state: FL

facility_name: Columbus Youth Academy

summary: PREA

raw_content:
PREA AUDIT: Auditor’s Summary Report
JUVENILE FACILITIES
Name of Facility: Columbus Residential Facility
Physical Address: 9502 E. Columbus Drive, Tampa, Florida 33619
Date report submitted: December 23, 2014
Auditor information: Flora Boyd
Address: 5 Rosemount Court, Blythewood, South Carolina 29016
Email: fbb4577@aol.com
Telephone number: 803-312-5199
Date of facility visit: July 16-17, 2014
Facility Information
Facility Mailing Address:
(if different from above) Same as Above
Telephone Number: 813-769-0445
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: Terry Mitchell Title: Facility Administrator
813-769-0445
Email Address: terry.mitchell@us.g4s.com Telephone Number:
A g e n c y I n f o r m a t i o n Telephone Number:
Name of Agency: G4S Youth Services, LLC
Governing Authority or Parent Agency: (if applicable)
G4S Youth Services, LLC
Physical Address: 6302 Benjamin Road, Suite 400,Tampa, Florida 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
Telephone Number: 813-514-6275 ext. 202
Email Address: jim.hill@us.g4s.com
Agency Wide PREA Coordinator:
Name: Bobbi Pohlman-Rogers Title: JJDA/PREA Director
Telephone Number: 954-818-5131
Email Address: bobbi.pohlman@us.g4s.com
1
AUDIT FINDINGS
NARRATIVE:
Columbus Juvenile Residential Facility (CJRF) is a 50-bed residential program for moderate-risk
boys up to the age of 18, who are in need of sexual offender specific treatment. Located in
Tampa, Florida, CJRF is operated by G4S Youth Services, LLC, under contract with the Florida
Department of Juvenile Justice (FDJJ). The program provides sexual offender treatment services
for youth with a documented history based upon a psychosexual assessment. Substance abuse
treatment is provided to youth based on their psychosocial history and substance abuse
screening. Substance Abuse treatment services are also provided for youth who have a primary
diagnosis of, or legal problems related substantially to, a substance abuse disorder. The average
length of stay is 12 to 18 months, including transition and is dependent upon the progress of the
youth’s treatment.
CJRF currently has 52 full- time employees including a Facility Administrator and an Assistant
Facility Administrator. Direct care staff provides a 1:8 staff to youth ratio during awake hours
and 1:10 during sleeping hours.
CJRF’s primary treatment model is STEPS of Progress which is a sex offender specific
curriculum provided through the modalities of weekly individual counseling sessions, daily
group therapy, and family therapy at least once per month or as otherwise indicated on the
youth’s treatment plan. The Hillsborough County Public School System provides general
academic instruction for CJRF residents. Vocational programming offered includes pre-
vocational services that identify the youths’ interests and skills, a culinary arts course, is
provided to each youth to prepare them for potential employment in the food service industry.
Once a youth completes the Culinary Arts program, they receive a Safe Serve certification. The
program also offers general education development testing preparation.
Columbus Juvenile Residential Facility also offers each youth assistance in setting transitional
goals, celebrating achievements, development of skill plans and comprehensive transition plans,
exploration of educational and vocational goals as well as active post release planning and follow
up to assist in sustainability of gains and continued goal advancement following release from the
program. CJRF employs a Transitional Services Manager who acts as the transition preparation
specialist and serves as a resource liaison within the transition process.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The facility consists of one main building which is divided into several sections including
administrative offices, dining hall/food preparation area, classrooms and three separate housing
units: Dorm 1 has 16 rooms, Dorm 2 has18 rooms and Dorm 3 has16 rooms. Each dorm has
single bed rooms for youth, therefore eliminating the need for room sharing. Each dorm houses a
common area, the day room, and bathroom facilities. The shower stalls and toilets are curtained
to ensure residents’ privacy. CJRF is equipped with a video monitoring system that has 32
cameras.
.
PREA AUDIT: AUDITOR’S FINAL REPORT 2
SUMMARY OF AUDIT FINDINGS:
The notification of the on-site audit was posted on June 2, 2014, six weeks prior to the first date of the
on-site audit. The posting of the notices was verified by photographs received electronically from the
PREA Compliance Manager. The photographs indicated notices were posted in various locations
throughout the facility including the housing unit and administrative areas. The Pre-Audit Questionnaire,
policies and supporting documentation were received on June 17, 2014. The Pre-Audit Questionnaire,
policies and some documents were uploaded to a UBS flash drive. The initial review revealed some key
documents were not provided. After providing a listing of noted concerns and documents needed, steps
were taken by the facility staff to ensure that available documentation was provided during the on-site
visit. Specific corrective actions taken to address some of the deficiencies are summarized in this report
under the related standard.
The on-site audit was conducted July 16-17, 2014. After meeting with one of the Facility Administrator,
a complete tour of the facility was conducted. During the tour, youth were observed to be under constant
supervision of staff while involved in school and other activities. The housing dorms were clean and
orderly. Observation of dorms revealed bathroom showers and toilets have curtains to provide residents’
privacy. There are three observation rooms with toilets however according to the Facility Administrator
the observation rooms have not been used in three years. Observation of the surveillance system
monitors in the control room revealed cameras do not capture showers, toilets or inside residents’ rooms
in the dorms but do capture a full view of the observation rooms including the toilet.
Over the two-day on-site visit, 11 staff including direct care staff from all three shifts were interviewed.
Overall, the interviews revealed staff are knowledgeable of PREA standards and were able to articulate
their responsibilities. Seven residents, two or three from each dorm were also interviewed. Residents
were informed of their right to be free from sexual abuse and harassment and how to report sexual abuse
and harassment. Policies and secondary documentation were thoroughly reviewed.
A corrective action plan was developed, with input from the FDJJ PREA Coordinator, and provided to
the facility’s Compliance Manager on July 21, 2014, to specify the minimum remedial steps to be taken
to comply with PREA standards. The FDJJ PREA Coordinator provided documentation of corrective
action that was taken by FDJJ to comply with the standards as indicated in the auditor’s comment
section under the related standard. Remaining non-compliance issues were addressed within the 180-day
corrective action period as indicated in the auditor’s comment section throughout this report.
Number of standards exceeded: 0
Number of standards met: 39
Number of standards not met: 0
Number of standards Not Applicable: 2
PREA AUDIT: AUDITOR’S FINAL REPORT 3
Standard 115.311-Zero Tolerance of Sexual Abuse and Sexual Harassment; PREA
Coordinator
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:
CJRF PREA Facility Operating Procedure (FOP) 10-25 mandates a zero-tolerance of sexual
abuse and sexual harassment and outlines how the facility carries out its approach to
preventing, detecting and responding to sexual abuse and sexual harassment. The policy
includes definitions of prohibited behaviors and sanctions for those found to have participated
in prohibited behaviors. The policy also provides strategies and responses for reducing and
preventing sexual abuse and harassment.
CJRF is a residential juvenile treatment facility operated by G4S Youth Services. G4S
employs an agency-wide PREA Coordinator who is in an upper-level management position
within the agency. The PREA Coordinator interview revealed she has sufficient time and
authority to develop, implement and oversee the agency’s efforts to comply with PREA
standards in all G4S operated facilities. The Facility Administrator serves as the PREA
Compliance Manager and indicated during an interview that he has sufficient time to oversee
the facility’s PREA compliance efforts and to perform his other duties.
Standard 115.312- Contracting 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)
X Does Not Apply
Auditor Comments:
G4S does not contract with other entities 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)
PREA AUDIT: AUDITOR’S FINAL REPORT 4
Auditor Comments:
CJRF PREA FOP 10-25 requires the facility to develop, implement and document an
approved staffing plan. Although the staffing plan was not provided during my initial review,
it was provided during the on-site visit. The staffing plan mandates a 1:8 staff to resident ratio
during waking hours or a 1:10 staff to resident ratio during sleeping hours. The staffing plan
is based upon the agency’s contractual agreement with FDJJ and an operating capacity of 50
residents. The policy requires the facility to document deviations from the staffing plan on
the Shift Report or in the logbook however there have been no deviations from the plan.
Documentation of the annual review of the staffing plan dated June 5, 2014 was reviewed
and found to be in compliance with all elements contained in (d)-1 of this standard.
CJRF utilizes video monitoring combined with direct staff supervision to protect residents
from sexual abuse and sexual harassment. Documentation of log entries were provided as
evidence that unannounced rounds are conducted by intermediate and upper level staff on all
shifts throughout the facility.
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:
CJRF PREA FOP 10-25 prohibits cross-gender strip searches, or pat down searches of youth,
except in exigent circumstances. 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. The policy 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 a
body cavity. All body cavity searches must be conducted by trained medical personnel in an
emergency room setting. Program staff are not authorized to conduct body cavity searches of
residents. During the past 12 months, there were no cross-gender strip or body cavity
searches and no cross-gender pat-down searches.
CJRF PREA FOP 10-25 states the facility must ensure residents are allowed to shower,
perform bodily functions and change clothing without staff of the opposite sex viewing their
bodies. The showers and toilets have curtains to ensure residents’ privacy. Resident
interviews verified they are allowed privacy when showering and using the toilet.
Observation of the surveillance system monitors in the control room revealed cameras do not
capture showers, toilets or inside residents’ rooms in the dorms but do capture a full view of
the observation rooms including the toilet. During the corrective action period, the cameras in
the observation rooms were repositioned to prevent cross-gender viewing of residents using
the toilet.
CJRF PREA FOP 10-25 requires opposite sex staff, volunteers and contractors entering
housing units to announce themselves. Resident interviews verified this is done on a consistent
PREA AUDIT: AUDITOR’S FINAL REPORT 5
bases.
CJRF Policy 8-14 prohibits the search of transgender or intersex residents for the sole purpose
of determining the resident’s genital status. Staff interviews verified compliance.
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:
CJRF PREA FOP 10-25 requires the Compliance Manager to ensure that residents with
disabilities or who are limited English proficient are provided meaningful access to all
aspects of the facility’s efforts to prevent, protect and respond to sexual abuse and
harassment. This policy also states the facility prohibits the use of resident interpreter,
resident readers or any kind of resident assistants except when a delay in obtaining
interpreters services could jeopardies a resident’s safety. Resident and staff interviews
verified the facility does not use resident assistants and there were no instances of resident
interpreter or readers being used in the past 12 months however there is no documentation of
how services would be provided, if needed. During the corrective action period, Policy 9-2
Classification and Orientation, was revised to include how PREA education for residents
with disabilities will be provided in a format they can understand.
CJRF PREA FOP 10-25 also requires staff to provide PREA education in a format
assessable to all residents including those who may be limited English proficient, deaf,
visually impaired or otherwise with a disability, as well as to residents who have limited
reading skills. Samples of education materials were provided.
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:
CJRF PREA FOP 10-25 and G4S Policy 3-16 requires criminal background screening for
new hires however the policies do not specifically require consulting with the child abuse
registry before hiring or enlisting services of any contractor who has contact with residents.
The FDJJ PREA Coordinator provided documentation that Florida State law does not allow
FDJJ to contact the abuse registry for the purpose of screening applicants.
Documentation of criminal background checks and that questions regarding past conduct
PREA AUDIT: AUDITOR’S FINAL REPORT 6
were asked and responded to during the interview process was reviewed and found to be in
compliance with the standard. G4S Policy 3-16 requires criminal background checks to be
conducted every five years. Applicants are required to sign acknowledging material
omission regarding misconduct, or false information are grounds for termination.
Standard 115.318- Upgrades to Facilities and Technology
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:
CJRF’s video monitoring system has 36 cameras. The existing video monitoring system has
not been updated during the past 12 months. The annual staffing plan assessment indicated a
recommendation to reposition the camera in Dorm 2 to cover more area.
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)
X Does Not Meet Standard (requires corrective action)
Auditor Comments:
CJRF PREA FOP 10-25 requires staff to report allegations of sexual abuse to local law
enforcement, the Florida Central Abuse Hotline and FDJJ’s Central Communication Center
(CCC). CJRF does not have a Memorandum of Understanding (MOU) or documented
attempts to obtain a MOU with local law enforcement. During the corrective action period,
the Facility Administrator sent a letter to the Hillsborough County Sheriff’s Department
along with the DJJ PREA Compliance Form advising investigating agencies to follow the
DJJ Inspector General Directive 3-05 (uniform evidence protocol that maximizes the
potential for obtaining usable physical evidence for criminal prosecution) when investigating
sexual abuse allegations at the facility.
An unsigned agreement between G4S and the Crisis Center of Tampa Bay for victims’
advocacy services and forensic examinations for five of its facilities in Pasco County was
provided for my review. The agreement did not address the requirement for SANE or SAFE
medical examiners to conduct forensic examinations nor was there any other documentation
of attempts to obtain this agreement. CJRF PREA FOP does not address forensic exams are
offered without costs to the victim. During the corrective action period a signed MOU with
the Crisis Center of Tampa Bay for victim’s advocacy services was provided and Policy 7-30
was revised to state that forensic exams are offered at no cost to the victim. Documentation
was also viewed verifying that forensic exams will be conducted by a SANE certified
medical examiner.
PREA AUDIT: AUDITOR’S FINAL REPORT 7
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:
CJRF PREA FOP 10-25 requires the immediate referral of all sexual abuse allegations to
local law enforcement, the Florida Abuse Hotline and CCC. In the past 12 months, CJRF had
no allegations of sexual abuse or sexual harassment. Interviews with the Facility
Administrator and other staff verified their knowledge of the policy’s requirements.
FDJJ’s website includes a PREA section which includes investigative responsibilities for
conducting investigations of allegations of sexual abuse in facilities.
Standard 115.331- Employees 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:
G4S Policy Chapter 5, the training curriculum, staff training records and staff interviews
indicates staff receive PREA training during initial training and annually during refresher
training. The training curriculum provided was consistent with the elements of the standard
except for numbers 6 and 11. During the corrective action period, documentation was
provided of staff training which included the common reactions of sexual abuse and
harassment of juvenile victims and relevant laws regarding the applicable age of consent.
All employees and contractors are trained as new hires regardless of their previous
experience. Employees training records were reviewed and staff interviews verified staff
comprehension of their responsibilities relating to PREA standards.
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:
G4S Policy 3-48 states that prospective volunteers and interns are directed by Human
PREA AUDIT: AUDITOR’S FINAL REPORT 8
Resources to JFJ Ministries to coordinate the application process and orientation training.
A review of volunteer records revealed completed criminal background screenings and
training records indicating topics covered during orientation. Training documents are signed
by the volunteer/intern and the trainer. An interview with a volunteer revealed he is
knowledgeable concerning his responsibilities relative to PREA and the agency’s zero
tolerance policy regarding sexual abuse and harassment.
Contractors who have contact with residents are required to have the same training as
employees.
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:
CJRF PREA FOP 10-25 requires that during intake residents are provided with information
on the facility’s zero tolerance policy regarding sexual misconduct and how to report sexual
abuse and sexual harassment. The 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.
Documentation of resident’s signatures were reviewed and confirmed during resident
interviews. All residents interviewed stated they received this information the same day
they arrived at the facility and periodically thereafter.
There was no documentation of education in formats accessible to all residents including
those who are limited English proficient, deaf, visually impaired or otherwise disabled, as
well as to residents who have limited reading skills. During the corrective action period,
Policy 9-2 Classification and Orientation, was revised to include how PREA education for
residents with disabilities will be provided in a format they can understand.
Resident interviews revealed they have limited to no knowledge of the victims’ advocacy
service; however, during the corrective action period documentation of residents’ education
of the Crisis Center of Tampa Bay was provided.
Standard 115.334- Specialized Training: Investigation
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the
standard for the relevant review period)
x Does Not Apply
Auditor comments:
Local law enforcement and the Florida Department of Children and Families conduct
PREA AUDIT: AUDITOR’S FINAL REPORT 9
criminal investigations into allegations of sexual abuse. CJRF does not conduct any
investigations.
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:
Certificates of Completion documented that nurses successfully completed the National
Institute of Corrections on-line course titled, PREA: Medical Health Care for Sexual Assault
Victims in a Confinement Setting. The facility’s PREA FOP 10-25 references G4S Policy
Chapter 5 and FDJJ Policy 1919 which requires specialized training for medical and mental
health staff.
Staff interviews verified that medical staff does not conduct forensic examinations.
Standard 115.341- Obtaining information from 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:
CJRF PREA FOP requires staff to complete the FDJJ’s Vulnerability to Victimization and
Sexually Aggressive Behavior (VSAB) form. Documentation and resident interviews
revealed that risk screenings are being conducted. Completed VSAB forms are maintained in
residents’ treatment files. 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.
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:
CJRF 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. The
instrument is scored prior to housing placement. Residents who score vulnerable to
victimization or sexually aggressive are included in the alert system, and referred for further
PREA AUDIT: AUDITOR’S FINAL REPORT 10
assessments. Residents who are identified or disclose prior sexual victims are referred to the
medical and mental health professionals within 14 days. An interviews with the PREA
Compliance Manager confirmed that information from the VSAB is shared on a “need to
know” basis.
CJRF Policy 8-14 precludes lesbian, gay, bi-sexual, transgender and intersex residents from
being placed in a particular housing area and states that LGBTI identification or status is not
an indicator of likelihood of being sexually abusive. Transgender or intersex resident’s own
view with respect to his/her safety will be given serious consideration. Staff interviews also
verified compliance with this standard.
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:
CJRF 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 residents are to be provided with the Abuse hotline number
which is provided at intake, included in the resident handbook and posted throughout the
facility.
CJRF 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, calling the Florida Abuse Hotline, the Florida Council against Sexual
Violence Rape Crisis Hotline, or the Crisis Center of Tampa Bay Florida Referral Line. The
abuse hotline number is included in the resident handbook.
Interviews with staff verified that they would accept and document reports made verbally, in
writing, anonymously, and from third parties.
The facility does not provide at least one way for residents to report abuse or harassment to a
public or private entity or office that is not part of the agency and that is able to receive and
immediately forward resident reports of abuse and harassment to agency officials allowing
the resident to remain anonymous upon request. Residents must ask to use the phone which
will not allow them to remain anonymous and may not provide them with unimpeded access.
During the corrective action period, FOP 8-3 was revised to require staff to allow residents to
use a telephone to call the hotline upon request, without having to obtain staff permission and
that mandates staff not to question residents about the reason for the call, staff are to dial the
hotline number and hand the phone to the youth and remain at a distance that allows the
youth to privately report. Documentation was provided of staff training and resident
education on the implementation of these procedures and documentation of staff and resident
training on the implementation of the procedures was provided.
Standard 115. 352- Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S FINAL REPORT 11
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:
CJRF Policy 8-4 states there is 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 grievances were filed. Interviews with residents
validated their knowledge of how to file a grievance for sexual abuse or harassment.
Standard 115. 353- Resident Access to Outside Support Services and Legal Representation
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:
CJRF PREA FOP 10-25 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.
An unsigned agreement with Crisis Center of Tampa Bay was provided however there is no
documentation of attempts to obtain the services required in this standard. During the
corrective action period, a signed MOU with Crisis Center of Tampa Bay was provided along
with documentation of residents’ education sessions regarding the victims’ advocate services
and how to access the services.
Attorneys and other legal representatives are provided with reasonable and private access
upon request. Residents may call their parents/legal guardians and receive visits from them
on the weekends.
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:
FDJJ’s website provides the public with information regarding third-party reporting of
sexual abuse or sexual harassment on behalf of a resident. Resident interviews revealed their
awareness of reporting sexual abuse or sexual harassment to others outside of the facility
PREA AUDIT: AUDITOR’S FINAL REPORT 12
including their parents/legal guardians.
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:
All CJRF staff are mandated reporters and are required by PREA FOP 10-25 to immediately
report any knowledge, suspicion or information they receive regarding sexual abuse and
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 or retaliation. Random
staff interviews also helped to verify the facility’s compliance with this standard.
An interview with the nurse confirmed her responsibility to inform residents 18 years old of
her duty to report and limitations of confidentiality.
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:
CJRF PREA FOP10-25 requires staff to take immediate action to protect a resident when he
is identified as being subject to substantial risk of imminent sexual abuse. There were no
residents identified as being at risk for sexual abuse in the past 12 months, as revealed in
interviews with the Facility Administrator and random staff.
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:
FDJJ Policy requires the Facility Administrator to notify the head of another facility within 72
hours upon receiving an allegation that a resident was sexually abused while confined at
another facility however this requirement is not addressed in CJRF PREA FOP 10-25 or in
the Abuse Neglect Policy 8-3. During the corrective action period, the PREA FOP was
revised to be in compliance with this standard.
PREA AUDIT: AUDITOR’S FINAL REPORT 13
During the past 12 months, there were no allegations received that a resident was sexually
abused while confined to another facility however while conducting resident interviews, a
youth disclosed to me that he was forced to perform a sexual act while confined in a detention
center. The resident also told me that he had shared this information with his therapist. I
immediately reported the resident’s allegation to the Facility Administrator. Upon consulting
with the therapist, it was discovered that the resident never reported the allegation to her. The
Facility Administrator provided documentation that he immediately reported the allegation to
the facility head at the other facility.
There were no allegations of sexual abuse received by CJRF from other facilities.
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:
CJRF PREA FOP 10-25 requires staff to take specific steps to respond to a report of sexual
abuse including; separating the alleged victim from the abuser; preserving any crime scene
within a period of time that still allows for the collection of physical evidence; request the
alleged victim not take any action that could destroy physical evidence; and ensure that the
alleged abuser does not take any action to destroy physical evidence, if the abuse took place
within a time period that still allows for the collection of physical evidence.
There were no allegations of sexual abuse during the past 12 months. Random staff
interviews revealed considerable knowledge of actions to be taken upon learning that a
resident was sexually abused.
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:
CJRF PREA FOP 10-25 describes specific actions to be taken by staff in response to an
incident of sexual abuse however a written plan to coordinate actions among staff first
responders, medical, and facility leadership was not available. During the corrective action
period, the facility’s coordinated staff response plan was provided.
Interviews with the Facility Administrator and other staff revealed that they are
knowledgeable of their duties in response to an allegation of sexual abuse.
Standard 115. 366- Preservation of Ability to Protect Residents from Contact with Abusers
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S FINAL REPORT 14
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 Non-Applicable Standard
Auditor Comments:
G4S is not a collective bargaining agency therefore this standard is not applicable.
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:
CJRF PREA FOP 10-25 requires the protection of residents and staff who have reported
sexual abuse or harassment or who have cooperated in a sexual abuse or sexual harassment
investigation. The monitoring will take place for a period of 90 days or longer, as needed.
The Facility Administrator is responsibility for monitoring retaliation. There were no
incidents of retaliation in the past 12 months.
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:
CJRF would only restrict a resident to his single room as a last measure to keep a resident
who alleged sexual abuse safe and then only until an alternative means for keeping the
resident safe can be arranged.
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:
CJRF PREA FOP10-25 states that FDJJ does not conduct criminal investigations of
PREA AUDIT: AUDITOR’S FINAL REPORT 15
residents’ allegations of sexual abuse. Local law enforcement and the Florida Department of
Children and Families handle criminal investigations. FDJJ’s Office of Inspector General
(OIG) reviews allegations to identify any misconduct by staff related to FDJJ regulatory
guidance.
There were no investigations of alleged resident sexual abuse at CJRF during past 12
months.
Standard 115. 372- Evidentiary Standards 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:
CJRF does not conduct administrative investigations. All allegations of abuse are reported to
CCC.
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:
CJRF PREA FOP 10-25 states that at the conclusion of any law enforcement investigation
where a sexual abuse incident has been reported, the victim or victim’s parents or legal
guardians should be notified that the investigation is concluded, either by the investigating
law enforcement agency or through a victim service agency officer or representative. At the
conclusion of the OIG administrative investigation, the victim’s parents or legal guardians
will be notified by receipt of a final administrative investigative report”.
During the corrective action period, the PREA FOP was revised to require the
documentation of notifications to victims.
Standard 115. 376- Disciplinary 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:
PREA AUDIT: AUDITOR’S FINAL REPORT 16
CJRF PREA FOP 10-25 mandates staff disciplinary sanctions up to and including termination
for violating agency’s sexual abuse or sexual harassment policies. The policy also mandates
the violation be reported to local law enforcement. No employees have been terminated in the
past 12 months for violation of the facility’s sexual abuse or harassment 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:
CJRF PREA FOP 10-25 requires that 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. Documentation of the specific language that they be
reported to relevant licensing bodies or that they be prohibited from contact with youth was
not included. The corrective action plan requires that the policy be revised to include this
requirement.
There were no reports of any allegations of sexual abuse or harassment by contractors or
volunteers in the past 12 months, therefore no reports to law enforcement or licensing bodies
and no remedial measures were taken.
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:
As a treatment facility, CJRF Policy 8-1 and the resident handbook outline how the facility’s
behavior motivation program is designed to foster compliance with program rules and teach
youth alternative pro-social methods dealing with problems utilizing rewards and a
progressive discipline.
Standard 115. 381- Medical and Mental screening; 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:
CJRF PREA FOP requires residents who disclose a history of sexual abuse or who disclose
PREA AUDIT: AUDITOR’S FINAL REPORT 17
previously perpetrating sexual abuse to be referred for medical and mental health screening
services within 24 hours of the screening. Staff interviews verified compliance with this
standard and documentation demonstrating the immediate notification of the medical and
mental health staff was provided.
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:
CJRF PREA FOP 10-25 requires timely and unimpeded access to emergency medical
treatment, crisis intervention services and victim advocacy services. The resident victim
would be transported to a local hospital for a forensic examination at no cost to the victim.
Medical staff are required to document the response and timeliness of emergency medical
treatment and follow-up.
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:
CJRF PREA FOP requires that a medical and mental health evaluation and treatment, as
determined by medical/mental health staff, be offered to resident victims of sexual abuse.
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:
CJRF PREA FOP 10-25, mandates that the facility shall create a Review Team with specific
staff consistent with those outlined in section (c) of the standard. 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. The
PREA AUDIT: AUDITOR’S FINAL REPORT 18
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.
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:
FDJJ has developed a standardized instrument with definitions to collect accurate, uniform
data for every allegation of sexual assault. The instrument includes the data necessary to
answer all questions from the most recent version of the Survey of Sexual violence
conducted by the Department of Justice. CJRF PREA FOP requires CCC to collect all data
relating to PREA. A review of the annual report revealed it was completed according to this
standard.
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:
FDJJ’s annual report for fiscal year 2013-2014 indicates 32 PREA related allegations
reported by detention centers and residential facilities throughout the agency. The FDJJ
PREA Coordinator reviews data to improve the effectiveness of its prevention, protection and
response policies, practices and training. The annual report is made available to the public on
FDJJ’s website.
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)
Does Not Meet Standard (requires corrective action)
Auditor comments:
CJRF PREA FOP 10-25 directs that the facility shall ensure records are maintained and the
Facility Administrator ensures requests for additional information from the FDJJ PREA
Coordinator are responded to in a timely manner. The G4S Agency Head Designee interview
verified that G4S maintains an incident report tracking system and G4S facilities provide
data to FDJJ though CCC and FDJJ publishes the annual report on its website. FDJJ Policy
1919 established that aggregated sexual abuse data be reviewed annually and placed on the
PREA AUDIT: AUDITOR’S FINAL REPORT 19
facility’s website after all personal identifiers are removed. All data collected is maintained
for at least 10 years after the date of the initial collection.
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.
Auditor’s Signature Date: December 23, 2014
PREA AUDIT: AUDITOR’S FINAL REPORT 20

source: DJJ

report_type: PREA

program_name_raw: columbus juvenile residential facility