center MQI Program Code: 2
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Escambia County / Circuit 1 Number of Beds: 50
Review Date(s): August 8-11, 2023 Lead Reviewer Code: 210
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Limited Ratings Failed Ratings
2.09 Daily Activity Schedule 2.1 Educational Access*
4.15 Medication Management 5.06 Logbook Reviews
5.16 Continuity of Operations Planning (COOP) Drills 5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 59 (Revised July 2023)
Standard 1: Management Accountability
Detention Rating Profile
Indicator Ratings
Standard 1 - Management Accountability
1.01 Initial Background Screening* Satisfactory
1.02 Five-Year Rescreening/Renewal Satisfactory
1.03 Staff Code of Conduct Satisfactory
1.04 Incident Reporting CCC * Satisfactory
1.05 Protective Action Response (PAR) Satisfactory
1.06 Pre-Service/Certification Requirements * Satisfactory
1.07 In-Service Training Satisfactory
1.08 Grievances Satisfactory
1.09 Entering Alerts(JJIS) and Sharing of Alert Information * Satisfactory
1.10 Data Trend Analysis Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 59 (Revised July 2023)
Standard 2: Youth Management
Detention Rating Profile
Indicator Ratings
Standard 2 - Assessment and Performance Plan
2.01 Admission Satisfactory
2.02 Orientation Satisfactory
2.03 Classification Satisfactory
2.04 Notification of JPO Circuit Gang Rep Satisfactory
2.05 Admission and Storage of Youth Personal Property Satisfactory
2.06 Release Satisfactory
2.07 Release of Youth Personal Property, Medication, and Aftercare Instructions Satisfactory
2.08 Review of Youth in Secure Detention and Home Detention Satisfactory
2.09 Daily Activity Schedule Limited
2.10 Educational Access* Failed
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do
so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 59 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Indicator Ratings
Standard 3 - Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA) Satisfactory
3.02 Licensed MH/SA Clinical Staff * Satisfactory
3.03 Non-Licensed MH/SA Clinical Staff Satisfactory
3.04 MH/SA Admission Screening Satisfactory
3.05 MH/SA Assessment/Evaluation Satisfactory
3.06 MH/SA Treatment Satisfactory
3.07 Treatment and Discharge Planning Satisfactory
3.08 Psychiatric Services * Satisfactory
3.09 Suicide Prevention Plan * Satisfactory
3.10 Suicide Prevention Services * Satisfactory
3.11 Suicide Precaution Observation Logs * Satisfactory
3.12 Suicide Prevention Training * Satisfactory
3.13 Mental Health Crisis Intervention Services * Satisfactory
3.14 Emergency Care Plan * Satisfactory
3.15 Crisis Assessments * Satisfactory
3.16 Baker and Marchman Acts * Non-Applicable
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 59 (Revised July 2023)
Standard 4: Health Services
Detention Rating Profile
Indicator Ratings
Standard 4 - Health Services
4.01 Designated Health Authority/Designee* Satisfactory
4.02 Facility Operating Procedures Satisfactory
4.03 Authority for Evaluation and Treatment Satisfactory
4.04 Parental Notification/Consent Satisfactory
4.05 Healthcare Admission Screening & Rescreening Form Satisfactory
4.06 Youth Orientation to Healthcare Services/Health Education Satisfactory
4.07 DHA/Designee Admission Notification Satisfactory
4.08 Health-Related History Satisfactory
4.09 Comprehensive Physical Assessment/TB Screening Satisfactory
4.10 Sexually Transmitted Infection Screening & HIV Screening Satisfactory
4.11 Sick Call Process Satisfactory
4.12 Episodic/First Aid Care/Emergency Care Satisfactory
4.13 Off-Site Care/Referrals Satisfactory
4.14 Chronic Conditions/Periodic Evaluations Satisfactory
4.15 Medication Management Limited
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 59 (Revised July 2023)
Standard 5: Safety and Security
Detention Rating Profile
Indicator Ratings
Standard 5 - Safety and Security
5.01 Active Supervision of Youth * Satisfactory
5.02 Behavior Management System/Unauthorized Use of Punishment* Satisfactory
5.03 Ten-Minute Checks* Satisfactory
5.04 Census Counts and Tracking Satisfactory
5.05 Logbook Maintenance Satisfactory
5.06 Logbook Reviews Failed
5.07 Key Control Satisfactory
5.08 Vehicles and Maintenance Satisfactory
5.09 Tool Inventory and Management Satisfactory
5.10 Youth Access & Use of Tools, Cleaning Items * Satisfactory
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous Items Failed
5.12 Access to all Flammable, Toxic, Caustic, and Poisonous Items * Satisfactory
5.13 Disposal of all Flammable, Toxic, Caustic, and Poisonous Items Satisfactory
5.14 Confinement Under Twenty-Four Hours Satisfactory
5.15 Confinement Over Twenty-Four Hours Non-Applicable
5.16 Continuity of Operations Planning (COOP) Drills Limited
5.17 Escape Drills Satisfactory
5.18 Fire Drills Satisfactory
5.19 Search and Contraband Procedures Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program
operates below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to
do so will result in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 59 (Revised July 2023)
Program Overview
The Escambia Regional Juvenile Detention Center is a state-owned detention facility, operated
by the Department, located in Pensacola, Florida. The center serves youth in Escambia and
Santa Rosa counties in Circuit 1 and is co-located with the Escambia Juvenile Assessment
Center. Male and female youth who are detained pending adjudication, disposition, or
placement in a residential commitment program are housed in the fifty-bed center. Youth are
provided services which include youth orientation, behavior management, safety and
emergency procedures, transportation, mental health, and healthcare services. The center’s
educational services are provided by the Escambia School Board. The center’s management
team includes the superintendent, two assistant superintendents, one administrative assistant,
seven juvenile justice detention officer (JJDO) supervisors, and forty-four JJDOs. Mental health
and healthcare services are provided through the contracted provider, VitalCore Health
Strategies, LLC. Mental health services are provided by one designated mental health clinician
authority (DMHCA), one psychiatrist, and two licensed mental health professionals. Clinical
services provided by the center include mental health and substance abuse evaluations, mental
health treatment planning, individual, group, and family therapy, mental health crisis intervention
services, on-site psychiatric services, and availability for substance abuse services for youth
with co-occurring disorders. Medical services are provided by one designated health authority
(DHA), one advanced practice registered nurse (APRN), two licensed practical nurses (LPNs),
and one records clerk. The medical clinic maintains nursing coverage seven days a week from
8:00 a.m. to 5:00 p.m., Monday through Friday and 8:00 a.m. to 4:30 p.m. Saturday and
Sunday. Food services are provided by Department staff and include menus, meal planning,
meal schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has three living modules which are divided by male and female.
There are sixty-four security cameras at the center, of which sixty-three were operational. At the
time of the annual compliance review, the center had three vacancies, which included two
JJDOs and two JJDO supervisors.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 59 (Revised July 2023)
Strengths and Innovative Approaches
• The center has a food pantry program. The program allows youth and parents/guardians
to get available food as needed.
• The center has a clothing program for youth. Any youth being released is encouraged to
get clothing items and take as much as needed. Clothing is donated to the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 59 (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.
Seventeen staff were reviewed for initial background screening. All reviewed staff had a
background screening completed prior to hire date. Five criminal history reports were reviewed,
and exemptions were obtained prior to working with youth. Four staff had a break in service
documented in a review of the Department’s Staff Verification System (SVS). Three of the staff
received a new background screening. One staff’s break in service was less than a year,
therefore, a new background screening was not required. The detention center utilizes
Ergometrics for pre-employment testing for direct care applicants. Thirteen of the seventeen
staff were applicable to complete a pre-employment assessment tool. All thirteen staff received
passing scores. One staff reviewed was applicable for the Clearinghouse employment roster.
This staff was added to Clearinghouse employment roster, as required. Two of the reviewed
staff were dual employed with Department providers and the background screenings were
completed as required. The detention center did not have any contracted/grant providers,
volunteers, mentors, or interns who assisted or interacted with youth on an intermittent basis.
The detention center’s Annual Affidavit of Compliance with Level 2 Screening Standards and
the education Annual Affidavit were completed January 10, 2023.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
Six staff were applicable and reviewed for five-year rescreening. All six staff had the five-year
rescreening completed every five years, calculated from the agency hire date. The center did
not have any contracted provider staff who required a rescreening.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 59 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
Seven staff records were reviewed for staff code of conduct. Six of the seven staff had signed
codes of conduct in their personnel files. One staff record did not contain a signed code of
conduct form. Three staff received disciplinary actions for violations of the code of conduct
during the annual compliance review period. Management took immediate action to investigate
or address all allegations or violations of the code of conduct. One staff resigned during the
investigation and an investigation was still being completed at the time of the annual compliance
review for the remaining two staff, who are both currently on no youth contact. There were no
commendations rewarded for the seven staff reviewed. Seven youth were interviewed. Six
youth reported they have never needed or requested to call the Florida Abuse Hotline. One
youth reported being allowed to call the Florida Abuse Hotline when requested. All seven youth
reported staff are respectful when talking to other youth. Three youth reported never hearing a
staff using profanity when speaking with youth and four youth reported they have occasionally
heard staff use profanity. All seven youth reported never hearing staff threaten youth. Six youth
reported they feel safe at the detention center. One youth reported not feeling safe due to other
youth in the center but felt safe with the staff. Seven staff were interviewed and appropriately
summarized the process for a youth calling the Florida Abuse Hotline or the Department’s
Central Communications Center (CCC). Three staff reported never hearing other staff using
profanity towards youth, one staff reported hearing another staff using profanity on one
occasion, and three staff reported they have occasionally heard staff use profanity around the
youth. All seven staff reported never observing a co-worker using threats, intimidation, or
humiliating a youth, when working with the youth. Five reported the working conditions are
good, one staff reported it as being fair, and one staff reported it being poor. The superintendent
was interviewed and appropriately summarized the employee code of conduct.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 59 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center had a total of forty calls to the Department’s Central Communications Center (CCC)
during the annual compliance review period. Five incidents were reviewed. Four of the five were
called within the two-hour required time frame. One was called in twelve minutes late. A review
of logbooks revealed all five incidents were documented appropriately. There was an additional
incident which was not reported to the CCC. The superintendent and captain were notified, and
the captain called the CCC; however, the incident was deemed not reportable by the CCC. The
superintendent was interviewed and appropriately summarized the incident reporting process.
1.05 Protective Action Response (PAR) Satisfactory Compliance
The center uses physical intervention techniques in accordance with Florida Administrative
Code. Any time staff uses a physical intervention technique, such as countermoves, control
techniques, takedowns, or application of mechanical restraints (other than for regular
transports), a PAR Incident Report is to be completed and filed in accordance with the Florida
Administrative Code.
During the annual compliance review period the center had a total of 232 Protective Action
Response Right Interactions model (PAR/RI) incidents involving physical intervention
techniques. The center’s PAR/RI rate during the annual compliance review period was 28.72,
which is above the statewide Detention PAR/RI rate of 17.52. Nine PAR/RI incidents were
reviewed for the annual compliance review period. All nine PAR/RI Reports were completed by
the end of the staff’s workday and included statements from all staff involved. None of the
reviewed PAR/RI incidents resulted in serious injury of the youth or staff. None of the youth
involved in the PAR/RI incidents requested to contact the Florida Abuse Hotline. Eight of the
nine PAR/RI Reports were reviewed by a supervisor, a post-PAR/RI interview was conducted
with the youth by the administrator, or designee, and was reviewed by the superintendent or
designee after all other reviews and comments were made within seventy-two hours. One
PAR/RI Report did not include any of the required reviews. Five PAR/RI Reports indicated a
PAR/RI medical review was conducted and it was documented in the youth’s Individual
Healthcare Record (IHCR). The remaining four PAR/RI Reports did not indicate a PAR medical
review was necessary or the youth refused a medical review. No mechanical restraints were
utilized, and no youth were sent off-site for an evaluation. Seven staff were interviewed and
reported verbal redirections are to be utilized before physical restraints or mechanical restraints.
The superintendent was interviewed and appropriately summarized the process for monitoring
PAR/RI incidents and use of force.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 13 of 59 (Revised July 2023)
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
Seven staff were reviewed for pre-service and certification requirements being completed within
180-days of hire. Each of the seven staff completed a new staff orientation within thirty days of
hire. Six staff were applicable for completion of pre-service training and five of the six staff were
certified within the first 180-days of employment. One staff completed certification at 188 days.
All six staff completed Phase One and Phase Two of training. One staff returned after
separation for two years. The staff was returning as a supervisor and explained they would not
need to complete pre-service requirements again for they were not considered in a direct care
position. The returning staff completed all annual update requirements for certification or
trainings. All required trainings were documented in the Department’s Learning Management
System (SkillPro).
1.07 In-Service Training Satisfactory Compliance
All center staff, including food service and maintenance staff, are required to complete
twenty-four hours of in-service training, including mandatory topics specified in Florida
Administrative Code, each calendar year, effective the year after pre-service/certification
training.
Supervisory staff must complete eight hours of training (in addition to the twenty-four hours of
in-service training) in the areas specified in Florida Administrative Code.
Seven training records, including three supervisors, were reviewed for in-service training. All
seven staff completed the required twenty-four hours of in-service training, including mandatory
topics, with the exception of one staff who did not complete the annual mental health and
substance abuse trainings in the Department’s Learning Management System (SkillPro). All
three supervisory staff completed over the required eight hours of supervisory training which
included coaching, leadership, and personal accountability. All seven reviewed staff completed
emergency care plan, infection control training, exposure control plan including bloodborne
pathogens and infection control education, and escape prevention trainings. Six of seven staff
completed fire prevention plan/disaster procedures. An informal interview was held with the
licensed nurse regarding in-service education. Documentation was provided which verified the
licensed nursing staff provided in-service education on girls’ healthcare annually to all non-
healthcare staff involved in the supervision and treatment of girls. The training included topics
on monitoring, observing, and emergency care of pregnant youth. The center maintains an
annual in-service training calendar, which is updated as changes occur, and follow the training
plan as outlined in the Florida Administrative Code. In a formal interview, the superintendent
was able to accurately summarize the management training received and the required training
for staff.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 59 (Revised July 2023)
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
A review of the Department’s Facility Management System (FMS) revealed the facility did not
have any grievances during the annual compliance review period. There were grievance forms
available for the youth in each youth living module. The superintendent’s interview was
reviewed, and the superintendent was able to appropriately summarize the grievance process,
to include the three phases. Seven youth were interviewed and were able to accurately describe
the grievance process for the facility. All seven youth reported they have never filed a grievance.
Seven staff were interviewed and were able to accurately summarize the grievance process.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 15 of 59 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
Seven youth records were reviewed for entering alerts in the Department’s Juvenile Justice
Information System (JJIS). A total of eighteen alerts were applicable for the seven youth records
reviewed. Two of the eighteen alerts were not entered into the logbook as required. All alerts
were entered into JJIS and the internal alert system within the required time frame. The JJIS
alert reports were reviewed daily by supervisors and administrators. The information regarding
youth alerts is shared with staff during shift briefings. The center’s process for updating alerts in
JJIS is the medical and mental health staff are responsible for updating all alerts in their
respective areas. The supervisors are responsible for updating all other alerts in JJIS. Annual
compliance review team members reviewing case management, medical, mental health, and
safety and security found no other alerts which should have been entered into the alert system.
The superintendent was interviewed and was able to appropriately summarize the process for
entering alerts for the center. Seven staff were interviewed and reported they are informed of
alerts through logbook entries, shift debriefings, JJIS, and email. The staff also reported they
are provided a hard copy of the alerts to keep on their person during their shift. Three of the
seven staff reported the communication at the center is good and four staff reported
communication is very good.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 59 (Revised July 2023)
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
An informal interview was completed with a captain at the center regarding the center’s data
trend analysis. The center utilizes information gathered from various reports and information is
discussed during the superintendent’s monthly meetings. Management reviews the reports and
any trends noticed are discussed in management meetings. Monthly meetings are held with
administrative and center staff during which an agenda with specific topics is discussed, then
the meeting is opened up for staff to discuss any issues, ask questions, and bring up any new
topics. Documentation of only two agendas of the monthly meetings were able to be provided
for annual compliance review period, one in 2022 and one which did not have the date of the
meeting or included a sign-in sheet. No other monthly agendas were able to be provided. The
superintendent provided documentation of the data reviewed which included Protective Action
Response Right Interactions model (PAR/RI) and confinement data and trends. After reviewing
the data, administrative staff were noticing a trend of confinements increasing when certain staff
were on duty, mainly at bedtime and on the weekends, as well as these staff being the less
experienced staff on duty during at those times. The management team decided to change the
schedule to include more experienced staff on those shifts with the less experienced staff, with
the goal of decreasing confinements and PAR/RIs. This was implemented during the month of
June 2023, and since the schedule change, management noticed confinements and PARs were
slowly decreasing.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 59 (Revised July 2023)
Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, full body visual searched, by an officer of
the same sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to his/her
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center has facility operating procedures (FOPs) for admissions. Seven youth case
management records were reviewed for youth admission. All seven records contained a
completed arrest affidavit/custody order, a Detention Risk Assessment Instrument (DRAI), and a
Suicide Risk Screening Instrument (SRSI). All seven records had the Department’s Juvenile
Justice Information System (JJIS) Admission Wizard printed and placed in the record. Each of
the seven Admission Wizards documented youth were full-body and electronically searched by
an officer of the same gender. All seven youth records documented youth were allowed to make
a telephone call. In three of the seven youth records, the parent/guardian could not be reached.
All seven youth were offered a snack or meal. Screenings were completed to identify medical,
mental health, and substance abuse needs during intake. An admission was not observed
during the annual compliance review week. According to the superintendent and captains, no
admissions occurred while the review team was on-site.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 59 (Revised July 2023)
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years old or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center maintains facility operating procedures (FOPs) regarding the orientation process
which shall occur within twenty-four hours of the youth being admitted into detention. Seven
youth case management records were reviewed for orientation. Documentation indicated
orientation was completed within twenty-four hours of admission for each youth. There were
individual documents signed by each youth, which included the date of admission. The
orientation process included rules and regulations, grievance procedures, visitation, telephone
calls, access to medical, mental health, and substance abuse services, access to the Florida
Abuse Hotline and the Department’s Central Communications Center, behavior expectations
and related consequences, possible new law violations for destruction of property, youth rights,
and Prison Rape Elimination Act (PREA) related information. An admission could not be
observed during the annual compliance review week for no youth were admitted while the
annual compliance review team was on-site, but orientation documentation included all
elements as outlined in the center’s policy. Seven youth records included the signed PREA
video acknowledgment form; however, three youth did not signify viewing the video by checking
“YES”. Additionally, the PREA video acknowledgment form needed updating to reflect the
current governor of Florida and the current secretary of the Department. The center responded
by advising the annual compliance review team the form had been updated. According to youth
interviews, all seven youth reported staff provided them with information about the center’s rules
and regulations, daily schedule, education services, visitation, abuse reporting, and the behavior
management system.
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2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses;
8. Vulnerability to victimization; and
9. Suicide risk identified or suspected.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has facility operating procedures (FOPs) to ensure all youth admitted to the center
are classified to provide the highest level of safety and security. Seven youth case management
records were reviewed, and all included a review of information concerning the youth’s history
and status. The Department’s Juvenile Justice Information System (JJIS) Admission Wizards
were completed in each record, which included a review of each youth’s sex, gender, height,
weight, age, and level of aggressiveness. The identified special needs taken into consideration
included mental illness, intellectual disabilities, physical disabilities, history of violent behavior,
gang affiliation, criminal behavior, any history of sexual offenses including sexual battery
charges which were reduced to a lesser offense, Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB), and identified or suspected medical, suicide, escape, and security
risks. Youth were assigned to rooms based on classification procedures and youth are
reclassified if changes in behavior or status are observed. Youth with a history of committing
sexual offenses or who have been the victim of a sexual offense are placed in a room alone.
Four youth were reclassified due to changes in behavior or status observed. The superintendent
has one juvenile justice detention officer (JJDO) as the gang liaison for the facility. The JJDO
reported completing gang certification classes. During the superintendent interview, it was
reported all risk factors are considered when assigning a youth to a room. Any youth whose
VSAB results indicate they are vulnerable to victimization and/or are sexually aggressive must
be placed on single room only (SRO) status, an alert to indicate SRO must be entered into JJIS,
and a mental health referral shall be completed. Room assignment will not be made prior to the
review of the VSAB.
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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 a screening process for youth newly admitted into the center to determine if the
youth is a gang member or gang affiliate. The circuit does not have an identified gang liaison;
however, the facility has assigned a juvenile justice detention officer (JJDO) as the detention’s
gang representative. An unofficial interview was completed with center’s gang representative
who indicated he has completed gang certification for the state of Florida and national
certification through the National Gang Intelligence Center (NGIC). The gang representative
provided youth information for three youth identified as having gang involvement. Additionally,
the gang representative provided documentation indicating contacts were made with the youth’s
assigned juvenile probation officer (JPO) and local law enforcement. The center provided
information, by email, to the assistant chief probation officer (ACPO) and chief probation officer
(CPO) of the youth’s residing circuit, along with any indications of gang activity for the youth.
The email included pictures, copies of written statements, drawings, graffiti, and a description of
what gang signs the youth was flashing, when applicable. The center entered a youth alert into
the Department’s Juvenile Justice Information System (JJIS), along with detailed information
within the alert note. All JJIS alerts are provided to staff during shift briefings.
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 maintains facility operating procedures (FOPs) to ensure a youth's personal property
is maintained securely. Seven youth case management records were reviewed, each record
documented the youth’s property was inventoried by the admitting juvenile justice detention
officer (JJDO) and entered in the Department’s Juvenile Justice Information System (JJIS). A
Property Receipt form was printed and signed by the youth in six of the seven reviewed records.
One Property Receipt form was not signed by the youth and two were not signed by staff. All
seven youth records contained a letter of acknowledgment regarding unclaimed property,
signed by each youth. Currency and other personal items of value are placed in a clear tamper-
proof bag and placed in a drop safe, which is under camera surveillance. The tamper-proof
bags are labeled with the youth’s name, the Department’s identification number, and a listing of
the items in the bag. A log is maintained to document items placed in the drop safe and includes
the date, time, youth’s name, name of the officer who secured the property, and the officer’s
initials. No reviewed youth had property which needed to be placed into the drop safe. None of
the youth refused to sign the Property Receipt form. The personal property was placed in an
assigned bag, as documented on the Property Receipt form in in all seven reviewed active
youth records. Seven youth were interviewed. Six youth stated when they arrived at the center,
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staff checked their personal property and had them sign a form stating the personal property
was correct. One youth stated he was on drugs and was sort of out of it at the time he was
admitted. The superintendent was interviewed and advised the intake staff ensure youth's
personal property is stored. The JJDO and the youth, under video surveillance, conduct safe
drops together and document the drop in the safe logbook. Youth's personal property is stored
in a bag with a property sheet documenting all the youth's property. Property is stored behind a
locked door where only JJDO supervisors or higher have access. A review of the Department’s
Central Communications Center (CCC) reports for the annual compliance review period
indicated there were no incidents regarding youth property reported. An admission was unable
to be observed during the annual compliance review week to confirm the center’s practice for
admission of youth property as no admissions occurred while the annual compliance review
team was on-site.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center maintains facility operating procedures (FOPs) to ensure all releases are verified by
the court’s authorization. Four closed youth records were reviewed for release. Each record
contained documentation of a detention order advising the youth to be released. The on-duty
supervisor reviewed all paperwork prior to the youth being released. All four youth were
identified prior to being released and the identification of the parent/guardian or responsible
adult was verified prior to the release with an identification card (ID) which was photocopied and
placed in each record. None of the youth were identified as an endangered person. All four
youth and parents/guardians were provided future court dates and times upon release. All four
closed files admission and release dates correlated with the dates documented in the
Department’s Juvenile Justice Information System. An observation of a youth being released
from the detention center could not completed due to a release not being conducted while the
annual compliance review team was on-site.
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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 maintains facility operating procedures (FOPs) to ensure a youth's personal property
is maintained securely and returned to the youth in a timely manner upon their release. Upon
the release of the youth, the releasing juvenile justice detention officer (JJDO), the youth, and
the legal guardian/parent shall review and sign the Property Receipt Form and account for all
the youth’s personal property. Four closed youth records were reviewed of youth released with
personal property, medication, and aftercare instructions. In one record the youth’s signature
was missing and in the other record both the parent/guardian and youth signatures were
missing and the staff signature was illegible. Two records indicated the youth were released
with medications; however, a medication receipt form was found in only one of the records. An
informal interview with medical staff confirmed the one youth was not taking medication and
determined the release wizard was incorrectly checked. Three applicable youth records
included documentation a reminder was provided to the youth and the person to whom the
youth was released of any health or welfare issues, including medical, mental health, and/or
substance abuse needs and any pending appointments. One was not applicable for a reminder.
There were no properties held more than thirty days during the annual compliance review
period. The center maintains facility operating procedures for the disposal of property left in the
safe which states, if the youth or parent cannot be located, the superintendent or designee will
ensure all money and property are counted and inventoried. A money order shall be sent to the
regional fiscal manager. The regional fiscal manager will then forward the money order to the
headquarters’ designee. A record must exist for any property disposed of or cash forwarded to
headquarters.
Four additional closed records were reviewed for the Property Receipt form. One record
included the signed release form. The form was signed by the youth, parent/guardian, and staff.
One youth was being transported to a commitment facility. The information in the Juvenile
Justice Information System (JJIS) Release Wizard indicated the detention staff signed the
Property Release form. Two of the reviewed youth records did not include a Property Release
form. One youth’s JJIS Release Wizard indicated the youth was released to a detention center
staff, however there were no documents uploaded to review. A review of the case notes
indicated the youth was released from secure detention to the youth’s parent/guardian. Three of
the four youth records included documentation the youth was released to an appropriate person
and a copy of their identification was obtained. One youth record did not include documentation
of an identification card. One of the four youth records indicated the youth was taking
medications at the time of release. The youth record included a signed release of medications
on the appropriate form. Two of the four youth had upcoming appointments scheduled. The
individual the youth was being released to was made aware of the upcoming appointments for
both youth.
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2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center maintains facility operating procedures (FOPs) ensuring detention reviews are
conducted weekly for proper management of youth and the appropriate sharing of information.
Detention reviews are held weekly at 11:00 a.m. on Tuesdays and attended either in person or
video by circuit probation staff, commitment managers, education, medical, mental health, and
administrative staff within the center. An observation was made of the detention review
occurring during the annual compliance review week. The detention review included
representatives from administration, probation, commitment, mental health, education, and
medical. Each attendee was provided a copy of the current youth confinement list. Topics of
discussion were youths next court date and time, school standing, and mental health and
medication compliance. Committed youth were updated as to the youth’s placement on the
commitment wait list for their program and if any commitment staffings were required. Safety
concerns were addressed due to construction being completed in and around the facility. The
superintendent’s interview confirmed the weekly reviews are attended by the superintendent or
designee, medical, mental health, education, probation, and commitment manager. The
superintendent reported information included Authority for Evaluation and Treatment (AET)
forms needed, release dates, court dates, behavioral issues, status updates of committed youth,
and youth appointments.
2.09 Daily Activity Schedule Limited Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center maintains facility operating procedures (FOPs) to ensure youth participate in
constructive activities which benefit the youth and the program. The daily activity schedule is
posted in each living area and outlines the days and times for each youth activity. The schedule
includes times for wake-up, personal hygiene, mealtimes, visitation, education, recreation and
physical activities, indoor activities, shift change, bedtimes, groups, and open program time.
Youth were observed in the school classrooms or on the modules, locked in their rooms during
educational hours. The center reported the situation as a “rolling school schedule” or “rolling
lock down” due to not having enough detention staff to meet youth to staff ratio according to
Prison Rape Elimination Act (PREA) requirements. The rolling school schedule could be seen
posted throughout the education hallway, which appeared to be what the center was utilizing
during the annual compliance review. The youth are split in half by population, with one half of
the youth going to school, while the others are locked down in their rooms for half the day. The
center indicated youth who are locked down are provided school worksheets to complete. A
minimal amount of youth were observed to be working on the worksheets in their room during
the facility observation tour. Seven staff were interviewed, six staff reported the center’s daily
schedule is followed and one staff said it is not followed. One staff further commented stating it
depends on the total amount of staff present for the day. Another staff reported the center tries
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to stay with the schedule as much as possible, but it is difficult when there is a lack of staff.
Seven interviewed youth reported the center does have a daily activity schedule. One of the
seven youth responded the daily activity schedule is followed and six youth said it is not
followed. All seven youth mentioned they are on rolling lock down. Three youth mentioned this
is due to the center being short staffed. Five youth reported the rolling lock down has been on-
going for a month and one youth said it has been like this for a few weeks.
2.10 Educational Access (Critical) Failed Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has facility operating procedures to address educational access. Educational
services are provided by the Escambia County School District, who also approves the school
calendar. The schedule allows for 242 days of instruction. The 250-day schedule was discussed
with the school district. According to the collective bargaining contract, the 242-day calendar is
allowed. This calendar allows for two days of teacher planning. The center’s activity schedule
reflects youth are to be in school five hours a day; however, since implementing the rolling
lockdown schedule, youth are not in school in accordance with the schedule. The rolling
lockdown schedule is a double session. The first session starts at 8:30 a.m. and ends at 12:25
p.m. The second session starts at 1:10 p.m. and ends at 2:40 p.m. This schedule does not meet
the required twenty-five hours of weekly instructional time. The lead teacher provided the daily
schedule for review. School has been cancelled, at times, due to lack of detention staff. Four
days reviewed in the center’s logbooks for July showed inconsistencies with the daily school
schedule. One day noted eleven out of fifty-eight youth attended school; however, the youth
from the other two modules were unaccounted for during educational time. The logbook review
indicated at times youth being moved to the lab or dining hall which were contradictory to the
schedule. Three days of education reviewed on video indicated only the female youth attended
school. The male youth were on the modules or in their rooms during the school day. At the time
of the annual compliance review the female youth had been transferred to another detention
center. Seven youth interviews were reviewed. All seven youth reported they have been
following a rolling lockdown schedule for school due to lack of detention staff. The
superintendent was interviewed and reported the staff are in the classroom to maintain order
and ensure the school staff and youth are safe. The superintendent also reported the detention
staff do not interfere with school staff during instruction time. Seven staff were interviewed and
reported there is minimal interference during educational instruction. One staff indicated the
youth are provided reading material when not in education.
2.11 Career Education Satisfactory Compliance
The center shall collaborate with the school district to ensure implementation of a career
education competency development program.
The center has facility operating procedures to address Career Education. The Type 1 career
instruction is provided by the Escambia County School District. Middle school students are
enrolled in Personal, Career, and School Development Skills as well as Career Research and
Decision Making. High school students are enrolled in Personal, Career, and School
Development Skills, Leadership Skills, and Development and Research. Every Wednesday is
designated Career Day and allows students access to unique career exploration opportunities
on a larger scale. The school district began a partnership with the American Federation of
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Teachers, Share My Lesson program on career exploration. This partnership allows the
teachers to design lessons and presentations which will help prepare students for future career
choices. The career education programming includes communication, interpersonal skills, and
decision-making skills. Seven interviewed youth reported they attend math, science, history,
reading, and social studies classes along with career education.
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Office of Accountability and Program Support Page 26 of 59 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
VitalCore Health Strategies, LLC., has a contractual agreement with the Department to provide
mental health and medical services to youth in detention centers. The center staffs only licensed
mental health staff to provide mental health and substance abuse services for youth. The
designated mental health clinician authority (DMHCA) is licensed and serves as the clinical
supervisor, supervising the other licensed staff. The DMHCA is a licensed mental health
counselor and has a license expiration date of March 31, 2025. In addition, the center employs
two additional licensed therapists with a license expiration date of March 31, 2025, who also
serve as the back-up DMHCA as needed. A review of the contract requirements, job description
of the DMHCA, and logbook sign-in sheets for the annual compliance review period confirmed
weekly hours of coverage as specified in the contract. The DMHCA was interviewed and stated
mental health and substance abuse services are provided based on youth needs. The DMHCA
reported each youth who enters the facility is screened and evaluated by a mental health
counselor within twenty-four hours to determine if mental health/substance abuse services are
warranted. All youth are informed of how to access mental health services while in secure
detention during the intake process. Youth who are prescribed psychotropic medications are
scheduled for initial evaluation with psychiatrist within fourteen days of arrival and every thirty-
days thereafter until released. For those youth who are not prescribed psychotropic medication,
they are seen by mental health staff by their fourteenth day for mental health orientation. Youth
receiving mental health services are seen by the clinical staff once a week at minimum. Any
youth in secure detention by their thirty-first day receive a Substance Abuse and Mental Health
Assessment to determine if services are needed.
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 clinical supervisor, who serves as the designated mental health clinician authority
(DMHCA), ensures the licensed staff working under their supervision are performing services
they are qualified to provide based on their training, education, and experience. At the time of
the annual compliance review, the center had two additional therapists who are also licensed.
Both licensed staff maintain a current and active license meeting all requirements for providing
clinical services.
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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 does not have any therapeutic staff who are non-licensed and require direct
supervision. The center does not maintain a Chapter 397 license. The center employs only
licensed mental health staff to provide mental health and substance abuse services for youth.
The designated mental health clinician authority (DMHCA) is licensed and serves as the clinical
supervisor, supervising the other licensed staff employed. The DMHCA is a licensed mental
health counselor and has a license expiration date of March 31, 2025.
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 requirements. All seven youth records had evidence a screening was completed
using the Suicide Risk Screening Instrument (SRSI) and Massachusetts Youth Screening
Instrument, Second Version (MAYSI-2). All seven youth had both screenings completed and
documented upon admission. The mental health and medical staff completed each section of
the SRSI as required. Five of the seven records contained documentation of positive responses
completed within the screening results section. Each of the applicable youth had alerts entered
as required within the Department’s Juvenile Justice Information System (JJIS) for suicide risk.
The MASYI-2 was completed by a trained staff and documented in JJIS. Results of the MAYSI-
2 indicated there were elevated subscales beyond the cutoff for five the seven youth records
reviewed. One youth’s MAYSI-2 was marked invalid due to all negative responses and one
youth did not have any elevated subscales; however, was overridden based on history of
suicide risk. All seven referrals were made based on the results for each youth, and the
superintendent/designee was documented as being notified. Each youth was indicated as
placed on suicide precautions and a mental health referral was completed, which documented
the need for an Assessment of Suicide Risk (ASR). Each of the seven reviewed youth were
applicable for a comprehensive assessment. For these seven youth, there was evidence of a
completed comprehensive assessment, which were all completed by the licensed mental health
staff person.
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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 substance abuse evaluation
requirements. All seven youth records had documentation the youth received a comprehensive
assessment completed by the detention center provider. None of the youth were applicable for
having a comprehensive assessment completed by a community provider. The Comprehensive
Mental Health/Substance Abuse Evaluation consisted of the Substance Abuse and Mental
Health (SAMH) assessment in the Department’s Office of Health Services (OHS) Electronic
Medical Record. All seven assessments were completed by the youth’s thirty-first day from
admission.
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 requirements. Three
of seven youth required an initial treatment plan due being prescribed psychotropic medications.
Five youth refused mental health and substance abuse services and were not prescribed
medication. For the three applicable youth, there was evidence each had an initial treatment
plan done within seven days of onset of treatment, as required. Each applicable plan was
documented using the Department’s Initial Mental Health/Substance Abuse Treatment Plan
form. The reason for the referral for treatment was documented, along with the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis/symptoms, and initial
treatment goals and methods. In all three initial treatment plans, psychiatric services were
documented including psychotropic medication and frequency of monitoring. The medication the
youth were taking was documented as required. A mini-treatment team meeting was unable to
be observed during the annual compliance review week. Each plan included the youth signature
and had evidence each youth was assigned a mini-treatment team which included all required
participants. The designated mental health clinician authority (DMHCA) was interviewed and
stated all treatment plans are mailed to the parent/guardian and a copy provided to the youth’s
assigned juvenile probation officer. Individualized treatment plans are created, signed, and
reviewed every thirty days for all youth admitted past thirty days, even if refusing services. All
seven reviewed records contained a completed individualized treatment plan. Each plan was
developed within the first thirty-days at the center. Each of the seven youth individualized
treatment plans included all required elements such as treatment goals, DSM-5 diagnosis,
psychiatric services and pharmacological interventions, when applicable, and strengths and
needs of the youth. When psychotropic medications were listed on the plan, they included
frequency and matched youth’s prescribed medication. The progress notes for each youth
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validated the youth was receiving services as stipulated in the plans, which in some records
indicated refusal of services. Each youth treatment plan was signed and dated by all required
parties. Attempts to contact the parent/guardian of the youth were documented on the plans as
required. Four of the seven reviewed youth records were applicable for individualized treatment
plan reviews. The remaining three youth did not require an Individualized Treatment Plan
Review. For the four applicable youth, each review was done in the required thirty-day
increment and found no discrepancies. Modifications were clearly documented on one of the
four reviewed. The remaining three youth reviews indicated no modifications were required.
Each review was completed using the Department’s Individualized Mental Health/Substance
Abuse Treatment Plan Review form. Individualized treatment plan reviews were signed by all
required parties. None of the reviewed youth were documented as an alleged victim of a Prison
Rape Elimination Act (PREA) event. All seven youth records selected for review were indicative
of each youth still active in treatment, thus none were applicable for a review of discharge
summary requirements. Three additional closed records were reviewed for a discharge
summary. Each included documentation of the youth discharge plans being completed on the
Department’s Mental Health/Substance Treatment Discharge Summary form. One summary
signed by the youth was provided to the youth, parent/guardian, and juvenile probation officer
(JPO). One youth was transferred to another detention center and the summary signed by the
youth was mailed to the youth’s parent and JPO. The last summary was mailed to the
parent/guardian and JPO, however, the youth did not sign the document prior to being
discharged from the detention center.
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. All
records indicated the youth required treatment and were assigned to a mini-treatment team. The
team consisted of mental health staff, a direct care representative, representative from
administration, food service, medical staff, and community juvenile probation officer. All seven
records indicated the youth received individual and group counseling in accordance with the
treatment plans, with four youth indicating refusal of services on their treatment plan. Four
treatment plans were applicable for substance abuse treatment. Documentation indicated three
youth received treatment according to the frequency required by their plan. One of the youth’s
treatment plans indicated a need for substance abuse treatment; however, the treatment was
not specified clearly in the progress notes, which only documented other group and individual
counseling. Each of the seven plans included individual or group therapy at least weekly. Six
youth had a clear Authority for Evaluation and Treatment (AET) in their record. One youth had
recently turned eighteen years of age. Consent for any substance abuse treatment was
obtained for the four applicable youth through the signed Mental Health/Substance Abuse form.
Treatment notes were documented using the Department’s Counseling/Therapy Progress Notes
(MHSA 018) containing all required elements. A review of video, logbooks, sign-in sheets, and
therapeutic progress notes verified groups were conducted as scheduled. Group therapy was
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limited to ten or fewer youth with mental health diagnoses, and fifteen or fewer youth with a
substance abuse diagnosis. Seven interviewed youth rated the mental health and substance
abuse services at the center. One youth rated the services as fair, four rated them as good, and
two rated the services as very good. The designated mental health clinician authority (DMHCA)
was interviewed and stated the center provides psychiatry, mental health, and substance abuse
services. The DMHCA further stated the facility operating procedures are reviewed once, at a
minimum. Initial treatment plans are developed seven days from the date the youth was
evaluated by the psychiatric staff. Individual treatment plans are developed based on the
comprehensive assessment by the thirty-first day the youth is in secure detention. A review of
all plans must be conducted every thirty days while youth is in secure detention.
3.08 Psychiatric Services [Contract Provider] (Critical) Satisfactory Compliance
Psychiatric services include psychiatric evaluation, psychiatric consultation, medication
management, and medical supportive counseling provided to youth with a diagnosed DSM-
IV-TR or DSM-5 mental disorder and each youth receiving psychotropic medication in the
program as set forth in Rule 63N-1, F.A.C.
The center has a contract with a psychiatrist through VitalCore Strategies, LLC to provide
psychiatric services to detention youth. The contract was reviewed and outlined the provision of
tele-psychiatry, if needed. The center’s psychiatrist has a license expiration date of January 31,
2025. The center did not require a back-up licensed psychiatrist during the annual compliance
review period. The center does not require a psychiatric advanced practical registered nurse
(APRN) and; therefore, has no collaborative practice protocol. The designated mental health
clinician authority (DMHCA) was interviewed and stated the center’s psychiatrist is required to
be on-site for a minimum of two hours weekly, Monday through Friday. Mental health
professionals may be notified twenty-four hours a day, seven days a week. A licensed clinician
is available on-call each day. Individuals can be notified using referrals, emails, phone calls, and
in-person notification. Three of seven reviewed youth records were applicable for the youth
taking psychotropic medication. Each of these youth entered the facility already under orders for
the medication. Each youth was referred to the psychiatrist, and an initial psychiatric interview
was conducted within fourteen days of the youth’s admission. Each youth’s initial psychiatric
interview included all required elements. An in-depth psychiatric evaluation was conducted for
all three applicable youth reviewed within thirty-days of the referral/admission. Each was
completed using all three pages of the Department’s Clinical Psychotropic Progress Note
(CPPN) form. No changes in youth psychotropic medication were indicated for any of the youth
reviewed. The signature of the psychiatrist was documented on each of the forms.
Documentation for psychotropic medication included identifying data, youth diagnosis, target
symptoms, side effect monitoring, and a list of prescribed medications. One of the three youth
CPPNs did not include the route of the medication, although this was clearly documented within
the youth’s Medication Administration Record (MAR). Each reviewed MAR indicated the youth
was receiving the medication as ordered. Any refusals for medication made by the youth were
clearly documented on the MAR. The nursing staff and psychiatrist documented monitoring for
Tardive Dyskinesia as required if applicable. Two of the youth had an approved Authority for
Evaluation and Treatment (AET) signed. In addition, one of these youth had a court order
authorizing the psychotropic medication administration. None of the three applicable youth were
eighteen years of age at the time of this review. Two of three youth were applicable for, and
received, tele-psychiatry. The tele-psychiatry was consented for by the parent/guardian and
approved in writing by the Office of Health Services.
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3.09 Suicide Prevention Plan [Detention Staff] (Critical) Satisfactory Compliance
The center follows a suicide prevention plan to safely assess and protect youth with elevated
risk of suicide in the least restrictive means possible, in accordance with Rule 63N-1, Florida
Administrative Code.
The center has a written plan detailing suicide prevention procedures which is reviewed and
signed by the designated mental health clinician authority (DMHCA) and superintendent. The
plan is incorporated with the center’s written facility operating procedures and addresses all
required topics to include identification and assessment, staff training, suicide precautions, level
of supervision, referral, communication, documentation, notification, staff response, and review
processes. The center’s plan includes an established review process for every serious suicide
attempt or serious self-inflicted injury and a mortality review for a completed suicide which
included topics such as circumstances surrounding the event, center procedures, relevant staff
training, pertinent medical and mental health services involving the victim, precipitating factors,
and any recommendations as needed.
3.10 Suicide Prevention Services [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Suicide Precautions are the methods utilized for supervising, observing, monitoring, and
housing youth identified through screenings, available information, or staff observations as
having suicide risk factors or identified through assessment as a potential suicide risk.
Any youth exhibiting suicide risk behaviors must be placed on suicide precautions
(precautionary observation or secure observation), and at a minimum of constant supervision.
All youth identified as having suicide risk factors by screening, information obtained regarding
the youth, or staff observations must be placed on suicide precautions and receive an
Assessment of Suicide Risk (ASR).
Seven youth records were reviewed for suicide prevention services requirements. All seven
youth records had evidence a screening was completed using the Suicide Risk Screening
Instrument (SRSI) and Massachusetts Youth Screening Instrument, Second Version (MAYSI-2).
All seven youth had these screenings completed and documented upon their admission. A
Department Juvenile Justice Information System (JJIS) alert for suicide risk was completed for
each youth in a timely manner by a licensed clinical staff. Each of the seven youth were
determined to need precautionary observation due to the screening instruments. Assessment of
Suicide Risk (ASR) forms were completed for each youth on the required Department form and
documented in real time. Suicide Precaution Observation Logs were documented and
completed in their entirety to include required signatures from the licensed clinical staff and shift
supervisor. One of seven reviewed forms did not clearly document safe housing areas as
required. For all seven, there was evidence the staff documented a consultation with the
designated mental health clinician authority (DMHCA) or licensed mental health professional on
the mental health/substance abuse referral summary. The superintendent or designee was
immediately notified of suicide risk in each event. The DMHCA was interviewed and stated the
center’s superintendent is notified immediately of the youth’s placement on precautionary
observation through receipt of an automated email notification. Examples of this process were
provided during the review process. The date and time each of the reviewed seven youth were
placed on precautionary observation was noted. Each of the ASR forms were completed within
twenty-four hours. A follow-up ASR was not applicable for any of the reviewed youth.
Documentation was found in all seven youth records confirming a conference was held by the
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superintendent and licensed mental health professional to reduce the level of supervision. Each
youth was documented as reduced to standard supervision. Suicide risk assessments were all
completed by a licensed mental health staff. Results of assessments included recommendations
for supervision and follow-up. Logbook documentation was reviewed for each youth indicating
the placement date and times from precautionary observation status and placed back to
standard supervision. All JJIS alerts were removed following youth being removed from
precautionary observation for each of the seven records reviewed. According to an interview
with the center’s DMHCA, none of the selected youth were applicable for secure observation.
The center has an established review process for serious suicide attempts or serious self-
inflicted injury and a mortality review for a completed suicide. The plan contains all required
elements, which denote the role of the multi-disciplinary review process.
Seven youth were interviewed. Three stated they have been placed on suicide watch before at
the center. Each of the three youth stated staff watched them all the time during this process.
Four stated they have not been placed on suicide watch. Seven interviewed staff gave
examples of their responsibilities in the event a youth expressed suicidal thoughts which
included notification of the mental health authority and documentation of supervision of the
youth. The superintendent was interviewed and confirmed the center may utilize secure
observation for potentially suicidal youth. The superintendent stated if a youth is on
precautionary observation and then begins to act out and becomes combative, the youth will
then be placed on secure observation and placed in a room to maintain order and the safety of
others.
3.11 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
Seven youth records were reviewed for Suicide Precaution Observation Log completion
requirements. Each of the youth had evidence of a completed Department’s Suicide Precaution
Observation Log maintained for the duration the youth was on suicide precaution status. The
level of supervision and observations of the youth’s behavior were documented in real time and
not exceeding thirty-minute intervals for all seven youth reviewed. None of the seven records
were applicable for requiring warning signs being documented. The logs were reviewed and
signed by each shift supervisor and by the mental health clinical staff for all seven reviewed
records. Six of the seven documented safe housing requirements. One did not have safe
housing documented as required. For the seven reviewed youth, none of the precautionary
observation time frames were able to be reviewed due to being outside the video review thirty-
day playback capability. Three random samples of video review were conducted as part of this
annual compliance review, which showed samples of youth being observed on precautionary
observation status. There were no discrepancies or issues noted with the video footage
observed.
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3.12 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
Seven in-service and seven pre-service staff training records were reviewed for suicide
prevention training requirements. All records had evidence of the completed required suicide
prevention training. The center has a total of three suicide response kits, which include a knife-
for-life, wire cutters, and needle nose pliers. The kits are located in master control, supervisors’
office, and medical office. The center operated on three shifts at the times of the annual
compliance review. The center conducts suicide drills at a rate of once a month for each shift.
Documentation of these drills was observed and included life saving measures and techniques
such as performing the Heimlich maneuver, cardiopulmonary resuscitation (CPR) and first aid,
and use of the Automated External Defibrillator (AED). A total of forty staff were reviewed for
their participation in suicide drills for the first six months. Thirty-five of the forty completed at
least one drill as identified on the drill documentation. For the second six months, a total of forty-
three staff were reviewed and found thirty-eight completed at least one drill. Seven interviewed
staff reported they have participated in various drills over the course of the annual compliance
review period, which included mock suicide drills.
3.13 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
The center has a mental health crisis intervention plan which is combined with the emergency
services plan. The plan includes all required elements such as a notification and alert system,
means of referral, to include self-referral, communications, supervision, and documentation
review.
3.14 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
The center’s emergency care plan included all required elements such as immediate staff
response, notifications, communication, supervision, transport authorization process for
emergency mental health and substance abuse services, documentation, training, and review
process. The plan was noted as approved and last updated by detention services administration
on August 7, 2023. The plan is located in the conference room and supervisor offices and is
accessible to staff.
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3.15 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
The designated mental health clinician authority (DMHCA) reported the center had three youth
during the annual compliance review period who were applicable for having a Crisis
Assessment completed. Each reviewed youth Crisis Assessment included the reason for the
assessment, Mental Status Examination and interview, determination of danger to self and
others, initial clinical impressions, supervision and treatment recommendations,
recommendations for follow-up and further evaluation, and notification to the parent/guardian of
follow-up treatment. The Crisis Assessment was completed by a licensed professional and was
conducted within twenty-four hours as required. One of three youth were applicable for being
placed on precautions after completion of the assessment. For this youth, the mental health
alert was entered as required into the Department’s Juvenile Justice Information System (JJIS).
None of the three youth were documented as alleged victims of a Prison Rape Elimination Act
(PREA) event.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Non-Applicable
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
The center did not utilize Baker or Marchman Act procedures during the annual compliance
review period; therefore, this indicator is rated non-applicable.
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Office of Accountability and Program Support Page 35 of 59 (Revised July 2023)
Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center’s designated health authority (DHA) is a board-certified physician who is a licensed
medical doctor (MD) specialized in family medicine. The DHA’s license is unrestricted and
meets all requirements to practice in the State of Florida. The license expires on January 31,
2024. The center utilizes an advanced practice registered nurse (APRN) who has a
collaborative practice protocol in place, which is signed by the DHA and APRN. The APRN
license expires April 30, 2024. During the annual compliance review period, it was found the
DHA has been on-site at least once a week with no time lapse more than nine days between
visits, which is in compliance. The center does not utilize a physician’s assistant (PA) or needed
to utilize a backup DHA during the annual compliance review period. No tele-medicine was used
during the annual compliance review period. The DHA was interviewed and stated their role was
performing Comprehensive Physical Assessments, conducting periodic evaluations, sick call,
and policy and procedure development. The DHA stated communication with the program staff
regarding youth medical needs is completed by phone or when on-site. If off-site, the DHA is on
call twenty-four hours a day, seven days a week and staff call with any needs or concerns. Any
off-site care findings, instructions, or information is reviewed by the DHA on a weekly basis.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center utilizes facility operating procedures (FOPs) for all health-related procedures and
protocols, written and authorized by the designated health authority (DHA). The DHA,
superintendent, and psychiatrist signed and dated all respective treatment and operating FOPs
on August 2, 2023. New employed healthcare personnel received a comprehensive clinical
orientation to the Department’s health FOPs, which was conducted by a registered nurse (RN).
Nursing staff signed an acknowledgment to confirm the review of all FOPs.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Seven youth Individual Health Care Records (IHCRs) were reviewed for Authority of Evaluation
and Treatment (AET) requirements. Five of seven reviewed youth records included a valid filed
AET obtained prior to providing medical services. Two AETs were originals and three were
copies stamped as a copy. Each applicable AET was signed by a Department representative.
One of the seven reviewed youth turned eighteen while in the center and had a signed release
of information filed in the IHCRs. Two reviewed records included a filed court order authorizing
treatment obtained prior to providing medical services. None of the youth were involved with the
Department of Children and Families at the time of the annual compliance review.
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4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for parental
notification/consent requirements. Four out of seven youth were found to have parental
notification for over-the-counter (OTC) medications beyond those covered by the Authority of
Evaluation and Treatment (AET). Verbal consent was obtained from all parents/guardians for
each medication outside what was covered by the AET and documented with a second witness
in the IHCR, along with written notifications sent utilizing the Department’s Parental Notifications
of Health Related Care: General Parental Notification or the Medication forms. Three of the
seven youth were taking psychotropic medications. Four records were applicable for new
medication being prescribed. In each of the records documentation confirmed the
parents/guardians were notified by telephone documented in progress notes and on page three
of the CPA, as well as letter notification being sent. None of the seven youth were in the
Department of Children and Family’s care. All seven youth’s vaccines were verified within thirty
days of youth’s admission with no updated vaccines needed. None of the seven youth required
a “Religious Exemption from Immunization” as all seven youth’s AET’s gave consent for any
necessary vaccinations.
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for healthcare admission
screenings requirements. All seven youth received a screening documented on the
Department’s Medical and Mental Health Admission Screening form completed on the date of
admission by the juvenile justice detention officer (JJDO) or the juvenile justice detention officer
supervisor (JJDOS). Each form was reviewed with the youth by a licensed nurse within twenty-
four hours as required. Notification was made to the designated health authority (DHA) for all
seven youth and documented in the youth’s IHCR. No change in physical custody took place for
any of the reviewed youth, therefore, no rescreening was needed. The nursing interview verified
the Juvenile Assessment Center initiates the screening and the nursing staff review and verify
during admission. None of youth required a rescreening, however, the nursing staff were
knowledgeable of any youth who needs a rescreening.
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’s facility operating procedures (FOPs) included access to medical care, sick call
access, what constitutes an “emergency” and when to notify staff, medication process to include
side effect monitoring, the right to refuse care and how it is documented, what to do in the case
of a sexual assault or attempted sexual assault, the non-disciplinary role of the healthcare
provider, and the review of the list of healthcare contacts to ensure accuracy. Seven reviewed
youth Individual Healthcare Records (IHCRs) confirmed each youth received a general
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healthcare orientation within twenty-four hours of admission which was documented on the
health education form.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for notification requirements
to the designated health authority (DHA). Two of the seven youth were admitted with known or
suspected chronic conditions. One additional record was reviewed for chronic conditions. Each
record confirmed a referral was made to the DHA within twelve hours. None of the youth were
identified as in need of emergency care upon admission. The notification to the DHA for all three
youth was documented in the youth’s IHCR in the Chronological Progress notes. Three of the
seven youth were taking psychotropic medications upon admission. The psychiatrist was
notified within twelve hours of admission for each youth and documented in the chronological
progress notes section in each youth’s IHCR. The interviewed nursing staff stated the DHA is
notified within twenty-four hours of admission as well as the psychiatrist, if the youth are
admitted on any psychotropic medications.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for Health-Related History
(HRH) form completion. Each HRH form was updated or completed within seven calendar days
of admission. The HRH form was completed prior to the Comprehensive Physical Assessment
(CPA) or focused evaluation by evidence of a signature and date by a licensed nurse. The
designated health authority (DHA) or advanced practice registered nurse (APRN) reviewed
each HRH for all seven youth by documenting the reviews on the HRH with a date and
signature. Interviewed nursing staff stated the HRH is completed or reviewed by the nursing
staff with the youth no later than seven days from admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for the Comprehensive
Physical Assessment (CPA) and Tuberculosis (TB) screening requirements. All seven physical
assessments were completed on the Department’s CPA form. Five out of seven youth had a
current CPA on file at the time of admission. Two youth did not have a CPA on file at the time of
admission and a CPA was completed within seven calendar days of admission. Four of the
seven CPAs were conducted by the designated health authority (DHA). Three CPAs were
completed by the advanced practice registered nurse (APRN). The correct Medical Grade was
listed on all seven CPAs and no missing or incomplete elements were noted. The five already
completed CPAs were current with no changes in the youth’s medical condition. The current
CPAs were reviewed by the DHA or APRN and signed off on within seven days of admission.
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All sections of the CPAs were marked as required and included further details in the comment
section to elaborate abnormalities, if applicable. All seven reviewed youth refused the genital
exam, and each refusal was documented in the chronological progress notes which was signed
by the youth, a licensed nurse, and the DHA or APRN. All seven youth problem lists were
updated to reflect any current issues and documented as resolved if any issues were resolved.
All seven CPAs had a current Tuberculosis Skin Test (TST) documented in the IHCR, if
administered within the last year. The results of all seven youth TST were also found
documented on the Infectious and Communicable Diseases forms, which matched the results
documented on the CPA. A Tier I TB screening was completed within seventy-two hours of
admission. None of the seven reviewed youth required further evaluation or transportation for
hospitalization. The nursing staff confirmed the DHA is notified for all youth who are admitted
and documented in the youth’s IHCR. The Health Related History form and CPA’s are
completed within seven days.
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. Seven
reviewed IHCRs documented the youth were sexually active and screened for STIs. Further
evaluation was required for one youth and the referral was documented on the STI form.
Testing was ordered and conducted within seven days of admission with the results
documented on the Infectious Communicable Diseases (ICD) form and filed in the lab section of
the IHCR. None of the seven youth received a gynecological exam. None of the seven youth
were ever out of the Department’s physical custody. All seven youth were offered counseling
and testing for HIV. One youth received testing for HIV and a documented consent was
obtained. The HIV test results were filed in a sealed envelope marked “Confidential”. The
designated health authority (DHA) did not sign the envelope, but did comment in the youth’s
chronological progress notes of being contacted by a licensed nurse of the results.
Documentation of Pre-test and Post-test counseling was contained in the Individual Health
Education Record and in the progress notes. The youth’s status of the HIV results was
protected by not including the results on the program’s internal alert system. The nursing staff
interview confirmed all applicable youth are screened for STIs and they were able to describe
procedures as well as how the results are stored. All seven interviewed youth stated they are
able to request an HIV test if they desire to be tested.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for sick call process
requirements. Five out of seven youth received sick call services. All five youth’s sick calls were
documented on the sick call referral log. None of the five youth presented with a similar sick call
complaint three or more times within a two-week period, therefore, no referral was needed to
the designated health authority (DHA). One youth had a complaint of severe pain with which the
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nurse referred immediately to the DHA and was seen within seven days from the sick call
complaint. All five youth completed a sick call on the Sick Call Request form. Only nursing staff
completed the Sick Call Request form. Three out of the five youth’s sick calls were conducted
by a licensed practical nurse (LPN) and was reviewed by a registered nurse (RN) the same day
of each sick call. All five sick calls for each youth were filed in the IHCR in reverse chronological
order. None of the seven reviewed youth were in restricted housing during sick call hours. All
five youth sick call forms were not documented in accordance with Health Services Rule 63M-2.
All five youth sick call forms were missing youth signatures at the bottom of the form. Instead,
the youth signatures were found on the sick call log beside each of the complaints. The
Department’s Office of Health Services was consulted and reported the youth signatures on the
sick call log was acceptable. All five youth sick calls were documented on the sick call index
inside their IHCR with the dates listed on the sick call forms matching the dates of the sick call
index. Sick call process and dates/times are posted in visible areas for the youth and staff. A
registered nurse was interviewed during the compliance review week and noted sick calls hours
are Monday through Friday from 11:00 a.m. until 12:00 p.m. and 5:00 p.m. until 6:00 p.m.
During the weekend, sick call is conducted from 10:00 a.m. until 11:00 a.m. Sick call hours are
posted on the medical door outside facing the hallway, at the medication window at medication
pass, and in the youth living areas. There are approved treatment protocols for both RN and
LPN level staff to utilize. Only licensed nurses complete sick calls. 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 but within four hours after the request is submitted and notifies the
DHA. The center has facility operating procedures (FOPs) for room restrictions/confinements.
The FOP states youth in restricted housing shall be afforded access to healthcare at equal or
greater intervals of youth who are in regular housing. A sick call was observed after receiving
the verbal consent by the youth. The nurse identified themselves and stated why the youth was
being seen. The youth was seen in a private area with no other youth present. The nurse
conducted the examination on the exam table, with the juvenile justice detention officer (JJDO)
standing at the door in view of the youth but not in ear distance of the exam. Seven youth were
interviewed. One youth stated they are seen immediately, one stated they are seen within one
day, two stated they were seen within two days, one youth stated they were seen within three
days, and two youth stated they never requested a sick call. Five of the seven interviewed youth
stated the nurses conduct sick call and two youth stated they have not requested a sick call.
Seven staff were interviewed, three staff stated the nurse reviews and conducts sick calls and
four staff stated medical staff and supervisors review and conduct sick calls.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for episodic/first-
aid/emergency care requirements. All seven youth required on-site first-aid or episodic care.
Five youth received episodic care or first-aid by a licensed healthcare staff which was
documented in a subjective, objective, assessment, and plan (SOAP) format. Two youth
received episodic or first-aid care by a non-healthcare staff after nursing hours and care was
documented on the Department’s Report on the of On-Site Health Care by Non-Health Care
Staff form. All seven youth complaints were documented with findings by the staff rendering
care. Six out of seven youth received treatment and one youth did not require any treatment
needed. One youth required a referral to off-site care. Education and instructions were
documented for all seven youth. A plan for follow-up care was found on six of the seven youth
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progress notes with one youth not requiring any follow-up care. One youth was required to be
placed on the alert list and was found on the alert roster. Parental notification was made and
documented for four of the seven youth, three youth were not applicable for parental notification.
All seven youth’s episodic/first-aid care was documented on the episodic/first-aid care log. Only
two of the seven youth required a follow-up evaluation from a licensed healthcare staff.
The center has a total of nineteen first-aid kits located throughout program areas and accessible
to staff in the event of an emergency. A first-aid kit is available for each of the six transport
vehicles. The first-aid kits included an approved list of items present and documented on each
kit. Three kits were opened and examined. All three had contents within their date of expiration.
First-aid kits are inventoried monthly by the medical staff. Documentation of all the inventory
was conducted and maintained on the monthly first-aid kit and automated external defibrillator
(AED) logs. The center has a total of two AED units with one located in a main hallway and the
other in the medical office. Both are inspected monthly by medical staff and a log is kept
documenting any findings or discrepancies fixed, with dates of pads or batteries changed. The
batteries and pads of the device were observed within their date of expiration. A licensed
medical staff was observed performing an inspection of the AED during the annual compliance
review week. The device was operating as required. Emergency drills have been conducted
every month, on each shift, and unannounced in which a simulated episodic care event took
place. During two months, drills were conducted in which cardiopulmonary resuscitation (CPR)
was rendered and the use of the AED was conducted to show proper techniques.
Documentation of all drills was kept in the medical office and reviewed. A list of emergency
numbers was found accessible to licensed and unlicensed staff, which included the number to
the Poison Information Center. The numbers were not accessible to any youth. All authorized
direct care staff were appropriately trained by a registered nurse on the administration of an
epinephrin auto-injector. Seven staff records were reviewed which showed training
requirements were met regarding episodic care, first-aid, and emergency care.
The use of Naloxone (Narcan) was updated into the Department’s policy on August 2, 2022.
The policy states for the emergency treatment of a known or suspected opioid overdose
emergency with signs of breathing problems and severe sleepiness or not being able to
respond. Narcan is a prescription strength medicine. The center will maintain at least one
prescribed stock nasal spray kit for emergency purposes of accidental overdose for use for
youth in the Department’s care. Narcan should not be ordered for each individual youth. A
Narcan kit stock must be maintained in a designated area, in the center’s medication cart. The
medication cart must be locked at all times, but still accessible to both nurses and supervisory
staff trained to assist in the delivery of medications when the emergency arises. There must be
a process in place for supervisors to access the stock Narcan and the epinephrine auto-injector
when there is no medical staff in the facility. In addition, as with all stock prescription
medications, a perpetual/daily inventory of medication utilization must be maintained. The
Narcan is stored at room temperature, away from light, avoiding extremes of heat or cold (e.g.,
do not freeze nasal spray). Shift supervisors may administer Narcan. Nursing staff and
supervisory staff shall be trained on administration of Narcan. Training and refreshers must be
conducted for all new supervisory staff and at least annually by a registered nurse or higher. A
Department’s Office of Health Services (OHS) power point training was provided to assist with
this training. As with the use of the epinephrine auto-injector for an emergency, the youth must
go out via emergency medical services if there is use of Narcan. At the discretion of the center’s
designated health authority (DHA), Narcan may be signed out from the medication cart during
transport (i.e., to court and back, recreational activities or to another detention center). The
Narcan must be ordered by the DHA and approved for the transport of the youth, based on
medical or court order and shall not be for leisure activities when risk is present. The Narcan
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must be signed out for transport only for the specific youth, utilizing the Department’s forms, and
kept in a cool container or stored at an average temperature as per the manufacturer guidelines
during transport. The Narcan mut be documented as returned to stock at the facility if not used.
It must be documented as used on the youth Medication Administration Record (MAR) or
Medication Distribution Record where applicable if the necessity occurs. The center stores
Narcan in the medication cart which is accessible to the registered nurse, licensed practical
nurse, superintendent, captain, commander, and sergeant. Each staff with access to Narcan
has been trained on when and how to use it and it is inventoried by a licensed nurse weekly.
Three of the seven interviewed youth reported the medical care at this center good, two youth
rated it very good, and the last two youth stated they have not received any medical services.
Seven interviewed staff stated they are able to call 9-1-1 if they feel it was necessary.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for completion requirements
concerning off-site care/referrals. Two youth were applicable for requiring off-site care. One
additional IHCR was reviewed. Each record contained the Department’s Summary of Off-site
Care Consultation Report form which was utilized and filed in the IHCR and was also
documented on the Episodic Care Log. Parental notifications were made for each youth and
documented in the IHCRs. Discharge documents were filed in each IHCR and the designated
health authority (DHA) reviewed the discharge instructions, findings, and care rendered within
seven days from the incidents by evidence of signature and date. Documentation the DHA was
notified was found in all three youth IHCRs in the chronological progress notes section, with the
date and time the DHA was notified of the event. Two of the youth required follow-up
appointments and the referrals were entered on the center’s referral tracking log. After review, it
was found the youth did receive appropriate and timely follow-up care.
4.14 Chronic Conditions/Periodic Evaluations [Contract
Satisfactory Compliance
Provider]
The center shall ensure youth who have chronic conditions receive regularly scheduled
evaluations and necessary follow-up.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for chronic
conditions/periodic evaluation requirements. Two youth were applicable as being identified on
the Facility Entry Physical Health Screening (FEPHS) forms for having a chronic condition. One
additional record was reviewed. None of the reviewed youth had a communicable disease. Two
of the youth were diagnosed with abnormal weights, one being obesity and one having a low
body mass index (BMI), and one was diagnosed with diabetes. Two youth were classified with a
Medical Grade two and one was classified as a Medical Grade four. All three were placed on
the chronic conditions list. None of the youth were female, therefore they were not identified as
pregnant. Two of the youth were applicable for receiving a periodic evaluation every ninety-
days, however, all three received evaluations at least once a month. None of the youth were
identified as taking anti-tuberculosis medication. The Department’s Problem List was updated in
accordance with the Department’s Health Services Rule 63M-2 for each applicable youth. The
designated health authority was interviewed and stated all youth with chronic conditions are
seen for evaluations for chronic conditions every ninety days or sooner, if needed. Inside the
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medical clinic, the center’s chronic care board is maintained by the registered nurse to
determine when the youth is due for periodic evaluations.
4.15 Medication Management [Contract Provider] Limited 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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for medication management
requirements. Three of the seven youth were taking medication at admission and the
medication was verified prior to being admitted into the center. Prescription verifications for all
three youth were completed utilizing the Department’s Prescription Mediation Verification
Checklist form. For all three youth, the psychiatrist was notified within twelve hours of admission
and an order was obtained to continue the current prescribed medication documented on a
practitioner order form. All three youth medications were verified on the Department’s
Medication Receipt Transfer Disposition form inside each youth’s IHCR. None of the reviewed
youth were in restricted housing during medication administration hours.
Five out of the seven reviewed youth were given over-the-counter (OTC) medications which
were not listed on the Authority for Evaluation and Treatment (AET) form, however, medication
was given in accordance with approved protocols or doctor’s orders with the permission of the
parent/guardian. One youth turned eighteen years old at the time of the order and consented for
OTC medications themself. All seven youth utilized a standard Department Medication
Administration Record (MAR) in the Electronic Medical Record (EMR). Each reviewed MAR
clearly indicated medication start and stop dates. Three of the seven youth received
medications assisted by a trained non-healthcare staff after hours when a licensed staff was not
on-site. No MARs were created to document the given medication. The staff did not complete a
MAR for any of the three youth. Notification of this was made to the Department’s Office of
Health Services (OHS). The protocol provided by OHS stated, “All non-licensed staff trained in
medication administration should have access to the EMR after hours when licensed staff are
off-site to administer any medications covered by the AET according to non-licensed staff
protocols written by the designated health authority (DHA).”
Nursing staff documented side effect monitoring for all seven youth weekly. Only one youth was
applicable for refusal of medication. The youth refused medication nine times which was
documented the MAR as required with the youth’s initials indicating refusal. No refusal forms
were found in the youth’s IHCR indicating the date of the refusal, medication refused, reason for
refusal, the youth’s signature, date, or staff signature with date. OHS was contacted and relayed
the youth’s initial’s on the MAR is an acceptable notification of refusal. Seven of the reviewed
youth’s MARs contained all required elements to include the youth’s name, Department
identification number, date of birth, youth allergies, Medical Grade, medical alerts, and current
picture of the youth attached. Three of six applicable MARs documented precautions, however,
three did not document the precautions. All seven reviewed MARs were found to have licensed
staff initials and youth initials for each medication given. None of the seven reviewed youth
required parenteral medication. For the three youth who entered on psychotropic medications,
the psychiatrist conducted an Initial Diagnostic Psychiatric Interview with the youth within
fourteen days of admission. Every thirty days after the initial interview with the psychiatrist, the
three youth were seen for follow-up medication monitoring and review. The center’s medical
department reported there are no standing orders or emergency treatment orders for
psychotropic medications.
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A medication pass was observed. Medication administration was completed by the licensed
medical staff. Youth were escorted to medical by the juvenile justice detention officer. The youth
approached the nurse station individually. The medical provider identified themselves and
prepared the medications for each youth as prescribed. The allergy and alert status were
verified on the MAR. Each youth initialed for their medication after receiving and the licensed
staff indicated the medication was provided. The Six Rights of Medication Delivery were
completed.
Seven staff were interviewed regarding medication delivery to youth. One staff indicated they
give medications and six staff stated they do not give medications. Seven youth were
interviewed regarding who gives medications. One youth stated the doctor administers
medications, three stated the nurse, and one stated the staff. Four youth reported not having to
take medications. One youth reported a supervisor provides medication on the weekends, but
nursing provides medications all other times.
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 medical office was found to be neat, clean, organized, and inaccessible to youth in the area
where sharps and medications were maintained. Medical equipment classified as sharps were
found secured and inventoried utilizing a routine perpetual inventory descending count as each
sharp was utilized or disposed of in the medical clinic. A sample of three sharps was reviewed
and counts of the items matched the ending inventory numbers. All medications were identified
and secured in the locked area designated for storage of medications inside the medical office.
The medication cart was found to be clean and organized with stock items separate from youth-
specific medications. All medications were stored in a separate, secured area, inaccessible to
youth. Narcotics and other controlled medications were stored behind two locks. No oral
medications were stored with topical medications. Medications requiring refrigeration were
found inside a secured refrigerator labeled “Medication Only”. For youth on controlled
medications, a perpetual shift-to-shift inventory count was conducted and documented on the
Individualized Controlled Medication Inventory Record.
Non-healthcare staff were trained in the delivery and oversight of medication self-administration
when nursing staff are not on-site. This training was delivered by a registered nurse. Three
controlled medications samples were reviewed with no discrepancies and counts matched
ending counts. Three over-the-counter (OTC) medication samples were reviewed with no
discrepancies and counts matching ending counts. Perpetual weekly inventories of all sharps
and OTC medications were observed. Observations of inventories conducted confirm the
center’s medical staff conduct inventories of medications and sharps as required.
The procedure for reporting inventory discrepancies states any medication inventory
discrepancy shall require notification to the Department’s Central Communications Center
(CCC) and completion of an internal investigation, and a root cause analysis utilizing a
medication error report shall be maintained. The center has facility operating procedures
regarding the disposal process for medications. The disposal process indicates a registered
nurse (RN) shall be responsible for the disposal of medications in conjunction with the
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pharmacy consultant. Non-Controlled medications are disposed using the approved Drug Buster
disposal system.
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.
Seven youth Individual Healthcare Records (IHCRs) were reviewed for infection control,
exposure control, and education requirements. All seven of the reviewed youth records
documented infection control training was completed on admission to include hand-washing
techniques, universal/standard precautions, prevention/transmission of communicable disease,
vaccinations, and the Center for Disease Control and Prevention (CDC) guidelines for infection
control. The Exposure Control Plan was written in accordance with Occupational Safety and
Health Administration (OSHA) guidelines and included a risk assessment listing job
classifications in which staff have the potential for occupational exposure, including tasks and
procedures which would cause staff in specific job classifications to have an occupational
exposure. A method of compliance outlining infection control practices and engineering and
work practice controls was also found in the plan. Infection control procedures in place included
prevention, containment, treatment, and reporting requirements related to infectious diseases,
according to OSHA and CDC guidelines. Infection control procedures outlined all required
elements such as, common infectious diseases of childhood, the common cold, viral or bacterial
infections, Hepatitis A-B-C, human immunodeficiency virus (HIV), pediculosis, food-borne
illnesses, chemical exposure, bio-terrorist agents, and Methicillin-Resistant Staphylococcus
Aureus (MRSA). Tuberculosis (TB) was not specified in the plan itself but was included in the
center’s facility operating procedures for the admission process, to include screening for TB and
exposure control. The infection control plan includes processes for needle stick post-exposure
evaluation. No Hepatitis B immunizations are made available for staff. All staff have access to
protective equipment. The registered nurse stated there have been no instances in which
infectious diseases and sexually transmitted infections needed to be reported to the local health
department or the Department’s Central Communications Center (CCC). There were also no
hospitalizations or quarantine of at least ten percent of the total population for youth or staff. The
superintendent was interviewed and stated they maintain a separate file containing all
documents for youth and staff who have experienced facility/occupational exposure for ten
years as required. All staff received pre-service or in-service training on the center’s specific
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.
No female youth were at the center at the time of the annual compliance review. None of the
female youth were applicable for prenatal care during the annual compliance review period. A
review of in-service training was found to include observation and monitoring of emergency care
needs/symptoms for possible miscarriage and has nursing protocols and treatment in place for
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pregnant youth. All staff in pre-service were trained in the supervision and treatment of a
pregnant youth. All seven interviewed youth were male indicating they did not need these
services.
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Standard 5: Safety and Security
5.01 Active Supervision of Youth (Critical) Satisfactory Compliance
Staff are aware of the location of youth assigned to their supervision at all times. Staff monitor
the movement of youth in their direct care from one location to another.
Youth are in sight of at least one juvenile justice detention officer (JJDO) at all times (with the
exception of sleeping hours or time secured in rooms).
Officers are responsible for the care of youth at all times. At no time shall another youth be
allowed to exercise control over or provide discipline or care of any type to another youth.
When a youth leaves the group or program area of the center for any reason, all staff
assigned to supervise the youth are informed.
Master control authorizes all movement of youth prior to the actual movement, and no
movement occurs until cleared by master control.
Staff moves youth from one area of the center to another in accordance with Florida
Administrative Code.
The center has facility operating procedures (FOPs) to ensure 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 with the exception of education. The
modules would take turns in rolling lock downs due to the lack of detention staff. Eight staff had
no contact orders with youth and six staff were newly hired and in training. While youth were in
lock down, they received education packets to complete. Three full days of group video were
observed. Positive interactions between staff and youth were observed in all three days. Staff
maintained continuous sight supervision of all youth in their assigned area. Staff were observed
supervising youth by controlling line movements, positioning themselves appropriately, and
giving clear directions to youth. The center staff were interacting appropriately with youth. All
movements were authorized by master control prior to the youth being moved. A review of the
center’s logbooks during the annual compliance review period confirmed all movements were
logged and counts were conducted consistently. Tracking daily census is completed by
conducting head counts throughout the shift and documenting in the logbook. Seven staff were
interviewed, and each stated there were enough staff to provide adequate supervision.
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5.02 Behavior Management System/ Unauthorized Use of
Satisfactory Compliance
Punishment (Critical)
The center provides a system of rewards, privileges, and consequences to encourage youth
to fulfill the center’s expectations.
Each center shall implement and maintain a behavior management system to meet the needs
of the youth and the center. The system shall include rewards for positive behavior and
consequences for inappropriate behavior.
The behavioral norms and expectations for youth shall be posted in all living areas and shall
clearly specify appropriate and inappropriate behaviors.
The system restricts certain types of penalties on youth who demonstrate negative behaviors.
Group punishment shall not be used. However, corrective action taken with a group of youth
is appropriate when the behavior of a group jeopardizes safety or security, and this should
not be confused with group punishment.
Corporal punishment shall not be used in detention centers. All allegations of corporal
punishment of any youth by staff shall be reported to the Florida Abuse Hotline and the
Department’s Central Communications Center (CCC).
The use of drugs to control the behavior of youth is prohibited. This does not preclude the
proper administration of medication as prescribed by a licensed physician.
The center has facility operating procedures (FOPs) detailing the behavior management system
(BMS) to ensure the safety and security of youth and staff. During a walkthrough of the center,
BMS posters were observed throughout the building in all common areas where youth
may be able to review. The center provides a BMS which includes a system of rewards,
privileges, and consequences based on behavior. A review of the center’s BMS FOPs ensure
compliance with the components outlined in the center’s policies and procedures. The BMS is
explained to each youth upon their admission. All youth are admitted to the center as a level
two. Each level guarantees youth receive all their basic needs and their level progresses every
three days if the youth continue to display positive behavior. Level three youth receive additional
privileges and incentives. Level one is the most restrictive level. Only youth who have exhibited
major problem behaviors or have been placed in confinement may be dropped to level one.
While on level one the youth’s privileges are suspended. All youth levels are tracked using level
cards. Each youth has a level card, and their behavior is documented on the card each day by
staff and supervisors. The BMS incentive calendar was also observed to be posted in the youth
housing units, the dining hall, and the main hallway. The youth are able to attend different
activities and receive various rewards which are scheduled throughout the month. Youth will
receive the scheduled incentives based on their current behavior level the day of.
Seven interviewed staff were able to explain the center’s BMS practices and the posted
locations. In addition, each staff was able to describe the types of rewards provided as part of
the BMS as well as confirmed things cannot be taken away from a youth as a consequence.
Staff stated snacks, candy, and additional telephone calls are different types of rewards the
center provides as part of the BMS. All seven staff believe the center’s BMS is effective. Each
staff speaks with youth to discuss the consequences being imposed and gives the youth an
opportunity to explain their behavior. Staff speak with youth about alternative acceptable
behaviors. Each staff was able to explain the feedback process from supervisors regarding
implementation of BMS. Six staff stated they received feedback information daily, and the
remaining staff stated as needed. All staff stated points and levels can be taken away as a
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consequence. None of the staff interviewed have ever seen a co-worker take meals, snack,
clothing, education, or medical care from a youth because they were acting out. None of the
staff have ever observed any staff encouraging youth to beat up another youth.
Seven youth were interviewed, and two youth rated the center’s BMS as poor, three youth rated
it as good, and the remaining two rated the BMS as very good. All seven youth were able to
explain the difference between each level and how to move from one level to the next. In
addition, each youth was able to provide examples of how they are rewarded in the center and
agreed the staff use the rewards the same. All youth stated they are not allowed to punish
another youth. Two out of the seven youth stated they have been sent to their room for
punishment, and the door was shut and locked during this time. The remaining five stated they
have never been sent to their room for punishment. Three out of the seven youth stated they
received fair consequences. The remaining four have never received any consequences. All
youth agreed level and points are taken away for consequences. One youth added confinement
in a room was given as a consequence. All seven interviewed youth stated they have never
witnessed handcuffs or leg irons used on out of control youth to prevent them from hurting
themselves or others.
The interviewed superintendent stated a standardized BMS is used for all twenty-one detention
centers around the state. It will enhance the safety and security as it relates to youth behavior
and promote the health and well-being of youth by providing an environment which fosters
social, emotional, intellectual, and physical development. It's a three level system which tracks
the youth behavior. Level one is the most restrictive level. Level one youth still have all of their
basic rights. All youth will be placed on level two upon admission and the youth gain some
additional activities and incentives. Level three is the highest level and the higher youth goes up
with earning days, the more incentives they can obtain.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center maintains facility operating procedures (FOPs) requiring ten-minute checks to be
conducted when youth are in their rooms. The center has sixty-four surveillance cameras, and
sixty-three were operational during the week of the annual compliance review. The center has
the capacity to store video recordings for up to thirty days. An electronic wand system is used in
the center to document and collect data of the ten-minute visual checks. Staff tap an electronic
wand on the check point sensors on the outside of each youth’s assigned sleeping room door
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and the data is downloaded as wand reports. A review of twelve samples of video over three
different days and their corresponding wand reports, including samples from each living module,
revealed staff conducted ten-minute checks as required. Staff were observed looking into the
windows of each sleeping room before tapping the wand to the check point sensor. Seven staff
were interviewed and six of the seven staff stated room checks are conducted every ten
minutes when placed in their room for sleeping or non-punishment reasons. The remaining staff
stated the checks are every five minutes. The superintendent was interviewed and reported
when youth are on standard supervision, staff assigned to monitor a youth will not go beyond
ten-minutes throughout the youth's stay in his/her room and/or sleeping area. Visual checks
must be made of the youth's condition, (outward appearance, behavior, position of the room) at
intervals not to exceed ten minutes. Youth who are appropriate to be on standard supervision
have been determined to be found not a potential suicide risk.
5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center maintains facility operating procedures (FOPs) to address census, counts, and
tracking which require staff to know the exact number and location of all youth under their
supervision at all times. An observation of counts being conducted was conducted at master
control during the annual compliance review and no issues were observed. Master control
documented all counts in the logbook. A sample of logbooks for twelve months, three full days
each month, was reviewed for the annual compliance review period. Census counts were
conducted at the beginning of each shift, prior to and following routine group movements,
population change, randomly at least once a shift, head counts, and youth movements. Seven
interviewed staff all indicated youth counts are conducted beginning and end of every shift. In
addition, one staff stated counts are also before and after school and another staff stated counts
are conducted before and after meals. All staff stated a recount would be conducted if the count
is not correct. When asked when emergency counts are conducted, five out of seven staff
stated when a youth is believed to be missing, four of seven stated when visibility is hindered
such as an electrical outage, and four of seven stated after a major disturbance. Staff also
reported emergency counts are conducted during emergencies, fire drills, code white, code
green, any disruption in the center, escape, or any time there is an issue which deems an
emergency count necessary.
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5.05 Logbook Maintenance Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved.
At a minimum, each logbook entry includes the date and time of the event, the names of staff
and youth involved, a brief description of the event, the initials of the person making the entry,
and the date and time of the entry. Logbook entries are made in black or blue ink, with no
erasures or whiteout areas. No logbook entries are obliterated or removed; errors are struck
through with a single line and initialed by the person correcting the error.
Log entries regarding Medical, Special Needs, and Mental Health alerts, or other issues
impacting facility safety and security shall be highlighted.
The center has facility operating procedures (FOPs) for logbook maintenance. The center has
separate logbooks for master control, each living module, visitors, and vehicles. A review of nine
logbooks 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. Twenty-two
days out of thirty-four in the master control logbook contained the date documented at the top of
page and twelve did not have the date. 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. Six out of thirty-four days
reviewed in the master control logbook had errors which were not struck through with a single
line and “void” written after the error followed by staff initials. 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 reviewed and the
date and time the review was completed. The master control logbook included emergency
situations, incidents, all drills, documentation of receipt of medical/mental health alerts,
population counts at the beginning and end of each shift, population counts throughout shifts as
count changes, youth counts following emergency situations, youth group movement,
admissions and releases, presence of law enforcement, names of youth placed in confinement
with the time confinement began and the time confinement ended, and name of youth placed on
precautionary/secure observation along with the time initiated and time ended.
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5.06 Logbook Reviews Failed Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) regarding logbook requirements. The
master control and living module logbooks for the annual compliance review period were
examined. The review revealed the superintendent or designee did not review all logbooks on a
weekly basis and did not provide recommendations as to the completeness and accuracy of the
information recorded. The juvenile justice detention officer supervisor (JJDOS) reviewed the
center logbook maintained at master control when assuming responsibility. The JJDOS and/or
lead officer reviewed logbooks maintained in each living area daily. The juvenile justice
detention officers (JJDOs) reviewed logbooks maintained in their assigned living area when
accepting responsibility for the living area at shift change. The superintendent, assistant
superintendent, or staff in charge of center toured the youth living areas at least once during
each shift and documented their visit in each area’s logbook. The superintendent was
interviewed and stated the administrative team reviews the logbooks on a weekly basis and
signs off in the logbook after each review.
5.07 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys.
All keys shall be placed on a tamper-resistant key ring designed to inhibit the removal of
keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch.
The key(s) on these rings shall provide egress through facility exterior doors providing access
to evacuation areas.
A key inventory shall be maintained by the Superintendent or designee at all times.
(For the entire indicator statement, please reference the Monitoring and Quality Improvement
FY 2020-2021 Detention indicators.)
The center has facility operating procedures (FOPs) describing the center’s process for key
control, issuance of keys to staff, key restrictions, inventory and tracking, storage, missing or
lost keys, and reporting and replacement of damaged keys. The center maintained an inventory
of the non-operational and operational keys. All keys were accounted for upon review. The
master control operator was observed during the annual compliance review collecting personal
keys upon entrance to the center. The juvenile justice detention officer supervisor (JJDOS)
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Office of Accountability and Program Support Page 52 of 59 (Revised July 2023)
documents in the key logbook maintained in conference room the operational keys retrieved
from the lock box and to which staff they will be assigned. The key assignments are also
documented in the supervisor shift report on SharePoint. The key assignments documented on
the shift report and key logbook included the date and time of issue, name of staff issuing the
key ring, staff who received the key ring, and time the key ring was returned. Emergency key
rings must be maintained separately from other center keys in a secure location designated by
the superintendent in consultation with the local state fire marshal. Emergency key rings must
be included as part of the center’s key inventory. The emergency keys were secured in master
control in a lock box on the wall. The master control operator and supervisors have access to
the key. The emergency keys were included on the key inventory. The master key inventory
included the ring number, number of keys on each ring, capability of each key, and to whom the
key was issued. The key rings were numbered, and each indicated the number of keys on the
ring. All facility keys were maintained on a tamper resistant ring and were color coded according
to function, officer’s hub is blue, supervisor’s hub is yellow, administration hub is black, medical
and mental health hubs are white, food service hub is green, education hub is brown, and
emergency hub is red. Observations indicated staff carried issued keys on their person at all
times, youth did not have access to the center keys, and keys were not removed from the facility
grounds. The key box was locked and not easily accessible while locked. There were no
incidents reported to the Department’s Central Communications Center (CCC) or program
monitoring and management regarding key control during the annual compliance review period.
A sampling of five key rings were observed and compared with the center’s inventory with no
issues noted. Three staff were able to accurately list the number of keys on their key ring and
the function of each key. An informal interview with the master control operator revealed the
restricted keys do not provide access to medical or mental health records or the property room.
Seven staff were interviewed, and all stated medical records and mental health records keys
were restricted. Five staff stated the youth property area and kitchen were restricted. Three staff
stated education keys were restricted. All staff confirmed they understood the key control
process and were able to explain the center’s procedures. The superintendent was interviewed
and stated permanent keys were issued to staff. Permanent issued keys are assigned to
specific personnel at the discretion of the superintendent, which authorizes the individual to
remove the keys from the facility or the facility grounds. The superintendent, captains,
maintenance mechanic, administrative assistant, and food service director are the only staff who
have permanently issued keys.
5.08 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center maintains facility operating procedures (FOPs) for transportation, operation, and
maintenance of each vehicle used to transport youth. The center has a total of seven vans
which are used to transport youth. An annual inspection was completed by a certified mechanic
on all seven vans, documentation was provided to confirm the inspections. Documentation was
reviewed confirming monthly inspections were completed by the center’s maintenance
mechanic or staff and included checking the vehicles water coolant, lights, oil, emergency
equipment, brakes, horn, interior, exterior, and cleanliness of the vehicle. Three vehicles were
overdue for an oil change in March of 2023. Inspections are also conducted on the tires, battery,
windshield, wipers, windows, mirrors, and inspected for any damages. A physical inspection of
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Office of Accountability and Program Support Page 53 of 59 (Revised July 2023)
all the vehicles was conducted, each vehicle contained the appropriate number of seatbelts, a
seatbelt cutter, window punch, fire extinguisher, and first-aid kit. Each vehicle had an assigned
logbook for transport documentation which included acknowledgement the vehicle was
checked, destination, number of youth and staff names, name of the officer riding in the back of
the van, time transport began, and time transport ended. There were no transports scheduled
during the time of the annual compliance review for observation. Four vehicles from
the center were checked to ensure vehicles were locked when not in use, all vehicles were
secured. Seven youth were interviewed, all stated they felt staff are driving safely when
transporting youth. In addition, all stated they have never seen anyone place contraband in
transport vehicle.
5.09 Tool Inventory and Management Satisfactory Compliance
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried.
The center maintains facility operating procedures (FOPs) ensuring all tools and equipment
related to maintenance and kitchen are properly maintained, stored, and inventoried.
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
accompanied by designated center staff at all times while in the secure area of the center. A
review of the monthly inventory sheets during the annual compliance review period confirmed
there were no missing maintenance or kitchen tools. A review of the inventory used to document
the issuance and return of maintenance tools found no discrepancies. An informal interview with
maintenance and kitchen staff determined they understood the process when there are missing
or damaged tools. A sampling of ten maintenance tools revealed all tools were secured, marked
for easy identification, inventoried accurately, and signed by the superintendent.
Seven interviewed staff were able to explain the center’s practice for damaged and missing
tools. The superintendent was interviewed and stated the maintenance mechanic, major, and
captains have access to tools. Youth may use cleaning items such as mops, brooms, buckets,
and other common household items under direct supervision. Tools and equipment which can
cause death or serious injury must have strict control. Staff are to use professional judgement in
the identification of youth who participate in the cleaning activities.
5.10 Youth Access & Use of Tools, Cleaning Items (Critical) Satisfactory Compliance
Youth are forbidden to use or access any tools, including kitchen or medical equipment.
Youth may use cleaning items such as mops, brooms, buckets, and other common
household items under direct supervision.
The center maintains facility operating procedures (FOPs) prohibiting youth from having access
to any tools, including kitchen and/or medical equipment. Youth are allowed to use cleaning
items such as mops, brooms, and other common household items when completing general
cleaning under staff supervision. There were no observations of youth using the permitted items
during the annual compliance review week. Seven interviewed staff stated youth are allowed to
use mops and brooms.
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Office of Accountability and Program Support Page 54 of 59 (Revised July 2023)
Seven youth were interviewed and five stated they are allowed to use mops and brooms. The
remaining two youth stated they don’t use tools. Six of the seven youth stated they use cleaning
agents such as bleach, laundry soap, window, and toilet cleaners with the staff spraying the
chemicals and the youth wiping. The remaining youth has never used cleaning agents.
5.11 Inventory of all Flammable, Toxic, Caustic, and Poisonous
Failed Compliance
Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the Material Safety Data Sheets
(MSDS) on hand in the facility. Toxic or caustic materials shall not be allowed to enter into the
facility unless an MSDS is on file in an MSDS logbook and posted near items. A master copy
of the MSDS logbook shall be maintained in an accessible binder for all personnel to review
at all times.
No hazardous chemicals should be mixed, as this could result in an explosion or emission of
toxic gas.
The center maintains facility operating procedures (FOPs) ensuring the proper use, storage,
disposal, and inventory of chemicals including poisonous, flammable, and toxic materials.
Observations of B1 living module utility room, G1 living module utility room, G1 living module
supply room, and kitchen utility room did not have inventories of any flammable, toxic, caustic,
and poisonous items during the annual compliance review. The center developed a document to
begin maintaining inventory for chemicals in each location while the annual compliance review
team was on-site. A Safety Data Sheet (SDS) binder was not located in either G1 utility room or
G1 storage room, however, one was located in both B1 utility room and kitchen. A sampling of
five items in the kitchen were selected randomly for review and each had an SDS present when
selected.
5.12 Access to all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items (Critical)
Flammable, toxic, caustic, and poisonous fluids and other dangerous substances may only be
drawn or acquired by authorized personnel.
Youth shall not be permitted to use, handle, or clean-up dangerous or hazardous chemicals
or respond to chemical spills. Youth shall not be permitted to clean, handle, or dispose of any
other person’s bio hazardous material, bodily fluids, or human waste.
The center maintains facility operating procedures (FOPs) to ensure limited access to
flammable, toxic, caustic, and poisonous items. Only authorized personnel are permitted access
and use to 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. Seven interviewed staff
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Office of Accountability and Program Support Page 55 of 59 (Revised July 2023)
stated youth are not allowed access to toxic, flammable, or poisonous substances. Seven
interviewed youth stated they do not have access to toxic, flammable, or poisonous substances.
5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center 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 not used for cooking. An informal interview with the maintenance mechanic
indicated all hazardous materials are disposed appropriately.
5.14 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures (FOPs) ensuring confinements under twenty-four
hours are used as an immediate, short-term response to incidents which affect the physical
safety of youth or others. The center had a total of 640 confinements during the annual
compliance review period. A sample of twenty confinement reports were reviewed. Thirteen of
twenty documented youth had received a meal or snack and seven did not document one was
provided. One youth requested access to mental health care and received it. Eleven out of
twenty reports documented showers were received, as required, and nine did not. Seventeen of
twenty documented clean clothing and mattress and bedding had been provided, as required,
three reports did not document these were provided. Twelve of twenty documented education
materials were provided, as required, however, eight did not document education materials
were provided. Seventeen reports documented the youth was notified of their right to grieve a
confinement placement whereas three did not have this documentation. The supervisor
approved all twenty confinements. Reviewed documentation found only one youth was placed in
each confinement room. All rooms were searched, and documentation of the search entered in
facility management system (FMS). Sixteen of twenty Visual Observation Reports (VOR)
confirmed the staff supervised youth every five minutes the first hour. Four records indicated the
staff documented checks on the VORs every ten minutes. Four records did not have
documentation of a VOR to verify youth supervision.
Two confined youth had a physical injury as documented in the Individual Healthcare Record
and all procedures were followed with no discrepancies. All twenty youth received explanation
on why they were in confinement. Nineteen of twenty youth records documented a supervisor
conducted an initial confinement review within the required one hour from the incident. The
supervisor conducted the initial confinement review at two hours for the remaining record.
Nineteen of twenty confinements reports were completed by the end of the shift, as required.
One was completed the next day. Seventeen reports documented the supervisor conducted
additional reviews with the youth at a minimum of every three hours and documented the
reviews in FMS, as required whereas three did not document the review. Each confinement
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Office of Accountability and Program Support Page 56 of 59 (Revised July 2023)
report confirmed the supervisors/staff continually counseled the youth and considered removing
the youth from confinement as soon the youth was able to safely rejoin the population and there
was no threat to safety. Nineteen of the twenty confinement reports were reviewed by the
superintendent or designee within forty-eight hours to determine if each confinement was
appropriate. The remaining was approved five days later. None of the confinements interfered
with visitation. None of the confinements had a medical professional object to the placement. No
alternative recommendations were necessary in the reviewed reports. There were no pregnant
youth confined during the annual compliance review period.
Seven interviewed staff were able to explain the center’s step by step process for placing a
youth in confinement. In addition, all staff stated youth are provided with education materials
when placed in confinement. The superintendent was interviewed and stated the administrative
team, major, and captains review all incidents and confinement reports. The reports are
reviewed within forty-eight hours to ensure the youth were placed in confinement for cause. The
reports are reviewed on a monthly basis by regional staff.
5.15 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
The center did not have confinement reports over twenty-four hours during the annual
compliance review period; therefore, this indicator is rated non-applicable.
5.16 Continuity of Operations Planning (COOP) Drills Limited Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains facility operating procedures (FOPs) establishing a procedure for
conducting drills to address the Continuity of Operations Plan (COOP). Only one drill out of the
required two drills were completed during the annual compliance review period. A review of the
conducted hurricane drill did not have a brief scenario, participant names, findings, and
recommendations. Seven staff were interviewed, and only one staff confirmed participation in a
COOP drill for a major disturbance drill during the annual compliance review period. Five staff
did not state if they participated in COOP drills and one staff stated due to shift hours is not
always present when drills are being conducted. The interviewed superintendent stated the
facility conducts at least two COOP drills per year. At least one drill is required to be conducted
before the start of the hurricane season which begins June 1st. The facility shall conduct
quarterly escape drills for all shifts. Fire drills shall be conducted monthly for each shift; medical
drills shall be conducted monthly by each shift; mock suicide drills shall be conducted monthly
by each shift.
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Office of Accountability and Program Support Page 57 of 59 (Revised July 2023)
5.17 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center maintains facility operating procedures (FOPs) to address escape drills and escape
prevention. Quarterly drills were conducted on each shift as required and documented in the
center’s logbook. Seven in-service training records were reviewed, and each staff completed
training in security and escape prevention annually. Seven staff were interviewed, and five
confirmed completing escape drills annually. One stated they have not participated in any drills
due to shift hours and not always present when drills are being conducted. The remaining staff
did not mention completing escape drills.
5.18 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a 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. Thirty-four of thirty-six fire drills were documented in the logbook, and two were not
documented. 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 six stated they
had not been instructed on what to do in case of a fire. The remaining youth stated they had
been instructed on what to do in case of a fire.
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Office of Accountability and Program Support Page 58 of 59 (Revised July 2023)
5.19 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) for search and contraband procedures.
Strip searches shall be conducted during admission, if there is a reasonable suspicion a youth is
harboring contraband, and when deemed appropriate by the shift supervisor. All searches are to
be documented in the logbook. Staff shall wear gloves during all searches. There was one
incident report reviewed for a strip search during the annual compliance review period. Both
staff were the same gender and present when conducting the search. Electronic searches are
conducted on all staff and visitors entering the facility. All bags, cases, jacket pockets, and other
items were searched. All personal keys, personal cell phones, and other contraband items were
prohibited from entering the secure area. Prior to admission, all youth are searched for
contraband by electric wand and strip searches when deemed appropriate by the shift
supervisor due to reasonable suspicion the youth is harboring contraband. All searches were
documented in the logbook. Room searches are conducted upon a youth’s release, prior to new
youth being placed in a room, and searched for contraband on each awake shift. A sampling of
one day from each month during the annual compliance review period indicated room searches
were completed during each awake shift. There were no instances which may have
compromised the safety and security of the center throughout the annual compliance review
period. Searches of all staff, visitors, and contractors/vendors were completed prior to entering
the secure area. During the annual compliance review period there was one item confiscated
but it was not documented in the logbook. An incident report was completed and law
enforcement was not called due to the item found not being considered illegal as defined in
Florida Statutes. The item was confiscated by the discovering officer and obtained by the
supervisor. The Department’s Central Communications Center (CCC) was notified of the
discovery and confiscation. Notifications were completed as required.
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Office of Accountability and Program Support Page 59 of 59 (Revised July 2023)

source: DJJ

report_type: QI Detention

rule: Indicator 2.09

excerpt: Daily Activity Schedule

rating: Limited Compliance

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Failed Compliance

rule: Indicator 4.15

rule: Indicator 5.06

excerpt: Logbook Reviews

rule: Indicator 5.11

rule: Indicator 5.16