facility_name: hastings comprehensive mental health treatment facility gulf academy

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY REPORT
JUVENILE FACILITIES
Name of Facility: Hastings Comprehensive Mental Health Treatment Facility/Gulf Academy
Physical Address: 465 E. St. John Avenue, Hastings, Florida 32124
Date report submitted February 21, 2015
Auditor information : Lois Jenkins
Address P. O. Box 23905; Columbia, SC 29224
Email: lljenk2@bellsouth.net
Telephone number: 803-463-9554
Date of facility visit : January 22-23, 2015
Facility Information
Facility Mailing Address: Same as Above
(if different from above)
Telephone Number: 904-692-2920
The Facility is: Military County Federal
Pr ivate for profit Municipal State
Private not for profit
Facility Type: Detention C orrection Other:
Name of PREA Compliance Manager: Andrew Eldridge Title: Facility Administrat or
Email Address: Andy.Eldridge@us.g4s.com Telephone Number: 904-692-2920 x122
Agency Information
Name of Agency: G4S Youth Services, LLC
Governing Authority or
G4S
Parent Agency: (if
applicable)
Physical Address: 6302 Benjamin Road, Suite 400; Tampa, FL 33634
Mailing Address: (if
different from above) Same as Above
Telephone Number: 813-514-6275
Agency Chief Executive Officer
Name: James C. Hill, Jr. Title: President
Email Address: jim.hill@us.g4s.com Telephone 813-514-6275, ext. 202
Number:
Agency Wide PREA Coordinator
Name: Bobbi Pohlman-Rogers Title: JJDPA/PREA Director
Telephone
Email Address: bobbi.pohlman@us.gus.com 954-818-5131
Number:
PREA AUDIT: AUDITOR’S SUMMARY REPORT 1
AUDIT FINDINGS
NARRATIVE:
The Hastings Comprehensive Mental Health Treatment Program (HCMHTF) is a 64 bed, moderate risk
residential commitment facility for males, ages 13 to 19. All residents have been adjudicated delinquent
and are placed at HCMHTF by the Florida Department of Juvenile Justice. The program provides
comprehensive mental health treatment services for youth and also provides substance abuse treatment
overlay services. Co-located on site is Gulf Academy. Gulf Academy is a 56-bed, moderate risks
residential commitment facility for males ages 12-19. Like HCMHTF, residents at Gulf Academy have
been adjudicated delinquent and placed there by the Florida Department of Juvenile Justice. The program
provides intensive mental health treatment services for youth. For the purposes of this audit, this facility
will be referred to as Hastings Comprehensive Mental Health Treatment Program/Gulf Academy or
HCMHTP/GA. HCMHTP/GA is a G4S Youth Services, LLC operated program located in Hastings,
Florida. Currently, the 120 bed facility operates under contract with the Florida Department of Juvenile
Justice (FDJJ). The average length of stay for youth is 7 to 10 months depending on the youth's pace of
success in completing his individualized treatment plan and goals.
As stated in the employee handbook, the mission of G4S Youth Services, LLC is, “to provide innovative
program solutions responsive to the needs of our customers. We achieve this through our best people who
positively impact the lives of those whose welfare and safety is entrusted to us.” To accomplish this,
HCMHTP/GA employs a multi-disciplined staff to address the needs of youth placed there. Daily
operational oversight is provided by a full-time Facility Administrator, Assistant Facility Administrators,
Health Services Administrator, Director of Clinical Services, and other administrative staff supported by a
diverse workforce of direct care service providers focusing on treatment, safety, security, and order.
Mental health and substance abuse professionals work under the supervision of a licensed psychologist.
Two licensed psychiatrist provides psychiatric services including psychiatric evaluations, medication
management, and 24-hour, seven days a week emergency consultation. During the time of the on-site
audit there were 133 staff employed at HCMHTP/GA.
At HCMHTP/GA the continuum of treatment services allows for assessments and identification of the
specific mental health and/or substance abuse treatment needs of each resident. The treatment protocol
includes daily group therapy sessions, individual supportive counseling sessions with an assigned
therapist, and monthly family therapy sessions.
Educational services at HCMHTP/HSAP are provided by G4S through a contract with the St. Johns
County School District and offers English, Math, Science, Social Studies and Reading. Career and
technical opportunities include Business Education courses.
DESCRIPTION OF FACILITY CHARACTERISTICS:
HCMHTP/GA is located in a rural setting adjacent to a beautiful lake and surrounded by a security
perimeter fence. The facility consists of 4 resident housing units referred to as Buildings A, B, C, and
D(Alpha, Bravo, Charlie, and Delta), with 2 wings separated by dayrooms and staff work areas, one of
which was not in use as a housing unit during the time of the on-site audit. Additionally, there is an
Administration/Operations building that houses the Master Control area; the Facility Administrator and
other administrative staff offices; intake, case management, and mental health staff offices; educational
classrooms and staff offices; kitchen/cafeteria, maintenance, and visitation area. There is adequate out-
door recreation space located within the perimeter fence. During the onsite audit there were a total of 104
residents, (50 assigned to HCMHTF, and 54 assigned to HSAP). The facility has a total of 160
surveillance cameras in various locations both inside and outside of buildings.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 2
SUMMARY OF AUDIT FINDINGS:
The notification of the on-site audit was posted on December 11, 2014, six weeks prior to the first date of
the on-site audit. The posting of the notice was verified by photographs received electronically from the
Facility Administrator/PREA Compliance Manager. The photographs indicated notices were posted in
various locations throughout the facility including the housing units and administrative areas.
A conference call was held with the G4S PREA Coordinator on December 31, 2014. The Pre-Audit
Questionnaire, policies and supporting documentation were uploaded to a flash drive and received via
Federal Express delivery from the HCMHTP/GA PREA Compliance Manager on January 2, 2015. The
information received was well organized and easy to navigate. Upon review of the information, it was
noted that the Pre-Audit Questionnaire was not completed on the most recent version prompting a phone
call to the PREA Compliance Manager who submitted an updated Pre-Audit Questionnaire. A follow-up
call was placed on January 14, 2015 to discuss the Pre-Audit Questionnaire, discuss the on-site audit
process and additional documentation to be available for review during the on-site audit. An itinerary and
audit protocol was sent electronically to the PREA Compliance Manager.
The on-site audit was conducted January 22-23, 2015, and began with a brief meeting with the Facility
Administrator/PREA Compliance Manager. After the meeting we took a tour of the facility and observed
all of the physical plant and grounds. I was accompanied on the tour by the Facility Administrator and
two Assistant Facility Administrators. While touring I observed that residents were in school and under
supervision of teachers and security staff. I also observed that the audit notices were posted in various
locations in all buildings and posters in multiple languages were prominently posted in all living units and
in various other locations throughout the facility stating the agency’s zero-tolerance for any form of
sexual abuse or harassment with instructions on how to report sexual abuse and harassment. Surveillance
cameras are not located in the residents’ rooms or bathrooms allowing residents to dress, shower and
toilet in private.
During the two-day on-site visit, 21 staff was interviewed, including workers from all three shifts. Staff
interviews revealed they have been trained on PREA Standards and understand their responsibilities and
duties to prevent, detect, and respond to sexual abuse and harassment. Twelve random residents were
interviewed. The residents were informed of their right to be free from sexual abuse and harassment, and
retaliation, as well as how to report sexual abuse and harassment.
Finally, during the on-site audit process, all HCMHTP/GA staff encountered was cooperative and
responsive in providing any requested documentation or audit logistical needs. At the conclusion of the
on-site audit, an exit meeting was conducted with the Facility Administrator/PREA Compliance Manager.
A summary of audit findings are provided below.
Number of standards exceeded: 0
Number of standards met: 37
Number of standards not met: 0
Number of standards Not Applicable: 4
PREA AUDIT: AUDITOR’S SUMMARY REPORT 3
Standard 115.311 – Zero To tolerance of sexual abuse and sexual harassment.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 dated September 22, 2014, conforms to that of its contracting
agency, Florida Department of Juvenile Justice,(FDJJ) Policy 1919 revised April 10, 2014. Page
3 of the HCMHTP/GA policy has clearly written language mandating a zero tolerance for all
forms of sexual abuse and sexual harassment. Within the 10 page policy, the agency’s approach
to preventing detecting and responding to acts of sexual abuse and harassment is outlined.
The agency, G4S, has a PREA Coordinator who oversees PREA compliance efforts for the
agency. Page 3 of policy 10-25 designates the HCMHTP/GA Facility Administrator as the PREA
Compliance Manager and outlines the specific related duties. When interviewed, both the PREA
Coordinator and PREA Compliance Manager indicated they had authority and sufficient time to
manage PREA compliance related responsibilities.
Standard 115.312 - Contract with other entities for the confinement of residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable
HCMHTP/GA is a G4S Youth Services, LLC program that operates under contract with the
Florida Department of Juvenile Justice (FDJJ) and does not contract with other entities for the
confinement of residents.
Standard 115.313 - Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA is a G4S Youth Services, LLC program and operates through contractual
arrangement with the Florida Department of Juvenile Justice (FDJJ). Policy 10-25 mandates that
a Staffing Plan Assessment be completed compliant with the requirements outlined in section (a)
of this standard. According to the most recent Staffing Plan Assessment and interview with the
PREA Compliance Manager, the facility maintains a minimum staffing ratio of 1:8 during resident
waking hours and 1:12 during resident sleeping hours. The program utilizes a holdover schedule
and no deviations from the staffing plan during the past 12 months were found. There are no
findings of inadequacies from judicial, federal investigative agencies, nor internal or external
PREA AUDIT: AUDITOR’S SUMMARY REPORT 4
oversight bodies; and there were no documented deviations from the staffing plan.
The Staffing Plan Assessment and interviews with staff served to validate that in establishing and
maintaining the agreed upon ratios, consideration was given to needs of the residents to be served,
physical location and layout of the facility, as well as the location of available video surveillance
cameras.
HCMHTP/GA Policy 10-25 mandates that Administrative Duty Officer (ADO) shall conduct
unannounced rounds on all shifts and that they be documented. The ADO at HCMHTP/GA is
upper or intermediate level staff. Documentation of logs, Fidelity Check reports, and video clips
from the master surveillance system were provided as documentation that unannounced rounds are
occurring on all shifts.
Standard 115.315 - Limits to cross gender viewing and searches
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA policies 10-25, 10-3, and 8-14 outline all mandates in compliance with this
standard. Policy requires that only in exigent circumstances will cross-gender searches be
conducted and that any such search will be documented as to the reason for the search and why a
same sex staff was not available. HCMHTP/GA Policy 10-3, states that strip searches must be
conducted in a private room with two staff members of the same sex as the resident.
HCMHTP/GA Policy 10-3 further states that body cavity searches must be approved by the
Facility Administrator or the Operations Administrator only when it is strongly suspected that a
youth has concealed contraband in the body cavity. All body cavity searches must be conducted
by trained medical personnel in an emergency room setting. Program staff is not authorized to
conduct a body cavity search of a youth. During the past 12 months, there were no cross-gender
strip and body cavity searches and no cross-gender pat-down searches.
Policy prohibits searching or examining a transgender or intersex resident for the sole purpose of
determining the resident’s genital status.
Further, policy also mandates that residents have access to shower, perform bodily functions, and
change clothing without non-medical staff of the opposite gender viewing; and that staff of the
opposite sex shall announce their presence when entering resident housing facility or an area
where residents are likely to be showering or performing bodily functions or changing clothing.
Interviews with staff and residents verified that these practices are in place at HCMHTP/GA.
HCMHTP/GA provided documentation that security staff received training on how to conduct pat
down searches in a professional and respectful manner.
Standard 115.316 - Residents with disabilities and residents who are limited English proficient
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 5
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 requires the PREA Facility Compliance Manager ensure residents
with disabilities and residents who are limited English proficient have an equal opportunity to
participate in or benefit from all aspects of the facility’s efforts to prevent, detect, and respond to
sexual abuse and harassment. The policy also states the facility will take steps to provide
interpreters who can interpret effectively, accurately, and impartially.
The policy prohibits the use of youth as interpreters, readers, or other assistant to perform such
functions except in limited circumstances where an extended delay in obtaining interpreters
services could jeopardize residents’ safety. The facility does not use resident assistants and there
were no instances of resident interpreter or readers being used in the past 12 months. Resident
and staff interviews validated compliance.
Policy 9-2, Classification and Orientation, provides further guidance for staff in meeting the
standard requirements.
Documentation for interpreter services and youth education materials was provided by the PREA
Compliance Manager.
Standard 115.317 - Hiring and promotion decisions
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
Elements required by this standard are outlined in HCMHTP/GA Policies10-25 and 3-16 which
conforms to FDJJ Policy 1919, except for contacting the abuse registry for screening applicants.
Documentation that Florida law does not permit contacting the abuse registry for the purpose of
screening applicants was provided.
Persons desiring employment with HCMHTP/GA completes the application packet; a portion of
which is sent from HCMHTP/GA to the FDJJ Office of the Inspector General for background
screening. Details of the screening are described on the FDJJ’s website and include conducting
two background screenings; the Level II pre-employment screening and a 5-year re-screening.
Upon request, background screening is conducted on state and contract provider directors,
owners, applicants, employees, volunteers, mentors, and interns. The term contract provider
includes grant recipient employees, volunteers, mentors, and interns. Background
screenings consist of a state and national fingerprint check through the Florida Department of
Law Enforcement and the Federal Bureau of Investigations, and a demographic search of the
Florida Clerk of the Courts. As a criminal justice agency, the Department has access to juvenile,
sealed, and expunged criminal history information.
Interview with Human Resources (HR) staff confirmed that the policy is in practice for staff and
contractors. The auditor’s review of 21 HR files, and 4 contractor files validated at 100% that
criminal background records checks were completed, and applicants seeking employment are
asked about previous misconduct outlined in section (a) of this standard consistent with PREA
requirements and Florida Statutes. Of 21 files reviewed 6 met the five-year threshold for
PREA AUDIT: AUDITOR’S SUMMARY REPORT 6
rescreening and contained documentation validating the rescreens were completed in a timely
fashion at various times throughout 2014.
HCMHTP/GA has in place a process for contacting prior employers for information before hiring
and sharing information with employers.
FDJJ policy 1919 states that staff being considered for promotion shall disclose any sexual
misconduct and material omission regarding such misconduct, or the provision of materially false
information shall be grounds for termination.
Standard 115.318 - Upgrades to facilities and technology
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable
HCMHTP/GA has not acquired any new facilities, or made any expansion or modification since
August 20, 2012. HCMHTP/GA has not installed or updated a video monitoring or surveillance
system since August 20, 2012.
Standard 115.321- Evidence protocol and forensic medical examinations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA does not conduct administrative or criminal sexual abuse investigations and by
policy upon learning of such an event HCMHTP/GA staff must immediately make a report
through the Florida Department of Juvenile Justice (FDJJ) Central Communications Center
(CCC) hotline. Policy also mandates a call to local law enforcement and the Florida Department
of Children and Families Abuse Registry hotline. Criminal investigations are conducted by the St.
Johns County Sheriff’s Office. The FDJJ has outlined for the local authorities how such
investigations should be conducted in compliance with the requirements outlined in sections (a)
through (e) of this standard.
Policy 7-30 states that all services for sexual assault allegation shall be provided at no cost to the
victim. Staff interviews validated that staff is aware of this policy. Documentation provided
revealed that HCMHTP/GA has secured an agreement with the Betty Griffin House to provide
access to services available through the rape crisis center certified by the Florida Council Against
Sexual Violence. There were no forensic medical examinations conducted in the past 12 months.
Standard 115. 322 - Policies to ensure referrals of allegations for investigations
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 7
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA policy 10.25 requires that any staff receiving a report of sexual misconduct or
possible sexual misconduct must ensure that it is immediately reported to their supervisor who
shall ensure that it is reported to local law enforcement if criminal in nature.
As stated in policy, the FDJJ does not conduct criminal investigations of youth-related sexual
misconduct reports. Local law enforcement agencies and the Department of Children and
Families handle such investigations. During the past 12 months, HCMHTP/GA received two
allegations of youth on youth sexual abuse and both were reported to the St. Johns County
Sheriff’s Office the Florida Department of Children and Families, and the FDJJ Office of the
Inspector General, CCC hotline for administrative investigation. At the time of the onsite audit,
the results of the investigations were still pending.
The FDJJ Policy 1919 describes the agency’s investigative responsibilities and duties for its
facilities and is published on the website.
Standard 115.331 - Employee training
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policies 10-25 and FDJJ Policy 1919 outline training requirements for staff that is
consistent with this standard. All newly hired employees are trained and the agency provides
PREA refresher trainings.
Review of employee staff training logs for PREA training with pre and post test results, 69 signed
staff training Acknowledgement Forms with post training test scores, staff training curricula, and
other materials included as a part of PREA training, as well as staff interviews, all served to
validate that HCMHTP/GA staff has been trained in compliance with this standard. The training
curriculum provided was consistent with the elements of 115.331(a).
Standard 115. 332 - Volunteer and contractor training
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy requires that all persons providing volunteer or contractor services at
HCMHTP/GA to be trained on the agency’s zero-tolerance policy regarding sexual abuse and
harassment and how to report such incidents. Additional training provided to volunteers and
PREA AUDIT: AUDITOR’S SUMMARY REPORT 8
contractors is based on the service they provide and the level of contact they have with residents.
Before volunteers can have access to HCMHTP/GA and provide services they must take the FDJJ
PREA training, “A Course for Volunteers” and upon completion, sign the form acknowledging
that they have completed the course and understand FDJJ PREA Policy 1919. This was verified
through review of 12 Volunteer Acknowledgement of training forms.
Contractors such as dentist, psychiatrist, and medical doctors sign the Acknowledgement of the
Prison Rape Elimination Act form declaring they have been informed and understand that
HCMHTP/GA has a zero tolerance and that sexual contact of any kind is forbidden, the possible
penalties for such behaviors, and that they have a duty to report.
Documentation of 21 signed Teacher Acknowledgement of PREA training forms was provided.
Standard 115.333 - Resident education
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 requires that during intake all residents will be provided with
information on zero-tolerance regarding sexual misconduct including how to report sexual abuse
and suspicion of any sexual misconduct. Policy also requires that within 10 days of intake, all
residents will be provided with additional comprehensive training regarding their rights to be free
from sexual misconduct; their right to be free from retaliation for reporting; and the agency’s
sexual misconduct response policies and procedures.
As a part of the orientation, youth are given a resident handbook, and handouts with telephone
numbers for outside services including the Abuse hotline and acknowledge through signature that
they received the information and that they understand their right to be Safe from Sexual
Misconduct, Abuse and Harassment. Policy 9-2, Classification and Orientation, provides further
guidance for staff in meeting the standard requirements. Interviews with intake and clinical staff
verified that youth are provided with PREA required education when admitted to the facility.
Interviews with 12 random residents validated that they received education on PREA the same
day they arrived at the facility.
During the tour of the facility, posters in multiple languages outlining the sexual abuse zero
tolerance policy, duty to report, and instructions for reporting, were posted in various locations in
including the living units.
Youth Education handouts in multiple languages were provided to the auditor.
Standard 115.334 - Specialized training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 9
Not Applicable
HCMHTP/GA does not employ facility investigators. Criminal and administrative investigations
are referred to outside agencies.
Standard 115.335 - Specialized training: Medical and mental health care
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 and FDJJ Policy 1919 mandates medical and mental health care
providers will be subject to sexual abuse training similar to that of FDJJ employees as well as
medical and mental health specialized training consistent with the requirements of section (a) of
this standard.
Staff interviews verified that HCMHTP/GA medical staff does not conduct forensic
examinations.
Documentation of electronic verification of completion of PREA sexual abuse training and
medical and mental health specialized training by all HCMHTP/GA medical and mental health
staff was provided to the auditor.
Standard 115.341 – Obtaining Information from Residents
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 9-1 describes the process staff is to use for screening for Vulnerability to
Victimization and Sexual Aggressive Behavior (VSAB). Within 24 hours of a resident’s arrival
at the facility, trained staff meets with residents and complete the VSAB form. Information is
gathered from multiple sources to include parents, records from FDJJ, PDR reports, and
interviews with the youth. The instrument is scored prior to housing placement. Those residents
who score vulnerable to victimization or sexually aggressive are included in the alert system, and
referred for further assessments, as identified. Residents who are identified or report as prior
sexual victims are referred to the medical and mental health professionals within 14 days.
Interviews with the clinical director and PREA Compliance Manager confirmed that policy is in
practice and that information from the VSAB is disseminated on a “Need to Know” basis.
The screening for vulnerability to sexual victimization and sexual aggressive behavior instrument
met the 11 minimum required elements outlined in section (c) of the standard.
Standard 115. 342 – Placement of residents in housing, bed, program, education, and work
assignments
PREA AUDIT: AUDITOR’S SUMMARY REPORT 10
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy10-25 clearly states that the information gathered from screening for
vulnerability to sexual victimization and abusiveness shall be to guide treatment plans and security
and management decisions, including housing bed, work, education and program assignments.
HCMHTP/GA reported that no resident alleging sexual abuse was placed in isolation.
Policy directs HCMHTP/GA staff to maintain a continually updated internal alert system that
keeps staff alerted who are security or safety risks in multiple categories including sexual predator
risks.
HCMHTP/GA Policies direct staff in the treatment of LGBTI residents consistent with those
outlined in sections (c) through (g) of this standard. There were no identified LGBTI residents in
the population at the time of the audit. Interviews with staff indicated they are aware of the
policy and would comply.
Standard 115. 351 - Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 8.3.4 (B) Abuse and Neglect Reporting – states clearly that all youth shall
have unimpeded access to the Florida Abuse Hotline without interference or retaliation of any kind
and further outlines in detail that the Abuse hotline number is to be provided at intake. The
number is also, included in the resident handbook and posted throughout the facility.
HCMHTP/GA provides instruction and multiple ways for residents to report sexual abuse and
harassment including telling a staff member, writing a grievance, asking to speak with the Facility
Administrator or a therapist, or calling the Florida Abuse Hotline. The abuse hotline number is
included in the resident handbook.
Staff and residents validated that they have access to the tools necessary to make a report. Also,
policy outlines procedures for staff to follow preventing them from denying a youth an abuse call,
delaying the call or listening in on the call. For security reasons staff may maintain sight
monitoring of the youth while the call is placed.
Interviews with staff validated that they would accept and document reports made verbally, in
writing, anonymously, and from third parties.
Standard 115.352 - Exhaustion of administrative remedies
PREA AUDIT: AUDITOR’S SUMMARY REPORT 11
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 8-4 outlines the administrative procedures for resident grievances regarding
sexual abuse or sexual harassment. The policy aligns nicely with this standard including no time
limit for a resident to file a grievance; and any grievance received that alleges a resident is
substantially at risk for imminent sexual abuse shall be immediately directed to the Facility
Administrator, who shall provide immediate response to the grievance.
During the past 12 months no sexual abuse grievance was filed. Interviews with residents
validated their knowledge of how to file a grievance for sexual abuse or harassment. During the
facility tour a locked grievance box was visible in the living unit.
Random resident interviews verified that they are aware of the procedures for filing an emergency
grievance.
Standard 115.353 - Resident access to outside confidential support services and legal representation
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy10-25, page 5 of 10 requires that residents shall have access to outside victim
advocates, the facility shall make accessible mailing addresses and telephone numbers, including
hotline numbers of victim advocacy or rape crisis organizations, and residents shall have
reasonable and confidential access to attorneys, parents or legal guardians.
Review of youth education materials including youth handbook, posters, brochures and handouts
verified that the information is made available to HCMHTP/GA residents. Further, interviews
with residents and staff, suggest HCMHTP/GA residents have been provided mailing addresses
and telephone numbers of local, state, or national victim advocacy or rape crisis organizations.
Documentation was provided verifying that HCMHTP/GA has secured an agreement with the
Betty Griffin House for victim advocacy services available through the rape crisis center certified
by the Florida Council Against Sexual Violence.
HCMHTP/GA does not detain residents solely for immigration purposes.
Standard 115.354 - Third-party reporting
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 12
HCMHTP/GA is a FDJJ contracted facility and HCMHTP/GA through the FDJJ website informs
the public with information regarding third-party reporting of sexual abuse and harassment on
behalf of facility residents. The FDJJ website also has a section dedicated to parents and among
other information includes this statement, “Abuse and neglect are serious issues that need to be
handled with care. In the event of an emergency abuse situation, ALWAYS call 911 FIRST and
call the Florida Abuse Hotline second at 1-800-962-2873. In a non-emergency situation, contact
the Florida Abuse Hotline via phone, fax, or web to receive assistance.” Complaints concerning
the delivery of services, safety, or security at a DJJ facility or program should be immediately
reported to the Central Communications Center. All other complaints can be reported to the
Bureau of Investigations. Incident/Complaint Hotline: (800) 355-2280. Complaints can also be:
Faxed to the Office of the Inspector General at (850) 414-7182;E-mailed to
OIG.Complaints@djj.state.fl.us; or Mailed to the: Department of Juvenile Justice, Office of the
Inspector General; 2737 Centerview Drive; Tallahassee, FL 32399-3100”
HCMHTP/GA can receive third-party reports of sexual abuse and harassment through the Florida
Department of Children and Families Abuse hotline and the FDJJ Office of the Inspector General -
Central Communications Center hotline.
Interviews with residents revealed they are aware sexual abuse or harassment may be reported
through a third party.
Standard 115.361- Staff and agency reporting duties
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
The employees at HCMHTP/GA are mandatory reporters and HCMHTP/GA Policy 8-3 directs
staff to immediately report any abuse, knowledge, suspicion or information they receive regarding
an incident of abuse or harassment. Policy also directs staff to report any retaliation against
residents or other staff who reported an incident; and any staff neglect or violation of
responsibilities that may have contributed to an incident of abuse or retaliation. HCMHTP/GA
policies further direct staff in complying with the elements outlined in sections (b) through (f) of
this standard. Interviews with Health Services Administrator, Facility Administrator/PREA
Compliance Manager, and random selected staff served to validate that the staff are aware of the
policies and their duty to report. Staff interviews also confirmed their knowledge of limits of
liability and consents required. Review of medical and mental health files verified
documentation of applicable consent forms with resident signatures.
Standard 115.362 - Agency protection duties
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 13
HCMHTP/GA Policy 10-25 requires that when staff learns that a resident is subject to a substantial
risk of imminent sexual abuse it shall take immediate action to protect the resident from harm or
further threat. During the past 12 months no residents were identified to be of such risk.
Interviews with the Agency Head Designee, Facility Administrator/PREA Compliance Monitor
and random sample of staff validated that staff is aware of their mandate to immediately take steps
necessary to keep the resident safe.
Standard 115.363 - Reporting to other confinement facilities
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
During the past 12 months HCMHTP/GA staff did not receive any reported allegations that a
HCMHTP/GA resident was abused while confined at another facility. Likewise, HCMHTP/GA
did not receive any reports of allegations of sexual abuse from other facilities that residents
previously confined at HCMHTP/GA were sexually abused.
HCMHTP/GA policy 10-25 requires that the Facility Administrator or designee shall notify the
program Administrator or Director upon receiving an allegation that a youth was sexually abused
while confined at that facility where the abuse occurred.
Standard 115.364 - Staff first responder duties
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 mandates in responding to sexual abuse that staff take specific steps
consistent with those outlined in sections (a) and (b) of this standard. These steps include
identifying the victim and perpetrator, keeping the victim safe and separate from the alleged
perpetrator, preserving any crime scene within a period that still allows for the collection of
physical evidence; requesting the alleged victim not take any action that could destroy physical
evidence; and ensuring the alleged abuser does not take any action to destroy physical evidence.
HCMHTP/GA does not have investigators so beyond the steps already mentioned, staff are
directed to report and cooperate with the investigators when they arrive. Staff was able to
articulate these duties and responsibilities during interviews which indicated they have been
trained and is aware of the policies.
Standard 115.365 - Coordinated response
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 14
Does Not Meet Standard (requires corrective action)
A Coordinated Response Plan specific to HCMHTP/GA was provided to the auditor. The Plan
outlines the specific tasks to be completed by multiple people beginning with the 1st responder and
ending with the PREA Compliance Manger convening the Incident Review Team and final
decisions. Interview with the Facility Administrator/PREA Compliance Manager revealed
knowledge of the policy and responsibilities and duties of staff.
Standard 115.366 - Preservation of ability to protect residents from contact with abusers.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable
HCMHTP/GA does not participate in collective bargaining.
Standard 115.367 - Agency protection against retaliation
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policies 10-25 and 8-3 establish that residents and staff are to be protected from
retaliation for reporting sexual abuse or harassment and/or cooperating with investigations of
sexual abuse and harassment. The monitoring will take place for a period of at least 90 days and at
each 30 day interval the Facility Administrator/PREA Compliance manager will determine if
retaliation is occurring by reviewing such items as disciplinary reports, status and fidelity checks,
housing or program changes, and negative performance reviews or staff reassignment. There were
no incidents of retaliation in the past 12 months reported.
Standard 115.368 - Post allegation protective custody
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA reported that no resident alleging sexual abuse was placed in isolation.
Standard 115.371 - Criminal and administrative agency investigations
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 15
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA does not employ facility investigators and does not refer for prosecution. All
allegations of abuse are reported to the Florida Department of Children and Families, the St.
Johns County Sheriff’s Office, and the FDJJ Office of the Inspector General – Central
Communications Center.
Standard 115.372 - Evidentiary standards for administrative investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA does not conduct administrative investigations. All allegations of abuse are
reported to FDJJ Office of the Inspector General – Central Communications Center. Staff from
the Inspector General’s office conducts the administrative investigation and provides a report
back to HCMHTP/GA.
Standard 115.373 - Reporting to residents
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 page 9 reads, “At the conclusion of any investigation where a sexual
abuse incident has been reported, the Facility Administrator shall notify the victim or victim’s
parents or legal guardians that the investigation is concluded.”
There were no investigations completed during the past 12 months and therefore no notifications
to victims, victim parents or legal guardians. During interview the PREA Compliance Manager
was knowledgeable of the reporting requirement.
Standard 115.376 - Disciplinary sanctions for staff
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
It is written in G4S HCMHTP/GA Policy 10-25 that sexual activity between staff, volunteers or
contracted personnel and youth, as well as between youth is prohibited and subject to
PREA AUDIT: AUDITOR’S SUMMARY REPORT 16
administrative and criminal disciplinary sanctions. The policy also mandates that violations be
reported to law enforcement. The G4S Employee Handbook makes clear that employee sexual
harassment is prohibited and when an allegation is substantiated, disciplinary action up to and
including termination will be imposed.
During the past 12 months no staff from HCMHTP/GA has been disciplined, terminated or
resigned for violating agency sexual abuse or harassment policies. Likewise, no HCMHTP/GA
staff has been reported to law enforcement or licensing boards for violating agency sexual abuse
and sexual harassment policies.
Standard 115.377 - Corrective Action for contractors and volunteers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-22 requires that like staff, volunteers and contracted personnel in
violation of the facility’s policies and procedures regarding sexual abuse and harassment of
residents will be reported to local law enforcement, unless the activity was clearly not criminal,
and to relevant licensing bodies.
HCMHTP/GA reports not having any allegations of sexual abuse or harassment by contractors or
volunteers therefore no reports to law enforcement or licensing bodies and no remedial measures
were taken. Interviews with the Facility Administrator/PREA Compliance Manager revealed
knowledge of the remedial measures that would be taken.
Standard 115.378 - Disciplinary sanctions for residents
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA is designated as a treatment facility. During the past 12 months there has been no
administrative finding of resident-on-resident sexual abuse; and no criminal finding of guilt for
resident-on-resident sexual abuse at HCMHTP/GA. No residents were placed in isolation
resulting from allegations of sexual abuse. Interviews with the Facility Administrator, medical,
and mental health staff verified that residents are informed that in the event of a criminal finding of
sexual violence, that charges could be filed. If not prosecuted, then the Treatment Team would
make decision for any necessary treatment modification(s). Policy 8-1 provides guidance for staff
in holding youth accountable for their behaviors.
Standard 115.381 - Medical and mental health screenings; history of sexual abuse
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
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standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 requires that if during intake screening, health/mental health
screening, or health history, a resident discloses prior sexual victimization or perpetrated sexual
abuse, whether it occurred in a facility setting or in the community, staff shall ensure the youth is
referred for medical and mental health services within 14 day of the screening. Policy also
mandates that sensitive information shall be on a need-to-know basis and shall not be exploited to
the resident’s detriment by staff or other residents. Classification meetings that include medical
and mental health staff occur after intake allowing for immediate referrals for any necessary
follow-up medical or mental health services. For youth 18 years or older the Release of
Information Authorization form is completed requiring the youth’s signature.
HCMHTP/GA reports no resident disclosing prior victimization during their initial screening
process. Interviews with the medical and mental health staff and review of documentation review
in 20 MH files and 20 medical files verified compliance with this standard.
Standard 115.382 - Access to emergency medical and mental health services
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 7-30 requires that residents who are victims of sexual assault shall have
immediate medical care. The Health Services Administrator verified that any sexual assault
victim would be provided unimpeded access to emergency medical treatment immediately and
according to the medical staff’s professional judgment; the victim would be offered timely
information about access to emergency contraception and sexually transmitted infection
prophylaxis; and that the services would be provided without cost to the victim. These services
are documented in the youth’s medical files. The two residents who reported sexual abuse
verified when interviewed that they had a chance to see the nurse and received mental health
treatment.
Standard 115.383 - Ongoing medical and mental health care for sexual abuse victims and abusers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 7-30 mandates ongoing medical and mental health care for sexual abuse
victims and abusers to include mental health evaluations and services as appropriate and medical
health care services consistent with the community level of care. HCMHTP/GA is an all-male
residential facility. Interviews with the Health Services Administrator and Clinical Director
verified that there are procedures in place compliant with the requirements of this standard.
Standard 115.386 - Sexual abuse incident reviews
PREA AUDIT: AUDITOR’S SUMMARY REPORT 18
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25, page 8 mandates that the facility shall conduct a sexual misconduct
review at the conclusion of every sexual misconduct investigation or administrative review,
including those where the allegation has not been substantiated, unless the allegation has been
determined to be unfounded. The policy further mandates that the Review Team shall ordinarily
conduct the incident review within 30 days of the conclusion of every sexual misconduct
investigation or administrative review. Page 9 of the policy outlines the specifics of the Review
Team’s duties the same as those in section (d) of the standard; and directs that Review Team
recommendation must be implemented or justification provided for not implementing the
recommendations. Review Team meetings and findings would be documented on the PREA
Review Report. Interview with Facility Administrator/PREA Compliance Manager verified that
the facility is in compliance with this standard.
Standard 115.387 - Data collection
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 directs that the facility shall ensure records are maintained and the
Facility Administrator shall ensure that requests for additional information from the FDJJ PREA
Coordinator are responded to in a timely manner. FDJJ Policy 1919 requires the Department to
collect uniform data in the Office of the Inspector General’s – Central Communications Center for
every allegation of sexual misconduct at its facilities, both state-operated and contracted providers.
Interview with the G4S Agency Head Designee verified that G4S maintains an Incident Report
(IR) Tracking system and that G4S facilities such as HCMHTP/GA feed data to FDJJ and FDJJ
publishes the Annual Report.
Standard 115.388 Data review for corrective action
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ Policy 1919 requires the PREA Coordinator to review data collected and aggregated in order
to assess and improve the effectiveness of the Department’s sexual misconduct prevention,
detection and response policies, practices, and training. Policy also requires that FDJJ will prepare
an annual report of sexual misconduct incidents, findings, and corrective actions for all facilities,
state and contracted, and the Department as a whole. The report includes a comparison of the
current years’ data and corrective actions with those from prior years. The report is made
PREA AUDIT: AUDITOR’S SUMMARY REPORT 19
available to the public through the FDJJ website.
Standard 115.389 Data storage, publication and destruction
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
Does Not Meet Standard (requires corrective action)
HCMHTP/GA Policy 10-25 directs that the facility shall ensure records are maintained and the
Facility Administrator shall ensure that requests for additional information from the FDJJ PREA
Coordinator are responded to in a timely manner. Interview with the G4S Agency Head Designee
verified that G4S maintains an Incident Report (IR) Tracking system and that G4S facilities such
as HCMHTP/GA feed data to FDJJ and FDJJ publishes the Annual Report. FDJJ Policy 1919
established that aggregated sexual abuse data be reviewed annually and placed on the facility’s
website after all personal identifiers are removed. All data collected will be maintained for at least
10 years after the date of the initial collection.
AUDITORTOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and
no conflict of interest exists with respect to his or her ability to conduct an audit of the agency under
review.
February 20, 2015
Auditor Signature Date
PREA AUDIT: AUDITOR’S SUMMARY REPORT 20