state: FL

facility_name: Duval Academy

summary: QI Detention - FY23-24

raw_content:
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
BUREAU OF MONITORING AND
QUALITY IMPROVEMENT
Annual Compliance Report
Duval Regional Juvenile Detention Center
Department of Juvenile Justice
(State-Operated)
1241 E. 8th St
Jacksonville, Florida 32206
Review Date(s): January 30-February 2, 2024
Promoting Continuous Improvement and Accountability
in Juvenile Justice Programs and Services
Rating Definitions
Ratings were assigned to each indicator by the review team using the following definitions:
No exceptions to the requirements of the indicator; or limited,
unintentional, and/or non-systemic exceptions which do not result
Satisfactory
in reduced or substandard service delivery; or systemic
Compliance
exceptions with corrective action already applied and
demonstrated.
Systemic exceptions to the requirements of the indicator;
Limited exceptions to the requirements of the indicator which result in the
Compliance interruption of service delivery; and/or typically require oversight
by management to address the issues systemically.
The absence of a component(s) essential to the requirements of
Failed
the indicator which typically requires immediate follow-up and
Compliance
response to remediate the issue and ensure service delivery.
Review Team
The Bureau of Monitoring and Quality Improvement wishes to thank the following review team
members for their participation in this review, and for promoting continuous improvement and
accountability in juvenile justice programs and services in Florida:
Kristine Harshaw, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 2)
Renette Crosby, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Tara Gilligan, Office of Accountability and Program Support, Regional Monitor (Standard 3)
Patrick McKinstry, Office of Accountability and Program Support, Regional Monitor (Interviews)
James K. Phillips, Office of Accountability and Program Support, Regional Monitor (Interviews)
Molly Stewart, Detention Services, Detention Analyst/Special Projects Unit (Standard 5)
LaTonia Taylor, System Improvement Coach, Office of System Innovation (Standard 2)
Program Name: Duval Regional Juvenile Detention Center MQI Program Code: 131
Provider Name: Department of Juvenile Justice Contract Number: N/A
Location: Duval County / Circuit 4 Number of Beds: 95
Review Date(s): January 30 – February 2, 2024 Lead Reviewer Code: 187
This review was conducted in accordance with FDJJ-2000 (Contract Management and Program
Monitoring and Quality Improvement Policy and Procedures), and focused on the areas of (1)
Management Accountability, (2) Youth Management, (3) Mental Health and Substance Abuse
Services, (4) Health Services, and (5) Safety and Security, which are included in the Detention
Standards.
Overall Rating Summary
Overall Rating Summary
All indicators have been rated Satisfactory and no corrective action is needed at this time.
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 57 (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 57 (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 Satisfactory
2.10 Educational Access* Satisfactory
2.11 Career Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 57 (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 * Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result in
a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 57 (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 Satisfactory
4.16 Medication/Sharps Inventory and Storage Process Satisfactory
4.17 Infection Control/Exposure Control/Education Satisfactory
4.18 Prenatal Care/Education Satisfactory
* The Department has identified certain key critical indicators. These indicators represent critical areas that require immediate attention if a program operates
below Department standards. A program must therefore achieve at least a Satisfactory Compliance rating in each of these indicators. Failure to do so will result
in a program alert form being completed and distributed to the appropriate program area (detention, residential, probation).
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 57 (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 Satisfactory
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 Satisfactory
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 Satisfactory
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory
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 57 (Revised July 2023)
Program Overview
The Duval Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Jacksonville, Florida. The center serves youth in Clay, Duval, and
Nassau counties in Circuit 4. Male and female youth who are detained pending adjudication,
disposition, or placement in a residential commitment program are housed in the ninety-five-bed
center. Youth are provided services which include youth orientation, behavior management,
safety and emergency procedures, transportation, mental health, and healthcare services. The
center’s educational services are provided by the Duval County School Board. The center’s
management team includes the superintendent, two assistant superintendents, two
administrative assistants, nine juvenile justice detention officer (JJDO) supervisors, and sixty-
four JJDOs. Mental health and healthcare services are provided through the contracted
provider, VitalCore Health Strategies, LLC. Mental health services are provided by a licensed
mental health counselor (LMHC) serving as the designated mental health clinician authority
(DMHCA) and a psychiatrist. The DMHCA supervises four 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 a licensed medical
doctor serving as the center’s designated health authority (DHA), one part-time advanced
practice registered nurse (APRN), three registered nurses (RNs), one part-time RN, and one
full-time licensed practical nurse. The medical clinic maintains nursing coverage from 6:00 a.m.
to 6:00 p.m., Monday through Friday, and from 7:00 a.m. to 5:00 p.m. on weekends. Food
services are provided by Department staff and include menus, meal planning, meal schedules,
special diets, nutritional analysis, daily allowance, food preparation, health certifications, food
product standards, sanitation, and cleaning. Staff are responsible for the custody and control of
youth in their care, providing youth supervision twenty-four hours a day, seven days a week.
The center has five living modules which are divided by male and female. There are 109
security cameras at the center, of which 109 were operational. A completed tour of the center’s
buildings, grounds, all youth living modules, administrative offices, recreation areas, kitchen,
and maintenance areas found areas to be clean with no noticeable graffiti or odor. Most of the
center has been recently painted and some areas were still in the process of being painted
during the annual compliance review week. At the time of the annual compliance review, the
center had six vacancies, which included three JJDOIs and three JJDOIIs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 57 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures to ensure all staff, contracted providers,
volunteers/interns, and mentors with access to youth undergo a criminal history background
check prior to hire or providing services. A review of the center’s staff roster showed the center
hired thirty-nine new Department staff, thirty-two new volunteers, and five new contracted staff
providing services to youth since the last annual compliance review. A review of personnel
records for all newly hired staff showed a background screening reflecting each received
clearance from the Department’s Background Screening Unit (BSU) for Department staff and
the Clearinghouse for contracted staff or volunteers prior to each staff’s hire date and/or contact
with youth and confidential youth records. Thirty-six direct care staff were applicable for a pre-
employment assessment tool to be administered. All thirty-six staff earned a passing score. A
copy of the pre-employment assessment was maintained within each staff record. Three
Department staff had a break in service and were previously employed by center. A new
background screening was completed on all three staff prior to hiring. The center’s Annual
Affidavit of Compliance with Level 2 Screening Standards was completed and submitted on
January 4, 2024, meeting the annual requirement. The Annual Affidavit of Compliance with
Level 2 Screening Standards for school board teachers was submitted to the
BSU/Clearinghouse on January 10, 2024.
1.02 Five-Year Rescreening Satisfactory Compliance
Background rescreening and resubmission is conducted for all Department staff and
volunteers and all contracted provider and grant recipient staff, volunteers, mentors, and
interns with access to youth and confidential youth records. Staff and volunteers are
rescreened every five years.
The center has facility operating procedures to ensure all staff, contracted providers, volunteers,
mentors, and interns with access to youth undergo a criminal history background check every
five years. A review of staff personnel records found three center staff were applicable for the
completion of a five-year rescreening since the last annual compliance review. All three staff
had a five-year rescreening submitted to the Department’s Background Screening Unit
(BSU)/Clearinghouse at least ten days prior to the five-year anniversary date, as required.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 10 of 57 (Revised July 2023)
1.03 Staff Code of Conduct Satisfactory Compliance
Center staff adheres to a code of conduct prohibiting any form of abuse, profanity, threats,
harassment, intimidation, “horseplay,” or personal relationships with youth.
Officers shall maintain the confidentiality afforded to all youth and shall not release any
information to the general public or the news media about any youth in the center or who has
been in the custody of the Department.
Officers shall not verbally abuse, demean or otherwise humiliate any youth, and shall not use
profanity in the performance of their job.
Officers shall not engage in or allow horseplay, either verbal or physical, with and/or between
any youth.
Officers shall not engage in personal relationships nor discuss personal information related to
themselves or other officers with any youth.
Management takes immediate action to investigate or address all allegations or violations of
the code of conduct.
The center has facility operating procedures addressing the code of conduct. At hire, each staff
signs the code of conduct acknowledging they have read and understand all expectations and
consequences of any violations. There were three substantiated conduct violations by staff
during the annual compliance review period according to an informal interview with the
superintendent and a review of reports to the Department’s Central Communication Center
(CCC). All three of the reviewed incidents resulted in either the termination or resignation of the
staff. Three detention staff received commendations during the annual compliance review
period, including employee of the month, perfect attendance, and Field Training Coordinator of
the Year. The interview with the superintendent indicated the center follows facility operating
procedures regarding the Staff Code of Conduct.
Nine staff were interviewed, and each indicated they are knowledgeable in the process for
allowing youth to call the Florida Abuse Hotline or CCC. All nine staff indicated youth are able to
make the call if requested, typically with the supervisor. Four staff stated they have never heard
other staff using profanity, four staff stated they have heard other staff use profanity once, and
one staff reported occasionally; however, when asked these staff reported the cursing was not
directed towards the youth. All nine staff stated they have never observed staff using threats or
intimidation when interacting with youth. Two of nine staff stated the working conditions were
very good at the center during the annual compliance review period, six stated they were good,
and one staff stated the working conditions were fair. Nine of nine interviewed youth stated staff
at the center are respectful, they have never heard staff threaten any youth, exchanged
telephone numbers, emails, or social media contact with staff, and they feel safe at the program.
One interviewed youth stated they have never been stopped from reporting abuse and eight
youth stated they have never needed to make an abuse call. When asked if they have heard
staff using profanity, six youth stated never, two youth stated once, and one youth stated
occasionally; however, each of these three youth confirmed the profanity was never directed at
youth.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 57 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures in place regarding incident reporting. A tour of the
center was conducted, and observations reflected there were signs posted throughout the
center of the Florida Abuse Hotline and the Department’s Central Communications Center
(CCC) telephone numbers. The center had ninety-two incidents reported to the CCC during the
annual compliance review period, of which nine were reviewed. Each of the nine incidents
reflected being reported to the CCC within the mandatory two-hour time frame and in
accordance with the CCC reporting procedures. A review of internal incidents/grievances for the
past twelve months determined there were no incidents which should have been reported to the
CCC but were not. The center is to document all incidents, whether accepted or not accepted by
the CCC, in the master control logbook. A review of the master control logbook reflected all nine
CCC reports were documented in the logbooks. An interview with the center’s superintendent
confirmed within two hours of being notified of an incident, a supervisor or above will call CCC
or the Florida Abuse Hotline to report said incident. If a youth is requesting an abuse call, the
youth will be given a private space to conduct the call immediately. Once the call is made, the
supervisor ensures there is an incident report conducted, a call to the parent/guardian and
detention leadership is made, and lastly informing any other pertinent party such as local law
enforcement, medical, or mental health staff.
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.
The center has a facility operating procedure to ensure staff use physical intervention
techniques in accordance with the Florida Administrative Code requirements. The center had
265 Protective Action Response Right Interactions model (PAR/RI) incidents since the last
annual compliance review. A review of nine PAR/RI Reports was completed, and each was
completed the same day as the PAR/RI incident. Each report contained statements from all the
staff involved. Each report was reviewed by a supervisor, PAR/RI instructor, and the assistant
superintendent within the required time frame. Each PAR/RI Report documented a post-PAR/RI
interview was conducted with the youth by the center’s superintendent and/or designee within
thirty minutes after the incident. A review of internal incident reports, grievances, and logbooks
indicated there were no additional PAR/RI incidents which did not have a report. None of the
reviewed PAR/RI incidents were applicable for mechanical restraints, a medical review, or a
post-PAR/RI medical review. An interview with the superintendent indicated prior to the end of
the shift, a supervisor will review the camera recordings and conduct a PAR/RI review to ensure
each was in compliance with the center’s policy. Within forty-eight hours, an administrator will
do the same and ensure it is all documented within the Department’s Juvenile Justice
Information System (JJIS). A review of nine pre-service and nine in-service training records
verified staff were trained in the use of PAR/RI. Nine staff were interviewed, and each indicated
staff utilize verbal interventions before use of physical restraints or PAR/RI techniques on a
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 12 of 57 (Revised July 2023)
youth. The center’s PAR/RI rate during the previous quarter was 11.96 which is below the
statewide Detention PAR/RI rate of 16.29.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures to ensure pre-service training is in accordance with
Florida Administrative Code. The center abides by the detention center statewide annual
training plan. The annual training plan serves as a written list of training curricula for all state-
operated secure detention centers in Florida. A review of nine staff training records indicated all
completed pre-service certification requirements within 180 days of hire to encompass Phase
One and Phase Two training. The nine reviewed staff received orientation within thirty days of
hire and the staff training included active shooter preparedness, human trafficking intervention,
cardiopulmonary resuscitation (CPR)/first-aid/automated external defibrillator (AED), information
security awareness, mental health and substance abuse, Prison Rape Elimination Act,
Protective Action Response Right Interactions model, professionalism, interpersonal
communication, and ethics, as well as sexual harassment, trauma responsive practices, and
suicide awareness and prevention. Reviewed documentation confirmed each applicable staff
completed all trainings required by the Department prior to having contact with youth. All pre-
service 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.
The center maintains a facility operating procedure to ensure staff successfully complete
ongoing in-service training, as required. The center requires twenty-four hours of in-service
training for staff through a combination of the Department’s Learning Management System
(SkillPro) and instructor-led classes. The policy requires supervisors to complete an additional
eight hours of supervisory training annually. Nine staff training records were reviewed for in-
service trainings including six direct care staff and three supervisory staff. Each reviewed record
reflected staff exceeded the required twenty-four hours of in-service training. All nine included
all the required topics with the exceptions of one staff missing Human Trafficking Awareness,
Information Security, and Trauma Responsive Practices, and another staff missing Active
Shooter Preparedness and Trauma Responsive Practices. This was shared with the center’s
superintendent. Three staff were applicable for a minimum of eight hours of supervisory training.
Each staff exceeded the required eight hours of supervisory training in the required topics. All
trainings were entered into SkillPro. The center’s licensed nursing staff provide in-service
training on girls’ healthcare annually to all non-healthcare staff involved in the supervision or
treatment of girls. The center’s annual training plan was approved on November 17, 2023. The
center has an annual in-service training calendar which is updated as changes occur. The
superintendent indicated their supervisory training included leadership development and
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Office of Accountability and Program Support Page 13 of 57 (Revised July 2023)
training, professionalism, stress management, communication, delivering constructive criticism,
and customer service.
1.08 Grievances Satisfactory Compliance
The grievance procedures establish each youth’s right to grieve and ensure all youth are
treated fairly, respectfully, without discrimination, and their rights are protected. The process
includes:
1. Informal phase, wherein the JJDO attempts to resolve the complaint or condition with
the youth using effective communication skills;
2. Formal phase, wherein the youth submits a written grievance resulting in a response
from a JJDO supervisor by the end of the shift (if possible), or otherwise within twenty-
four hours; and
3. Appeal phase, wherein the youth may appeal the outcome of the formal phase to the
superintendent or designee.
The center has a facility operating procedure to ensure each youth has the right to grieve and
ensure all youth are treated fairly, respectfully, without discrimination, and their rights are
protected. The policy indicates each youth has the right to grieve the actions of the center staff,
and youth cannot be punished for filing a grievance, whether it is substantiated or
unsubstantiated. The grievance process is explained to the youth during orientation. The
grievance process consists of three phases. The first is the informal phase which is completed
by staff whereby the youth and staff attempt to resolve the youth’s issue. A written grievance is
submitted to the juvenile justice detention officer supervisor (JJDOS). If the staff is unable to
resolve the issue, this begins the formal grievance process. The appeal phase requires a
response from the superintendent or designee. Grievance forms are electronically maintained in
the Department’s Facility Management System (FMS). Each grievance is forwarded to the on-
duty JJDOS within the required time frame, through FMS, and the youth is informed of the
findings. The superintendent or designee then reviews the completed grievance form within
seventy-two hours of receipt, excluding weekends and holidays. Grievance forms were
observed to be posted and accessible to the youth in each living module. The center had two
formal grievances during the annual compliance review period. Both of the formal grievances
were reviewed, and each was resolved as required. Neither entered into the appeal phase. A
formal interview with the superintendent confirmed the grievance procedures and indicated
when a youth completes a grievance form, the signed hard copy is maintained in a separate
grievance file uploaded in FMS. Grievance records are kept for three years. Nine youth were
interviewed, and one youth rated the grievance process as fair. Eight youth stated they have
never filed a grievance. Nine staff were interviewed, and each indicated they understood the
grievance process and procedures.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 14 of 57 (Revised July 2023)
1.09 Entering Alerts (JJIS) and Sharing of Alert Information
Satisfactory Compliance
(Critical)
Superintendents shall ensure critical and special alerts are reviewed and responded to
appropriately.
Upon completion of the Admission Wizard, the officer shall ensure all critical and special
alerts are listed in JJIS.
The JJIS alert report shall be reviewed daily by supervisors and administrators to ensure it
correctly reflects the status of youth.
If the electronic system is inoperable, for any reason, the juvenile justice detention officer
supervisor (JJDOS) shall ensure the last hard copy of the alerts shall have a written
notification or update of the recent admissions or changes to existing alerts on the alert sheet
and distribute to all staff within the center immediately.
Medical and mental health staff shall review alerts to ensure each alert is correctly tracked
and managed.
The responses and updates by medical, mental health, and other staff should be documented
in JJIS alerts as they pertain to the specific alert.
JJDOSs shall inform staff of alerts during shift briefing. When a JJDOS receives changes to
the alert list, he/she shall notify the staff affected by changes and add the information to the
shift briefing for the oncoming shift upon receipt of the information.
The center has facility operating procedures to ensure critical or special alerts are documented,
reviewed, and responded to appropriately. Alerts are entered into the Department’s Juvenile
Justice Information System (JJIS), as well as the internal alert system. Internal alerts and JJIS
alert reports are distributed and reviewed daily by the juvenile justice detention officer (JJDO)
supervisors and administration. Alerts are entered, downgraded, or discontinued in JJIS by the
appropriate staff on the date identified and/or when the alert is no longer applicable. All alerts
regarding youth medication or medical information are confirmed and verified between the
medical staff and youth’s parents/guardians. The center's practice is to have a copy of the
detailed alert list for all JJDOs during each shift briefing. An observation of a shift briefing during
the annual compliance review week supported youth alert information was consistently
discussed with the JJDOs at the meeting, and JJIS was updated by medical, mental health, and
other staff, as needed. Nine youth records were applicable for case management, medical, and
mental health alerts. Each applicable record documented all alerts were accurately entered into
JJIS. Logbooks were reviewed and reflected alert documentation included gang affiliation,
medical status, Prison Rape Elimination Act (PREA) status, security alerts, mental health alerts,
dietary restrictions, and activity/sports restrictions. The center’s superintendent stated youth
alerts are added by staff during the admission process based on information given at the time.
Medical staff then verify the alerts. Nine staff were interviewed, and each reported being
informed of alerts, seven reported learning of alerts through the alert forms, four staff stated
learning from JJIS, three staff reported they are informed of youth alerts during shift briefings,
and two from “bed sheets”, which are alerts lists specific for each dormitory. One staff reported
they learn alerts through a review of the center logbook. All nine staff reported management
informs staff about issues within the center during shift briefings, two said by documenting
information in the center logbooks, and two stated through shift meetings. Three of nine
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Office of Accountability and Program Support Page 15 of 57 (Revised July 2023)
interviewed staff stated communication is very good, four reported it is good, and two reported it
is fair.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center collects data in the Department’s Juvenile Justice Information System (JJIS) on a
daily basis, including Protective Action Response/Right Interactions model (PAR/RI) Reports,
the Department’s Central Communications Center (CCC) reports, alerts, confinements, Prison
Rape Elimination Act (PREA) documentation, and various additional reports. The facility collects
data weekly including behavior management system (BMS), youth supervision and uniforms,
logbooks, and education start and finish times. Additionally, the facility focuses on trends with
codes, confinements, and staff vacancies. Supporting documentation reflected regular data
collection and discussion during management and shift meetings. This information is shared
weekly with providers and stakeholders, as well as monthly with the advisory board, and
quarterly with the circuit advisory board/community safety board. This was documented in the
minutes from advisory board meetings. The center superintendent reported the center has used
the data to improve school times, reduce graffiti and paint peeling, increase proper uniform wear
by the youth, lowering staff vacancies, and improving the overall daily operations.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 16 of 57 (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 utilizes an Admission Wizard in the Department’s Juvenile Justice Information
System (JJIS) which documents admission requirements. Nine youth records were reviewed.
Eight youth records had the arrest affidavit/custody order in the record. One youth did not
receive an arrest affidavit. The center reported this youth was remanded in court and did not
receive an arrest affidavit. The Admission Wizard in each youth record documented all nine
youth received a full-body search/electronic search, a telephone call, and meal if needed. Each
youth received medical, mental health, and substance abuse screenings. One youth was
observed being admitted into the center during the annual compliance review week. The youth
was searched with the metal detection wand and given a chance to shower. The youth was
advised a meal would be brought in after the intake process was completed, and they would be
given an opportunity for a phone call. The youth watched an orientation video and personal
property was taken from the youth and placed in storage bag, labeled, and taken to the storage
area.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 17 of 57 (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 has a facility operating procedure to ensure each youth admitted into the center is
informed of the center rules and regulations, grievance procedures, visitation, telephone calls,
expectations for behavior, related consequences for failing to meet behavior expectations, and
youth rights within twenty-four hours of admission. Nine youth case management records were
reviewed. Each record included an orientation packet and documentation reflecting the youth
received orientation within twenty-four hours of admission. All nine reviewed youth records had
documentation to validate the orientation was explained verbally and in writing by the juvenile
justice detention officer (JJDO). All nine records had youth signatures as well as staff signatures
on the orientation form. Each orientation packet included information on rules and regulations,
youth rights, dress code, personal hygiene, visitation, telephone calls, education, daily schedule,
mental health, grievance procedures, access to medical, mental health, and substance abuse
services, access to the Florida Abuse Hotline, access to the Department’s Central
Communications Center (CCC), the behavior expectations, the behavior-related consequences,
and PREA-related information. Each of the nine reviewed case management records had an
orientation acknowledgement form signed by the youth. Nine youth were interviewed and each
youth indicated they had been provided information regarding the center’s rules and regulations,
daily schedule, education services, visitation, abuse reporting, and behavior management
system. An admission and orientation were observed during the week of the annual compliance
review, the observation confirmed the orientation was conducted as required.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 18 of 57 (Revised July 2023)
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 a facility operating procedure ensuring all youth admitted into the center are
classified to ensure the highest level of safety and security. The center’s policy listed all the
required elements, including human trafficking information, sex, height, and weight. All youth are
given a room assignment based upon their classification and may be reclassified if there are
any changes in the status or behavior. The center reviews several factors prior to placing the
youth into a room inclusive of height, weight, age, gender, level of aggression, mental illness,
developmental disabilities, physical disabilities, history of violence, gang affiliation, criminal
history, history of sexual offenses, vulnerability to victimization, suicide risk identified or
suspected, medical, and security and escape risk. Youth with a history of sexual offenses, a
victim of a sexual offense and/or abuse, or youth determined to be physically or sexually
aggressive are not to be placed in a room with any other youth. Additionally, the policy requires
a review of the Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) results
documented by the staff when making a youth’s room assignment. All youth requiring a single
room shall have an alert entered in the Department’s Juvenile Justice Information System
(JJIS). Nine youth case management records were reviewed for classification. In each of the
nine records, Admission Wizard documentation included the classification results and the
screening for the VSAB. Each reviewed youth case management record contained the VSAB
form and the Suicide Risk Screening Instrument (SRSI). Nine reviewed youth records contained
a classification form which identified the module or room classification of where the youth was
placed. One of the nine reviewed records notated the youth had suspected affiliation with a
gang. An interview with the superintendent confirmed all youth are screened and assigned to
rooms according to age, size, VSAB results, and other possible alerts. The superintendent
noted all youth are assessed and assigned rooms based upon all the above factors to ensure
the highest opportunity to provide a safe and secure atmosphere. Youth are housed based upon
classification.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 19 of 57 (Revised July 2023)
2.04 Notification of Juvenile Probation Officer Circuit Gang
Satisfactory Compliance
Representative
Each center shall identify the juvenile probation officer (JPO) designated as the circuit gang
representative to communicate suspected gang activity.
A referral for youth with suspected gang involvement shall be shared, by e-mail, with the
circuit gang representative, indicating suspicions of gang activity such as youth flashing gang
signs, gang tattoos, gang-related drawings, or related activity.
Center staff should include in the e-mail pictures (when appropriate), copies of written
statements, drawings, graffiti, and a description of what gang signs the youth was “flashing.”
The center has a facility operating procedure in place to ensure all information regarding
suspected youth gang affiliation is shared with the circuit gang representative. The
superintendent meets weekly with local designated Gang Task Force. The juvenile justice
detention officer (JJDO) communicates with the center’s superintendent who then corresponds
with the chief probation officer (CPO) regarding all suspected gang activity. Staff are notified of
all updates and alerts during shift briefings and on the daily alert sheet. An informal interview
with the superintendent confirmed the center’s practice. Nine youth case management records
were reviewed in which none were applicable for gang affiliation. The informal interview with the
superintendent revealed there were no additional instances of suspected gang activity at the
center during the annual compliance review period to warrant communication with the circuit
gang representative. The superintendent reported it is most common for juvenile probation
officers at the Juvenile Assessment Center to identify and report suspected or confirmed gang
affiliation prior to youth entering the center.
2.05 Admission and Storage of Youth Personal Property Satisfactory Compliance
The center takes possession of each youth’s personal property during admission. In the
presence of each youth, staff inventories all personal property in the youth’s possession and
records each surrendered item on the Property Receipt Form. The center safeguards each
youth’s personal property until it can be returned to the youth and/or parent/guardian.
The center has a facility operating procedure in place ensuring the proper safe handling and
security of personal property, including valuables, which are collected and secured at the time of
a youth’s admission. All youth personal and valuable property is maintained securely and
returned to the youth or the parent/guardian in a timely manner upon the youth’s release.
Personal items, such as clothing and shoes, are placed in a mesh bag and secured in the
center’s inventory locker room. Valuable items are listed and placed in a clear tamper-proof
property bag, identified with the youth’s name and Department identification number (DJJID),
then secured in the property cabinet located in the administrative office which is under video
surveillance. The center maintains a drop safe logbook to document the time, youth’s name,
name of the juvenile justice detention officer (JJDO) securing the property, and the JJDOs
initials. Nine youth case management records were reviewed, and each contained
documentation of a letter of acknowledgement of unclaimed property signed by the youth and
staff. Each record contained a Property Receipt form documenting the assigned locker for
personal items. An observation of all nine personal property bags was conducted and each
contained an inventory form. One reviewed record contained a Property Receipt form for
valuable items. One admission was observed during the annual compliance review week and
property was inventoried and stored as required. The drop safe bound logbook contained all
required elements for applicable reviewed records. A review of the Department’s Central
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 20 of 57 (Revised July 2023)
Communications Center (CCC) reports since the last annual compliance review found no
incidents regarding youth property. All nine interviewed youth stated staff checked their property
inventory and each youth signed stating the inventory was correct. The superintendent interview
confirmed the center’s property storage practice. Each admitted youth signs a property sheet,
verifying their property was accounted for and secured. The property is locked in a secure area
until the time of the youth's release from the center. The interview with the superintendent
verified only certified JJDOs have access to the youth property room where youth property is
stored. The area is under video surveillance and is only accessed by supervisors or
transportation staff. A letter is sent out to the last known address stating the youth has thirty
days to pick up property. If the property is not claimed, the property is disposed of and
documented. If there is money not claimed, a money order will be purchased and sent to the
regional fiscal manager, who then forwards it to the Department’s headquarters designee. The
Personal Property Receipt form includes the youth signature, staff signature, letter of
acknowledgment regarding unclaimed property signed by the youth. All money and personal
items of value shall be verified and secured in a clear tamper proof property bag, and the
tamper proof bag will be placed in a drop safe. An observation of the center receiving personal
property from a youth was made during the annual compliance review week. The youth’s
property was stored in the secure area with access limited to designated staff only.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth.
All releases from the center are court-ordered, with the exception of deaths, escapes, and
expirations of detention time period. In the absence of a written order, documentation of a
verbal order in open court may be used for release.
The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The JJDO
Supervisor is responsible for ensuring there are no holds, court orders, or other legal reasons
not to release the youth.
Questions concerning release are presented and addressed by the superintendent, or
designee, prior to release.
The releasing officer shall verify the identification of the youth.
The center has a facility operating procedure regarding youth release. In all three closed youth
case management records reviewed a juvenile justice detention officer supervisor (JJDOS)
reviewed all paperwork related to each youth’s release prior to release, including paperwork
received from the court. All three records included verification of youth identification prior to
release and a copy of photo identification of the parent/guardian or responsible adult picking the
youth up. None of the three the youth had previously been identified as an endangered person.
Each of the three records required a reminder of future court dates, which was documented.
The three records contained all required release forms, which were signed and the date of
admission and release on each case management record matched with the dates listed in the
Department’s Juvenile Justice Information System (JJIS). During the annual compliance review
week there were no releases occurring during the daytime, so the review team was unable to
observe a release.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 21 of 57 (Revised July 2023)
2.07 Release of Youth Personal Property, Medication,
Satisfactory Compliance
Aftercare Instructions
Upon a youth’s release from the center and retrieval of personal property, the releasing
officer, the youth, and the youth’s parent/guardian shall review and sign the Property Receipt
Form and account for all of the youth’s personal property. The center ensures there are
provisions in place to ensure prescribed medication, along with medical instructions,
accompanies detained youth upon release.
The center has facility operating procedures regarding the release of personal property and
medication. Three closed youth case management records were reviewed, and each
included a Receipt of Property form signed by each youth and their parent/guardian, as well as
a photocopied identification card of the person picking them up, showing each youth was
released to an appropriate person. None of the three youth were on medication at the time of
release. In an interview with the superintendent, it was explained if youth property is not
returned to the youth upon release, a letter is sent out to the last known address stating the
youth has thirty days to pick up the property. If the property is not claimed, the property is
disposed of, and this is documented. If money is unclaimed, a money order will be purchased
and sent to the regional fiscal manager, who then forwards it to the Department’s headquarters
designee.
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 a facility operating procedure ensuring detention reviews are conducted
weekly for youth placed on secure detention, home detention, or on electronic monitoring to
ensure proper management of youth and the sharing of information. Detention reviews are
conducted on a weekly basis to address the status of each youth. The center has a designated
staff appointed to coordinate the weekly detention reviews. The juvenile justice detention officer
II (JJDOII) reported updates are provided regarding the youth’s next court date, behavior while
in detention, residential placement status, and release status. Reviewed documentation found
the reviews were conducted with the center’s staff including medical, education, mental health,
commitment, and representatives from probation. All staff attending in-person signed the sign-in
sheets. Attendees from outside the center participated virtually utilizing video conferencing. An
interview with the superintendent confirmed detention reviews are conducted each Thursday by
video call, sharing each youth’s status updates, and attended by all required participants.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 22 of 57 (Revised July 2023)
2.09 Daily Activity Schedule Satisfactory Compliance
Youth are provided the opportunity to participate in constructive activities which will benefit
the youth and the center. The superintendent or designee develops a daily activity schedule,
which is posted in each living area and outlines the days and times for each youth activity.
Staff shall adhere to the daily activity schedules. Documentation of all activities shall be made
in all applicable logs. The on-duty supervisor must approve any significant changes in the
activity schedule and shall document the reason for the change(s) in the shift report.
Any cancellation of visitation shall be approved by the superintendent.
The center has a facility operating procedure addressing the daily activity schedule. The
center’s daily activity schedule includes daily expectations in accordance with the behavior
management system (BMS), wake up, personal hygiene, education, mealtimes, visitation,
indoor and outdoor recreation, shift changes, bedtimes, groups, and open program time. The
center provides and maintains weekday, weekend, and holiday schedules. Observations during
the annual compliance review week revealed schedules are posted throughout the center along
with a monthly activity calendar. Visitations are held twice a week for youth. During the morning
and early afternoon hours, youth are participating in education. Reviewed documentation
reflected activities included behavior management incentive parties and a variety of recreational
activities. A review of the center’s logbook and observations confirmed the center adheres to the
daily activity schedule. Nine youth were interviewed, eight youth indicated the center has a daily
schedule which is followed. One youth reported once or twice a month, when a teacher is
absent, the youth will have school on the module.
2.10 Educational Access (Critical) Satisfactory Compliance
The center shall integrate educational instruction (career and technical education, as well as
academic instruction) into the daily schedule in such a way which ensures the integrity of
required instructional time.
The center has a facility operating procedure to provide educational access. The center
provides education services through the Duval County School Board. The 250-day calendar,
which is distributed over twelve months, includes ten days used for teacher training and
planning. A review of the daily school schedule revealed the center provides three seventy-five-
minute classes and one ninety-five-minute class with a twenty-minute lunch break, fulfilling the
weekly requirement of twenty-five hours of instructional time. All youth receive credit for course
completion as appropriate. The superintendent reported all youth are in school for the required
five hours daily with minimal interference. Examples of interference would be court, visitors,
legal, or transport. A review of five random dates in the logbook revealed classes started and
ended on time or within a few minutes of the scheduled time except one day, in which classes
ended ten minutes early. Observations of video for three days indicated the school started and
ended on time or within a few minutes of the schedule. In all observations, the video revealed
the youth received above the required five hours of the required daily education requirements.
Nine staff were interviewed and reported there is minimal interference with educational
instruction. Nine youth interviewed reported the program was preparing them very well or well
regarding high school, high school equivalency diploma (GED), vocational school, employment,
and/or college. Eight of the interviewed youth attend school Monday through Friday. One youth
reported they do not attend school because they have already graduated.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 23 of 57 (Revised July 2023)
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 a facility operating procedure to provide career education. The center provides
Type 1 career education development integrated into the education curriculum, including
communication, interpersonal, life, and decision-making skills. Nine youth were interviewed, and
each reported taking math, history, science, reading, high school equivalency diploma (GED)
prep, and career education.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 24 of 57 (Revised July 2023)
Standard 3: Mental Health and Substance Abuse Services
3.01 Designated Mental Health Clinician Authority (DMHCA)
Satisfactory Compliance
[Contract Provider]
A designated mental health clinician authority (DMHCA) is required in each center. The
DMHCA is responsible and accountable for ensuring appropriate coordination and
implementation of mental health and substance abuse services in the center and shall
promote consistent and effective services and allow the superintendent and staff a specific
source of expertise and referral.
The center has a single licensed mental health professional who has been designated as the
designated mental health clinician authority (DMHCA) who is on-site forty hours each week and
ensures the appropriate coordination and implementation of mental health and substance abuse
services taking place. The Department maintains a contract with VitalCore Health Strategies,
LLC to provide mental health and substance abuse services to all applicable youth in the center.
The DMHCA is a licensed mental health counselor with a clear and active license in the State of
Florida expiring March 31, 2025. No other DMHCAs were used during the annual compliance
review period. The center has a back-up DMHCA with a clear and active license in the State of
Florida expiring March 31, 2025, who provides coverage in the DMHCA’s absence. Copies of
the DMHCA’s agreement and position description were reviewed and confirmed the weekly
hours of coverage are maintained, as required.
An interview with the DMHCA confirmed the center provides mental health and substance
abuse services and 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 while in secure
detention during the intake process. Youth who are prescribed psychotropic medication are
scheduled for an initial evaluation with the psychiatrist within fourteen days of arrival and every
thirty days thereafter until released. Youth who are not prescribed psychotropic medication are
seen by mental health staff by their fourteenth day for mental health orientation. Youth receiving
mental health services are seen by mental health staff once a week, at minimum. Any youth in
secure detention by their thirty-first day receives a Substance Abuse and Mental Health
Assessment to determine if services are needed. The DMHCA went on to explain
communication between the DMHCA and clinical staff takes place daily.
3.02 Licensed Mental Health and Substance Abuse Clinical
Satisfactory Compliance
Staff [Contract Provider] (Critical)
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The clinical supervisor ensures the licensed clinical staff working under their supervision are
performing services they are qualified to provide based on education, training, and experience.
The licensed mental health professional is licensed under the appropriate Florida Statute
chapter and copies of the licenses are available on-site. The center has four full-time licensed
mental health staff. The licenses of all four mental health professionals expire on March 31,
2025 and staffing was in accordance with the provider’s contract.
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Office of Accountability and Program Support Page 25 of 57 (Revised July 2023)
3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The Department maintains a contract with VitalCore Health Strategies, LLC to provide mental
health and substance abuse services to all applicable youth in the center. All mental health
services are being provided by a licensed mental health professional. There are no non-licensed
mental health staff providing services at the center. The center does not have a Chapter 397
license, as such, all substance abuse services are being provided by licensed mental health
professionals. The contract with the Department confirms the center is not required to have any
non-licensed clinical staff.
3.04 Mental Health and Substance Abuse Admission
Satisfactory Compliance
Screening [Detention Staff/Contract Provider]
The mental health and substance abuse needs of youth are identified through a
comprehensive screening process ensuring referrals are made when youth have identified
mental health and/or substance abuse needs or are identified as a possible suicide risk. The
superintendent has established procedures for a thorough review of preliminary screenings
conducted by the Office of Probation and Community Intervention.
Nine youth mental health records were reviewed. All nine youth had a Suicide Risk Screening
Instrument (SRSI) and Massachusetts Youth Screening Instrument, Second Version (MAYSI-2)
completed in the Department’s Juvenile Justice Information (JJIS). The nurse and/or mental
health staff completed the required sections in each of the nine SRSIs. The completed entries
included an accurate referral selection in the “Screening Results” sections, as required. The
youth who had any positive responses on the SRSI were placed on suicide precautions and a
mental health referral was completed which documented the youth's need for an Assessment of
Suicide Risk (ASR). Eight of nine SRSI screenings included a “yes” response when the youth
had any open or closed Suicide Risk Alerts in JJIS, as prompted within the JJIS SRSI
navigation screen in red font. All nine MAYSI-2 and SRSI screenings were completed by trained
staff. The results of the SRSI and MAYSI-2 indicated a need for further assessment in all nine
records. None of the MAYSI-2 screenings were determined to be “invalid” due to all negative
responses. All nine youth required further assessment, a referral was made and the
superintendent/designee was notified in all nine records. Five of the youth’s MAYSI-2s indicated
elevated suicide risk subscales and the youth were placed on suicide precautions and referred
for an ASR in all five records. The results of five of the MAYSI-2s indicated the need for
comprehensive assessment, and the screener referred all five youth for a comprehensive
assessment within the center. One additional youth was referred for a comprehensive
assessment based on the screener’s observations.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 26 of 57 (Revised July 2023)
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.
Nine youth records were reviewed for mental health and substance abuse evaluations. Three of
the nine youth were applicable for a new or updated evaluations made by the detention
provider. All three mental health and substance abuse evaluations were completed by the
center’s mental health provider on-site by the youth’s thirty-first day. Treatment
recommendations were made which corresponded to all diagnosed mental health or substance
abuse disorders in all three records. One youth was applicable to receiving a new
comprehensive assessment from a community provider. The center obtained the
comprehensive evaluation from the community provider and the assessment contained all the
required elements, including the signature of the licensed mental health professional.
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.
Nine records were reviewed for treatment and discharge planning. Eight of the youth were
applicable for having an initial treatment plan. One youth had not been in the facility long
enough for an initial treatment plan to be completed. For all eight applicable records, the initial
treatment plan was in place within seven days of the onset of treatment and developed on the
Department’s Initial Mental Health/Substance Abuse Treatment Plan form. All eight initial
treatment plans included the reason for referral for treatment, initial Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis/symptoms, initial treatment
methods including counseling and frequency, initial treatment goals, psychiatric services
including psychotropic medications and frequency of monitoring, the medication the youth was
admitted with, and the signature of the mental health professional and youth. All eight youth
were assigned to a mini-treatment team. The members of the treatment team were involved in
the development of the initial treatment plan in all eight records.
All eight youth received an individualized treatment plan which was developed for youth
receiving mental health and/or substance abuse treatment in the center by the thirty-first day of
the youth’s admission. All eight individualized treatment plans included the youth’s DSM-5
diagnosis, symptoms which are treatment focused, treatment goals which include mental health
services if the youth has a mental illness, substance abuse services if the youth has a
substance-related diagnosis, strengths and needs, psychiatric services including psychotropic
medication, and frequency of monitoring. Four youth were applicable for coming in on
psychotropic medications or being prescribed psychotropic meditations. The psychotropic
medications listed in the initial treatment plan matched the psychotropic medications the youth
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Office of Accountability and Program Support Page 27 of 57 (Revised July 2023)
was prescribed at the time the treatment plan was developed in all four applicable records. A
review of documentation reflected the individualized treatment plans were signed and dated by
the youth, mental health/substance abuse professionals, treatment team members, and
parent/guardian, or the center attempted to get the signature of the parent/guardian, in all eight
applicable records. Three of the individualized treatment plans included thirty-day periods
requiring individual treatment plan reviews. Eleven thirty-day individual treatment plan reviews
were completed and documented on the Individualized Mental Health/Substance Abuse Plan
Review form. All three plans were reviewed every thirty days by the treatment team, as
required. Modifications were documented on the review form and clearly identified as such. A
review of the documentation reflected the Individualized treatment plan reviews were signed
and dated by the clinical staff, youth, licensed mental health professional, treatment team
members, and parent/guardian. The treatment plans included treatment and services provided
by a licensed psychiatrist, in two applicable records. One youth was an alleged victim of a
Prison Rape Elimination Act (PREA) event, and the youth’s treatment plan included mental
health treatment services which addressed the youth’s needs.
None of the reviewed records were applicable for mental health/substance abuse treatment
discharge. As a result, the center provided three additional records for review. The discharge
plan was documented on the Department’s Mental Health/Substance (MH/SA) Treatment
Discharge Summary form and completed upon the youth’s transition/discharge in all three
records reviewed. A copy of the MH/SA Treatment Discharge Summary was provided to the
youth, parent/guardian (as allowed), and juvenile probation officer (JPO) in all three records. A
mini treatment team was observed and contained all the required elements.
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.
Nine youth records were reviewed for mental health and substance abuse treatment. Eight of
nine youth required treatment. The remaining youth declined services. All eight applicable youth
were assigned to a mini treatment team which consisted of mental health clinical staff, one staff
from a different service area, the youth, and the parent/guardian when possible. All eight youth
required mental health treatment and received individual, group, or family counseling according
to the frequency required by the plan, and the plan included individual, group, and/or family
therapy prescribed at least weekly. The proper consent for treatment was obtained in all eight
records. Four youth required substance abuse treatment and received individual, group, or
family counseling provided according to the frequency required by the plan. For all four youth
who required substance abuse treatment, the proper consent for substance abuse treatment
was obtained though the signed Department form, and the proper consent for release of
substance abuse treatment records was obtained through a signed Department form. Treatment
notes were documented on the Department’s Counseling/Therapy Progress Notes form in all
eight records.
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Videos of groups were reviewed for three random days and times. The video was compared to
logbooks and sign-in sheets. The facilitator was verified, and groups were conducted for the
required group time and length, as required. Mental health staff have adequate access to youth
and confidential space to provide treatment services. A review of records confirmed group
therapy was limited to ten or fewer youth with mental health diagnoses for mental health
treatment groups and fifteen or fewer youth with substance abuse diagnoses for substance
abuse treatment groups.
Nine youth were interviewed, three youth stated the mental health services at the center were
“very good,” two stated they were “good,” and four stated they were not receiving mental health
or substance abuse services. The superintendent was notified and stated the center would be
looking into the youth responses. The designated mental health clinician authority (DMHCA)
confirmed the initial treatment plan is developed within seven days from the date the youth was
evaluated by the psychiatrist. The individual treatment plan is developed based on the initial
assessment by the thirty-first day the youth has been in secure detention. The clinical staff
review individualized treatment plans, individualized substance abuse treatment plans, or
integrated mental health/substance abuse treatment plans every thirty days while the 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.
Psychiatric services are provided by a physician licensed pursuant to Chapter 458, Florida
Statutes who is board certified in child and adolescent psychiatry with a clear and active license
in the State of Florida expiring January 31, 2025. Services are not provided by an advanced
practice registered nurse. If the psychiatrist is not available, the center will use a back-up
psychiatrist with equal education to the psychiatrist, who is pulled from a pool of psychiatrists
contracted through the provider. The back-up psychiatrist used at the center in the annual
compliance review period is also licensed under Chapter 458 expiring January 31, 2025. The
center does not offer tele-psychiatry. An interview with the designated mental health clinician
authority (DMHCA) determined the DMHCA meets with the psychiatrist at a minimum of once a
week. The DMHCA also confirmed the center provides psychiatry, mental health, and substance
abuse services.
Nine youth records were reviewed for psychiatric services. Three of the nine youth entered the
center on psychotropic medication or were referred for a psychiatric interview and received an
initial diagnostic interview within fourteen days of the youth’s admission to the center. All three
initial psychiatric interviews included the reason for referral, youth’s history, mental status
examination, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
diagnosis, treatment recommendations specific to mental health and/or substance abuse
diagnosis, and prescribed medication. All three initial psychiatric interviews documented the
medication name, explanation of the need for psychotropic medication, and frequency of
monitoring. Three youth entered the center on psychotropic medications and one was referred
for an interview with the psychiatrist while at the center. An in-depth psychiatric evaluation was
conducted on all four referred youth within thirty days of referral/admission which stated the
reasons and factors leading to the referrals. The evaluations included all the required elements
of an in-depth psychiatric evaluation and page three of the Clinical Psychotropic Progress Note
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(CPPN) when the medication was prescribed or changes were made to the existing prescription,
and the CPPN was clearly identified as a psychiatric evaluation in all four records.
Whenever psychotropic medication was prescribed/dispensed/administered the identifying date,
diagnosis, target symptoms of each medication, evaluation, and description of effect of
medication on target symptoms was recorded for all four youth. Prescribed psychotropic
medication included the name, dosage and quantity of the medication, normal dosage range,
ordered dosage, frequency and route of administration, reasons for changes in medication
and/or dosage for all four records reviewed. Side effects, youth’s adherence to the medication
regime, height, weight, blood pressure, most recent drug serum levels as appropriate, telephone
contact with the parent/guardian, signature of the psychiatrist, and date of the signature were
also documented in all four records. The psychiatrist and nursing staff documented monitoring
for Tardive Dyskinesia on a monthly basis as indicated on the CPPN in all four records
reviewed. The consent for psychotropic medication included the Authority for Evaluation and
Treatment for all four records and verbal consent from the parent/guardian for new or
discontinued medication for one record where a youth was prescribed medication. One youth
reached eighteen years of age while in the center and was not incapacitated or otherwise
emancipated, and the youth was responsible for authorizing their healthcare and authorizing
release of their healthcare records. The center does not participate in tele-psychiatry.
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 suicide prevention plan detailing suicide prevention procedures, which
is reviewed and signed by the designated mental health clinician authority (DMHCA) and
superintendent annually. The plan includes the identification and assessment of youth at risk of
suicide, staff training, suicide precautions, levels of supervision, referrals, communication,
notification, documentation, immediate staff response, and a review process. The center has an
established review process for every serious suicide attempt or serious self-inflicted injury
(requiring hospitalization or medical attention) and a mortality review for a completed suicide.
The multidisciplinary review includes the circumstance surrounding the event, center
procedures relevant to the incident, all relevant training received by involved staff, pertinent
medical and mental health services involving the victim, possible precipitating factors, and
recommendations, if any, for policy changes, training, physical plant, medical or mental health
services, and/or operational procedures.
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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).
Nine youth records were reviewed for suicide prevention services. All nine youth were
determined to be a suicide risk during their admission screening. An alert in the Department’s
Juvenile Justice Information System (JJIS) was initiated for all nine youth when placed on
precautionary observation (PO), and a suicide risk assessment referral was made on the
required form. All nine youth had a qualified mental health professional involved when placed on
constant supervision and the Suicide Precaution Observation Logs were completed in their
entirety, to include documented “safe housing” areas and required signatures. None of the youth
were released prior to receiving an Assessment of Suicide Risk (ASR). 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 and the
superintendent or designee was notified immediately of suicide risk for all nine records. The
ASR or Follow-Up ASR was completed prior to the removal of each youth from PO, and there
was documentation of a conference held by the superintendent and licensed mental health
professional to reduce the level of supervision in all nine records. The discontinuation of close
supervision was documented in accordance with the center’s suicide prevention plan. All nine
suicide risk assessments were completed by a licensed mental health professional and results
of the assessments included recommendations for supervision follow-up. There was no
evidence the center needed to document in the center’s logbooks and on the suicide risk
assessment instructions related to the suicide risk assessment findings and suicide precaution
decisions. A review of JJIS determined alerts were appropriately entered and removed following
youth removal from PO. A review of logbooks determined the beginning and ending times for
PO were documented for youth in eight of nine youth records. One youth had a beginning time
but did not have the ending time recorded in the logbooks.
None of the reviewed youth records were applicable for secure observation. As such, the center
provided the only available record for review. For the applicable youth, placement in secure
observation was authorized by the superintendent and DMHCA and the secure room was
designated in writing. The Health Status Checklist was completed prior to placement in secure
detention and the Suicide Precaution Observation Logs were completed in their entirety for the
youth. Within eight hours of placement, a Follow-Up ASR was completed. The youth’s
parent/guardian and juvenile probation officer (JPO) were notified of the youth’s potential
suicide risk as indicated by the ASR. Mental health staff provided supportive counseling
services during secure observation and the observation log documented supervision for the
youth. The youth’s level of supervision was reduced after a conference with the superintendent
and licensed mental health professional. The discontinuation of secure observation and step-
down to close supervision was documented in the center’s logbook and in the youth’s mental
health record by mental health clinical staff.
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Nine youth were interviewed about being placed on PO and were asked if staff watched them at
all times. All nine youth denied ever being on PO. The superintendent was interviewed
regarding secure observation. The superintendent confirmed a youth is placed on secure
observation by mental health staff when the youth is determined to be a danger to him/herself. If
mental health staff are not in the building, a supervisor will call the DMHCA to get approval. A
referral will be entered, staff will remain at the door and provide constant sight and sound
supervision of the youth, and PO logs will be used to record checks every thirty minutes for the
duration of supervision. Nine direct care staff were interviewed and all stated they notify the
mental health authority, two staff stated they document supervision, and four staff stated they
provide constant sight and sound supervision when a youth expresses suicidal thoughts.
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.
Nine youth records were reviewed for Suicide Precaution Observation Logs. The Suicide
Precaution Observation Logs were maintained for the duration the youth was on suicide
precaution in all nine records. The appropriate level of supervision and observations of the
youth’s behavior were documented in real time and not exceeding thirty-minute intervals in all
nine records reviewed. Three youth records were applicable for warning signs. When warning
signs were observed, notification of the superintendent or designee and mental health clinical
staff was documented on the Suicide Precaution Observation Log in all three records. The logs
were reviewed and signed by each shift supervisor and signed by mental health clinical staff in
all three records. All nine Suicide Precaution Observation Logs documented safe housing
requirements. A review of video footage and corresponding documentation of three youth on
precautionary observation or secure observation confirmed the proper supervision was
maintained for youth placed on precautionary obervation.
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.
Nine pre-service and nine in-service staff training records were reviewed. Training includes
suicide drills no less than quarterly on each shift. The center has ten suicide response kits which
include a knife-for-life, wire cutters and needle nose pliers which are located in the vehicles,
maintenance, sub-control, laundry room, master control, administration, the supervisor office,
and on the mods. Suicide response kits are co-located with first-aid kits. A review of direct care
staff suicide prevention training showed thirty-eight staff for the first six months and sixty staff for
the second six months completed at least one drill. All direct care staff participated in at least
one drill which included the use of cardiopulmonary resuscitation (CPR) annually. Members who
were not present during a quarterly drill have the opportunity to review each drill scenario and
procedures in an effort to understand the process and receive the necessary training to respond
to an incident of a suicide attempt or serious self-inflicted injury. Nine staff stated suicide
response kits were located in sub-control, three stated they were located in master control and
medical, two stated they were located in the shift supervisor office, and one stated they were
located on the mods, in the clinic, and in the vehicles.
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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 written Crisis Intervention Plan for mental health services which includes a
notification and alerts system, means of completing referrals including self-referrals,
communication, supervision, documentation, and reviews.
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.
A review of the center’s emergency care plan confirmed it included immediate staff response,
notification, communication, supervision, authorization to transport for emergency mental health
or substance abuse services, transport for emergency mental health evaluation and treatment
under Chapter 349, Florida’s Baker Act, transport for emergency substance abuse assessment
and treatment under Chapter 397 Marchman Act, documentation, training, and review. The plan
was approved August 7, 2023. A copy of the plan is located on each mod and in sub-control.
Additionally, the facility uploads the policy to the K-drive annually.
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.
Nine youth records were reviewed for Crisis Assessments. None of the reviewed youth were
applicable for having a Crisis Assessment during the annual compliance review period, as such,
the center provided three additional records for review. Each reviewed Crisis Assessment
included the reason for the Crisis Assessment, Mental Status Examination and interview,
determination of danger to self/others, initial clinical impressions, supervision recommendations,
recommendations for follow-up or further evaluation, and notification to the parent/guardian of
follow-up treatment for all three youth. A mental health alert was entered into the Department’s
Juvenile Justice Information System (JJIS) when each youth was placed on precautions after
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completion of a Crisis Assessment for all three records. In all three records, the youth were
identified by direct care staff or clinical staff as having acute emotional or behavioral problems,
or acute physiological distress. All three Crisis Assessments were conducted by a licensed
mental health professional immediately, within two hours for emergencies, or within twenty-four
hours based on the needs of the youth. One youth was an alleged victim of a Prison Rape
Elimination Act (PREA) event, and the youth was offered ongoing mental health treatment, as
required.
3.16 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Nine youth records were reviewed for Baker Acts and Marchman Acts. None of the reviewed
youth were applicable for having a Crisis Assessment during the annual compliance review
period, as such, the center provided two additional records for review. The youth was placed on
suicide precautions upon re-admission from a Baker Act or Marchman Act facility in both
records reviewed. A mental health referral was completed for a Mental Status Examination
(MSE) for both youth. The MSE was completed by a licensed mental health professional in both
records, and each youth was maintained on a minimum of constant supervision until properly
transitioned to a lower level of supervision. The youth’s supervision level was not lowered until
an appropriate assessment was conducted and mental health staff conferred with the licensed
supervisor and superintendent or designee in both records. The discontinuation of the suicide
risk alert in the Department’s Juvenile Justice Information System (JJIS) and precautions were
based upon an Assessment of Suicide Risk for both records. For one youth who also had a
mental health alert in JJIS, the discontinuation of the mental health alert and constant
supervision was based on the results of the youth’s Crisis Assessment.
An interview with the center’s designated mental health clinician authority (DMHCA) confirmed
the center had only two Baker Acts and no Marchman Acts during the annual compliance review
period.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center has a licensed physician who holds an unrestricted license and meets all
requirements for independent and unsupervised practice in the State of Florida to serve as the
designated health authority (DHA). The DHA’s specialty is internal medicine, and their license
expires on January 31, 2025. The DHA has an advanced practice registered nurse (APRN) who
provides clinical services on-site and has a collaborative practice protocol in place. The DHA
performs all administrative duties. A review of the sign-in logs for the annual compliance review
period indicated the DHA was on-site once a week four hours a week as contractually required.
If the DHA has scheduled absences the center has a backup DHA who can be utilized from a
licensed pool. There were no instances of a back-up DHA utilized during the annual compliance
review period. There were no instances of tele-medicine utilized during the annual compliance
review period. The DHA interview confirmed specific duties, which included Comprehensive
Physical Assessments (CPAs), focused medical reviews, periodic evaluations, sick calls, weekly
clinic visits, and review/approval of medical facility operating procedures/policies annually.
4.02 Facility Operating Procedures [Contract Provider] Satisfactory Compliance
There shall be Facility Operating Procedures (FOP) for all health-related procedures and
protocols utilized at the facility.
The center has facility operating procedures (FOPs) for all health-related procedures and
protocols utilized at the center. The designated health authority (DHA) and superintendent
reviewed all applicable facility operating procedures. The DHA revised/signed on August 11,
2023. The superintendent revised/signed August 7, 2023. The psychiatrist revised/signed on
August 8, 2023. The nursing staff reviewed, signed, and dated a cover page on which medical
FOPs, treatment protocols, and other procedures were listed on October 4, 2023, October 5,
2023, and October 17, 2023. There were no new policies or changes in policies made during
the year which required a signature. An annual review of medical FOPs and protocols was
signed on August 11, 2023. The center has FOPs for all health-related procedures and
treatment protocols utilized at the center. All newly employed healthcare personnel receive a
comprehensive clinical orientation to the Department’s healthcare policies and procedures,
given by a registered nurse. The approval of treatment protocols or standing procedures are
written and authorized by the DHA.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
Each center shall ensure the completion of the Authority for Evaluation and Treatment (AET)
or Limited Consent for Evaluation and Treatment authorizing specific treatment for youth in
the custody of the Department.
Nine Individual Healthcare Records (IHCRs) were reviewed for an Authority for Evaluation and
Treatment (AET). Eight of nine IHCRs included the original AET form with the “Copy” stamped
on the form. One youth was over eighteen and did not require an AET. Seven of eight AET’s
were signed by a parent/guardian and a department representative and one of eight included a
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court order filed in the IHCR due to the parent/guardian refusing to sign the AET. An AET was
obtained prior to providing medical services in all eight applicable records, one youth was over
eighteen. All eight AET’s were valid. The one youth who was eighteen did not have a release of
information in accordance with the youth’s request. None of the youth were in the custody of
Department of Children and Families (DCF).
4.04 Parental Notification/Consent [Contract Provider] Satisfactory Compliance
The center shall inform the parent/guardian of significant changes in the youth’s condition and
obtain consent when new medications and treatments are prescribed.
Three of nine Individual Healthcare Records (IHCR) reviewed were applicable for
parental/guardian notifications. The applicable IHCR’s written notifications were sent utilizing the
Department’s Parental Notification of Health-Related Care: General or Parental Notification of
Health-Related Care: Medication forms. All three had consent provided by the parent/guardian.
Three of the nine youth were on psychotropic medications and a staff witnessed two of three
telephone call attempts and conversations with the parent/guardian. Three youth received new
medications and documentation indicated the written parental/guardian notices were sent
regardless of telephone notifications. Two of nine youth had a new psychotropic medication
prescribed or discontinued, or the drug dosage was significantly changed. The parent/guardian
verbal consent was documented on the Clinical Psychotropic Progress Note (CPPN) page
three, and a written notification was sent. None of the youth were in the care of the Department
of Children and Families (DCF). Nine IHCRs had vaccines verified within thirty days of
admission. An interview with the nurse confirmed the medical staff attempt parental/guardian
notification immediately after qualifying event occurs.
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.
In all nine Individual Healthcare Records (IHCRs) reviewed the Medical and Mental Health
Admission Screening form was completed on the day of admission by the registered nurse
(RN). In all nine IHCRs, the notification to the designated health authority (DHA) was
documented. Three of the youth were applicable for rescreening due to a change in custody.
The center completed a healthcare admission re-screening each time the change of custody
occurred. The nurse interview indicated it is expected the entry screening will be reviewed with
the youth by the licensed nurse within twenty-four hours of admission to the center. Newly
admitted youth will have admission packets placed in the basket at the medical clinic, and the
facility roster is reviewed daily for newly admitted youth.
4.06 Youth Orientation to Healthcare Services/Health
Satisfactory Compliance
Education [Contract Provider]
All youth are to be oriented to the general process of healthcare delivery services at the
center.
The center has facility operating procedures which include access to medical care, sick call,
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
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sexual assault or attempted sexual assault, the non-disciplinary role of the healthcare providers
and a review of the list of healthcare contacts to ensure accuracy. In all nine Individual
Healthcare Records each youth received a general healthcare orientation, which was
documented on the Department’s Health Education Record 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.
Four of nine Individual Healthcare Records (IHCRs) were applicable for known or suspected
chronic conditions. In all four records the designated health authority (DHA) notification was
documented in the progress notes. None of the four youth required emergency care upon
admission. Three of the youth were taking psychotropic medication upon admission and the
psychiatrist was notified in all three IHCRs. The nurse interview indicated the DHA is notified
within twenty-four hours of youth being admitted into facility. All notifications shall be
documented on the admission progress note of the IHCR by the licensed medical staff.
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.
In nine Individual Healthcare Records the Health-Related History (HRH) form was completed
within seven days of admission. The HRH form was completed prior to the Comprehensive
Physical Assessment (CPA) as evidenced by signature and date. The HRH form was completed
by a licensed nurse or practitioner in all nine IHCRs. All nine HRH forms were reviewed by the
designated health authority or advanced practice registered nurse as indicated by a checkbox
on the CPA. The nurse interview indicated the HRH form shall be completed or reviewed by
nursing staff through an interview with the youth no later than seven calendar days from youth’s
admission into the center.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Nine Individual Healthcare Records (IHCRs) were reviewed for a Comprehensive Physical
Assessment (CPA) and Tuberculin Skin Test (TST). The youth’s physical assessments were
completed on the Department’s CPA form. Nine youth records were reviewed, each record had
a new CPA completed within seven days of admission by the advanced practice registered
nurse (APRN). The Medical Grade was noted on each CPA. All sections of the CPAs were
completed in full. All nine youth records had documentation of youth refusing part of the exam,
which was documented on the CPA and on a Youth Refusal of Care form. The Department’s
Problem List in each record was updated. A TST was documented on the CPA and the
Infectious and Communicable Disease (ICD) form in all nine records reviewed. All nine youth
records had documentation the Tier 1 Tuberculosis (TB) screening was completed within
seventy-two hours. None of the youth required further evaluation as a result of the TST. The
nurse interview confirmed if a CPA has not been performed, is not current, or there are changes
to the condition of the health of the youth, the youth shall have a CPA as soon as possible.
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4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
In eight of nine reviewed Individual Healthcare Records (IHCRs), each youth was clinically
screened and evaluated for sexually transmitted infections (STIs) within twenty-four hours of
admission. The remaining youth had been screened one day prior at another center before
being transferred to this center. In eight, further evaluation was required and a referral was
made to the designated health authority (DHA), which was documented on the Department’s
STI form. In the eight applicable IHCRs testing was ordered and conducted. The testing results
were documented on the Infectious and Communicable Disease (ICD) form and maintained in
each IHCR. None of the youth consented to a gynecological exam or were out of the
Department’s physical custody. In the eight applicable IHCRs, each youth was offered
counseling and testing for human immunodeficiency virus (HIV) which four declined and four
agreed to be tested. All four youth had documented consent for testing in their IHCR. Two of
four youth had HIV test results filed confidentiality in a sealed envelope marked “confidential”.
Two youth were awaiting results. The two applicable records had proof of review by a
practitioner documented on the sealed envelope and documentation of pre-test/post-test
counseling documented on the Individual Health Education Record. All nine youth interviews
indicated they can ask for a HIV test.
4.11 Sick Call Process [Detention Staff/Contract Provider] Satisfactory Compliance
All youth in the center shall be able to make sick call requests and have their complaints
treated appropriately through the sick call system. The center shall respond appropriately, in
a timely manner, and document all sick call encounters as required by the Department. All
youth in restricted housing/confinement shall have timely access to medical care, as required
by Rule.
Nine Individual Healthcare Records (IHCRs) were reviewed for sick call. Four of the youth had
documentation of sick call on the sick call referral log. None of the youth presented with similar
sick call complaints three or more times within a two-week period. All four youth completed a
Sick Call Request form. The nurse completed the Sick Call Request form in all four applicable
youth IHCRs. All the sick call request forms were filed in the youth’s IHCR in reverse
chronological order. The sick call forms and progress notes were documented in accordance
with Florida Administrative Code. The youth’s sick calls were documented on the sick call index
and all dates corresponded to the appropriate sick call form. Sick call is conducted one hour a
day seven days a week in the medical clinic. Sick call hours are posted outside of medical and
on the mods. Nursing staff provide sick call care and there are approved treatment protocols for
both registered nurse (RN) and licensed practical nurse (LPN) level staff. When there is not a
licensed nurse on-site, there are procedures in place for the shift supervisor to review all sick
call requests no longer than four hours after a request is submitted. There were no sick call
requests submitted during the annual compliance review week; therefore, observations of the
sick call process were not conducted. The nurse interview confirmed youth have access to
request medical evaluations. Nine youth were interviewed, three youth advised they are seen
immediately when requesting a sick call, four youth advised within one day, one youth advised
within two days, and one youth never requested sick call. Eight youth advised a nurse conducts
sick call and one youth advised youth are seen by the doctor. Nine staff were interviewed, and
all advised the nurse reviews and conducts sick call.
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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.
Three of nine Individual Healthcare Records (IHCRs) were applicable for episodic care. In the
three applicable IHCRs there was indication each youth required episodic care, which was
conducted by a licensed healthcare staff on-site and documented in problem-oriented charting.
In all three, the nature of the event, the findings of the person rendering care, the treatment
provided, instruction to the youth, and plans for follow-up care were included. None of the youth
required off-site care, and none needed placement on the alert list or parental/guardian
notification. All events were documented on the Episodic Care Log and none of the youth
needed a follow-up evaluation. The first-aid kits are located in master control, front intake,
kitchen, laundry, maintenance, supervisor office, consequence sub control, B1 sub control, B2
sub control, B3 sub control, B4 sub control, G1 sub control, and ten are used for transport. A
review of three first-aid kits indicated all were stocked with designated health authority (DHA)
approved contents. The center’s process for ensuring contents are maintained and stored in
accordance with guidelines to prevent expiration or deterioration includes monthly monitoring by
nursing staff and documentation in the inspection log. A review of monthly first-aid kit checks for
the last full year indicated all were conducted as required. The center has two automated
external defibrillators (AEDs) containing the operating procedures, located in the B1 and G1
modules and both were in working order during the annual compliance review week. The
nursing staff conducted checks monthly, as indicated by a review of the AED checks for the last
year. The AED batteries in B1 and G1 modules expire in March 2025.The batteries had been
changed in March of 2021. The pads for B1 and G1 modules expire December 28, 2025.
Emergency medical drills and mental health drills with medical components completed since the
last annual compliance review were reviewed. Drill documentation showed at least one medical
drill conducted on each shift monthly. Cardiopulmonary resuscitation (CPR)/AED was
demonstrated at least annually on each shift, in accordance with facility operating procedures. A
list of emergency telephone numbers is maintained by master control and in the medical clinic.
The telephone numbers are inaccessible to youth. All licensed healthcare staff maintain current
CPR and AED certifications. Eighteen staff records were reviewed, and staff training
requirements were met regarding episodic, first-aid, and emergency care. 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, Naloxone Nasal Spray is used. The
program maintains at least one prescribed stock Nasal Spray Kit for emergency purposes of
accidental overdose for use for youth in care. A Naloxone Nasal Spray 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. Nursing staff and supervisors have
access to the medical cart and have been trained on when and how to use Naloxone Nasal
Spray. The medication is inventoried along with all other medication. An interview with the nurse
confirmed the location of the first-aid kits. Nine staff were interviewed, all advised being able to
call 9-1-1 if needed. Nine youth were interviewed, three youth rated medical care as good, five
very good, and one never received medical care.
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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.
Nine Individual Healthcare Records (IHCR) were reviewed, and three were applicable for off-site
care. All three applicable youth records had documentation the Summary of Off-Site Care form
was utilized for the off-site care. Each of the off-site care events were documented on the
episodic care log. Parental/guardian notification efforts were documented in two of three
records, one youth was over the age of eighteen. All three were applicable and had discharge
documents filed in the IHCR. The designated health authority (DHA) was notified of the off-site
care for each youth. The DHA or the advanced practice registered nurse (APRN) initialed off-
site findings, instructions, and information. None of the youth required follow-up appointments or
referrals. An interview with the nurse advised youth are tracked utilizing a monthly log kept with
other monthly logs. The DHA is contacted upon the youth’s return to the center and discharge
instructions/orders are discussed.
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.
In four of nine Individual Healthcare Records (IHCRs) reviewed each youth was identified on the
Facility Entry Physical Health Screening form to have a current chronic health condition. One
youth was taking prescribed medication on an on-going basis, three were classified with a
Medical Grade between two and four, and all four were placed on a chronic conditions list. None
of the youth were pregnant, taking tuberculosis medication, received an off-site evaluation, or
indicated any lapses in care or periodic evaluations. The nursing interview indicated youth with
chronic conditions are tracked on a log in medical. The clinic manager also performs weekly
reviews of medical charts. The designated health authority (DHA) interview indicated the
registered nurse is responsible for maintaining a log of individuals requiring routine periodic
evaluations.
4.15 Medication Management [Contract Provider] Satisfactory Compliance
Medication shall be received, stored, inventoried and provided in a safe and effective manner
which shall be demonstrated by observation, review of documentation of procedures and
processes.
Nine Individual Healthcare Records (IHCRs) were reviewed for medication management. Three
youth were admitted with medication and had documentation of medication verification included
in the IHCR chronological progress notes. The designated health authority (DHA) and/or
psychiatrist was contacted to resume the specified medications for each youth.
All medications had a current, valid order, were administered pursuant to current prescription,
and all had an order on the Practitioner Order form. The standard Department Medication
Administration Record (MAR) is used to document all medication and treatment and is
completed for each youth monthly. Each MAR contained the youth’s name, Department
identification number, date of birth, youth allergies, precautions, Medical Grade, medical alerts,
and a current picture of the youth. At a minimum, the nursing staff documented side effect
monitoring weekly on the MARs. The MAR is usually completed electronically. If the electronic
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MAR is not working, the MAR is printed, the medication administration is documented by hand,
and the printed MAR is uploaded into the Electronic Medical Record. Each MAR clearly
indicated medication start and stop dates. Nursing staff and youth initialed each administered
medication entry. Trained non-healthcare staff may assist in the delivery of medications only
when licensed staff are not on-site, though there were no examples of this in the records
reviewed. None of the youth required parenteral medication. Two of the youth had refusals and
a signed refusal was documented in the IHCR. Three of the reviewed youth were on prescribed
psychotropic medication upon admission. The psychiatrist was notified upon admission. Each
youth had an Initial Diagnostic Psychiatric Interview within fourteen days of admission. There
were no standing orders, pro re nata (PRN) orders, or emergency treatment orders for
psychotropic medications. Medication administration was observed for one youth with their
consent. Medication administration was the sole responsibility of the nurse during the
administration. The youth were escorted to the medical clinic one at a time by direct care staff,
who maintained supervision of the youth during the medication administration. Youth
approached the nurse individually and the Six Rights of Medication Administration were verified.
The nursing staff asked each youth how they were feeling. Nursing staff observed youth to
confirm the medication was swallowed. There was no pre-pouring of medications. The nurse
interview indicated upon admission to the center, the youth and parent/guardian (if available)
will be interviewed about the youth’s current medications. This will be conducted as part of the
Medical and Mental Health Screening form. Medication verification will also occur during the
completion of the review of the Medical and Mental Health Screening form, the initial medical
admission screening completed within twenty-four hours of admission, the Health-Related
History (HRH) form, and/or the Comprehensive Physical Assessment completed by medical
staff. Nine staff were interviewed, five staff advised the nurse provides the medication, and four
supervisors advised they have been trained and can provide medication. Nine youth were
interviewed, two advised the nurse provides the medication, and seven advised not taking
medication.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The medical equipment classified as sharps were secured and inventoried utilizing a routine
perpetual inventory, descending count as each sharp was utilized and disposed for the annual
compliance review period. All medications were identified and secured in the locked area
designated for storage of medications. The medication cart was clean and organized with
stocked items separate from youth-specific medications, and all controlled substances have a
perpetual inventory and are stored separately from other medications. All medications are
stored in a separate, secured area, inaccessible to youth. Narcotics and other controlled
medications are stored behind two locks. Medications which require refrigeration are stored in a
secured refrigerator, which is used for medication only. The facility maintains a shift-to-shift
inventory count of all controlled substances documented on the youth’s individualized controlled
medication inventory record. Supervisory-level, non-healthcare staff were trained in the delivery
and oversight of medication self-administration, and training was delivered by the registered
nurse (RN). The center had no controlled medication during the annual compliance review
period. Three over-the-counter (OTC) medications and three sharps were reviewed, and the
inventory on-hand matched the perpetual inventory. Discrepancies in the inventory are
investigated, and if not resolved, the nurse will notify the designated health authority (DHA),
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superintendent, and the Department’s Central Communications Center (CCC). A RN shall be
responsible for the disposal of medications in conjunction with the pharmacy consultant.
Controlled and non-controlled medications for disposal shall be inventoried prior to disposal and
disposed in the presence of the pharmacy consultant. Controlled and non-controlled
medications must be disposed of by utilizing the Drug Enforcement Administration (DEA)
approved Drug Buster disposal system and in accordance with state board of pharmacy and
DEA disposal plan. Documentation of the disposal of all medications shall be maintained. An
interview with the nurse confirmed the process for destruction of medications, and storage of
medications.
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.
Nine Individual Healthcare Records (IHCRs) were reviewed for infection control education. All
nine youth records had documentation the youth received infection control training within seven
days of admission. Training topics included hand-washing techniques, universal precautions,
prevention/transmission of communicable diseases, vaccinations, and Center for Disease
Control and Prevention (CDC) guidelines for infection control. The exposure control plan is
written in accordance with Occupational Safety and Health Administration (OSHA) guidelines.
The plan includes risk assessment and methods of compliance. The infection control
procedures in place include prevention, containment, treatment, and reporting requirements
related to infectious diseases, according to OSHA and CDC and prevention guidelines. The
infection control procedures include common diseases of childhood, self-limiting episodic
contagious illnesses, viral or bacterial infectious disease, tuberculosis, hepatitis, bloodborne
pathogens, outbreaks or epidemics, lice or scabies, Methicillin-Resistant Staphylococcus
Aureus (MRSA), foodborne illnesses, bioterrorist agents, and chemical exposures in the
workplace. A review of the facility operating procedures indicated the center’s process for
needle stick post-exposure evaluation is to notify the manager. The manager is responsible for
notifying the regional manager and follow-up with testing and prophylaxis treatment is
conducted. Hepatitis B immunizations are available for staff upon hire. Staff have access to
biohazardous kits for protective equipment. There were no incidents of a facility occupational
exposure. The nurse interview advised the medical staff conduct training regarding the site-
specific exposure control plan, to include the prevention of transmission of blood-borne
pathogens within ninety days of hire and annually thereafter. A record of the training is kept in
the staff personnel records.
4.18 Prenatal Care/Education [Contract Provider] Satisfactory Compliance
The center shall provide access to prenatal care for all pregnant youth. Health education shall
be provided to both youth and staff.
The center has nursing protocols and treatment plans addressing pregnant youth. None of the
nine Individual Healthcare Records (IHCRs) reviewed were applicable for pregnant youth. The
center did not have any examples for the annual compliance review period. Nine pre-service
and nine in-service training records confirmed all staff received training on pregnant females
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and related topics, which was conducted by a nurse. The nursing interview indicated all
pregnant female youth receive necessary and appropriate services and procedures. The
services shall include, but are not limited to, designated health authority (DHA) recommended
prenatal, postnatal, and neonatal (as applicable) medical care, coordination of routine
healthcare services such as physician appointments, childbirth education, lactation
consultations, postpartum examinations, and well-baby care, nutrition, mental health services to
address mental health issues during pregnancy and promote mother-infant bonding,
attachment, and aftercare planning including community referrals. Nine youth were interviewed,
and all nine youth advised the services were not needed.
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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, staff were observed maintaining continuous
sight supervision of all youth in their assigned area, during education, meals, transportation, and
line movements. All movements are 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. Staff were adhering to the
daily activity schedule. The center’s staff were interacting appropriately with youth. Each day of
the annual compliance review week, the center had adequate staff to meet the required staff-to-
youth ratio. Observations of shift change confirmed the juvenile justice detention officers
(JJDOs) received their assignments and youth alerts during the shift briefing. Nine staff were
interviewed, and eight stated there were enough staff to provide adequate supervision, one
stated there was not enough staff at the moment and the center has to use holdovers.
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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 where youth may be able to review them.
These posters clearly specified rules, norms, and expectations. The center provides a BMS
which includes incentives for positive behavior and consequences for inappropriate behavior.
The BMS includes the use of a three-tiered level system where youth are given the opportunity
to earn points by meeting required expectations. A review of completed point cards and logbook
entries during the annual compliance review period supported the center utilized the BMS in
compliance with the components outlined in the center’s FOPs. The center uses a BMS
leadership team to ensure the BMS is used with the components outlined in the center’s FOPs.
Fidelity monitoring is completed by the BMS leadership team by reviewing completed point
cards, incentives, and consequences provided to the youth. Nine staff were interviewed, and
each confirmed the BMS includes a point and level system, the BMS is posted throughout the
facility, and is included in the orientation process. In addition, each staff confirmed the youth
receive several incentives and believe that the center’s BMS is effective. All nine staff stated
each youth who earns their level receives incentives for positive behavior including the token
store, Breaking Bread, later bedtimes, extra phone time, poetry club, step/aerobics class, movie
night, game night, and other special activities. All nine staff stated they speak with youth to
discuss the consequences being imposed. All nine staff stated youth are given an opportunity to
explain their behavior and discuss alternative acceptable behaviors. None of the staff reported
they have seen a staff encourage a youth to beat up another youth or had a youth’s basic rights
taken away. An interview with nine youth found six youth rated the BMS as being very good, two
stated it was good, and one stated it was fair. All nine youth were able to explain the difference
between each level and how to move from level to level. Nine youth also stated they receive
rewards such as book club, Breaking Bread, snacks, staying up later, playing cards,
poetry/creative writing club, step classes, movie night, and special events. Nine interviewed
youth stated all staff use rewards the same, staff are fair, and give all youth the same rewards.
Nine interviewed youth stated they are not allowed to punish other youth. Eight of nine
interviewed youth stated they have never been sent to their room for punishment reasons, one
youth stated they had been sent to their room for punishment before, and the door was shut and
locked. This was reported to be due to the youth being in confinement and this youth reported it
was a fair consequence. All interviewed youth stated they did not witness handcuffs or leg irons
used on out-of-control youth. The superintendent was interviewed and stated the standardized
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BMS follows policy. All youth entering the center will be placed on level 2.1 and after three
consecutive days of positive behavior, youth will be placed on level three. Youth can move up or
down the level system depending on their behavior. The superintendent also confirmed all youth
are provided basic rights no matter their levels.
5.03 Ten-Minute Checks (Critical) Satisfactory Compliance
Staff shall visually observe youth on standard supervision at least every ten minutes while
they are in their sleeping quarters, either during sleep time or at other times, such as during
an illness or room restriction.
Staff conduct observations in a manner ensuring the safety and security of each youth and
documents each check in real time, manually or electronically. Documentation must include
the actual time of each visual observation and initials of the staff conducting the check;
preprinted times are not acceptable.
There shall be no obstructions (e.g., clothing, memos, pictures) over windows and areas
where direct line of sight is needed.
If an officer, in the course of completing visual observation, is unable to see the youth or any
part of the youth’s body, the officer shall, with the assistance of another officer, open the door
to verify the youth’s presence.
The center has facility operating procedures (FOPs) requiring ten-minute checks to be
conducted when youth are in their rooms. The center has 109 surveillance cameras, all of which
were operational during the week of the annual compliance review. The surveillance cameras
have a thirty-day recording capacity. An electronic wand system is used in the center to
document and collect data of the ten-minute visual checks. Staff tap an electronic wand on the
check point sensors on the outside of each youth’s assigned sleeping room door and the data is
downloaded as wand reports. A review of video in comparison with wand checks was completed
for five random days and times. This observation revealed staff conducted each ten-minute
check as required. Staff were observed looking into the windows of each sleeping room before
tapping the wand to the check point sensor. Facility administration provides management
oversight by conducting weekly reviews of ten-minute checks to ensure fidelity. Nine staff were
interviewed, and all nine indicated room checks are conducted every eight to ten minutes when
a non-suicidal youth is placed in their room. The superintendent interview confirmed when a
youth is secured in a room, an officer will conduct checks every ten minutes. They will approach
the door, stop, and look in the room to ensure the youth is safe, log the check, and then move to
the next door until completion of each room.
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5.04 Census, Counts, and Tracking Satisfactory Compliance
Officers must know the exact number and location of all youth under their supervision at all
times. Census counts of youth shall be taken, called into Master Control, and documented, at
a minimum:
• At the beginning and end of each shift.
• Following any emergency to include power outages, evacuation due to emergency
drills, and any code called outside the secure walls. In the event a code is called in
any location outside the main walls of a facility, it is critical all youth counts are
reconciled prior to the movement of any group of youth.
• Prior to and following routine group movement.
• Any time a population change occurs.
• Randomly, at least once on each shift.
Staff should not include youth in the count who are not physically present with the staff
person at the time of the count (e.g., court, clinic, confinement).
The center has facility operating procedures (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. Living module counts are recorded in their assigned module logbooks. Logbook
reviews since the last annual compliance review indicated counts were conducted at the
beginning of each shift, prior to and following routine group movement, anytime a population
change occurred, randomly, at least once occurring on each shift, for regular head counts, and
during youth movements. Nine staff were interviewed and indicated random counts are
completed throughout the day. Staff indicated if the count is incorrect, the facility stops all
movement and secures the area to complete a recount. Each of the nine interviewed staff stated
emergency counts were conducted if a youth is believed to be missing, when visibility is
hindered such as an electrical outage, after drills, and following codes or major disruptions.
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) regarding logbooks. The center has
separate logbooks for master control and each living module, visitors, and vehicles. A review of
eleven logbooks found they were bound with numbered pages. Two logbooks had loose covers;
but all pages were accounted for. All entries in the logbooks were legible and written in ink with
no erasures or whiteout areas. A review of logbooks for three full days each month during the
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annual compliance review period found counts were conducted and documented at the
beginning and end of each shift, prior to and following any movement of youth, at least once
randomly during the shift, any time the population changed, and following routine group
movement. Observations during the annual compliance review week showed there was no
youth movement until master control confirmed the count. Entries included the date and time of
the event, name of the staff and youth involved, a brief description of the event, and initials of
the person making the entry. Documentation included highlighted entries for special needs,
mental health alerts, the opening and closing populations, and emergency situations including
drills. Admissions and releases, line movements, and the presence of law enforcement were
documented. Names of youth placed in confinement were documented, including the time
confinement began and ended. Calls to the Florida Abuse Hotline and the Department’s Central
Communications Center (CCC) were documented in the master control logbooks. Nine staff
were interviewed, all of whom indicated youth counts are conducted at the beginning of each
shift. Six staff indicated counts were conducted at the end of each shift. Two staff indicated
counts are conducted before and after meals and before and after school. Six staff indicated
counts are conducted randomly throughout the day. All staff stated emergency counts were
conducted if a youth is believed to be missing, when visibility is hindered such as an electrical
outage, after drills, and following codes or major disruptions.
5.06 Logbook Reviews Satisfactory Compliance
The superintendent or designee reviews all logbooks on a weekly basis.
The supervisor(s) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility.
The juvenile justice detention officer (JJDO) supervisor(s) reviews logbooks maintained in
each living area daily.
The JJDO(s) reviews the logbook maintained in his/her assigned living area when he/she
accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) regarding logbook requirements. The
master control and living module logbooks were reviewed for three full days each month of the
annual compliance review period. The juvenile justice detention officer supervisor (JJDOS)
reviews the logbooks each shift, including the master control logbook, when accepting the shift
to document they are aware of current relevant situations in the center. The juvenile justice
detention officers (JJDOs) assigned to each living module review the module logbook upon
accepting the shift. The superintendent was interviewed and stated the superintendent or
designee reviews all logbooks at a minimum of weekly and document the review.
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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 key control,
issuance of keys to staff, inventory and tracking, key restrictions, storage, missing or lost keys,
and reporting and replacement of damaged keys. When detention staff enter the center, their
personal keys are to be secured in lockers on the non-secure side of the center or given to
master control prior to being issued a key set by the master control operator or during shift
briefing. Visitors and contracted staff secure personal keys in a locker outside of master control.
An observation during the week of annual compliance review and an informal interview with the
center’s master control staff revealed the facility keys are stored on a tamper-resistant key ring
which prohibits the removal of keys and is color coded specific to the position to which the keys
are assigned. These keys are stored in master control which is secured. An observation of key
distribution at shift briefing, review of the key control logs, and observations of the collection of
keys by supervisors and master control confirmed the issuance and return of keys, key ring
number, and staff assigned. Issued key sets are also documented on the daily shift reports in
SharePoint. Keys are consistently checked and maintained by supervisors and above. Staff
were observed always carrying the facility keys on their person during the week of the annual
compliance review and youth did not have access to facility keys. In addition, an informal
interview with the master control staff and superintendent validated youth have no access to
facility keys. The center maintained a master key inventory located in the superintendent’s office
which accounts for all key rings by ring number, the number of keys on each ring, and the
capability of each key. Emergency keys which provide egress through exterior doors are also
stored in the superintendent’s office. Staff who are assigned permanent keys sign a “Permanent
Key Issued” document stating the rules of being in possession of those keys. A review of the
master key control inventory confirmed the inventory report matched the actual key rings in use.
Missing or lost keys must be documented and the juvenile justice detention officer supervisor
(JJDOS) must be notified immediately; a Department’s Central Communications Center (CCC)
report is generated if any key is not found or located. During the annual compliance review
period, the center contacted the CCC two times due to missing keys; however, both sets were
found, and no corrective action was required. No keys were reported as broken during the
annual compliance review period. The keys carried by three staff were examined and were
confirmed to have the correct number of keys on the ring as well as the correct assigned key
ring number documented for the shift. These three staff were also questioned and able to
indicate the function of each key. Nine staff were interviewed and stated the restricted keys are
for medical or mental health records, case management records, youth property, kitchen, and
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egresses. Each staff reported they knew the key control process and were able to explain the
process for missing and/or broken keys. The superintendent stated a key inventory must be
maintained at all times. The inventory must account for all keys by tracking the ring number, the
number of keys on each ring, the capability of each key, and to whom (or where) each
permanent key ring is issued.
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 which is used to transport youth. The center’s maintenance
mechanics and transportation coordinator are responsible for the weekly and monthly vehicle
inspections. The maintenance mechanics, transportation coordinator, or staff using vans for
transport complete the vehicle checks daily to ensure all vehicles are equipped and readily
available to drive. The center had a total of ten vehicles at the time of the annual compliance
review, six vans currently at the facility, one van on a transport, two vans at the shop, and one
van out for an oil change (maintenance van). Each vehicle had an annual safety inspection
conducted by a certified automobile mechanic. Observations of six vehicles in the sally port
confirmed five were locked. All six vehicles had the appropriate number of seatbelts, a seatbelt
cutter, a window punch, and up-to-date fire extinguishers. A first-aid kit with approved items by
the designated health authority (DHA) is checked out for transport from the transportation
coordinator’s office. A binder is maintained for each vehicle which contains the vehicle mileage
log, vehicle inspection log, vehicle oil change log, automobile accident reporting form, driving
directions and maps, AmeriSys information, gas card, vehicle registration, and relevant vehicle
policies. Weekly visual vehicle inspection checks are conducted on all vehicles as required and
documented on the preventive maintenance check sheets. Prior to each transport, a pre-trip
vehicle inspection is conducted by staff and documented in the vehicle logbook and vehicle
inspection log. An observation was conducted of five youth transported to court by two officers
during the annual compliance review week and the transporting staff were observed following all
required transportation procedures prior to transport. An observation was conducted of five
youth transported from court by two officers during the annual compliance review week and the
transporting staff were observed following all required transportation procedures after transport.
Staff are given a mobile telephone to take with them on the transport. The assigned mobile
telephones are kept in master control. All vehicle logbooks indicated each vehicle was searched
for contraband prior to use and again upon return. The number of youth transported and the
destination with date and time were documented for each trip. Nine youth were interviewed and
all indicated they feel staff drive safely during transports and none of the youth ever observed
anyone place contraband in a 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) detailing the requirements for tool
inventory and management. A perpetual tool inventory list is maintained by the center and
inventoried monthly by the maintenance mechanics. All tools are stored in a locked area when
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Office of Accountability and Program Support Page 50 of 57 (Revised July 2023)
not in use. Tools are maintained on a shadow board and are identified with a number which
coincides to the tool inventory sheet. Observations indicated there were no missing or damaged
tools. All tools are checked out on a tracking form prior to use and checked in after they are
returned. An interview with the maintenance mechanics indicated there were no instances of
missing or broken tools since the last annual compliance review. An itemized inventory of
kitchen equipment and tools is also maintained. All items, including knives, are inventoried twice
daily and then again in SharePoint on a weekly basis. The kitchen knives and other hazardous
kitchen sharps are stored in a locked cabinet. No service vendors were observed during the
week of the annual compliance review. An informal interview with the maintenance mechanics
indicated all service vendors are identified prior to entering the secure area of the center and
are accompanied at all times. Youth are removed from the area being serviced and are not
allowed to re-enter the area until it has been searched and cleared by center staff. The vendor
checks for all their tools to ensure they leave with the tools they entered into the center with.
Nine staff were able to explain the process when there are missing or damaged tools by
reporting, removing a damaged item, and securing it until repaired. During an interview with the
superintendent, it was confirmed only maintenance staff, supervisors, and administration have
access to facility tools. Inspections and inventories are uploaded into SharePoint and the
superintendent or designee review them.
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 scrub brushes when completing general cleaning. Youth are
under staff supervision when these items are in use. Nine interviewed youth indicated they only
use mops, and brooms. All youth stated they do use cleaning agents, but they are not allowed
to handle the cleaning agents. The staff handles the cleaning agents, such as spraying a table,
and then the youth can wipe it down. Nine interviewed staff stated youth are allowed to use
mops, brooms, and scrub brushes. The nine interviewed staff reported youth are not allowed to
handle substances which are toxic, flammable, and poisonous.
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5.11 Inventory of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items.
All flammable, toxic, caustic, and poisonous items shall be inventoried and secured when not
in use. The use of hazardous material shall be consistent with the manufacturers’ instruction
and all safety precautions shall be followed.
All flammable, toxic, caustic, and poisonous items shall have the 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) to ensure the proper inventory of
flammable, toxic, caustic, and poisonous items. All items are inventoried and securely stored. All
items observed had a Safety Data Sheet (SDS) on record. Five chemical items were reviewed
on-site during the week of annual compliance review for which the center maintained a
corresponding SDS, and complete and accurate inventories. Flammable, toxic, caustic, and
poisonous items were observed to be stored securely in areas inaccessible to youth.
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. These items can only be used by authorized
staff. 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 the annual
compliance review. An interview with nine youth indicated each stated they do not have access
to flammable, toxic, caustic, and/or poisonous items. An interview with nine staff indicated each
stated youth are not allowed to clean with substances which are toxic, flammable, or poisonous.
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5.13 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) addressing proper use, storage, and
disposal of flammable, toxic, caustic, and poisonous items. The maintenance mechanics
reported in the event a chemical is to be disposed of, it is done so in accordance with the Safety
Data Sheet (SDS) requirements. The center’s maintenance mechanics also reported the center
does not utilize grease for cooking and all kitchen liquid waste is disposed in the kitchen drain.
Medical sharps and waste are disposed of through a contracted medical waste disposal
company. No disposal of chemicals could be observed during the annual compliance review
week. The superintendent and the maintenance staff reported the center has not experienced
any chemical spills or leaks during the annual compliance review period.
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 utilizes rooms in the main hallway for confinement. The
center had approximately 800 instances of confinement under twenty-four hours during the
annual compliance review period, with the average confinement time of a little over twenty
hours. Twenty confinement reports were reviewed. Confinement reports for each confinement
confirmed all rooms were searched prior to youth being placed in confinement, all non-fixed
items were removed from the room, and each documented approval by a juvenile justice
detention officer supervisor (JJDOS). Observations of the confinement rooms indicated some
windows were scratched but did not interfere with visual checks. All youth had access to mental
health and education, as needed, and each youth showered and wase given clean clothes if in
confinement during this time except in two incidents when the youth were making threats and
too combative to bring out of their rooms. All youth were notified they could grieve the situation
of being placed in confinement. All twenty confinement reports were completed before the end
of the applicable shift. Documentation showed five-minute checks were conducted for the first
hour for each confinement. Each reviewed report indicated a JJDOS conducted an initial
confinement review with the youth within two hours from the incident. A JJDOS evaluated each
youth every three hours and documented the need for confinement. Each report indicated the
youth were released from confinement within twenty-four hours. Each of the twenty confinement
reports indicated the superintendent or designee reviewed the confinement report within forty-
eight hours. There were no pregnant youth confined during the annual compliance review
period. None of the reviewed youth confinement records had any notation of physical injury,
youth complaint of injury or illness, a known chronic health condition, or experienced an injury
which would have required a healthcare professional to be immediately notified for timely
assessment and treatment. Nine staff were interviewed. Three staff mentioned counseling the
youth. Five stated the confinement process is explained, and the youth has a right to the
grievance process. Five stated checks are completed. The superintendent interview confirmed
confinements are tracked for appropriateness by the center’s administration within the
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Department’s Juvenile Justice Information System (JJIS). A supervisor will approve the
confinement and review it within the first two hours and then every three hours thereafter.
Checks will be conducted on the youth’s behavior every five minutes for the first hour and every
ten minutes thereafter. The behavior is what determines when the youth is released from
confinement. Once released, an administrator will review the confinement within forty-eight
hours. The superintendent also stated regional leadership reviews the use of confinement,
lockdown, and restraints daily and provides data bi-weekly.
5.15 Confinement Over Twenty-Four Hours and
Satisfactory Compliance
Confinement 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 maintains facility operating procedures (FOPs) addressing confinements over
twenty–four hours. A review of the Department’s Juvenile Justice Information System (JJIS)
revealed the center had nine confinements over twenty-four hours since the last annual
compliance review. There were no pregnant youth confined over twenty-four hours during the
annual compliance review period. Four of the confinement reports were reviewed. All reports
documented supervisory reviews were conducted as required throughout the duration of the
confinement and the supervisor continuously counseled the youth. None of the reviewed youth
confinement records had any notation of physical injury, youth complaint of injury or illness, a
known chronic health condition, or experienced an injury which would have required a
healthcare professional to be immediately notified for timely assessment and treatment. The
confinement review was chaired by the regional director, completed at least two hours prior to
the youth being in confinement for twenty-four hours, and the conference was held by
telephone. Prior to requesting the extension, the superintendent and mental health staff visited
with the youth and a copy of the report was electronically sent to the regional director. The
regional director’s decision was documented, and mental health staff counseled the youth
regularly thereafter. The youth was removed from confinement as soon as their behavior was
appropriate to do so and did not compromise the safety and security of the center. The
superintendent was interviewed and confirmed the confinement process and reported all
confinements are reviewed on a daily basis.
5.16 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center maintains facility operating procedures (FOPs) to manage various emergencies and
disaster events. Two drills were required to be conducted during the annual compliance review
period, and both were conducted, as required. Documentation confirmed the center conducted
hurricane drills twice during the annual compliance review period. Written scenarios, drill forms,
training rosters, copies of logbook pages, Delegation of Authority, Cooperative Agreements,
Continuity of Operations Plan (COOP) checklists, and emails were used for documentation.
Nine staff were interviewed and staff indicated they have participated in COOP, bomb threat,
escape, fire, mental health, and medical drills. The superintendent interview reported the facility
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Office of Accountability and Program Support Page 54 of 57 (Revised July 2023)
has a COOP in place along with a Memorandum of Understanding (MOU) with other facilities to
continue operations in an emergency situation and COOP drills are conducted twice a year.
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. The policy requires the center to conduct escape drills at least quarterly. All twelve
required drills during the annual compliance review period were conducted, as required. The
documentation of the drills included scenarios, as well as the dates and times of the drills. The
drill documentation form included the signatures of the supervisory staff and the staff
coordinating the drill. Recommendations and critiques of the drills were included in each report.
A review of logbooks revealed each escape drill was documented in the logbook, as required. All
documentation was also uploaded into SharePoint and signed off by the superintendent or
designee. A review of twenty staff training records in the Department’s Learning Management
System (SkillPro) validated each staff completed escape prevention training. Five of the nine
interviewed staff indicated they had participated in an escape drill in the past twelve months.
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. There are evacuation egress plans posted throughout the
center. Each egress plan defined the primary and secondary exit route and the locations of
emergency equipment such as fire extinguishers and first-aid kits. The center’s disaster plan,
fire prevention plan, and evacuation plan were reviewed and approved by the local fire marshal.
Reviewed documentation also revealed the center fire extinguishers are inspected annually.
Documentation verified the center conducts fire drills each month, on each shift, during different
times. Drills are also reviewed during shift briefings. All documentation is uploaded into
SharePoint and signed off by the superintendent or designee. Nine youth were interviewed and
seven stated they have been instructed on what to do in case of a fire. Two youth stated they
could not recall if they had been instructed on what to do in case of a fire. Nine staff were
interviewed, and eight stated fire drills take place at least monthly.
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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. Full
body visual 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 documented in the logbook. Staff shall wear gloves during all searches. Electronic
searches are conducted on all staff and visitors entering the facility. All shoes, bags, cases,
jacket pockets, and other items were searched. All personal keys, personal cellular telephones,
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, verified electronically
using the Admission Wizard. One admission was observed during the annual compliance review
week. The youth was electronically searched, and frisk search conducted by an officer of the
same gender. The youth also received a full body search by two officers present of the same
gender. Frisk searches were also observed three times during the annual compliance review
week prior to and upon completion of a transport. The staff completing the searches were of the
same gender and wearing gloves. The superintendent stated 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. Searches of all
staff and visitors were observed prior to entering the secure area every day of the annual
compliance review week. Attestation forms and training rosters for the FOPs were reviewed. All
direct care staff were trained in search procedures. There were no instances which
compromised the safety and security of the center throughout the annual compliance review
week. During the annual compliance review period nine incidents of contraband were reported.
Two of the nine reported incidents were vape pens confiscated during the intake process. Six of
the nine reported were vape pens recovered during room searches. One of the nine reported
was a filed down toothbrush discovered through an attorney/client interview. All nine items were
confiscated and secured. The Department’s Central Communications Center (CCC) was notified
of the discovery and confiscation. Notifications were completed as required. The
superintendent’s interview stated the youth are frisk searched at the Juvenile Assessment
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Center (JAC) then brought to the detention center. The search is called in and documented in
the logbook. Once at the detention center, the youth is again frisk searched, wand searched,
and then a strip search is conducted. Additional random searches take place throughout the
facility on a daily basis and all searches are documented. The superintendent stated if
contraband is found, the CCC and regional leadership are contacted. If the contraband is found
on a youth, the youth’s parent/guardian is also contacted, local law enforcement is notified, and
an internal investigation is conducted to find the source with corrective action to follow.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 57 of 57 (Revised July 2023)

source: DJJ

report_type: QI Detention

file_name: DRJDC-Final FY2324.pdf