summary: QI Detention - FY24-25 - 1 finding

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 32286
Review Date(s): January 14-January 17, 2025
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:
Devon Whitten, Office of Accountability and Program Support, Lead Reviewer (Standard 1)
Lori Bright, Office of Accountability and Program Support, Regional Monitor (Standard 2)
Jeff Campbell, Office of Education, Northeast Education Coordinator (Standard 2)
Kristine Harshaw, Office of Accountability and Program Support, Regional Monitor (Interviews)
Michele Maynard, Office of Accountability and Program Support, Regional Monitor (Standard 4)
Christi Stua, Office of Detention Services, Senior Management Analyst II (Standard 5)
Meghan Thrasher, Office of Accountability and Program Support, Regional Monitor (Standard 3)
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 14 – January 17, 2025 Lead Reviewer Code:
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
Florida Department of Juvenile Justice Detention Services Quality Improvement Report
Office of Accountability and Program Support Page 3 of 52 (Revised July 2023)
Lim ited R atings
2.10 E ducational A ccess*
Failed R atings
Standard 1: Management Accountability
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 4 of 52 (Revised July 2023)
1 .0 1
1 .0 2
1 .0 3
1 .0 4
1 .0 5
1 .0 6
1 .0 7
1 .0 8
1 .0 9
1 .1 0
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 1 - M a n a g e m e n t A c c o u n ta b ility
In itia l B a c k g ro u n d S c re e n in g * S a
F iv e -Y e a r R e s c re e n in g /R e n e w a l S a
S ta ff C o d e o f C o n d u c t S a
In c id e n t R e p o rtin g C C C * S a
R ig h t In te ra c tio n s (R I) S a
P re -S e rv ic e /C e rtific a tio n R e q u ire m e n ts * S a
In -S e rv ic e T ra in in g S a
G rie v a n c e s S a
E n te rin g A le rts (J J IS ) a n d S h a rin g o f A le rt In fo rm a tio n * S a
D a ta T re n d A n a ly s is S a
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 2: Youth Management
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 5 of 52 (Revised July 2023)
2 .0 1
2 .0 2
2 .0 3
2 .0 4
2 .0 5
2 .0 6
2 .0 7
2 .0 8
2 .0 9
2 .1 0
2 .1 1
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 2 - A s s e s s m e n t a n d P e r fo r m a n c e P la n
A d m is s io n S a tis fa c
O rie n ta tio n S a tis fa c
C la s s ific a tio n S a tis fa c
N o tific a tio n o f J P O C irc u it G a n g R e p S a tis fa c
A d m is s io n a n d S to ra g e o f Y o u th P e rs o n a l P ro p e rty S a tis fa c
R e le a s e S a tis fa c
R e le a s e o f Y o u th P e rs o n a l P ro p e rty , M e d ic a tio n , a n d A fte rc a re In s tru c tio n s S a tis fa c
R e v ie w o f Y o u th in S e c u re D e te n tio n a n d H o m e D e te n tio n S a tis fa c
D a ily A c tiv ity S c h e d u le S a tis fa c
E d u c a tio n a l A c c e s s * L im ite
C a re e r E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
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Standard 3: Mental Health and Substance Abuse Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 6 of 52 (Revised July 2023)
3 .0 1
3 .0 2
3 .0 3
3 .0 4
3 .0 5
3 .0 6
3 .0 7
3 .0 8
3 .0 9
3 .1 0
3 .1 1
3 .1 2
3 .1 3
3 .1 4
3 .1 5
3 .1 6
3 .1 7
* T h e D e p
b e lo w D e p
in a p ro g ra
aam rtm
rtm
a
eele n t h
n t s
rt fo
a s id e n
ta n d a rd
rm b e in
tifie d c e rta in
s . A p ro g ra m
g c o m p le te d
S ta n d a r d 3 - M e n ta l H e a lth a n d S u b s ta n c e A b u s e S e r v ic e s
D e s ig n a te d M e n ta l H e a lth C lin ic ia n A u th o rity (D M H C A )
L ic e n s e d M H /S A C lin ic a l S ta ff *
N o n -L ic e n s e d M H /S A C lin ic a l S ta ff
M H /S A A d m is s io n S c re e n in g
M H /S A A s s e s s m e n t/E v a lu a tio n
M H /S A T re a tm e n t
T re a tm e n t a n d D is c h a rg e P la n n in g
P s y c h ia tric S e rv ic e s *
S u ic id e P re v e n tio n P la n *
S u ic id e P re v e n tio n S e rv ic e s *
S e c u re O b s e rv a tio n *
S u ic id e P re c a u tio n O b s e rv a tio n L o g s *
S u ic id e P re v e n tio n T ra in in g *
M e n ta l H e a lth C ris is In te rv e n tio n S e rv ic e s *
E m e rg e n c y C a re P la n *
C ris is A s s e s s m e n ts *
B a k e r a n d M a rc h m a n A c ts *
k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia
m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in
a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
te a tte n tio n if a p ro
d ic a to rs . F a ilu re to
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m o p
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e ra te s
ill re s u lt
Standard 4: Health Services
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 7 of 52 (Revised July 2023)
4 .0 1
4 .0 2
4 .0 3
4 .0 4
4 .0 5
4 .0 6
4 .0 7
4 .0 8
4 .0 9
4 .1 0
4 .1 1
4 .1 2
4 .1 3
4 .1 4
4 .1 5
4 .1 6
4 .1 7
4 .1 8
* T h e D e p a rtm
o p e ra te s b e lo w
s o w ill re s u lt in
S ta n d a r d 4 - H e a lth S e r v ic e s
D e s ig n a te d H e a lth A u th o rity /D e s ig n e e * S a tis fa c
F a c ility O p e ra tin g P ro c e d u re s S a tis fa c
A u th o rity fo r E v a lu a tio n a n d T re a tm e n t S a tis fa c
P a re n ta l N o tific a tio n /C o n s e n t S a tis fa c
H e a lth c a re A d m is s io n S c re e n in g & R e s c re e n in g F o rm S a tis fa c
Y o u th O rie n ta tio n to H e a lth c a re S e rv ic e s /H e a lth E d u c a tio n S a tis fa c
D H A /D e s ig n e e A d m is s io n N o tific a tio n S a tis fa c
H e a lth -R e la te d H is to ry S a tis fa c
C o m p re h e n s iv e P h y s ic a l A s s e s s m e n t/T B S c re e n in g S a tis fa c
S e x u a lly T ra n s m itte d In fe c tio n S c re e n in g & H IV S c re e n in g S a tis fa c
S ic k C a ll P ro c e s s S a tis fa c
E p is o d ic /F irs t A id C a re /E m e rg e n c y C a re S a tis fa c
O ff-S ite C a re /R e fe rra ls S a tis fa c
C h ro n ic C o n d itio n s /P e rio d ic E v a lu a tio n s S a tis fa c
M e d ic a tio n M a n a g e m e n t S a tis fa c
M e d ic a tio n /S h a rp s In v e n to ry a n d S to ra g e P ro c e s s S a tis fa c
In fe c tio n C o n tro l/E x p o s u re C o n tro l/E d u c a tio n S a tis fa c
P re n a ta l C a re /E d u c a tio n S a tis fa c
e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re
a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
to ry
to ry
to ry
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to ry
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to ry
to ry
to ry
to ry
to ry
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to ry
to ry
to ry
to ry
to d o
Standard 5: Safety and Security
Detention Rating Profile
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 8 of 52 (Revised July 2023)
5 .0 1
5 .0 2
5 .0 3
5 .0 4
5 .0 5
5 .0 6
5 .0 7
5 .0 8
5 .0 9
5 .1 0
5 .1 1
5 .1 2
5 .1 3
5 .1 4
5 .1 5
5 .1 6
* T h e D e p a
o p e ra te s b e
d o s o w ill re
S ta n d a r d 5 - S a fe ty a n d S e c u r ity
A c tiv e S u p e rv is io n o f Y o u th * S a tis fa c to ry
B e h a v io r M a n a g e m e n t S y s te m /U n a u th o riz e d U s e o f P u n is h m e n t* S a tis fa c to ry
T e n -M in u te C h e c k s * S a tis fa c to ry
C e n s u s C o u n ts a n d T ra c k in g S a tis fa c to ry
L o g b o o k M a in te n a n c e a n d R e v ie w s S a tis fa c to ry
K e y C o n tro l S a tis fa c to ry
V e h ic le s a n d M a in te n a n c e S a tis fa c to ry
In v e n to ry , M a n a g e m e n t, Y o u th A c c e s s , & U s e o f T o o ls C le a n in g Ite m s * S a tis fa c to ry
In v e n to ry o f a n d A c c e s s to a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s S a tis fa c to ry
D is p o s a l o f a ll F la m m a b le , T o x ic , C a u s tic , a n d P o is o n o u s Ite m s S a tis fa c to ry
C o n fin e m e n t U n d e r T w e n ty -F o u r H o u rs S a tis fa c to ry
C o n fin e m e n t O v e r T w e n ty -F o u r H o u rs N o n -A p p lic a b le
C o n tin u ity o f O p e ra tio n s P la n n in g (C O O P ) D rills S a tis fa c to ry
E s c a p e D rills S a tis fa c to ry
F ire D rills S a tis fa c to ry
S e a rc h a n d C o n tra b a n d P ro c e d u re s S a tis fa c to ry
rtm e n t h a s id e n tifie d c e rta in k e y c ritic a l in d ic a to rs . T h e s e in d ic a to rs re p re s e n t c ritic a l a re a s th a t re q u ire im m e d ia te a tte n tio n if a p ro g ra m
lo w D e p a rtm e n t s ta n d a rd s . A p ro g ra m m u s t th e re fo re a c h ie ve a t le a s t a S a tis fa c to ry C o m p lia n c e ra tin g in e a c h o f th e s e in d ic a to rs . F a ilu re to
s u lt in a p ro g ra m a le rt fo rm b e in g c o m p le te d a n d d is trib u te d to th e a p p ro p ria te p ro g ra m a re a (d e te n tio n , re s id e n tia l, p ro b a tio n ).
Program Overview
The Duval Regional Juvenile Detention Center is a state-owned detention facility, operated by
the Department, located in Duval, 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 regional chief acting as the superintendent, three assistant
superintendents, two administrative assistants, nine juvenile justice detention officer (JJDO)
supervisors, and sixty-one 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 five 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), five registered nurses (RNs), and one
full-time licensed practical nurse (LPN). The medical clinic maintains nursing coverage from
6:00 a.m. to 6:00 p.m., Monday through Friday, and on weekends, from 7:00 a.m. to 5 p.m.
Food services are provided by Department staff and include menus, meal planning, meal
schedules, special diets, nutritional analysis, daily allowance, food preparation, health
certifications, food product standards, sanitation, and cleaning. Staff are responsible for the
custody and control of youth in their care, providing youth supervision twenty-four hours a day,
seven days a week. The center has five living modules which are divided by male and female.
There are 110 security cameras at the center, of which all were operational. A completed tour of
the center’s buildings, grounds, all youth living modules, administrative offices, recreation areas,
kitchen, and maintenance areas found all to be clean with no noticeable graffiti or odor. At the
time of the annual compliance review, the center had twenty vacancies, which included one
superintendent, one assistant superintendent, one other personnel service (OPS) maintenance
mechanic, one OPS chaplain, two food service workers, three JJDOIIs, and eleven JJDOIs.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 9 of 52 (Revised July 2023)
Standard 1: Management Accountability
1.01 Initial Background Screening (Critical) Satisfactory Compliance
Background screening is required for all Department staff and volunteers, as well as all
contracted provider and grant recipient staff, volunteers, mentors, and interns with access to
youth and confidential youth records. A contracted provider may provide training and
orientation to a potential staff before the screening process is completed. However, these
individuals may not have contact with youth or confidential youth records until the screening
is completed, the determination is “Eligible,” a copy of the criminal history report has been
reviewed, and the staff demonstrates he or she exhibits no behaviors warranting the denial of
employment. An Annual Affidavit of Compliance with Level 2 Screening Standards is
completed annually.
The center has facility operating procedures (FOPs) for volunteers, mentors, and interns who
work with youth less than ten hours a month requiring sight and sound supervision. The center
also has FOPs 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 twenty-one new Department staff
and eight 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 prior to each staff’s hire date and/or
contact with youth and confidential youth records. Seventeen direct care staff were applicable
for a pre-employment assessment tool to be administered. Nine of the staff earned a passing
score and eight did not pass but received remediation and were approved by hire. A copy of the
pre-employment assessment was maintained within each staff record. The center’s Annual
Affidavit of Compliance with Level 2 Screening Standards was completed and submitted on
January 2, 2025, 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 8, 2025.
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 (FOPs) 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 four center staff were
applicable for the completion of a five-year rescreening since the last annual compliance review.
All four 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 52 (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 (FOPs) addressing the code of conduct. Upon 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 a review of discipline
reports provided by the acting superintendent. All three of the reviewed incidents resulted in
written reprimands. Three staff received commendations during the annual compliance review
period, all of which were employee of the month awards. The interview with the acting
superintendent indicated the center follows facility operating procedures regarding the staff code
of conduct. Nine staff were interviewed. All confirmed the supervisor is notified when a youth
requests a call to the Florida Abuse Hotline or the Department’s Central Communications
Center (CCC). Seven of nine staff further explained the supervisor will take the youth to a
telephone and allow the youth to make the call. One staff also mentioned the call is
documented. Seven of the nine staff reported they have never heard staff use profanity when
speaking to youth. Two staff said they have heard it often; however, it was in conversation and
not aimed at youth. Eight of nine staff have not observed a coworker using threats, intimidation,
or humiliation when interacting with the youth. One staff reported witnessing it once, and the
staff was terminated. Seven of nine staff rated the working conditions at the center as good, one
staff said very good, and one said fair. Eight out of nine interviewed youth confirmed they have
not been refused an abuse call and staff are respectful when speaking to youth. One youth
reported never having the need for a call and one youth said some staff are respectful. Three
youth stated staff have never cursed at youth, two youth said it has occurred once, three youth
reported occasionally, and one said staff curse often. Each of the six youth informed the
interviewer staff were not cursing at youth but using curse words in regular conversation. None
of the nine youth have heard staff use threats towards youth and none have exchanged contact
information with youth. All nine youth reported they feel safe at the center.
Florida Department of Juvenile Justice Detention Annual Compliance Report
Office of Accountability and Program Support Page 11 of 52 (Revised July 2023)
1.04 Incident Reporting (CCC) (Critical) Satisfactory Compliance
The center shall notify the Department’s Central Communications Center (CCC) within two
hours of the incident, or within two hours of any center staff becoming aware of the reportable
incident.
The center has facility operating procedures (FOPs) 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 126 incidents reported to the CCC during the annual
compliance review period, of which ten were reviewed. Each of the ten 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 logbooks reflected six of the sampled
CCC reports were documented in the logbooks, four were not. During the annual compliance
review week, a shift briefing was observed where the captain addressed the importance of
documenting all CCC reports in the logbook. An interview with the center’s acting
superintendent confirmed within two hours of being notified of an incident, a supervisor or above
will call the CCC or the Florida Abuse Hotline to report the incident.
1.05 Right Interactions (RI) Satisfactory Compliance
Right Interactions (RI) is the department approved Protective Action Response (PAR)
curriculum. The center uses physical intervention techniques in accordance with Florida
Administrative Code. Any time staff uses a physical intervention technique, such as
countermoves, control techniques, takedowns, or application of mechanical restraints (other
than for regular transports), a RI Report is to be completed and filed in accordance with
the Florida Administrative Code.
Right Interactions (RI) is the Department approved Protective Action Response (PAR)
curriculum. 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 132 RI incidents since the last annual compliance review. A review of nine RI
Reports was completed, and each was completed by the end of the reporting staff’s workday.
Each report contained statements from all the staff involved. Seven of nine reports were
reviewed by a supervisor, RI instructor, and the superintendent and/or designee within the
required time frame. Two reports were reviewed by the RI instructor and the superintendent
and/or designee within the required time frame; however the supervisor reviewed the reports
after the superintendent. Each RI Report documented a post-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 RI incidents which did not have a report. None of the reviewed RI incidents were
applicable for contacting the Department’s Central Communications Center (CCC) due to
serious injury to the youth or staff, or for contacting the Florida Abuse Hotline because of the
youth’s alleged abuse. None of the reviewed RI incidents were applicable for mechanical
restraints, a medical review, or a post-RI medical review. An interview with the acting
superintendent indicated the use of physical and mechanical restraints are tracked using the
Department’s Juvenile Justice Information System (JJIS) reports. They also indicated reports
are reviewed and signed off on by the administration team. A review of nine pre-service and
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nine in-service training records verified staff were trained in the use of RI. Nine staff were
interviewed, and each indicated staff utilize verbal interventions before use of physical restraints
or mechanical restraints on a youth. The center’s RI rate during the previous quarter was 7.64,
which is below the statewide Detention RI rate of 9.79.
1.06 Pre-Service/Certification Requirements (Critical) Satisfactory Compliance
Staff are trained in accordance with Florida Administrative Code. Detention staff are to
complete pre-service/certification requirements specified by Florida Administrative Code
within 180 days of hiring.
The center has facility operating procedures (FOPs) to ensure pre-service training is in
accordance with Florida Administrative Code. The center abides by the 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. Nine newly hired staff training records were
reviewed. Each of the nine records reflected all pre-service and certification requirements were
completed within 180-days of hire, new staff orientation was completed within thirty days of hire,
and all nine completed the Department’s Academy training. All trainings were recorded 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 (FOP) 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 in-service training records were reviewed. All
nine staff completed more than the required twenty-four hours of in-service training. All critical
required trainings were completed by each staff. All additional trainings were completed by each
staff with the exceptions of two staff missing mental health and substance abuse, one staff
missing active shooter preparedness, one staff missing information security awareness, and
one staff missing emergency care plan. All completed in-service trainings were documented in
SkillPro. A licensed nurse provides in-service education on girls’ healthcare annually to all non-
healthcare staff involved in the supervision or treatment of girls, to include training on
monitoring, observation, and emergency care of the pregnant youth. The center maintains an
annual in-service training calendar, which is updated as changes occur. The annual in-service
training calendar was approved by the superintendent, the assistant secretary of Detention, and
the director of the Department’s Office of Talent, Leadership, and Culture. The center’s acting
superintendent is a Certified Public Manager (CPM), and completed courses including conflict
management, Emotional Intelligence, fundamentals for coaching, human resource matters,
interviewing, Real Colors for Leaders, supervising for success, fundamentals of leadership,
accountability coaching, multi-generational workforce, real team management, and
implementation science.
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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 (FOP) 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. Grievance forms were observed to be posted and accessible to the youth in
each living module. The center had no formal grievances during the annual compliance review
period. A formal interview with the acting superintendent confirmed the grievance procedures
and indicated when a youth completes a grievance form, the hard copy is maintained in a binder
in administration. Grievance records are kept for one year and then put into storage. Nine youth
were interviewed. Four of the nine youth were aware of the grievance process. Three did not
know how to file a grievance, and two stated they did not know because they have never
needed to file a grievance. All nine youth indicated they have never filed a grievance. Each of
the nine interviewed staff were able to discuss the center’s grievance process, including how to
help youth complete it.
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 (FOPs) 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 daily and are put into
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JJIS by the appropriate staff on the date identified and removed when the alert is no longer
applicable. 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. Eight of nine
records documented all alerts were accurately entered into JJIS. Once record did not have the
name of the staff entering the alert into JJIS. The program was made aware of this during the
annual compliance review week, and they educated staff on entering their name and title on all
alerts. 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 acting superintendent stated
youth are seen by medical staff upon admission and those staff put needed alerts into JJIS.
Nine staff were interviewed, and each stated they are informed of youth alerts at shift briefings
and on alert forms given out during the briefing. Two staff additionally mentioned alerts are
listed in the logbook. Each of the nine staff reported management informs staff about issues
within the center during briefings, two staff said meetings, and one staff said they are informed
of issues during the “pass down” from the previous shift’s staff. Six of the nine staff said this
process was good and three said it is very good.
1.10 Data Trend Analysis Satisfactory Compliance
Department program areas and contract providers shall include the review and analysis of
data in decision-making practices. Data trends shall be shared among administrators and
with staff to proactively make policy, practice, and programming changes designed to foster
system and program improvement.
The center collects data in the Department’s Juvenile Justice Information System (JJIS) on a
daily basis, including Right Interaction (RI) Reports, the Department’s Central Communications
Center (CCC) reports, confinements, and vacancies. The center can track 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, monthly with the advisory board, and quarterly with the circuit
advisory board. The acting superintendent reported the center has used the data to improve
school times, lower staff vacancies, and improve the overall daily operations.
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Standard 2: Assessment and Performance Plan
2.01 Admission Satisfactory Compliance
All youth are admitted to the center in accordance with Florida Administrative Code through a
process, at a minimum, addressing the following:
1. Review of required paperwork from law enforcement and screening staff.
2. All youth shall be electronically searched, strip searched, by an officer of the same
sex as the youth.
3. All youth shall be allowed to place a telephone call at the center’s expense to their
parent/guardian and the call shall be documented on all applicable forms, or
document refusal to make a telephone call.
4. If the admission process is completed two hours or more before the serving of the
next scheduled meal, youth shall be offered something to eat.
5. All youth shall be screened to identify medical, mental health, and substance abuse
needs.
The center uses the Admission Wizard in the Department’s Juvenile Justice Information System
(JJIS). The Admission Wizard documents admission requirements. Nine youth records were
reviewed. Each record contained the arrest affidavit/custody order, Detention Risk Assessment
Instrument (DRAI), and Suicide Risk Screening Instrument (SRSI). The Admission Wizard
documented in all nine youth records the youth received a full-body search, a telephone call, a
meal or snack, and a medical, mental health, and substance abuse screening. One youth was
observed receiving an admission during the annual compliance review week. The youth was
screened with metal detection and frisk searched before taking a shower. The youth was given
a lunch but refused it. The youth answered questions and watched the orientation video. The
youth was given a chance to ask questions and the youth’s clothes were taken when showering,
placed in a storage bag, labeled, and taken to the storage room.
2.02 Orientation Satisfactory Compliance
Program orientation process shall occur within twenty-four hours of a youth being admitted
into the center and documented according to Facility Operating Procedures. During the
orientation process, youth must be advised, both verbally and in writing, at a minimum, the
following:
1. Center rules and regulations;
2. Grievance procedures;
3. Visitation;
4. Telephone calls;
5. Available medical, mental health and substance abuse services and how to access
them;
6. How to access the Florida Abuse Hotline (or CCC for youth eighteen years of age or
older);
7. Expectations for behavior and related consequences;
8. Possible new law violations for destruction of property; and
9. Youth rights.
10. PREA-related information
The center has a facility operating procedure (FOP) which ensures each youth knows the
center’s rules and regulations, grievance procedures, visitation, telephone calls, availability of
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medical, mental health and substance abuse services, how to access the Florida Abuse Hotline
and/or the Department’s Central Communications Center (CCC), behavioral management
system, possible new law violations, and youth rights. In nine records reviewed, all were done
within twenty-four hours and each youth signed the orientation acknowledgement stating the
documents and contents were discussed. An orientation was observed, and the juvenile
detention officer provided verbally and in writing the required information including information
for the Prison Rape Elimination Act (PREA). The youth watched the orientation video and PREA
video and was asked if there were any questions. Nine youth were interviewed and eight stated
they received information on the rules and regulations, daily schedule, education services,
visitation, abuse reporting, and behavior management system; one youth stated they did not
receive any information.
2.03 Classification Satisfactory Compliance
All youth admitted to the center shall be classified to provide the highest level of safety and
security. Considerations shall include, at a minimum:
1. Physical characteristics (e.g. sex, height and weight);
2. Age and level of aggressiveness;
3. Special needs (mental illness, developmental disabilities, and physical disabilities);
4. History of violent behavior;
5. Gang affiliation;
6. Criminal behavior;
7. History of sexual offenses and any pending sexual offenses;
8. Vulnerability to victimization and/or sexually aggressive (VSAB);
9. Suicide risk, identified or suspected; and
10. Human Trafficking Involvement.
Youth shall be assigned to a room based on their classification and are reclassified if
changes in behavior or status are observed. Youth with a history of committing sexual
offenses or a victim of a sexual offense are not to be placed in a room with any other youth.
Youth with a history of violent behavior shall be assigned to rooms where it is least likely they
will be able to jeopardize safety and security.
All newly admitted youth are screened to determine if he or she is a criminal street gang
member or is affiliated with any criminal street gang. In the event hang involvement is
suspected, center staff should enter the “other suspected gang affiliation” alert into JJIS along
with as much detailed information within the alert note as possible.
The center has a facility operating procedure (FOP) which ensures admitted youth are classified
for safety and security. The youth’s history and status are reviewed including mental illness,
intellectual abilities, physical disabilities, history of violent behavior, history of sexual offenses,
vulnerability to victimization, medical, suicide risk, escape, security, and history of human
trafficking. The elements listed were reviewed and classified by the center in all nine youth
records. Before a youth is placed in a room, the factors taken into consideration include the
youth’s sex, youth’s height, youth’s weight, youth’s age, and level of aggression. The nine youth
records showed the youth were assigned a room based on their classification. Two of the youth
were placed in their own room due to sex offense charges. The staff reclassify if changes in
behavior or status are observed. All nine youth records reviewed had a Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB) in their record. An alert was placed in
the Department’s Juvenile Justice Information System (JJIS) if the youth is placed in a single
room. Nine reviewed youth records contained a classification form which identified where the
youth was placed. One youth’s record showed affiliation with a gang. The superintendent
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remains informed on how to identity and address local youth gangs. An interview with the acting
superintendent noted all factors are considered when placing a youth in a room, to ensure they
are not putting any youth in harm’s way. The youth’s safety is paramount.
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 (FOP) which ensures all information on suspected
gang affiliation is shared with the circuit gang representative who is a juvenile probation officer
(JPO). The center has a detention coordinator who acts as the liaison between the center and
probation. This position works under probation, but keeps up with detention reviews, gang
affiliation, and residential placement. The position keeps the youth and parents/guardians aware
of any new happenings within the system. Nine youth records were reviewed, and one youth
was a member of a gang. There were no other youth in the center who were known to have any
affiliation with a gang. The center, probation, and the detention coordinator were all aware the
youth was in a gang. Supervisors and above email JPOs when a youth has suspected gang
activity or affiliation with a gang. The superintendent reported in most cases JPOs at the
Juvenile Assessment Center identify and report suspected or confirmed gang affiliation prior to
the 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 (FOP) which ensures the safe handling of youth’s
personal property and valuables. Youth receive their personal property upon release from the
center. Clothes and shoes are maintained in a mesh bag and secured in the center’s inventory
locker room. Valuables are listed by the youth’s Department identification number (DJJID) and
placed in a clear bag in a locked file cabinet in a locked room by the center’s situation room.
The room is under video surveillance and only supervisors and above can drop off and retrieve
the items. There is a drop safe logbook to document the time, youth’s name, and name of the
staff securing the property along with their initials. Nine records were reviewed for admission
and storage of youth personal property. Five youth had valuables along with their personal
property and four only had personal property. The valuables were placed in a tamper proof clear
bag and included the date, youth’s name, DJJID, and a list of the bag’s items. An observation
was completed of both valuable items and personal items. The five youth’s records which
showed valuable item receipts were seen in the locked drop box and had the required elements
listed on the bag. The personal items were seen in the locker room in the back of the facility in
mesh bags. The drop safe logbook contained all required elements for each youth reviewed.
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There were no inventory incidents during the last annual compliance review period reported to
the Department’s Central Communications Center (CCC). According to the FOP, if the center
has unclaimed property, it will be disposed of and documented after ninety days. A letter is sent
to the last known address of the youth and parent/guardian. If there is money not claimed, a
money order is purchased and sent to the regional fiscal manager. Each of the nine interviewed
youth stated yes to staff checking their personal property and signing a form stating the
information was correct. The acting superintendent was interviewed and reiterated there is a
locked safe where all property is kept and only supervisors and above have access. The
property is purged after ninety days and is sent to headquarters. If there is money not claimed, a
money order is purchased and sent to the regional office.
2.06 Release Satisfactory Compliance
When releasing youth from the center, the releasing officer shall verify the court’s
authorization to release the youth. Care must be taken to ensure all case file information is
reviewed to prevent the negligent release of a youth. All releases from the center are court-
ordered, with the exception of deaths, escapes, and expirations of detention time period. In
the absence of a written order, documentation of a verbal order in open court may be used for
release. The on-duty JJDO supervisor reviews all paperwork prior to a youth’s release. The
JJDO Supervisor is responsible for ensuring there are no holds, court orders, or other legal
reasons not to release the youth. Questions concerning release are presented and addressed
by the superintendent, or designee, prior to release. The releasing officer shall verify the
identification of the youth.
The center has a facility operating procedure (FOP) for youth release. Three closed youth
records were reviewed, and each youth’s paperwork was inspected and signed off by the
juvenile justice detention officer supervisor (JJDOS) prior to the youth’s release. All youth had a
photocopy of the parent’s/guardian’s identification in their records. None of the youth had an
endangered person alert. It was documented the youth and parent/guardian were reminded of
any future appointments and court dates. All required parties signed the release paperwork, and
the date of admission and date of release documented in the case file correlated with the
Department’s Juvenile Justice Information System (JJIS). A release was not able to be observed
as the guardian/parent picked up youth after normal business hours.
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 a facility operating procedure (FOP) for the release of personal property,
valuables, and medication. Three closed youth records were reviewed, and all three had the
parent/guardian release receipt signed by the appropriate parent/guardian. None of the three
youth records showed the release of any type of medication and in all three records, the youth
and parent/guardian were reminded of any court dates, medical, mental health, and/or
substance abuse appointments pending. There were no examples of property held for more
than thirty days during the annual compliance review period. There was not an observation of
the release process conducted due to the parent/guardian picking up youth after normal
business hours.
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2.08 Review of Youth in Secure Detention Satisfactory Compliance
Detention reviews are conducted by the center on a weekly basis to ensure proper
management of youth placed in secure detention and the appropriate sharing of information.
The superintendent appoints an appropriate staff to coordinate detention reviews.
The center has a facility operating procedure (FOP) ensuring detention reviews are conducted
weekly for youth in secure detention. Detention reviews are held every Thursday and are run by
a juvenile justice detention officer supervisor (JJDOS) on video call. During an observation of
the call, each youth in secure detention was discussed by representatives of education,
medical, mental health, probation, detention, commitment manager, Department of Children and
Families (DCF), and Children in Need of Services/Families in Need of Services (CINS/FINS).
The documentation was reviewed in the Department’s Facility Management System (FMS) of
past detention reviews for the annual compliance review period. All required participants were
documented in FMS. The acting superintendent confirmed in an interview, reviews are held by
video call and the detention status, court dates, and release dates are discussed.
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 (FOP) addressing the daily activity schedule of the
youth. Youth participate in constructive activities which benefit both the youth and the center.
This includes daily expectations in accordance with the behavior management system (BMS).
The youth are provided activities throughout the day and week to include personal hygiene,
education, meals, visitation twice a week, recreation and physical activities, indoor activities,
bedtimes, and open program time. The BMS and the daily activity schedule were posted in each
living area. An observation of the center’s master control logbook confirmed the center adheres
to the daily activity schedule. Nine youth were interviewed and confirmed the daily activity
schedule is followed. Each of the nine interviewed staff reiterated the daily activity is followed
within the center.
2.10 Educational Access (Critical) Limited 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 program has a facility operating procedure (FOP) to provide educational access. The center
provides education services through the Duval County School Board and the 250-day calendar,
distributed over twelve months, includes ten days used for teacher training and planning. A
review of the daily school schedule revealed the center provides four forty-five-minute classes,
one seventy-five-minute class, and one sixty-five-minute class from 8:00 a.m. through 1:30 p.m.,
with a twenty-minute lunch incorporated in the schedule, fulfilling the weekly requirement of
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twenty-five hours of instructional time. All youth receive credit for course completion as
appropriate.
The superintendent reported the center interferes minimally with educational instruction. A
review of one day each month in the center’s logbook since the last annual compliance review
revealed classes started late, ended early, or were missing documentation in seven of the
twelve reviewed dates. Three of the dates documented reasons for the discrepancy in
educational times, for two days the youth were delayed due to an incident, and the remaining
day school time was made up at the end of the day after the youth started late. Nine youth and
nine staff were interviewed and all reported little to no interruption to the school day. Video
observations were conducted for three days and showed on one day school started five minutes
late and ended five minutes early, one day lunch was taken at a different time and youth were
forty-three minutes late in returning, and the remaining day showed no instructional time was
missed. Eight interviewed youth reported the program was preparing them very well or well for
high school, a high school equivalency diploma (GED), vocational school, employment, and/or
college. One youth reported not well, as a teacher was not helping them. Nine of the interviewed
youth reported attending school Monday through Friday. One youth reported they do not take
any education classes because they already graduated.
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 (FOP) for providing career education. Speaking
with the lead teacher revealed the center offers Type 1 career education development
integrated into the curriculum, which includes Career Learning Strategies such as interviewing
skills and techniques, career interests, résumé writing, completing employment applications,
and finances. Nine youth were interviewed, and each reported taking math, history, science,
reading, and social studies.
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Office of Accountability and Program Support Page 21 of 52 (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 works 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 a
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 also explained 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 and one as-needed part time mental health staff. The licenses of four mental
health professionals expire on March 31, 2025, with the remaining staff’s license expiring on
March 31, 2027, and staffing was in accordance with the provider’s contract.
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3.03 Non-Licensed Mental Health and Substance Abuse
Satisfactory Compliance
Clinical Staff [Contract Provider]
The superintendent is responsible for ensuring mental health and substance abuse services
are provided by individuals with appropriate qualifications. Clinical supervisors must ensure
clinical staff working under their supervision are performing services they are qualified to
provide based on education, training, and experience.
The 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; however, during the annual compliance review week the center had
one non-licensed staff working part-time who did conduct Assessments of Suicide Risk (ASRs)
but is no longer employed at the center. While on staff, the designated mental health clinician
authority (DMHCA) assured the non-licensed staff was performing services they were qualified
to provide and maintained documentation reflecting the staff received the minimum of one hour
a week of on-site, face to face direct supervision recorded on the Department’s Licensed Mental
Health Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision
Log form (MHSA 019). There was documentation the staff also completed twenty hours of
training and supervised experience in assessing suicide risk, mental health crisis intervention,
and emergency mental health services.
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 System (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). All the SRSIs 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-2s 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. None of the youth’s MAYSI-2s indicated elevated suicide risk subscales. The
results of six of the MAYSI-2s indicated the need for a comprehensive assessment, and the
screener referred all six youth for a comprehensive assessment within the center.
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3.05 Mental Health and Substance Abuse Evaluation
Satisfactory Compliance
[Detention Staff/Contract Provider]
The probation and JAC intake/detention screening process ensures youth identified through
preliminary screening with mental health and substance abuse issues or problems receive in-
depth mental health and/or substance abuse assessment shortly after intake to the juvenile
justice system.
Nine youth records were reviewed for mental health and substance abuse evaluations. Eight of
the nine youth were applicable for a new or updated evaluation made by the detention provider;
the remaining youth had not yet been at the center thirty-one days to receive their evaluation. All
eight 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. Five of the eight youth were also applicable for 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. An interview with the designated
mental health clinician authority (DMHCA) verified the center’s process of completing all
comprehensive assessments for youth referred by their thirty first day in detention.
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. None of the youth were
applicable for having an initial treatment plan, due to refusing services upon admittance to the
center; however, seven youth were applicable for having an individual treatment plan completed
by their thirty-first day in detention due to accepting services later. One youth had not been at
the center long enough to receive an individual treatment plan at the time of the annual
compliance review, and the remaining youth continued to refuse services. All seven 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 seven individualized treatment plans included the youth’s Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnoses, 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. Three 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 was prescribed at the time the treatment
plan was developed in all three 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
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get the signature of the parent/guardian, in all seven applicable records. All seven records
contained progress notes validating the youth was receiving treatment as stipulated in the
treatment plan. All seven of the individualized treatment plans included thirty-day periods
requiring individual treatment plan reviews. Fourteen thirty-day individual treatment plan reviews
were completed and documented on the Individualized Mental Health/Substance Abuse Plan
Review form. All seven 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. No youth was an alleged victim of a Prison Rape
Elimination Act (PREA) event. 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 Abuse Treatment Discharge Summary form and completed upon the youth’s
transition/discharge in all three records reviewed. A copy of the 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. An
interview with the designated mental health clinician authority (DMHCA) verified the treatment
planning and discharge process.
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. Seven of
nine youth required treatment. One youth declined services and the remaining youth had not
been in the center thirty days to determine what services would be implemented at the time of
the compliance review. All seven 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 seven 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 seven records. Two youth required substance
abuse treatment and received individual, group, or family counseling which was provided
according to the frequency required by the plan. For both 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 seven records. Videos of groups
were reviewed and 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
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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, one stated they were good, one
stated they were fair, and four stated they were not receiving mental health or substance abuse
services. Documentation reviewed for youth not receiving services indicated mental health staff
continually attempt to encourage youth participation in treatment services despite refusal. The
designated mental health clinician authority (DMHCA) confirmed the individual treatment plan is
developed according to 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, 2027. 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. A back-up psychiatrist was not used during the annual
compliance review period. 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 and received an initial diagnostic interview within fourteen days of the youth’s
admission to the center or referral. 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 their 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. One youth entered the center on psychotropic
medications and two were referred for an interview with the psychiatrist while at the center. An
in-depth psychiatric evaluation was conducted on all three 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 (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 three 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 three 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 three records reviewed.
Side effects, youth’s adherence to the medication regime, height, weight, blood pressure, most
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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 three records. The
psychiatrist and nursing staff documented monitoring for Tardive Dyskinesia on a monthly basis
as indicated on the CPPN in all three records reviewed. The consent for psychotropic
medication included the Authority for Evaluation and Treatment for two of the records and verbal
consent from the parent/guardian for new or discontinued medication for two records 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.
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.
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 in eight of the nine youth files, 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
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(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. In all nine
records the youth were placed on standard supervision after their assessment. 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 evidence the
center documented 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 three of nine youth records. The remaining six records all had ending times, but
logbooks did not reflect beginning times. The designated mental health clinician authority
(DMHCA) was interviewed and verified the suicide prevention services protocol. Nine youth
were interviewed, seven youth denied ever being on PO and the remaining two stated staff did
watch them all the time. Nine direct care staff were interviewed, and all stated they notify the
mental health authority, two staff stated they search the youth and their room, eight staff
indicated they document supervision, and all staff stated they provide constant sight and sound
supervision when a youth expresses suicidal thoughts.
3.11 Secure Observation [Detention Staff/Contract Provider]
Satisfactory Compliance
(Critical)
Youth placed on suicide precautions may be maintained on secure observation when less
restrictive means are not effective.
Nine youth records were reviewed for the use of secure observation (SO), and none were
applicable; therefore, the center provided two additional records for review. In both records, the
youth’s placement on SO was authorized by the superintendent and the designated mental
health clinician authority (DMHCA) as well as designated in writing. The Health Status Checklist
was completed prior to placement on SO and the Suicide Precaution Observation Logs were
completed in their entirety. Within eight hours of placement, a new or Follow-Up Assessment of
Suicide Risk (ASR) was completed or, if a mental health staff was not available, the ASR was
completed the following morning. The parent/guardian and juvenile probation officer (JPO) were
notified in both records of each youth’s potential suicide risk. Neither youth remained on SO
over twenty-four hours. While on SO, mental health staff continually provided supportive
counseling services. The Suicide Precaution Observation Logs for both youth documented
supervision. Each youth’s level of supervision was only reduced after a conference with the
superintendent and/or a licensed mental health professional. Discontinuation of SO and step-
down to close supervision were documented in the center’s logbook as well as the youth’s
mental health record for both youth.
3.12 Suicide Precaution Observation Logs [Detention
Satisfactory Compliance
Staff/Contract Provider] (Critical)
Youth placed on suicide precautions must be maintained on one-to-one or constant
supervision. The staff assigned to observe the youth must provide the appropriate level of
supervision and record observations of the youth's behavior at intervals of no more than thirty
minutes.
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Nine youth records were reviewed for Suicide Precaution Observation Logs. The Suicide
Precaution Observation Logs were maintained for the duration the youth were on suicide
precautions 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. None of the youth records were applicable for warning signs. The logs
were reviewed and signed by each shift supervisor and signed by mental health clinical staff in
all nine 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 observation.
3.13 Suicide Prevention Training [Detention Staff] (Critical) Satisfactory Compliance
All staff who work with youth must be trained to recognize verbal and behavioral cues
indicating suicide risk, suicide prevention, and implementation of suicide precautions.
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 seven suicide response kits
which include a knife-for-life, wire cutters and needle nose pliers and are located on all mods,
post two, and in master control. Suicide response kits are co-located with first-aid kits. A review
of training and drill documentation indicated the training included mock suicide drills held no less
than quarterly on each shift for all staff who come in contact with youth. All mock mental health
drills included response to a simulated suicide attempt and/or incident of self-injury. No youth
were used during mock mental health drills. The program provided semi-annual training on
emergency response procedures to include mock training in emergency response to a suicide
attempt or incident of serious self-inflicted injury. Any staff not present during a drill had the
opportunity to review each drill scenario and procedure in an effort to understand the process
and receive the necessary training to respond to an incident of a suicide attempt or incident of
serious self-inflicted injury within the facility. Interviews with nine staff verified where knife-for-life
kits were located throughout the center.
3.14 Mental Health Crisis Intervention Services [Detention
Satisfactory Compliance
Staff] (Critical)
Every center must respond to youth in crisis in the least restrictive means possible to protect
the safety of the youth and others while maintaining control and safety of the facility. The
program must be able to differentiate a youth who has an acute emotional problem or serious
psychological distress from one who requires emergency services. A youth in crisis does not
pose an imminent threat of harm to himself/herself or others, which would require suicide
precautions or emergency treatment.
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The center 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.
3.15 Emergency Care Plan [Detention Staff] (Critical) Satisfactory Compliance
Youth determined to be an imminent danger to themselves or others due to mental health or
substance abuse emergencies occurring in center, requires emergency care to be provided in
accordance with the center’s Emergency Care Plan. The Crisis Intervention Plan and
Emergency Care Plan may be combined into an integrated crisis intervention and emergency
services plan which contains all the elements specified in Rule 63N-1, Florida Administrative
Code.
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 September 22, 2023. A copy of the plan is located in mental health, the
Department’s Intranet site, and the superintendent’s office.
3.16 Crisis Assessments [Contract Provider] (Critical) Satisfactory Compliance
A Crisis Assessment is a detailed evaluation of a youth demonstrating acute psychological
distress (e.g., anxiety, fear, panic, paranoia, agitation, impulsivity, rage) conducted by a
licensed mental health professional (LMHP), or under the direct supervision of a LMHP, to
determine the severity of youth's symptoms and level of risk to self or others. When staff
observations indicate a youth's acute psychological distress is extreme/severe and does not
respond to ordinary intervention, the superintendent or designee must be notified of the crisis
situation and need for Crisis Assessment. A Crisis Assessment is to be utilized only when the
youth’s crisis (psychological distress) is not associated with suicide risk factors or suicide risk
behaviors. If the youth’s behavior or statements indicate possible suicide risk, the youth must
receive an Assessment of Suicide Risk (ASR) instead of a Crisis Assessment.
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,
and recommendations for follow-up or further evaluation. Notification to the parent/guardian of
follow-up treatment for all three youth was not applicable nor was a mental health alert entered
into the Department’s Juvenile Justice Information System (JJIS) due to each youth not needing
placement on precautions after completion of a Crisis Assessment. 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. All three youth were alleged victims of a
Prison Rape Elimination Act (PREA) event, and each youth was offered ongoing mental health
treatment, as required.
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3.17 Baker and Marchman Acts [Detention Staff/Contract
Satisfactory Compliance
Provider] (Critical)
Individuals who are believed to be an imminent danger to themselves or others because of
mental illness or substance abuse impairment require emergency mental health or substance
abuse services.
Nine youth records were reviewed for Baker Acts and Marchman Acts. None of the reviewed
youth were applicable for being Baker Acted during the annual compliance review period, as
such, the center provided two additional records for review. The youth were 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. None of the youth required a
mental health alert.
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Standard 4: Health Services
4.01 Designated Health Authority/Designee [Contract
Satisfactory Compliance
Provider] (Critical)
The designated health authority (DHA) is clinically responsible for the medical care of all
youth at the center.
The center’s designated health authority (DHA) is a board-certified physician who is a licensed
medical doctor (MD) who specializes in family medicine. The DHA’s license is unrestricted and
meets all requirements to practice in the State of Florida, which expires on January 31, 2026.
The center utilizes an advanced practice registered nurse (APRN) who has a collaborative
practice protocol in place which is signed by the DHA and APRN. 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. No tele-medicine was used during the annual
compliance review period. The DHA was interviewed and stated their role includes performing
Comprehensive Physical Assessments, conducting periodic evaluations, sick call, and policy
and procedure development. The DHA stated they communicate with the center staff regarding
youth medical needs by telephone or when they are on-site. If off-site, they are on call twenty-
four hours a day, seven days a week and staff call them with any needs or concerns. Any off-
site care findings, instructions, or information is reviewed by the DHA through paper records on
a weekly basis.
4.02 Healthcare Protocols, Policies, and Procedures
Satisfactory Compliance
[Contract Provider]
There shall be Protocols, Policies, and Procedures for all health-related procedures and
protocols utilized at the center.
The center utilizes facility operating procedures (FOPs) for all health-related procedures and
protocols. During the annual compliance review period, it was found the designated health
authority (DHA) signed the FOPs September 25, 2024, the superintendent signed on
September 25, 2024, and the psychiatrist signed on September 30, 2024, for all respective
treatment FOPs. No new policies or changes had been made during the annual compliance
review period. Newly employed healthcare personnel received a comprehensive clinical
orientation to the Department’s healthcare policies and procedures, which was conducted by a
registered nurse (RN). Nursing staff reviewed, signed, and dated a cover page between the
dates of October 24, 2024, and January 3, 2025, of all medical FOPs, treatment protocols, and
other procedures.
4.03 Authority for Evaluation and Treatment [Detention
Satisfactory Compliance
Staff/Contract Provider]
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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 youth Individual Healthcare Records (IHCRa) were reviewed for Authority of Evaluation
and Treatment (AET) requirements. Six of nine IHCRs included an AET obtained prior to
providing medical services with one containing a Limited Consent for Evaluation and Treatment
signed by the superintendent pending a court order. The remaining two records belonged to
youth who were eighteen years of age. Each of the six applicable youth’s AETs were either
originals or stamped as a “COPY” and filed in the youth’s IHCR. All six IHCRs were signed by
the youth’s parent/guardian. Each applicable AET was signed by a Department representative,
were valid and were obtained prior to the provision of medical services.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for parental/guardian
notification/consent requirements. Three out of nine youth were found to have parental/guardian
notification for over-the-counter (OTC) medications beyond those covered by the Authority for
Evaluation and Treatment (AET). All three youth IHCRs included documentation of consent
provided by the parent/guardian. All three youth IHCRs included written notification sent utilizing
the Department’s Parental Notification of Health-Related Care form. One of the nine youth was
taking psychotropic medications on admission. Three of the nine youth on OTC medications,
which included one also on psychotropic medications, had medications which were prescribed,
discontinued, or had a significant change in the dosage. Written notification was sent for all
three youth and telephonic contacts were recorded in the progress notes. None of the youth
IHCRs reviewed were involved with the Department of Children and Families (DCF). Six out of
nine youth’s vaccines were verified within thirty days of the youth’s admission with no additional
vaccines needed. The remaining three youth vaccines were verified three, ninety, and 191 days
late with no additional vaccines needed. None of the nine youth required a Religious Exemption
from Immunization.
The nurse was interviewed and reported the juvenile probation officer (JPO) is responsible for
ensuring the AET is fully executed by the parent/guardian of the youth and forwarded to the
holding facility. Where parental/guardian rights have been terminated, DCF has limited authority
to consent to treatment and youth eighteen years of age or older can provide consent. The
nurse detailed the procedures for parent/guardian notifications for emergency treatment,
medication changes, immunizations, and other services. The vaccination information for each
youth is obtained through the Florida Shots website and reviewed within twenty-four hours of
admission. Religious exemptions are documented on the designated form and filed in the
Electronic Medical Record (EMR).
4.05 Healthcare Admission Screening & Rescreening Form
(Medical and Mental Health Screening Form) (screening Satisfactory Compliance
entered into JJIS)
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Office of Accountability and Program Support Page 33 of 52 (Revised July 2023)
Youth are screened upon admission for healthcare concerns which may need a referral for
further assessment by healthcare staff.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for healthcare admission
screening requirements. Each of the nine youth received a medical and mental health
admission screening completed on the Department’s Facility Entry Physical Health Screening
form on the date of admission by the juvenile justice detention officer (JJDO) with the screening
reviewed with the youth by a licensed nurse within twenty-four hours. Notification was made to
the designated health authority (DHA) for all nine youth and documented in the youth’s IHCRs.
None of the reviewed youth changed physical custody since admission to the center. None of
the applicable youth received a qualitative urine pregnancy screening test as each youth was a
male.
The nurse was interviewed regarding healthcare admission screenings and re-screenings and
stated the youth are seen by medical staff within twenty-four hours of admission to the center.
At a minimum, vital signs are taken, and the youth is questioned concerning medical needs,
chronic conditions, medications and medical complaints. The admission packet is reviewed, and
each page must be signed and dated.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for youth orientation to
healthcare services and health education. The center’s facility operating procedures (FOPs)
included access to medical care, sick call access, what constitutes an emergency and when to
notify staff, medication process to include side effect monitoring, the right to refuse care and
how it is documented, what to do in the case of a sexual assault or attempted sexual assault,
the non-disciplinary role of the healthcare provider, and the review of the list of healthcare
contacts to ensure accuracy. All nine youth received a general healthcare orientation within
twenty-four hours of admission and was documented on the Health Education form.
4.07 Designated Health Authority/Designee Admission
Satisfactory Compliance
Notification [Contract Provider]
The DHA or designee is notified when youth admitted require emergency care or routine
notification in accordance with Department requirements.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for notification requirements
to the designated health authority (DHA). Three of the nine youth were admitted with known or
suspected chronic conditions, in which a referral was made to the DHA within twelve hours. No
youth were identified as in-need of emergency care upon admission. The notifications to the
DHA for all three youth were documented in the youth’s IHCRs in the chronological progress
notes. One youth was taking psychotropic medications upon admission. The psychiatrist was
also notified within twelve hours of admission of the youth and the notification was documented
in the chronological progress notes section in the youth’s IHCR. The nursing staff interview
stated the DHA is notified within twenty-four hours of admission, as well as the psychiatrist, if
the youth are admitted on any psychotropic medications. All notifications are documented on the
intake progress note of the IHCR by the licensed medical staff. If the notification is made by
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non-healthcare staff after hours, the report of Healthcare by Non-Healthcare Staff form is
completed and placed in the youth’s IHCR.
4.08 Health-Related History [Contract Provider] Satisfactory Compliance
The standard Department Health-Related History (HRH) form shall be completed for all youth
admitted into the physical custody the center.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for Health-Related History
(HRH) form completion. Eight of the nine applicable youth’s HRH forms were updated or
completed within seven calendar days of admission with one youth having a previous admission
date to the center. The HRH form was completed prior to the Comprehensive Physical
Assessment (CPA) or focused evaluation by evidence of a signature and date by a licensed
nurse. The designated health authority (DHA) or advanced practice registered nurse (APRN)
reviewed each HRH for all nine youth and documented their review on the HRH with a date and
signature. Nursing interviews were conducted, and the nurse stated the HRH is completed or
reviewed by the nursing staff with the youth no later than seven days from admission.
4.09 Comprehensive Physical Assessment/TB Screening
Satisfactory Compliance
[Contract Provider]
The Comprehensive Physical Assessment (CPA) form shall be completed for all youth
admitted into the physical custody of the center.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for the Comprehensive
Physical Assessment (CPA) and tuberculosis (TB) screening requirements. Each of the nine
youth’s CPAs were completed on the Department form. Two out of the nine youth had a current
CPA on file at the time of admission. Seven out of nine youth did not have a CPA on file at the
time of admission. Five of the seven applicable youth had a CPA completed within seven days
of admission with one youth’s CPA completed one day late and the remaining youth’s CPA
completed three days late. Seven youth CPAs were conducted by the advanced practice
registered nurse (APRN) and two conducted by the designated health authority (DHA). The
correct Medical Grade was listed on all nine CPAs with no missing or incomplete elements
noted. All nine youth’s CPAs were current with no changes in the youth’s medical condition.
Seven of the nine current CPAs were reviewed by the DHA or APRN and signed off on within
seven days of admission. In all nine IHCRs reviewed, all sections of the CPA were marked with
either an “O” or an “X” with any “X” documenting in further detail in the comment section to
elaborate on the abnormality. Seven of nine youth were not clinically in need of a portion of the
exam as noted by the examining practitioner. The two applicable youth refused a portion of the
exam, and a refusal was documented in the chronological progress notes which was signed by
the youth, a nurse, and the DHA or APRN. All nine youth’s problem lists were updated to reflect
any current issues and dates resolved if any issues were resolved. All nine CPAs had a current
Tuberculosis Skin Test (TST) documented in the IHCR and administered within the last year.
The results of all nine youth were found documented on the Infectious and Communicable
Disease forms which matched their results documented on the CPA. None of the nine youth
required further evaluation, treatment, or transportation for hospitalization as a result of the TST.
The nurse reported the DHA is responsible for conducting a new CPA at a minimum of every
two years for grades two through five but at the center all are completed yearly or with any
significant health changes.
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Office of Accountability and Program Support Page 35 of 52 (Revised July 2023)
4.10 Sexually Transmitted Infection/HIV Screening [Contract
Satisfactory Compliance
Provider]
The center shall ensure all youth are evaluated and treated (if indicated) for sexually
transmitted infections (STIs) and HIV risk factors.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for sexually transmitted
infection (STI) and human immunodeficiency virus (HIV) screening requirements. Five out of
nine youth stated they were sexually active and were screened for STIs. Further evaluation was
required for all five youth and the referral was documented on the STI form. Two of the five
requested to be tested, testing was ordered and conducted within seven days of admission, and
the results were documented on the Infectious Communicable Diseases (ICD) form and filed in
the lab section of the IHCR. None of the nine youth received a gynecological exam or were ever
out of the Department’s physical custody. All nine youth were offered counseling and testing for
HIV. Two of the nine youth were tested for HIV and a documented consent from each youth was
obtained. The results were filed in both youth’s IHCR in a sealed envelope marked
“CONFIDENTIAL”. Refusals were documented for the remaining seven youth. All nine
interviewed youth stated they were able to request a HIV test if they have the desire.
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 youth Individual Healthcare Records (IHCRs) were reviewed for Sick Call Process
requirements. None of the nine records were applicable, as such, the center provided three
more records for review. All three youth’s sick calls were documented on the Sick Call Referral
Log. None of the three youth presented with a similar sick call complaint three or more times
within a two-week period; therefore, no referral was needed to the designated health authority
(DHA). All three youth submitted a sick call on the Sick Call Request form. Only nursing staff
completed the Sick Call Request form. None of the youth’s sick calls were conducted by a
licensed practical nurse (LPN). All three youth’s sick calls were filed in the youth’s IHCR in
reverse chronological order. None of the youth reviewed were in restricted housing during sick
call hours. All three youth’s sick call forms were documented in accordance with Florida
Administrative Code. All three youth’s sick calls were documented on the Sick Call Index inside
the IHCR with the dates listed on the sick call forms matching the dates of the sick call index. A
nurse was interviewed and noted sick calls hours are seven days a week from 7:30 a.m. until
8:00 a.m. and 5:30 p.m. until 6:30 p.m. These hours are posted in the medical clinic area and
the common areas. There are approved treatment protocols for registered nursing staff to
utilize. Only licensed nurses complete sick calls. When there is not a licensed nurse on-site, the
center has procedures whereby the shift supervisor reviews all the sick call requests as soon as
possible within four hours after the request is submitted and notifies the DHA. The center has in
place a policy for room restrictions/confinement in which youth in restricted housing shall be
afforded access to healthcare at equal or greater intervals of youth who are in regular housing.
No observation of a sick call was completed during the annual compliance review week as
monitoring staff were not on-site during the hours sick call is scheduled. Nine youth were
interviewed and asked how quickly they were seen after submitting a sick call. Two youth said
they were seen within a day, one youth said within two days, and one youth said more than
three days. Five youth reported they have not had to request a sick call. Each of the nine youth
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Office of Accountability and Program Support Page 36 of 52 (Revised July 2023)
stated the nurses conduct sick call. Nine staff were interviewed, and all nine staff reported the
nurse reviews and conducts sick calls.
4.12 Episodic/First-Aid/Emergency Care [Contract Provider] Satisfactory Compliance
The center shall have a comprehensive process for the provision of episodic care and first aid
care.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for episodic/first-
aid/emergency care requirements. Five out of nine youth required on-site first-aid or episodic
care. All five youth received episodic care or first-aid by a licensed healthcare staff and was
documented in subjective, objective, assessment, and plan (SOAP) format. None of the youth
received episodic or first-aid care by a non-healthcare staff. All five youth complaints were
documented with findings of person rendering care to include received treatment. No youth
required a referral to off-site care. All five youth’s episodic/first-aid care was documented on the
Episodic/First-Aid Care Log. None of the five youth required a plan for follow-up care.
The center has a total of eighteen first-aid kits located throughout program areas which are
accessible to staff in the event of an emergency. A first-aid kit is available for each of the six
transport vehicles. Additionally, one is in master control and one in each of the five Sub
Controls, front intake, laundry, maintenance, supervisor’s office, consequence unit, and kitchen.
The first-aid kits include an approved list of items present and documented on each kit. Three
kits were opened and examined. All three had contents within their date of expiration. First-aid
kits are inventoried monthly by the medical staff. Documentation of all the inventory was
conducted and documented on the monthly first-aid kit and automated external defibrillator
(AED) logs. The center has a total of three AED units located in B1 sub control, G1 sub control,
and medical. All are inspected monthly by medical staff and a log is kept documenting any
findings or discrepancies fixed with dates the pads and batteries were changed. The batteries
and pads of the device were observed within their date of expiration with an expiration date of
December 28, 2025 for the pads and March 10, 2025 for the battery. A licensed medical staff
was observed performing an inspection of the AED during the annual compliance review week.
The device was operating as required.
Emergency drills have been conducted every month, on each shift, unannounced in which a
simulated episodic care event took place for the duration of the annual compliance review. Six
out of the twelve months an unresponsive person or suicide drill was conducted in which
cardiopulmonary resuscitation (CPR) was rendered and the use of the AED was conducted to
show proper techniques were being used. The center maintains documentation of all
emergency drills conducted. A list of emergency numbers was found accessible to licensed and
unlicensed staff which included the number to the Poison Information Center. The numbers
were not accessible to youth. All authorized direct care staff were appropriately trained by a
registered nurse on the administration of an epinephrin auto-injector. Nine staff records were
reviewed which showed training requirements were met regarding episodic, first-aid, and
emergency care.
The policy on the use, access, and inventory of NARCAN states the center must stock and
inventory NARCAN for emergency treatment of a known or suspected opioid overdose. The
center stores NARCAN in their medication cart which is accessible to the registered nurse and
non-healthcare supervisory staff. Each staff with access to NARCAN has been trained on when
and how to use it and it is inventoried by a licensed nurse weekly. Training sign in logs were
reviewed to ensure compliance.
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Office of Accountability and Program Support Page 37 of 52 (Revised July 2023)
Nine interviewed youth were asked to rate the medical care at the center. Four youth rated it
very good, one rated good, and one rated fair. Three youth stated they have not required
medical services. Each of the nine interviewed staff stated they can call 9-1-1 if needed.
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 youth Individual Healthcare Records (IHCRs) were reviewed for completion requirements
concerning off-site care/referrals. Four out of nine youth required off-site care in which the
Summary of Off-Site Care Consultation Report form was utilized and filed in the IHCR. Off-site
care was also documented on the Episodic Care Log. Parental/guardian notifications were
made for the youth and documented in the IHCR. Discharge documents were filed in the youth’s
IHCR, and the designated health authority (DHA) reviewed the discharge instructions, findings,
and care rendered within seven days from the incidents by evidence of signature and date. All
four youth received non-emergent off-site care. One of the four youth receiving off-site care
required follow up testing, referrals, or appointments. The nurse stated any off-site care
appointment or treatment is tracked in the episodic log. The DHA is contacted upon the youth’s
return to the center regarding outcomes and instructions. The DHA will review and sign all off-
site medical documentation during next on-site weekly shift. Nursing staff track any follow-up
appointments.
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.
Nine youth Individual Healthcare Records (IHCRs) were reviewed for chronic conditions/periodic
evaluation requirements. Two youth were identified on the Medical/Mental Health Screening
forms for having a chronic condition as such, the center provided an additional record to review.
None of the reviewed youth had a communicable disease. Two of the nine youth were taking
prescribed medication on an on-going basis. None of the youth were undergoing treatment for a
physical health condition. Three of the nine youth were classified with a Medical Grade of two to
four. One youth was identified as pregnant and placed on the chronic conditions list. All three
applicable youth had a periodic evaluation which was documented and found in the progress
notes section with proof the review was conducted. None of the youth were identified as taking
anti-tuberculosis medication. One of the nine youth required an evaluation by off-site care and
the designated health authority (DHA) completed a follow-up with the youth as evidenced by
signature and date on the discharge documentation. The Department’s Problem List was
updated in accordance with Florida Administrative Code for the three applicable youth. The
DHA was interviewed and stated all youth with chronic conditions are seen for evaluations every
ninety days or sooner if needed. The DHA also reported each youth with a chronic condition is
discussed at their weekly clinic meeting to ensure appropriate tracking and appointment
scheduling.
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Office of Accountability and Program Support Page 38 of 52 (Revised July 2023)
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 youth Individual Healthcare Records (IHCRs) were reviewed for medication management
requirements. Three of the nine youth were taking medication at admission and the medication
was verified prior to being admitted into the center. Prescription verifications for all three youth
were completed utilizing the Prescription Mediation Verification Checklist form. The physician
and psychiatrist were notified and an order to continue the medications was made. For the
youth who entered on psychotropic medications, the psychiatrist was notified within twelve
hours of admission, however, the youth was referred to be seen by the psychiatrist prior to the
medication order. The three prescription verifications were noted in the progress notes, IHCR,
and Electronic Medical Record (EMR). None of the nine youth reviewed were in restricted
housing during medication administration hours. Six of the nine youth were given over-the-
counter (OTC) medications which were not listed on the Authority for Evaluation and Treatment
(AET) form. Each of the six youth utilized a standard Department Medication Administration
Record (MAR) in the EMR. All six of the youth’s MARs clearly indicated medication start and
stop dates. None of the six youth received a medication by a trained non-healthcare staff after
hours when a licensed staff was not on-site. No lapses or errors in medication administration
were noted. Side effect monitoring and documentation was noted on all six youth’s MARs. None
of the six youth’s MARs contained any documented refusals. Each of the six youth’s MARs
contained all required elements to include the youth’s name, Department identification number,
date of birth, youth allergies, precautions, Medical Grade, medical alerts, and current picture of
the youth attached. All six MARs documented medical staff assisted in medication
administration and each instance was found to have the staff initials and youth’s initials for each
medication given. None of the six youth required parenteral medication. One of the nine youth
entered on psychotropic medications, and the psychiatrist conducted an initial diagnostic
psychiatric interview with the youth within fourteen days of admission. Two additional youth
were placed on psychotropic medications after admission. Two of the three youth received
medication monitoring by the psychiatrist every thirty days, as required. The third youth had not
been at the center for thirty days as of the date of the annual compliance review week. The
center’s medical department reported there are no standing orders or emergency treatment
orders for psychotropic medications. A medication pass was not observed as it was not held
while the review team was on-site. Nursing staff stated medication administration was
completed by the licensed medical staff. Youth are escorted to medical by the juvenile justice
detention officers (JJDOs). The youth approach the nurses’ station individually. The medical
provider identifies themself and prepares the medications for each youth as prescribed. The
allergy and alert status are verified on the MAR. Each youth initials for their medication after
receiving it and the nurse indicates they have given the medication by initialing. A mouth check
is completed to ensure the youth has swallowed the medication. The nurse stated non-
healthcare staff can administer medication if they are trained. The latest training was conducted
by a licensed nurse on September 30, 2024, and the training log and names of trained
supervisory staff remain in a binder in the medical clinic area.
Nine staff were interviewed all indicated they do not give medications to youth. Nine youth were
interviewed and asked who gives them medications. Three applicable youth reported the nurse
gives them their medication. The remaining six youth did not take medications. The nurse
indicated the disposal process for any medications included the proper logging and disposal
through a return to the pharmacy or the utilization of the RX destroyer in conjunction with the
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Office of Accountability and Program Support Page 39 of 52 (Revised July 2023)
pharmacy consultant. This system is monitored and verified by the designated health authority
and clinic manager.
4.16 Medication/Sharps Inventory and Storage Process
Satisfactory Compliance
[Contract Provider]
Any medical equipment classified as stock medication shall be secure and inventoried by
using a routine perpetual inventory descending count as each sharp is utilized and disposed
of or when the medication is utilized.
The medical office was found to be neat, clean, organized, and inaccessible to youth in the area
where sharps and medications were maintained. Medical equipment classified as sharps were
found secured and inventoried utilizing a routine perpetual inventory descending count as each
sharp was utilized or disposed of in the medical clinic. A sample of three sharps were reviewed
and counts of the items matched the ending inventory numbers. All medications were identified
and secured in the locked area designated for storage of medications inside the medical office.
The medication cart was found to be clean and organized with stock items separate from youth-
specific medications. All over-the-counter (OTC) medications were stored in a separate,
secured area, inaccessible to youth. Narcotics and other controlled medications were stored
behind two locks. No oral medications were stored with topical medications. Medications
requiring refrigeration were found inside a secured refrigerator labeled “Medication Only.” For
youth on controlled medications, a perpetual shift-to-shift inventory count was conducted and
documented on the youth’s individualized Controlled Medication Inventory Record. Non-
healthcare staff were trained in the delivery and oversight of medication self-administration
when nursing staff are not on-site. This training was delivered by a registered nurse. The center
had only one controlled medication and upon review, no discrepancies were found and counts
matched ending counts. Three OTC medication samples were reviewed with no discrepancies
and counts matched ending counts. Perpetual weekly inventories of all sharps and OTC
medications were observed. Observations of inventories confirmed the center’s medical staff
conduct inventories of medications and sharps as required. The procedure for reporting
inventory discrepancies states any medication inventory discrepancy shall require notification to
the superintendent and the Department’s Central Communications Center (CCC). Medical staff
are responsible for all disposal of medications, along with the pharmacy consultant. Each
disposal will be inventoried prior to destruction, with the pharmacy consultant present. The
nurse was interviewed and stated all outdated medications are removed and securely stored in
a quarantine area. Disposal utilizing the RX Drug Buster is completed at least monthly in the
presence of the pharmacy consultant. All disposals are documented in the Destroyed
Medication Log.
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 youth Individual Healthcare Records (IHCRs) were reviewed for infection control, exposure
control, and education requirements. All nine of the youth received infection control training on
admission to include hand-washing techniques, universal/standard precautions,
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Office of Accountability and Program Support Page 40 of 52 (Revised July 2023)
prevention/transmission of communicable disease, vaccinations, and the Centers for Disease
Control and Prevention (CDC) guidelines for infection control. The Exposure Control Plan was
written in accordance with Occupational Safety and Health Administration (OSHA) guidelines
and included a risk assessment listing job classifications in which staff have the potential for
occupational exposure, including tasks and procedures which would cause staff in specific job
classifications to have an occupational exposure. A method of compliance outlining infection
control practices and engineering and work practice controls was also found in the plan.
Infection control procedures in place included prevention, containment, treatment, and reporting
requirements related to infectious diseases, according to OSHA and the CDC guidelines.
Infection control procedures outlined all required elements such as common infectious diseases
of childhood, the common cold, viral or bacterial infections, tuberculosis, Hepatitis A, B, C,
human immunodeficiency virus (HIV), other outbreaks or epidemics caused by any other
infectious agent, pediculosis and/or scabies, food-borne illnesses, chemical exposure, bio-
terrorist agents, and Methicillin-Resistant Staphylococcus Aureus (MRSA). The facility operating
procedures (FOPs) containing the infection control plan include processes for needle stick post-
exposure evaluation. Hepatitis B immunizations are made available for staff. All staff have
access to protective equipment. The registered nurse stated there have been no instances in
which infectious diseases and sexually transmitted infections needed to be reported to the local
health department as required or the Department’s Central Communications Center (CCC).
There were not three or more cases of reportable infectious diseases which needed to be
reported to the local health department and/or CDC. There were also no hospitalizations or
quarantining of at least ten percent of the total population for youth or staff. The acting
superintendent was interviewed and stated a separate file is maintained containing all
documents for youth and staff who have experienced facility/occupational exposure for a ten-
year period as required. Nine staff training records were reviewed. All nine staff received pre-
service or in-service training on the center’s specific Exposure Control Plan by the clinic
manager as noted in the nursing interview results and found in the staff’s training 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.
None of the reviewed youth were identified as pregnant at the center at the time of the annual
compliance review. Three additional youth records were provided to review prenatal care and
education. All three youth received prenatal care immediately upon determination the youth was
pregnant at admission. One of the three youth received routine, focused medical evaluations
every thirty days or sooner, if ordered. The other two youth were released prior to the first thirty
day evaluation being due. All three were placed on an internal alert system for vital nutrition and
health awareness for staff along with an alert in the Department’s Juvenile Justice Information
System (JJIS). An alert was entered into the center’s internal alert system for sleeping
arrangements for two mattresses and pillows for support for the one applicable youth and a
doctor’s order was written for the third youth. One of the youth had complaints or issues during
their stay but daily monitoring for danger signs of pregnancy complications was not warranted.
The one applicable youth had a documented plan for post-birth psychological and physical care.
Education for all three youth was found in the youth’s Individual Healthcare Record (IHCR)
under the education tab to include alcohol and drug use, smoking, nutrition, sexually transmitted
infections, contraception, prenatal care, birthing process, postpartum care, basic baby care,
child/infant development, and parenting skills which was conducted by a licensed staff. The
youth received nutritious food and appropriate servings as ordered by the designated health
authority (DHA). One of the three youth received routine monitoring for nutrition and weight
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Office of Accountability and Program Support Page 41 of 52 (Revised July 2023)
status, the remaining two youth did not require/have an active order for this monitoring. A review
of in-service training was found to include observation and monitoring of emergency care
needs/symptoms for possible miscarriage and has nursing protocols and treatment in place for
pregnant youth. Staff training records were reviewed to ensure compliance.
The nurse was indicated each female youth is offered screening for pregnancy at admission.
Prenatal services begin immediately upon determination of pregnancy and the DHA will monitor
the pregnant youth at the minimum of once every thirty days. Nutritional and sleep
accommodations are ordered, and weight and nutrition are monitored by healthcare staff. Off-
site obstetrician appointments are managed by the center’s healthcare staff and all
documentation is reviewed by the DHA. A licensed healthcare staff will be responsible for
providing in-service training to all non-healthcare staff regarding pregnant youth and cover all
required topic areas.
Nine youth were interviewed. None of the youth stated they had received prenatal, obstetrical,
or gynecological services at the center. All nine interviewed youth stated they did not need
these services.
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Office of Accountability and Program Support Page 42 of 52 (Revised July 2023)
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) for the active supervision of youth.
Observations were completed daily during the annual compliance review week to ensure staff
actively supervised youth at all times. Youth movement was observed to ensure at least one
staff was present at all times and all movement was authorized by master control. Census
counts are conducted throughout each shift at both specified and random times, and
documented in logbooks. Observations found staff provided active supervision and interactions
with youth were positive.
Eight of the nine interviewed staff agreed there are enough staff to provide for the safety and
security of the youth and staff; however, three of these staff also noted more staff would be
preferrable. One staff said there is not always enough staff, and there are sometimes holdovers
from the previous shift.
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) for the behavior management system
(BMS). A tour of the facility found BMS postings were present in each living module. The BMS
postings included guidelines for appropriate/inappropriate behavior, consequences for negative
behavior, and monthly reward calendars. The BMS is a three-tier level system which affords the
youth opportunities to earn points towards rewards/incentives. The center utilizes point cards for
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daily documentation of the BMS. Cards are reviewed daily by shift supervisors and every other
day by the BMS lead to ensure staff are following the established guidelines. Each module has
a white board which is used to assist with tracking levels. Documentation was found in both the
module and master control logbooks to indicate when rewards were distributed. No group
punishment was noted in logbooks. Each of the nine interviewed staff were able to confirm the
center’s BMS including points and levels. Eight staff additionally stated the BMS is posted
throughout the center, and three staff said the BMS is included in the youth’s intake process.
Nine interviewed staff reported youth rewards include Breaking Bread, a weekly meal for
qualifying youth, sometimes including invited family, additional snacks, items from the token
store, special games nights, and a step class offered by volunteers. All nine staff stated they
believe the center’s BMS is effective and confirm staff speak with youth to discuss any
consequences being imposed, youth are given an opportunity to explain their behaviors, and
staff speak with them about alternative behaviors. The nine staff reported supervisors provide
feedback on the implementation of the BMS during briefings and in one-on-one meetings daily,
weekly, and as needed. Each of the nine staff confirmed nothing can be taken away from youth
as a consequence except their points and levels from the BMS. None of the staff have seen a
co-worker take meals, snacks, clothing, education, or medical care from a youth because they
were acting out or observed any staff encouraging youth to beat up another youth.
Nine youth were interviewed. Eight of nine youth were able to explain how the BMS worked.
One youth was new and unable to articulate any understanding of the BMS. Each of the eight
youth familiar with the BMS reported the rewards youth are given include Breaking Bread, a
weekly meal with higher level youth and/or their families, snacks, and games. All nine youth said
staff use rewards the same. Each of the nine youth confirmed youth are not allowed to punish
other youth. Three of the nine youth reported they have been sent to their room for punishment,
each were able to recount the reason for the confinement, and each confirmed their door was
shut and locked. Each of the three also indicated nothing except points and levels can be taken
as a consequence and the consequences they were given were fair. The remaining six youth
reported they have not received consequences. None of the nine interviewed youth have
witnessed staff using handcuffs or leg irons on out-of-control youth. Three youth rated the BMS
as very good, four youth said good, and two youth rated it as fair.
The acting superintendent advised the youth work through different levels. Level three is the
highest level, once they reach level three, they start getting rewards for positive behavior.
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
completed anytime youth are in their rooms. The center reported having 110 cameras, all
operable at the time of the annual compliance review. The camera system has the ability to
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store recordings for up to thirty days. The center uses a wand system to document the
completion of ten-minute checks. A review of wand checks compared to video was completed
for three samples of thirty-minute increments from each shift. The observations found staff
conducted each ten-minute check as required. Staff were observed stopping at each door to
look into the youth’s room and tapping the wand on the door sensor. The center’s management
conducts weekly reviews of ten-minute checks. Each of the nine interviewed staff confirmed
room checks are conducted every ten minutes when a non-suicidal youth is placed in their room
for sleeping or non-punishment reasons. The acting superintendent interview confirmed ten-
minute checks are conducted when youth are behind the door in their rooms.
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) which require staff to know the exact
number and location of all youth under their supervision at all times. Census counts are
completed by master control at the beginning, end, and at random intervals during each shift.
The counts are documented in master control and module logbooks. In addition, counts are
conducted following admissions/releases and during any emergency or unusual activities such
as power outages, drills, and codes. If a count is not cleared in a timely manner, all movement is
stopped, and a physical head count is completed. Observations were conducted and logbook
entries were reviewed, no issues were noted. Each of the nine interviewed staff reported counts
are conducted at the beginning and end of each shift, four said before and after school, and
three said before and after meals. Staff also mentioned counts are conducted after all youth
movements and the center is locked down if the count is not correct. Staff confirmed emergency
counts are conducted after actual emergencies and after drills. Five staff also mentioned
emergency counts are done when a youth is missing, and two staff said after a major
disturbance.
5.05 Logbook Maintenance and Reviews Satisfactory Compliance
The center maintains a chronological record of events, incidents, and activities in logbooks
maintained at master control and in each living area in accordance with Florida Administrative
Code. Each logbook is a bound book with numbered pages. If electronic logbook software is
used by the facility, it is password-protected and configured to prevent entries from being
deleted or altered after they are saved. At a minimum, each logbook entry includes the date
and time of the event, the names of staff and youth involved, a brief description of the event,
the initials of the person making the entry, and the date and time of the entry. Logbook entries
are made in black or blue ink, with no erasures or whiteout areas. No logbook entries are
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obliterated or removed; errors are struck through with a single line and initialed by the person
correcting the error. Log entries regarding Medical, Special Needs, and Mental Health alerts,
or other issues impacting facility safety and security shall be highlighted. The superintendent
or designee reviews all logbooks on a weekly basis. The juvenile justice detention officer
supervisor (JJDOS) reviews the facility logbook maintained at master control when he/she
accepts responsibility for the facility. The JJDOS reviews logbooks maintained in each living
area daily. The JJDO(s) and/or the lead officer reviews the logbook maintained in his/her
assigned living area when he/she accepts responsibility for the living area at shift change.
The center has facility operating procedures (FOPs) for the use of logbooks. The center
maintains a logbook in master control and each living module. Logbooks were bound with
numbered pages. Logbooks were observed for the annual compliance review period. There
were a number of module logbooks with covers in poor repair, however, all pages were
accounted for. Dates were documented at the top of each page. Entries were made in blue or
black ink and included the time of activity, name(s) of those involved, a brief description of the
activity, and the initials of the staff making the entry. Significant occurrences such as safety and
security events, medical and/or mental health information, and special alerts were highlighted. A
review of logbooks by the superintendent or designee was documented and highlighted. A
review by the shift supervisor was documented daily and highlighted. Master control and module
logbooks since the last annual compliance review documented entries for emergency situations,
incidents, all drills, medical and mental health alerts including start and end time of
precautionary/secure observation, formal and informal headcounts, changes to population
count, group movement, admissions and releases, law enforcement presence in facility, youth
searches, and youth in any type of confinement. The superintendent or designee reviews
logbooks on a weekly basis. The entries include the name and title of the person completing the
review and is highlighted. Shift supervisors review logbooks daily in master control and on the
living modules. Staff are required to review the module logbook for the area they are assigned
to, and documentation was noted in logbooks as required. The superintendent reiterated
administration is expected to review logbooks weekly and supervisors daily. The superintendent
interview confirmed management reviews logbooks.
5.06 Key Control Satisfactory Compliance
Each center is responsible for maintaining inventory and control of all facility keys. All keys
shall be placed on a tamper-resistant key ring designed to inhibit the removal of keys.
Emergency key rings shall be maintained separately from other facility keys, in master
control, in a secure location designated by the Superintendent. These keys shall be notched
or otherwise identifiable by touch. The key(s) on these rings shall provide egress through
facility exterior doors providing access to evacuation areas. A key inventory shall be
maintained by the Superintendent or designee at all times.
The center has facility operating procedures (FOPs) for key control. Keys are maintained on
tamper proof rings and secured in master control when not in use. The key inventory was
reviewed and matched the actual keys in use. The master inventory includes a ring number,
number of keys on each ring, capability of each key, and the assignment of the keys. All key
rings are numbered and color coded. Upon reporting for duty, staff receive their assigned keys
from the shift supervisor. Personal keys are secured in staff lockers prior to entering the secure
floor. Staff were observed carrying keys on their person, youth were not permitted to handle
facility keys. Keys are returned at the end of each shift prior to staff exiting the facility. Shift
reports and key inventories documented when keys were distributed and returned. Keys are
counted at the beginning and end of each shift by master control. The facility has a procedure
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for addressing missing, lost, and damaged keys. A sample of key rings was observed and
compared to the inventory and key log; no issues were found. An informal interview with the
master control operator confirmed youth do not have access to keys. Emergency keys are
maintained in a secured box in master control. Keys carried by three staff were observed and
examined to confirm they had the correct number of keys on the ring, their tag matched the
number of keys on the ring, and the number of keys matched the key inventory. The staff were
able to articulate the function of each key on their assigned key ring.
Each of the nine interviewed staff reported all center keys except the keys required for their
position are considered restricted, to include medical and mental health records, the youth
property area, case management records, and the kitchen. All nine staff confirmed their
personal keys are stored in personal lockers and center keys are distributed by the supervisor
during the briefing meeting held at the start of the shift. One staff also stated the center has a
key log and visitor keys are stored in a locker specifically for visitors.
The superintendent interview confirmed permanent keys are not issued to staff.
5.07 Vehicles and Maintenance Satisfactory Compliance
The center ensures any vehicle used by the center to transport youth is properly maintained,
as well as maintains documentation on the use and maintenance of each vehicle.
Youth and staff are not permitted to use tobacco products. Center vehicles are locked when
not in use.
The center has facility operating procedures (FOPs) for transportation and vehicle operations.
The center has a total of ten vans. At the time of the annual compliance review, two were out for
routine oil changes and one was recently assigned to maintenance. Vehicle logs and invoices
for routine services/inspections were reviewed. Vehicle inspections were documented as
required in SharePoint. The inspected vehicles had required equipment to include the
appropriate number of seatbelts and fire extinguishers. Each vehicle had a logbook, seatbelt
cutter, and window punch. First-aid kits are maintained in the transportation office and are
checked out at the time of transport. A transport was observed during the annual compliance
review week. The staff conducting the transport checked out a cellular telephone from master
control and retrieved a first-aid kit from the transportation office, inspected the van for
contraband, ensured there was a sufficient amount of fuel for the trip, checked the seatbelts and
cage, searched youth prior to placement in the van, ensured youth were wearing seatbelts, and
ensured youth were searched upon return to the center. Staff were also observed wearing their
seatbelts. Logbook entries in the vehicle logbooks were reviewed and found to include required
information. Each of the nine interviewed youth confirmed the staff drive safely when
transporting youth. None of the nine interviewed youth have seen anyone put contraband in a
transport vehicle.
5.08 Tool Inventory, Management, Youth Access to, and Use
Satisfactory Compliance
of Tools and Cleaning Items
The center ensures all tools and equipment related to maintenance and kitchen area are
properly maintained, stored, and inventoried. Youth are forbidden to use or access any tools,
including kitchen or medical equipment. Youth may use cleaning items such as mops,
brooms, buckets, and other common household items under direct supervision.
The center has facility operating procedures for tool control and inventories. A review of the tool
inventory was conducted with maintenance staff and all tools were accounted for. Tools are
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stored in a secured maintenance office which has restricted access. Youth do not have access
to tools. Tool inventories are completed and documented on SharePoint. Tools are marked or
etched to identify them as Department property. Any damaged or missing tools are reported to
the facility administration. At the time of the annual compliance review, there were no instances
of missing or damaged tools. A shadow board is used to house tools and an inventory is
conducted monthly. All vendors are accompanied by maintenance or a facility staff when in a
secure area. The kitchen has an itemized list of all utensils maintained by the food service
director and this list is on SharePoint. Inventories are documented weekly; knife inventories are
conducted daily. A review of ten tools confirmed each was accounted for on the inventory,
properly marked, and securely stored. Youth do not have access to tools, kitchen items or
medical equipment while at the facility. Youth are only permitted use of mops and brooms under
the direct supervision of staff.
Each of the nine interviewed staff confirmed they are to remove and secure any broken tools
from youth areas and inform the supervisor of any broken or missing tools. Each of the nine
staff reported youth are allowed to use mops and brooms at the center. Four staff said the youth
can use scrub brushes, and one said a dustpan. All the nine interviewed youth reported they are
allowed to use mops and brooms, with one of them saying youth use scrub brushes as well.
Each youth confirmed youth are not allowed to use any other tools at the center. The
superintendent interview confirmed only maintenance and management have access to tools.
5.09 Inventory of and Access to all Flammable, Toxic,
Satisfactory Compliance
Caustic, and Poisonous Items
The Superintendent is responsible for the implementation of a safety plan addressing proper
use, storage, and disposal of chemicals, including flammable, toxic, caustic, and poisonous
items. All flammable, toxic, caustic, and poisonous items shall be inventoried and secured
when not in use. The use of hazardous material shall be consistent with the manufacturers’
instruction and all safety precautions shall be followed. All flammable, toxic, caustic, and
poisonous items shall have the Safety Data Sheets (SDS) on hand in the facility. Toxic or
caustic materials shall not be allowed to enter into the facility unless a SDS is on file in an
SDS logbook and posted near items. A master copy of the SDS logbook shall be maintained
in an accessible binder for all personnel to review at all times. No hazardous chemicals
should be mixed, as this could result in an explosion or emission of toxic gas. Flammable,
toxic, caustic, and poisonous fluids and other dangerous substances may only be drawn or
acquired by authorized personnel. Youth shall not be permitted to use, handle, or clean-up
dangerous or hazardous chemicals or respond to chemical spills. Youth shall not be
permitted to clean, handle, or dispose of any other person’s bio hazardous material, bodily
fluids, or human waste.
The center has facility operating procedures (FOPs) which act as their Safety Plan. It addresses
the proper use, storage, and disposal of chemicals, including flammable, toxic, caustic, and
poisonous items. Chemicals are kept in a secured supply shed which is not accessible to youth.
The center maintains an inventory including flammable, toxic, caustic, and poisonous items. The
inventory accurately reflected the items housed in their supply area. A binder with Safety Data
Sheets (SDSs) is maintained for all chemicals used in the facility. A small amount of cleaning
materials are housed inside the facility and securely maintained. SDS binders were present in
the area with the cleaning materials. Five chemical items were reviewed to ensure the inventory
was accurate for what was on-site and the corresponding SDS was present. Only authorized
personnel are permitted access to flammable, toxic, caustic, and poisonous items. Youth do not
have access to these items and are not permitted to use them.
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Seven of nine interviewed youth reported staff spray cleaning chemicals and youth are allowed
to wipe off surfaces with a towel. Two of the nine said youth do not handle any chemicals, only
staff. All nine youth confirmed they do not have access to flammable, toxic, caustic, or
poisonous items.
All nine interviewed staff confirmed youth are not allowed to handle substances which are toxic,
flammable, or poisonous.
5.10 Disposal of all Flammable, Toxic, Caustic, and
Satisfactory Compliance
Poisonous Items
The maintenance mechanic or other trained staff who have the safety equipment for diluting,
handling, and disposing of hazardous waste and/or solid waste shall be responsible for
disposing of hazardous items and toxic materials in accordance with Occupational Safety and
Health Administration (OSHA) Standard 29 CFR 1910.1030 (amended 1-1-2004).
The center has facility operating procedures (FOPs) for the disposal of flammable, toxic,
caustic, and poisonous materials. There were no items which needed to be disposed of and no
reported chemical spills since the last annual compliance review. The maintenance mechanics
reported the center would follow the Safety Data Sheet (SDS) guidelines if a chemical needed
to be disposed of. The kitchen does not use grease so there is no need for external disposal
services
5.11 Confinement Under Twenty-Four Hours Satisfactory Compliance
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
The center has facility operating procedures (FOPs) for use of confinement under twenty-four
hours. Fifteen confinement reports were reviewed. Youth are offered and/or given three meals a
day, snacks, access to mental health and medical services, daily shower, clean clothing,
bedding, and educational materials when applicable. Confinements are approved by the shift
supervisor and only one youth may be assigned to each room. Rooms are searched for
contraband and findings are documented on the Facility Management System (FMS)
Confinement Report. Cameras and windows are free from obstructions. Youth were supervised
at five-minute intervals for the first hour and ten-minute intervals thereafter until released from
confinement. Supervisors conducted an initial review and additional reviews until the youth was
released from confinement. The superintendent or designee reviewed reports within forty-eight
hours of confinement. One of the fifteen reports had administrative reviews completed late.
Each of the nine staff stated when placing a youth in confinement, the confinement room must
be searched, the staff must conduct and document ten-minute checks, and complete the
confinement report. All nine staff confirmed youth are offered education materials if the
confinement occurs during school hours. The superintendent confirmed all reports are reviewed
and signed off on by administration. Regional management monitors the use of confinement
weekly.
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5.12 Confinement Over Twenty-Four Hours and Confinement
Non-Applicable
Hearings
Staff shall use behavioral confinement as an immediate, short term response strategy during
volatile situations in which a youth’s sudden or unforeseen onset of behavior imminently and
substantially threatens the physical safety of others or self.
Confinements should not exceed twenty-four hours; however, if a youth continues to exhibit
behavior which poses a risk to him or herself, staff, or others, a Confinement Review must be
conducted.
There were no confinements over twenty-four hours during the annual compliance review
period; therefore, this indicator is rated non-applicable.
5.13 Continuity of Operations Planning (COOP) Drills Satisfactory Compliance
COOP drills shall be conducted and documented, at minimum, twice a year, with one drill
being completed prior to the hurricane season, which begins June 1st.
The center has a Continuity of Operations Plan (COOP). Two COOP drills have been completed
since the last annual compliance review, one of them was conducted prior to the start of
hurricane season. Documentation of the drills was reviewed. Information included the type of
drill, date and time, participants, scenario, response, and recommendations if appropriate.
The superintendent was interviewed and reported there is a COOP in place for the safety and
security of youth and staff.
5.14 Escape Drills Satisfactory Compliance
The center shall develop, implement, and maintain an escape prevention plan incorporating
the Department’s established policies and procedure regarding escapes.
The center shall conduct and document quarterly mock escape drills.
The center has facility operating procedures (FOPs) in place to use as an Escape Prevention
Plan. Escape drills have been conducted quarterly on each shift since the last annual
compliance review. A total of twelve drills were reviewed. Documentation is completed and
entered into SharePoint. The drills are reviewed by administration. A review found all drills
documented in master control logbooks. Nine staff reported they have been in fire and escape
drills, seven staff in weather and major disturbance drills, five staff in flooding drills, four staff in
bomb threat drills, and three staff have participated in hostage situations and chemical spill
drills.
5.15 Fire Drills Satisfactory Compliance
Management has implemented a disaster preparedness plan and fire prevention plan.
Monthly fire drills (with procedures being approved by local fire officials) are documented and
conducted under varied conditions and on each shift.
The center has a disaster plan, fire prevention plan, and evacuation plan which addresses fire
safety. Fire drills are completed monthly on each shift. Drills are documented and reviewed by
administration. Drill information is entered on SharePoint and documented in the master control
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logbook. The fire extinguishers in the center and secure vehicles are inspected annually and
documentation is entered on SharePoint. Evacuation routes are posted throughout the buildings
at the center. Two of nine interviewed youth reported they have been instructed on what to do in
case of a fire. The remaining seven youth confirmed they have not been in a fire drill or do not
recall being told what to do in case of a fire. One youth informed the interviewer fire egress
plans are posted on the walls at the center. All nine interviewed staff confirmed fire drills are
conducted at least monthly.
5.16 Search and Contraband Procedures Satisfactory Compliance
The center’s policy must address illegal contraband and prohibited items. The center shall
delineate items and materials considered contraband when found in the possession of youth,
the list must include: sharps, escape paraphernalia, tobacco products, lighters or matches,
electronic or vaporless cigarettes, any unauthorized article of food or clothing, any
intoxicating beverage or any beverage which causes or may cause an intoxicating effect,
drugs, to include any prescription or non-prescription medication, any firearm or weapon of
any kind or any explosive substance, non-facility issued electronic equipment or devices to
include smartwatches, metals (unless authorized by policy), personal non-facility issued
cellular devices, and non-facility issued keys. The center shall have a policy on contraband
and searches. The center shall establish a system to prevent the introduction of contraband
and identify contraband items and materials through searches of the physical plant, facility
grounds, staff, youth, and visitors. All contraband must be documented in the master control
logbook. The center shall document the confiscation of any illegal contraband and the
manner of disposition. The center shall complete an incident report identifying findings for all
recovered illegal contraband, notify the regional director, and report to the Central
Communications Center (CCC) within two hours. If a confiscated item is not illegal or
prohibited, the center superintendent or designee has the discretion to discard of the item,
return it to its original owner, mail it to the youth's home, or return it to the youth upon release.
In all instances involving confiscation of illegal or prohibited contraband, the center shall turn
the item over to local law enforcement and a criminal report must be filed.
The center has facility operating procedures (FOPs) in place for searches and to ensure
contraband is prevented from entering the secure area of the center. The policy includes
procedures for electronic, frisk, strip, room, and staff/visitor searches. A youth search after
returning from a transport was observed. Staff inspected the secure vehicle, and a frisk and
electronic search of the youth were completed prior to the youth returning to their modules.
Searches of staff and visitors prior to entering the secure area were observed. Staff wore gloves
for all searches observed. Documentation of room searches was found in the module and
master control logbooks. A sample of shift reports since the last annual compliance review was
completed to determine room searches are completed daily on each shift. There were twelve
instances of contraband being found at the center during the annual compliance review period.
All instances were reported to the Department’s Central Communications Center (CCC) within
the required time frame and subsequent notifications were completed. Attestation forms and
training rosters were reviewed.
The superintendent reported searches are conducted during intake and anytime contraband is
suspected. If a youth or staff is found with contraband, depending on the contraband, law
enforcement will be called. If it is something deemed contraband by the superintendent an
incident report and a write up will be filed.
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Office of Accountability and Program Support Page 52 of 52 (Revised July 2023)

report_type: QI Detention

rule: Indicator 2.10

excerpt: Educational Access (Critical)

rating: Limited Compliance