state: FL

facility_name: union juvenile residential facility

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY REPORT
JUVENILE FACILITIES
Name of Facility: Union Juvenile Residential Facility
Physical Address: 14692 NE County Rd., 199, Raiford, FL 32083
Date report submitted: April 8, 2015
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: March 10, 2015
Facility Information
Facility Mailing Address: Same as Physical Address
Telephone Number: 386-431-1997
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention Correction X Other: Residential
Name of PREA Compliance Manager: Kristine Harshaw Title: Unit Director
Email Address: kristine.harshaw@sequelyouthservices.com Telephone Number:
386-431-1997
Agency Information
Name of Agency: Sequel Youth & Family Services
Governing Authority or Parent Agency: NA
Physical Address: 1131 Eagletree Lane, Huntsville, AL 35801
Mailing Address: Same as Above
Telephone Number: 256-880-3339
Agency Chief Executive Officer:
Name: John Stupak Title: Chief Executive Officer
Telephone 215-284-5043
Email Address: jstupak@sequelyouthservices.com
Number:
Agency Wide PREA Coordinator
Name: Sonja Schierling Title: Quality Manager/Sequel PREA Coord.
Email Address: sonyaschierling@sequelyouthservices.com
Telephone Number: 941-526-8763
1
AUDIT FINDINGS
NARRATIVE:
The Union Juvenile Residential Facility is located in Raiford, Florida and is operated by Sequel
Youth and Family Services through a contract with the Florida Department of Juvenile Justice (DJJ).
It is a 24-bed moderate risk residential program that serves male juvenile offenders between the ages
of 12-19. Each resident is assigned a staff mentor during their first treatment team meeting. The staff
mentor is expected to meet with their assigned resident at least one hour each week. The mentor/
direct care staff, assists the resident in the implementation of their treatment assignments, discuss
issues affecting the resident’s program, and serve as a role model to the resident.
Mental health services are provided by the Clinical Director and two Therapists; the contract
psychiatrist is at the facility twice a month. The mental health staff members conduct individual and
group therapy with residents and coordinates and facilitate therapeutic sessions with the family.
Medical services are provided on-site by two full-time Registered Nurses, with one serving as the
Director of Nursing. The contract physician visits the facility once a week. The school is operated by
education staff through the Union County School Board where residents may receive GED,
secondary, post-secondary, and career and technical education courses.
A treatment plan is developed for each resident with input received from his Case Manager,
Therapist, education staff, administration, community worker, and parents. The Case Manager
discusses the plan with the resident and his family and the plan is reviewed with the resident on a
monthly basis with the treatment team, facilitated by the Case Manager. Residents who demonstrate
consistently positive behavior may become eligible for home passes within 90 days of their
anticipated release date. Home passes may range from eight to 72 hours.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The front of the main building primarily contains the entrance lobby, administrative offices and a
conference room. Beyond this area are a large classroom and the medical clinic area. The walls
located just outside of the clinic contain bits of interesting medical facts that have been painted on the
wall. There is a hallway that leads to a large space where a control room is located, along with
separate entrances to Dorms A, B and C. Two additional classrooms are located in Dorm C. The
Dorms contain bathrooms where a reasonable amount of privacy is provided for the residents.
The Union Juvenile Residential Facility’s outside grounds are spacious and include a mobile unit that
serves as the administration building for the education unit and a maintenance shed that also houses
the tool room. Included in the education mobile unit are offices and an area used for testing. The
grounds also contain a basketball court, an area for running, obstacle course, and a gazebo. Direct
care staff supervises residents in daily activities and during the residents’ movement to and from
activities and services.
.
2
SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in various areas of the facility prior to the site
visit. Photographs were taken of the posted notices and the photographs were electronically sent to
this Auditor, noting their posted locations. Telephone conversations to review the audit processes
were held with the Unit Director who serves as the PREA Compliance Manager. The Pre-Audit
Questionnaire, facility policies and supporting documentation were uploaded to a flash drive, which
was received by the Auditor prior to the on-site audit. After reviewing the Questionnaire, written
notes were provided to the Compliance Manager seeking clarity and additional information.
Clarification and other documents were provided and corrective actions have been implemented as
needed during the audit process.
The on-site audit was conducted on March 10, 2015. An entrance meeting was held with the PREA
Compliance Manager. After the meeting, a staff member from the overnight shift was interviewed
by the Auditor. Following the interview, a comprehensive tour of the facility was conducted,
beginning with the Clinical Director and concluded by the Case Manager. During the tour, staff
members were observed to be providing direct supervision to the residents. Random staff,
specialized staff and residents were interviewed during the on-site audit which revealed their general
knowledge of PREA and the related procedures. The staff members interviewed were aware of the
PREA Policy against sexual assault and sexual harassment and related their duties and
responsibilities regarding PREA. The residents interviewed were aware of how to report sexual
assault and sexual harassment. A summary of the findings was provided to the PREA Compliance
Manager and the Executive Director.
Number of Standards Exceeded: 0
Number of Standards Met: 39
Number of Standards Not Met: 0
Number of Standards Not Applicable: 2
3
Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has a zero-tolerance PREA Policy. Policy 5.29 details how the facility will
implement its approach to preventing, detecting, and responding to sexual abuse. The
facility’s PREA Policy is used in conjunction with Florida’s Department of Juvenile Justice’s
PREA Policy 1919 (FDJJ 1919). Both policies contain definitions of the prohibited behaviors
and sanctions for those who participate in such behaviors. A staff member has been identified
as the PREA Compliance Manager; she also serves the facility in the capacity of Unit
Director.
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)
X Standard Not Applicable
Auditor Comments:
The facility does not contract with other agencies for the confinement of residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 refers to the facility staffing plan and its requirements. The Policy states that
documentation is required when deviations from the staffing plan occur. The facility reports
that there have been no deviations from the staffing plan. The documented staffing plan
shows the staff assignments and Policy 5.29 states that staffing is continuously monitored and
that adjustments are made as needed, which was also supported by staff interviews. Hold-
over staff members are identified on the work schedule, in advance, to fill in as needed.
4
Policy 5.29 and facility practice provide for unannounced rounds that are completed by
administrative staff. The Policy has been revised to include that staff will not alert other staff
when unannounced rounds are occurring. Documentation has been reviewed showing where
staff has received training regarding the revised Policy. A review of documentation and staff
interviews confirmed that unannounced rounds occur.
Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses staff not searching a transgender or intersex resident to determine the
resident’s genital status. It further provides that cross-gender strip searches, cross-gender pat-
down searches, and cross-gender visual body searches are prohibited. Staff training includes
the searching of residents. The viewing of residents by opposite gender staff while they are
showering, changing clothes, and performing bodily functions is not permitted.
The facility reports no cross-gender pat-down, strip or body cavity searches of residents
during this audit period. All staff and residents interviewed revealed that cross-gender
searches do not occur. Policy 5.29 requires female staff to announce their presence when
entering the housing area where residents may be showering, changing clothes or performing
bodily functions. Interviews with staff and residents confirmed this practice.
Standard 115.316 Residents With Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses the facility not relying on resident interpreters or resident readers. The
facility will utilize support services through Language Line Solutions in partnership with the
Florida Department of Health. Employees from another Sequel Youth and Family Services’
facility may also provide assistance in Spanish. Staff interviews confirmed that residents are
not used as interpreters.
5
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses the elements of the standard, providing information on background
checks on all employees. FDJJ 1919 provides the process that also includes the elements of
the standard. A review of documentation and interviews with staff show that applicants and
employees are asked about previous misconduct. Documentation provided and interviews
with staff confirmed that prior to the hiring of an employee or contractor, background checks
are conducted.
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)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable because there have not been any substantial expansions or
modifications and no technology updates since August 20, 2012.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Documentation was presented which shows collaboration between the facility and a victim
advocacy agency for the provision of victim services; a draft MOU has been developed.
Policy 5.29 addresses the availability of victim advocacy services to residents and services
provided to the victim at no cost. The provision of victim advocacy services was addressed in
interviews. There has not been a need for a forensic medical examination during this audit
period.
6
According to Policy 5.29 and FDJJ 1919, the facility is not responsible for conducting
administrative or criminal investigations. The DJJ Office of the Inspector General (OIG) is
responsible for conducting administrative investigations; the Florida Department of Children
and Families (DCF) is responsible for conducting allegations of child abuse; and local law
enforcement is responsible for conducting criminal investigations. The PREA Compliance
Form which contains the PREA requirements regarding investigations will be provided to law
enforcement investigators as needed.
Standard 115. 322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 identify the agencies that will conduct the criminal and
administrative investigations. According to FDJJ 1919 facility staff is to cooperate with the
OIG investigations. During the past 12 months, there were no allegations of sexual abuse or
sexual harassment. Policy regarding the referral of allegations of sexual abuse or sexual
harassment for an investigation is posted on the Sequel Youth and Family Services and DJJ
websites. PREA related information is also posted in the facility, accessible to the public.
Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 provides information regarding staff training. Employees receive training and
updates as needed on the facility’s zero-tolerance policy and through DJJ for additional and
specific training. The staff training includes the key areas referenced in the standard. A
review of training documents and interviews with staff confirm that training is provided in
accordance with the standard and the Policy.
Standard 115. 332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
7
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 requires volunteers and contractors who have contact with residents to be trained
on their responsibilities and the FDJJ prepared course regarding sexual assault prevention,
detection, and response is used. Receipt of the training is documented.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 requires that all residents receive age-appropriate training about PREA and how
to report incidents or suspicions of sexual misconduct, the facility response, and non-
retaliation for reporting. Residents receive education as supported by document review and
resident interviews. PREA education will be provided through accessible formats for
residents who are limited English proficient, deaf, visually impaired, or otherwise disabled,
as needed. Support services will be provided by Language Line Solutions and agency staff.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 states that staff in the OIG will be trained on the related policies and procedures
regarding the handling of sexual misconduct incidents and reports. The investigators have
been trained in conducting allegations in the FDJJ settings.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
8
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 address this standard. Documentation shows that the medical and
mental health staff members have completed on-line specialized training provided by FDJJ.
Forensic medical examinations will not be conducted by the facility medical staff.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses the use of the Screening for Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) instrument. It is administered to determine the
resident’s risk of victimization and abusiveness and other related information. The
instrument is completed on each resident. Staff and resident interviews and a review of
documentation confirmed that the screening is being conducted.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility uses the information from the VSAB to assist in determining housing and other
program assignments, according to Policy 5.29. Staff interviews and review of VSABs
supported the policies and practices. Residents confirmed through their interviews that
VASBs are being administered.
Policy 5.29 and facility practice do not provide for the use of isolation. The Policy prohibits
placing gay, bisexual, transgender, or intersex residents into separate housing or any other
assignment based solely on such identification or status. The facility prohibits considering
gay, bisexual, transgender, or intersex identification or status as an indicator of likelihood of
being sexually abusive.
9
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 provide for internal ways a resident may report allegations of sexual abuse;
sexual harassment; retaliation for reporting; and staff neglect or other violation that lead to
abuse. A resident may talk to any staff member; complete a grievance form and place it in the
grievance box; utilize the DJJ hotline; and third parties may report allegations. Reporting
information is also provided in FDJJ 1919. PREA related information is posted within the
facility, accessible to all residents. Resident interviews revealed that they are aware of the
reporting methods.
.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses resident grievances. If the grievance is PREA related, the resident is
instructed to fill in their name and date on the form and put it in the box which is checked
daily by the Clinical Director or his designee. The resident is not required to use the informal
process for any situation regarding sexual abuse. When a grievance is received, it is treated as
an allegation of abuse and the reporting procedures are implemented for investigation by the
OIG, DCF or local law enforcement. There were no emergency grievances received, alleging
risk of sexual abuse during this audit period.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
10
Auditor Comments:
Policy 5.29 provide for residents to have access to outside victim advocacy services.
Documentation was reviewed showing collaboration with a victim advocacy agency in
anticipation of signing a Memorandum of Understanding. Staff and resident interviews
confirmed that residents have confidential access to their attorney or other legal representative
and access to their parents or legal guardians.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility provides methods for third-party reporting of sexual abuse as supported by
Policies 5.29 and FDJJ 1919. Related information is posted in areas of the facility accessible
to the public. PREA information is available on the DJJ and the Sequel Youth and Family
Services websites regarding the reporting of sexual abuse or sexual harassment.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses this standard. All staff members are required to report any allegation
of sexual misconduct. Allegations must be reported to the Central Communications Center
(CCC), DCF and local law enforcement, as required by mandatory reporting laws and
facility and DJJ policies. FDJJ 1919 instruct staff members not to reveal any related
information to anyone other than those who are involved in treatment, investigation and
other security and management decisions.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
11
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29, when staff learns that a resident is subject to substantial risk of
imminent sexual abuse, actions will be taken to protect the resident. The facility reports that
there have been no incidents in the last 12 months where the facility took any action in
regards to a resident being in substantial risk of imminent sexual abuse.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29, upon receiving an allegation that a resident was sexually abused
while confined in another facility, the Director will notify the head of that facility or the
appropriate office as soon as possible but no later than 72 hours and the contact will be
documented. FDJJ 1919 require notifying the appropriate investigative agency of all
allegations of sexual abuse. In the past 12 months, there has not been a report of any
allegations of sexual abuse occurring to a resident while in another facility.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The staff first responder duties are incorporated in Policy 5.29 and are aligned with the
requirements of FDJJ 1919. The facility Policy also addresses the requirements of non-
security staff. Interviews confirmed that staff members are knowledgeable of their duties.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
12
Auditor Comments:
The facility’s coordinated response plan is aligned with FDJJ 1919 and the requirements of
the standard. Interviews with staff revealed that they are familiar with the institutional plan.
The plan coordinates the actions to be taken among facility first responders and other staff in
response to an incident of sexual abuse.
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)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable. The facility does not maintain any collective bargaining
agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses this standard and it is the responsibility of the Unit Director, who is
also the PREA Compliance Manager, to monitor for retaliation. The Policy requires that if the
retaliation conduct is identified, the monitoring would be conducted for at least 90 days and
longer if needed, regarding staff. The retaliation monitoring for a resident will be for the
duration of his stay. There have been no incidents of retaliation reported in the past 12
months.
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)
X Standard Not Applicable
13
Auditor Comments:
This standard is not applicable because segregated housing or isolation is not used at the
facility.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 provide direction for this standard. Administrative investigations
are conducted by the OIG and criminal investigations are conducted by local law
enforcement and DCF. FDJJ 1919 directs staff to cooperate with the OIG investigations.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 5.29 and FDJJ 1919 address this standard. The OIG, responsible for administrative
investigations, imposes a standard of a preponderance of the evidence for determining whether
allegations are substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 allow for the victim to be informed that an investigation has been
concluded. At the conclusion of an OIG investigation, the victim or the victim’s parents or
legal guardian will be notified unless the allegation is unfounded.
14
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 support this standard. Policy 5.29 provides for disciplinary
sanctions for staff including immediate termination for violation of the PREA policies
regarding sexual abuse and sexual harassment. In the past 12 months, no staff has been
terminated or has resigned for violating the facility’s PREA related policies.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 state that any contractor or volunteer engaging in sexual abuse of
residents will be subject to referral to local law enforcement regarding criminal charges and to
relevant licensing bodies. Both Policies require that the contractor or volunteer be prohibited
from having contact with residents. During the past 12 months, no contractor or volunteer has
been reported to law enforcement or any investigative agency for allegations of sexual abuse.
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 address this standard. Residents found in violation of the facility’s
zero-tolerance policy will receive disciplinary sanctions after a formal disciplinary process.
There have been no criminal or administrative investigations of sexual abuse in the last 12
months.
15
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses this standard. Residents who disclose prior sexual victimization or
who disclose previously perpetrating sexual abuse during an intake screening will be
provided a follow-up meeting with a medical or mental health practitioner. This meeting is
available from the first day of admission to the facility; all of the Therapists are trained in
this area. Staff interviewed confirmed awareness of the procedures.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 addresses this standard. The Policy requires that treatment services to every
victim will be provided at no cost to the victim. The Policy further states that victims will be
provided on-going medical and mental health treatment that include testing for sexually
transmitted infections and counseling. Interviews with staff confirmed their knowledge of
the procedures and that the scope and nature of the services will be based on the professional
judgment of the medical and mental health staff.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29 all residents have access to mental health evaluations and treatment
due to the type of program that is implemented within the facility. Evaluations and
appropriate treatment will be provided to victims and abusers. Policy 5.29 and FDJJ 1919
address ongoing medical and mental health care for sexual abuse victims and abusers.
Therapists at the facility are trained to counsel sexual abuse victims and abusers.
16
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 provide information regarding the incident review team and its
role. The Policies detail the make-up of the sexual abuse incident review team and the
general purpose. Interviews with staff and a review of the After Action Review form support
Policy 5.29 and FDJJ 1919.
Standard 115.387 Data collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29, FDJJ 1919 and interviews with staff confirmed that DJJ and the facility collect
incident-based, uniform and aggregated data regarding allegations of sexual abuse using a
standardized instrument. The Policies require the collection of accurate, uniform data for
every allegation of sexual assault. The facility and DJJ will provide DOJ with data as
requested.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 5.29 and FDJJ 1919 address this standard. A review will be conducted of the collected
and aggregated data to assess and improve the effectiveness of the PREA related efforts and
initiatives. The Policies state that annual reports will be prepared.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
17
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 5.29 and FDJJ 1919, it is required that data is collected and securely
retained for 10 years. The aggregated PREA data is reviewed and all personal identifiers are
removed.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
April 8, 2015
Auditor Signature Date
18

source: DJJ

report_type: PREA

program_name_raw: union juvenile residential facility


facility_name: walton youth development center

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Walton Youth Development Center
Physical Address: 286 Gene Hurley Road, DeFuniak Springs, FL 32435
Date report submitted: December 16, 2014
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: November 24, 2014
Facility Information
Facility Mailing Address: 286 Gene Hurley Road, DeFuniak Springs, FL 32435
Telephone Number: (850) 520-4642
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention X Correction Other:
Name of PREA Compliance Manager: Denny Skinner Title: QA Officer
Email Address: denny.skinner@uhsinc.com Telephone Number:
(850) 683-3900
Agency Information
Name of Agency: Gulf Coast Youth Services, Inc.
Governing Authority or Parent Agency: Universal Health Services
Physical Address of Agency: 1015 Mar Walt Drive, Fort Walton Beach, FL 32547
Mailing Address: Same as Above
Telephone Number: (850) 863-4160
Agency Chief Executive Officer
Name: Jeanette Jackson Title: Chief Executive Officer
Telephone (850) 863-4160
Email Address: jeanette.jackson@uhsinc.com
Number:
Agency Wide PREA Coordinator
Name: Denny Skinner Title: QA Officer
Email Address: denny.skinner@uhsinc.com Telephone Number: ( 8 5 0 ) 6 8 3 - 3 9 0 0
1
AUDIT FINDINGS
NARRATIVE:
The Walton Youth Development Center is located in DeFuniak Springs, Florida and is a 39-bed
facility for male juvenile offenders in the age range of 13-18. The facility is operated by Universal
Health Services, Inc. through a contract with the Florida Department of Juvenile Justice (DJJ) to
provide treatment services for committed youth. The length of stay is three to nine months for
moderate risk residents and nine to 12 months for residents identified as high risk. While in the
facility residents participate in programming that include education and vocational services; social
services; mental health services; recreation; and transition planning.
On-site medical care is provided by one Registered Nurse and one Licensed Practical Nurse. The
contract physician visits the facility weekly. Mental health services are provided on-site by the
Treatment Coordinator and two Therapists, with a contract psychiatrist visiting the facility at least
every other week. The parent agency has a Director of Nursing and a Designated Mental Health
Authority on staff, accessible to the facility medical and mental health personnel. Education services
are provided by teachers through the Walton County School District. Vocational education is
provided through the Home Builders Institute Pre-Apprenticeship Certificate Training program. Case
Managers ensure coordinated efforts for individualized treatment plans. Youth Care Workers provide
direct supervision of residents in daily activities and movement to and from activities and services.
Ninety staff members have been employed at the facility during the past year.
The Walton Youth Development Center is accredited by the Commission on Accreditation of
Rehabilitation Facilities (CARF). Additionally, the facility provides opportunities for community
service projects that are constructed at the facility and delivered to various sites located in the
community. Past projects, completed through vocational services, have included storage sheds for
Habitat Humanity; construction of dog houses for the humane society; and construction of basketball
racks for the local Boys and Girls Club.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program site consists of one main building where the front of it contains the entrance lobby and
administrative offices. Beyond the front area are a large conference room, the medical clinic, and the
entrance for the admission of new residents. The next part of the building includes the control room
which separates two living units; kitchen and dining room; and the education area which consists of
three classrooms, library, and computer lab. Located on the outside grounds are buildings that contain
the vocational program, including administrative offices; work areas; and storage.
Bathrooms are located in each housing unit and they provide a reasonable amount of privacy for the
residents. Each housing unit also has a laundry room. The outside grounds contain a recreation area
in ample size to accommodate various recreation and other activities. The grounds also contain a
chicken coop and several chickens in a fenced area. Under staff guidance, the residents take
responsibility in caring for the chickens. The care of the chickens is therapeutic and provides
vocational opportunities for the residents. The outside grounds also contain a garden.
2
SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in various parts of the facility at least six weeks
prior to the site visit. Photographs were taken of the various sites where the notices had been posted
and the photographs were electronically sent to this Auditor, noting their locations. An initial call
was made to the Program Director to discuss the audit process and data gathering. The Pre-Audit
Questionnaire and the supporting documentation were uploaded to a flash drive, which was received
approximately four weeks prior to the on-site audit. During the review of the information on the
flash drive, communication was maintained with the PREA Coordinator and additional information
was provided or clarified as requested. The parent agency’s Quality Assurance (QA) Officer serves
as the PREA Coordinator.
The on-site audit was conducted November 24, 2014. An entrance meeting was held with the
Program Director, Assistant Program Director and the Treatment Coordinator. After the meeting a
comprehensive tour of the facility was provided by the Assistant Program Director. During the tour,
staff members were observed to be directly supervising and interacting with the residents. Random
staff, specialized staff and residents were interviewed during the on-site audit process.
While on-site, additional information for the audit process was provided upon request and in a timely
manner. A close-out meeting was held at the conclusion of the on-site audit and a summary of the
audit findings was provided to the Program Director and the Assistant Program Director.
Number of Standards Exceeded: 0
Number of Standards Met: 39
Number of Standards Not Met: 0
Number of Standards Not Applicable: 2
3
Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has various policies that provide guidelines for implementing the agency’s
approach to complying with the requirements of the PREA standards. Policy 13.00 states a
zero tolerance toward all forms of sexual abuse and sexual harassment. The Policy contains
definitions of the prohibited behaviors and sanctions for those who participate in such
behaviors. The Florida Department of Juvenile Justice Policy 1919 (FDJJ 1919) is also used
and adhered to for support of the PREA standards.
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)
X Standard Not Applicable
Auditor Comments:
The facility does not contract with other facilities for the confinement of residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 9.010 addresses this standard and provides for the implementation of a staffing plan
with adequate staffing levels to protect residents against sexual abuse and that the ratios are
per the current program contract. The facility reported no deviations from the current staffing
plan in the past 12 months. The annual assessment of staffing and other areas has been
conducted to determine whether adjustments are needed in accordance with the standard. An
evaluation of staffing is documented through the completion of the Staffing Plan Assessment
form. Unannounced rounds of the facility for the maintenance of a safe environment are
conducted and documented by the appropriate staff. Interviews with staff confirmed the
practice.
Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
4
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 9.100 prohibits cross gender pat-down searches; there have been no cross gender pat-
down searches during this audit period. The Policy also prohibits staff from conducting cross-
gender strip or cross-gender visual body cavity searches of residents and none have been
conducted during this audit period. Policies 13.09 and FDJJ 1919 have been implemented and
provide for residents to shower, perform bodily functions, and change clothes without being
observed by staff of the opposite gender. Interviews with staff and residents confirmed these
practices.
Policy 13.11 states that staff shall not search or physically examine a transgender or intersex
resident to determine the resident’s genital status. The related training and reviews have been
provided. Policy 13.10 addresses opposite gender staff announcements. The facility has also
implemented the practice that female staffs announce their presence when entering an area
where residents may be showering, changing clothes or performing bodily functions.
Standard 115.316 Residents With Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 1.150 addresses support services for residents with disabilities and residents who are
limited English proficient so that they may benefit from and participate in PREA education.
Resident education materials are available in dominant languages other than English. Policy
1.150 provides that the facility will not rely on resident interpreters. The policy contains
information regarding the resources to be used and how they will be accessed. A review of
documentation and staff interviews confirmed that outside resources will be used as needed.
.
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 1.130, FDJJ 1800 and FDJJ 1919 provide for background checks on all employees
and contractors through a process that is used statewide. A review of documentation and
interviews with staff confirmed that prior to the hiring of an employee or contractor,
background checks are conducted as required.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
5
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
A camera system serves as support to the direct supervision of residents by staff. The
Program Director and the Assistant Program Director are able to view specific areas through
desk top monitoring. There are a total of 32 cameras that are strategically placed and
additional cameras have been requested. The preliminary work for the installation of the
additional cameras has begun and replacements have been made to provide better video
quality.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.18 addresses this standard. It states that staff will cooperate in investigations
conducted by the FDJJ Office of the Inspector General (OIG) for administrative
investigations and with the Florida Department of Children and Families and local law
enforcement regarding criminal investigations. Policy 13.13 provides for forensic medical
examinations to be completed at no financial cost to the victim. There have been no forensic
examinations in the last 12 months. The facility has a Memorandum of Understanding
(MOU) with the Shelter House, Inc. in Fort Walton Beach, Florida which provides victim
advocacy services that include accompaniment to forensic examinations and training for
staff and residents.
Standard 115. 322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 13.27 and FDJJ 1919 provides that staff report all allegations of sexual abuse and
sexual harassment and that the appropriate investigative entity be contacted when allegations
of sexual abuse are made. There has not been an allegation from a resident at this facility
during the past 12 months. The DJJ website contains information regarding the referral of
allegations for investigations of sexual abuse. The facility posts related information which is
accessible to the public.
Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
6
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 13.03 and FDJJ 1919 provides for the PREA training of all staff. The staff received
the DJJ training and the facility has conducted refresher training in the key areas referenced
in the standard. Documentation of staff participating in training is maintained.
Standard 115.332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.04 contains information regarding the training of volunteers and contractors who
have contact with residents. Receipt of the training is documented and it contains a review of
the agency’s zero tolerance policy.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 13.00, 1.150 and FDJJ 1919 address this standard. A review of documentation and
interviews with residents and staff confirm that residents receive information about the
facility’s zero-tolerance policy and how to report incidents of sexual abuse or sexual
harassment. According to policy, the facility will provide support services in accessible
formats for residents who are limited English proficient, deaf, visually impaired, or
otherwise disabled.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 states that staff in the OIG will be trained on the related policies and procedures
regarding the handling of sexual misconduct incidents and reports. Training is provided to
investigative staff regarding conducting investigations in the DJJ settings.
7
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.15 addresses PREA training for medical and mental health staff. A review of
documentation and staff interviews confirm the specialized training. The facility nurses do
not conduct forensic medical examinations.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 13.01 and FDJJ 1919 address this standard. The screening for risk of sexual abuse
victimization or sexual abusiveness toward other residents is being conducted on each
resident. The initial screening is done during the intake process and Policy 13.01 states that
residents receive reassessments periodically. Interviews with residents and staff and a review
of documentation confirmed that the screening is conducted.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.02 prohibits placing gay, bisexual, transgender, or intersex residents into
confinement based solely on such identification or status. Additionally, housing and program
assignments require determinations on each transgender or intersex resident on a case by
case basis. According to the Policy, the facility prohibits considering gay, bisexual,
transgender, or intersex identification or status as an indicator of likelihood of being sexually
abusive. There have been no residents placed in isolation because of victimization.
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
8
Auditor Comments:
According to Policies 13.22 and FDJJ 1919, there are internal ways a resident may report
allegations of sexual abuse; sexual harassment; retaliation for reporting; and staff neglect or
other violations that lead to abuse. A resident may file a grievance; complete a Youth Special
Request Form where a resident identifies specific staff he would like to talk to; write a note;
talk to any staff member; and third parties may report allegations to staff. The grievance may
be placed in the locked box located in the housing units. Interviews with staff and residents
support the practices.
PREA related information is routinely posted in each housing unit. Residents are provided
access to a telephone to report allegations of sexual abuse and sexual harassment to the abuse
reporting hotline. The hotline number is also accessible from any office phone in the
administration area of building. Interviews revealed that staff members are aware of their
responsibility to report sexual abuse and sexual harassment. They are also aware that they are
to accept reports of sexual abuse and sexual harassment made verbally, in writing,
anonymously, and from third parties in accordance with Policies 13.22 and FDJJ 1919.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 3.08 and 13.21 provide guidance about the grievance process and information is
contained in the resident handbook. Residents may put a completed grievance form in the
locked grievance box. Policy prohibits the use of an informal grievance process regarding
allegations of sexual abuse and sexual harassment. The facility has enhanced existing policy
and procedures for the filing of an emergency grievance alleging sexual abuse or sexual
harassment. The facility reports that there have been no grievances submitted relating to
sexual abuse or sexual harassment received in the past 12 months.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.23 requires the facility to provide the residents with access to outside victim
advocacy services. The facility has a MOU with Shelter House, Inc. that provides for
advocacy services to the victim. A telephone conversation with the representative from the
victim advocacy agency confirmed that victim services will be provided. The facility and the
advocacy agency report that no services have been requested.
9
Residents are allowed to see their parents at visitation on the weekends and they are also
allowed to make weekly phone calls. Attorneys or other legal representation may visit
residents in a confidential manner.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.14 provides guidelines regarding third-party reporting. The DJJ website provides
the public with information regarding third-party reporting of abuse. Parents receive
information about reporting incidents of sexual abuse through information posted in the
facility.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 1.07, FDJJ 1919 and Florida Statute 39.201, all staff members are
mandated reporters. Staff members are to immediately report any knowledge, suspicion or
information they receive regarding sexual abuse, sexual harassment; retaliation against
residents or staff who report any incidents; or any staff neglect or violation of responsibilities
that may have contributed to an incident. Staff interviews support the policies.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.12 addresses this standard and provides that when the agency or facility staff
learns that a resident is subject to substantial risk of imminent sexual abuse, immediate
action is taken to protect the resident. There have been no incidents in the last 12 months
where the agency or the facility took any action in regards to a resident being in substantial
risk of imminent sexual abuse.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
10
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 13.26, upon receiving an allegation that a resident was sexually abused
while confined in another facility, the Program Director/designee will notify the Central
Communications Center (CCC) of the allegation within 72 hours. The CCC notifies the
facility of which the allegation was made. Staff interviews provided support for this process.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 13.20 and FDJJ 1919 guide the response to this standard. There has been no
allegation by a resident regarding sexual abuse within the last 12 months. Staff training and a
refresher have been provided.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Institutional Plan documents the actions to be taken among staff in response to an
incident of sexual abuse. The Plan includes first responders, leadership, medical and mental
health staffs.
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)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable. The facility does not maintain any collective bargaining
agreements.
11
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.19 supports protection against retaliation for residents and staff who report
allegations of sexual abuse or sexual harassment. The Program Director, Assistant Program
Director and shift supervisors have been identified as the staff members designated with
monitoring for possible retaliation. The Policy instructs staff to report incidents of retaliation
and states that, if the conduct is identified, the monitoring will be is ongoing.
Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.29 addresses this standard and covers the requirements of how protective measures
are implemented. The protective measures do not include the isolation of residents; however,
the resident may be transferred to another room. The resident will be separated from
potential abusers, according to the Policy and staff interviews.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.18 and FDJJ 1919 address this standard. Administrative investigations are
conducted by the DJJ Office of Inspector General and criminal investigations are conducted
by the Department of Children and Families and local law enforcement. Both Policies direct
facility staff to cooperate with the investigations. According to FDJJ 1919, an investigation
is not terminated solely because the source of the investigation recants the allegation.
Substantiated allegations of conduct that appear to be criminal are referred for prosecution.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
12
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.28 supports that a standard of the preponderance of the evidence is used for
determining if allegations are substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.18 and FDJJ 1919 provides the process for notifying residents, following an
investigation, of whether an allegation has been determined to be substantiated,
unsubstantiated, or unfounded.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.17 and FDJJ 1919 provide for disciplinary sanctions for staff to be up to and
including termination for violation of the sexual abuse and sexual harassment policies. The
policies require that the violation be reported to local law enforcement and provides for
contacting relevant licensing bodies. In the past 12 months, no staff has been terminated or
has resigned for violating PREA related policies.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.16 and FDJJ 1919 indicate that an incident regarding sexual abuse by a contractor or
volunteer will be reported as required as well as relevant licensing bodies. The policies require
the facility to take remedial measures and prohibit future contact with residents in the case of
any violation of the facility’s PREA related policies. During the past 12 months, no contractor
or volunteer has been reported to law enforcement or any investigative entity for allegations of
sexual abuse.
13
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.24 addresses this standard. Any resident found in violation of the facility’s zero
tolerance policy against sexual abuse may be subject to disciplinary action, following a
formal process. The resident may be transferred to another facility following an
administrative or criminal finding of resident-on-resident sexual abuse. During the past 12
months there have been no incidents of resident-on-resident sexual abuse.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.05 states that residents who disclose a history of sexual abuse or who disclose
previously perpetrating sexual abuse will be offered a follow-up meeting with a medical or
mental health practitioner within 14 days of the intake screening. Staff interviewed
confirmed awareness of the policy and the requirements of the standard.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policies 13.05 and 13.06, timely access to emergency medical treatment and
crisis intervention services for victims of sexual abuse will be provided. The nature and
scope of the services are determined by medical and mental health practitioners according to
their professional judgment.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
14
Auditor Comments:
Policy 13.05 provides for ongoing medical and mental health care for sexual abuse victims.
It also provides for medical and mental health evaluations and appropriate treatment in
accordance with the standard. According to staff interviews and a review of documentation,
health care is consistent with the community level of care.
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.25 will serve as the guide for staff in conducting incident reviews. The incident
review team has been identified. Staff interviews indicated familiarity with the role of the
incident review team.
Standard 115.387 Data collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 13.30 and FDJJ 1919 require the collection of accurate, uniform data for every
allegation of sexual assault. DJJ has developed a data collection instrument that includes the
required data.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 13.30 and FDJJ 1919 address this standard. The Policies require the review of data
for corrective action towards improving the effectiveness of the agencies’ prevention,
protection and response policies, practices, and training.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
15
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 13.30 and FDJJ 1919 require that data is collected and securely retained for 10
years. The aggregated PREA data is reviewed and all personal identifiers are removed.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
December 16, 2014
Auditor Signature Date
16

program_name_raw: walton youth development center