state: FL

facility_name: frances walker halfway house

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Frances Walker Halfway House
Physical Address: 5332 Riveredge Drive, Titusville, FL 32780
Date report submitted: September 9, 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: August 8 & 11, 2014
Facility Information
Facility Mailing Address: Same as Physical Address
Telephone Number: 321-264-4033
The Facility is: Military County Federal
Private for profit Municipal State
X Private not for profit
Facility Type: Detention Correction X Other: Residential
Name of PREA Compliance Manager: Wendy Whittington Title: Director
Email Address: Wendy.Whittington@aspireHP.org Telephone Number:
321-264-4033
Agency Information
Name of Agency: Aspire Health Partners
Governing Authority or Parent Agency: NA
Physical Address: 5151 Adanson Street, Orlando, FL 32804
Mailing Address: Same as Above
Telephone Number: 407-245-0045
Agency Chief Executive Officer:
Name: Dick Jacobs Title: CEO
Telephone 407-245-0045
Email Address: Dick.Jacobs@aspireHP.org
Number:
Agency Wide PREA Coordinator
Name: Joseph Nixon Title: Administrator DJJ
Email Address: Joseph.Nixon@aspireHP.org Telephone Number: 3 2 1 - 6 3 7 - 1 8 6 6
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AUDIT FINDINGS
NARRATIVE:
The Frances Walker Halfway House (FWHH) is located in Titusville, Florida and is operated by
Aspire Health Partners through a contract with the Florida Department of Juvenile Justice (DJJ). It is
a moderate risk residential treatment facility that serves female juvenile offenders between the ages of
13 and 18. The facility capacity is 30. Forty-two residents have been admitted to the facility in the
past 12 months. The length of stay is six to nine months. The Frances Walker Halfway House
provides comprehensive gender-specific programming focusing on substance abuse treatment which
addresses and supports the developmental processes of the residents, using a cognitive behavior
therapeutic approach.
Forty-three staff members have been employed at the facility during the past year. Medical services
are provided on-site by a full-time Registered Nurse and a full-time Licensed Practical Nurse. An
Advanced Registered Nurse Practitioner visits the facility weekly. The contract physician is on-site at
least weekly and a contract physician is on call to the facility. The mental health unit consists of on-
site staff and includes the Clinical Manager; three Senior Counselors; Care Coordinator; and
Transitional Care Coordinator. The mental health counseling areas include but are not limited to:
substance abuse; anger and aggression; trauma/abuse; developing healthy peer relationships; self-
esteem; mood management; criminal thinking/high risk behavior; and restoring the family system.
The contract psychiatrist is on-site at least weekly and is available by phone. Education and related
services are provided to the facility by two teachers, school counselor and the Education Director
through the Brevard County School District. The education courses focus on English, Math, Science,
Social Studies and one elective course. The elective course is generally used to provide additional
reading assistance, if needed or for vocational training.
In addition to addressing their substance abuse, mental health, medical, and education needs, the
FWHH program addresses the transitional needs of each resident. Volunteers from the community
provide a variety of learning experiences and activities for the residents that include Girl Scouting,
learning to be a victim’s advocate; spiritual services; guest speakers; specialized style and make-up
services; and others.
DESCRIPTION OF FACILITY CHARACTERISTICS:
There are six buildings that encompass the program. The main building consists of administration and
a housing unit. In the administration area, which is the front of the building, there is a foyer where
visitors enter; Secretary’s office; Director’s office; and conference room. Adjacent to this part of the
building is one of the dormitory areas which consists of offices; 11 rooms; bathroom; closet; and at the
end of the building is a day room/common area. Across from the main building are the
recreation/multi-purpose building and the school building. In close proximity is the clinical mod which
contains the medical clinic; medication cart room; treatment staff offices; and two bathrooms.
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There is an open dormitory building, the LIFE House (Living Independently for Empowerment), that
has a bathroom and a laundry room. The LIFE House is where the resident will learn independent
living skills in addition to having several rewards that come with the placement. Residents must be on
a certain phase, complete an application, and interview for placement prior to being transferred to the
LIFE House.
Another building contains the kitchen; dining room; maintenance office; pantry; and attached to it is an
area that contains clothing, accessories and other items used for designated and special activities. The
meals for the residents are prepared and delivered by another Aspire Health Partners residential
facility. Residents are provided a reasonable amount of privacy during showers within their housing
units. The grounds of the facility provide space for various outside large muscle and other activities.
SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in buildings 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 locations. Telephone conversations were held with the Director who also
serves as the Compliance Manager to review the PREA audit processes. 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 information, notes were
sent to the Director to seek clarity of information and to note the additional documents needed. In
response to the issues noted, additional information was provided and discussed during the site visit
and corrective actions were taken to provide clarity and address the issues.
The on-site audit was conducted over a two-day period, beginning Friday, August 8 and concluding
Monday, August 11, 2014. An entrance meeting was held with the Director. After the meeting a
comprehensive tour of the facility was conducted by the Director, accompanied by the DJJ
Administrator for Aspire Health Partners. During the tour, staff members were observed to be
providing direct supervision and actively engaged with the residents. Random staff, specialized staff
and residents were interviewed during the on-site audit process. The interviews of both staff and
residents revealed their knowledge of PREA and the related issues. The staff members interviewed
were aware of the related policies, the facility’s operational procedures and understood their duties
and responsibilities regarding PREA compliance. The residents interviewed demonstrated their
knowledge of what PREA means and how to report sexual assault and sexual harassment. At the
conclusion of the audit, a summary of the findings were provided in a close-out meeting with the
Director.
Number of Standards Exceeded: 0
Number of Standards Met: 39
Number of Standards Not Met: 0
Number of Standards Not Applicable: 2
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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 Florence Walker Halfway House has a comprehensive document, Operating Procedure
A29, which details how the facility will implement the zero-tolerance approach to preventing,
detecting, and responding to sexual abuse. The Operating Procedure is aligned with the
Florida Department of Juvenile Justice PREA Policy 1919 (FDJJ 1919). Operating Procedure
A29 and FDJJ 1919 contain definitions of the prohibited behaviors and sanctions for those
who participate in such behaviors. The Director of the facility has been identified as the PREA
Compliance Manager.
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:
Operating Procedure A29 requires an annual assessment of the staffing plan. A review of
documents showed a completed internal assessment of staffing completed by the DJJ
Statewide PREA Coordinator. The staffing plan is in accordance with the current contract
with DJJ. The facility and DJJ are cooperatively working together regarding staffing, through
identifying and hiring additional staff, which will be in accordance with the standard. Hold-
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over staff members are identified for the shifts and a call-in process is in place to provide for
the staffing ratios prescribed in the standard. The Operating Procedure and practice provides
for unannounced visits that are completed by the Director and the Aspire Health Partners to
conduct unannounced rounds to deter sexual abuse. A review of documentation and staff
interviews confirmed the unannounced rounds.
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:
Operating Procedure A29 prohibits staff from searching a transgender or intersex resident to
determine the resident’s genital status. Operating Procedures A29 and E06 prohibit cross-
gender strip and cross-gender pat-down searches. The viewing of residents by opposite
gender staff while they are showering, changing clothes, and performing bodily functions is
not permitted, unless there are exigent circumstances.
There have been no cross-gender pat-down, strip or body cavity searches of residents during
this audit period. All staff interviewed said that the facility policy and practice are that cross-
gender searches are prohibited. The residents interviewed confirmed that no cross-gender
searches occur. The Operating Procedure requires staff of the opposite sex to announce their
presence when entering a housing area or area where girls may be showering, changing
clothes or performing bodily functions. Interviews with residents confirm this practice.
Training was provided to staff regarding the searches of transgender and intersex residents.
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:
According to A29, the facility will not rely on resident interpreters, resident readers or any
kind of resident assistance except when a delay in obtaining interpreter services would
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jeopardize a resident’s safety or an investigation. Based on a review of the Operating
Procedure and other documentation and staff interviews, the facility provide residents with
sign language services and other interpreting services.
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:
Operating Procedure A29 and other facility policies provide for background checks on all
employees and a process that includes the elements of the standard and DJJ policies.
According to policy, a review of documentation and interviews with staff, applicants and
employees are asked about previous misconduct. Documentation showed 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)
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 is used for monitoring activities along with direct supervision of staff. The
system enables staff to observe activities in various areas on the campus. Twenty-five
cameras are strategically placed inside buildings and outside. Radios are used for staff
communications within and outside of the various buildings.
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)
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Auditor Comments:
According the Memorandum of Understanding with Sexual Assault Victim Services (SAVS),
victim advocacy services will be provided. When requested, a qualified staff member from
the agency will provide support services including accompanying the victim through the
forensic medical examination process and investigatory interviews; crisis intervention;
information and referrals; and emotional support. The provision of services to be provided
was confirmed through a representative of the advocacy agency. Further review of
documentation revealed that SAVS has a rape crisis center staffed with sexual assault nurse
examiners. The facility’s Operating Procedure and information from SAVS provide that
forensic medical examinations will be provided at no cost to the victim. There has not been a
need for a forensic medical examination during this audit period.
According to 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 the local law enforcement
agency, Brevard County Sheriff’s Office, is responsible for conducting criminal
investigations.
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:
A29 and FDJJ 1919 identify the agencies that will conduct the criminal and administrative
investigations. Both documents instruct the facility staff to cooperate with the investigations
and provide that an administrative or criminal investigation is completed for all allegations of
sexual abuse and sexual harassment. During the past 12 months, there was one allegation of
sexual abuse or sexual harassment, alleging inappropriate touching. The contacts were made
by facility staff to the investigative agencies. The notifications included the Brevard County
Sheriff’s Office, who investigated the case resulting in the case being closed. An
investigation was also conducted by the Office of the Inspector General and the allegation
was unsubstantiated. The policy regarding the referral of allegations of sexual abuse or sexual
harassment for an investigation is available to the public on the DJJ website.
Standard 115.331 Employee 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:
Operational Procedure A29 provides for the PREA training. The staff training is
comprehensive of the key areas referenced in the standard. A review of the training
documentation and interviews with staff confirm that the training is provided in accordance
with the standard.
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:
A29 states that all volunteers and contractors must be trained on their responsibilities under
the Operational Procedure and FDJJ 1919 regarding sexual misconduct prevention,
detection, and response and according to the Florida Administrative Code Rule 63-H.
According to the A29, the training is based on the services provided. Receipt of the training
is documented as confirmed through document review.
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:
Operational Procedure A29 requires that newly admitted residents and those that may
transfer to the facility receive information about the facility’s zero-tolerance policy and how
to report incidents or suspicions of sexual abuse or sexual harassment. Residents receive
comprehensive education regarding PREA and periodic refreshers through a review of the
information. A signed acknowledgement statement by the resident of having received the
training is maintained. PREA education will be provided through accessible formats for
residents who are limited English proficient, deaf, visually impaired, or otherwise disabled.
8
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. Documentation from the
Brevard County Sheriff’s Office stated that their investigators receive advanced training in sex
crimes, domestic violence, and interviews and interrogations, in addition to the law
enforcement certification.
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 A29 addresses this standard. Documentation shows that the medical and mental health
staff members have completed on-line specialized training through the National Commission
on Correctional Healthcare. 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:
Operational Procedure A29 contains a section that outlines the process of screening for risk
of victimization and abusiveness and the information to be obtained. The Screening for
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) instrument is
completed on each resident. Staff and resident interviews and a review of documentation
confirmed that the screening is being conducted.
9
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. Operational Procedure A29 prohibits placing gay, bisexual,
transgender, or intersex residents into confinement based solely on such identification or
status. Housing and program assignments require determinations on each transgender or
intersex resident on a case by case basis. 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 isolated in the last 12 months because she was at risk
of sexual 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)
Auditor Comments:
There are internal ways a resident may report allegations of sexual abuse; sexual harassment;
retaliation for reporting; and staff neglect or other violation(s) that led to abuse. A resident
may talk to any staff member; complete a grievance form and place it in the locked grievance
box; complete a “Hear My Voice” form to request to speak to a specific counselor, the
Director, Program Manager, or other administrative or treatment staff; the DJJ hotline
numbers are available and accessible; and third parties may report allegations to the facility or
use the hotline numbers. A dedicated phone is provided in the clinical mod, accessible to all
residents, to call the rape crisis center hotline number to report sexual assault.
.
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)
10
Auditor Comments:
The facility has an administrative procedure for dealing with resident grievances. Operational
Procedure A29 and the resident handbook contain information regarding the grievance
system. A locked box is posted in the main building accessible to the residents. The residents
are directed to complete a grievance form and put it in the box where an administrative staff
member checks the box daily. The resident is not required to use the informal process for any
situation regarding sexual abuse. The grievance system has a level of appeal. According to
A29, there is no time limit for a resident to submit a grievance regarding an allegation of
sexual misconduct and the resident will not be referred to the staff member who is the subject
of the complaint. There were no emergency grievances alleging substantial risk of imminent
sexual abuse filed 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:
Operational Procedure A29 states that all of the residents shall have access to outside victim
advocacy services. A Memorandum of Understanding has been obtained with the local rape
crisis center through Sexual Assault Victim Services. The information about the services is
explained to the resident during the intake process and it is accessible to the residents. A
dedicated phone is provided in the Clinical Mod for the resident to call the rape crisis center
hotline number, if needed.
The facility also has a MOU with trained staff at another Aspire Health Partners facility to
provide support services as they relate to child abuse. The services include but are not limited
to crisis intervention; therapy; and education for staff and residents on preventing child abuse,
including sexual assault. The Procedure and staff and resident interviews reveal 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)
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Auditor Comments:
The facility provides methods for third-party reporting of sexual abuse. The Parental
Reference Guide is provided to parents and legal guardians of residents regarding reporting
sexual abuse. A Handbook is provided to community board members that contain
information on reporting sexual abuse. Posters and brochures are located in areas of the
facility accessible to the public. Employees, volunteers and contractors sign an
acknowledgement form stating their awareness of the PREA policies and the form provides
hotline numbers for reporting sexual abuse. PREA information is available on the facility’s
website and there is a link to the DJJ website regarding the reporting of sexual abuse or
sexual harassment on behalf of a resident. Policy Operational Procedure A29 provides for
third party assistance to a resident in filing a grievance alleging sexual abuse.
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:
Operational Procedure A29 and the Florida Administrative Code Rule 63F-11 address this
standard. All staff members are required to report any allegation of sexual misconduct or
resident-on-resident sexual activity to the Central Communications Center (CCC). The
Procedure states that staff members are prohibited from revealing any related information to
anyone other than those who are involved in treatment, investigation and other security and
management decisions. Policy and procedures require that staff members are to immediately
report any knowledge, suspicion or information they receive regarding sexual misconduct;
retaliation against residents or staff who report any incidents; any staff neglect or violation of
responsibilities that may have contributed to an incident or retaliation.
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:
According to A29, when staff learns that a resident is subject to substantial risk of imminent
sexual abuse, immediate action must 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.
12
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 A29, 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 after receiving the
allegation. The Operational Procedure and FDJJ 1919 require notifying the appropriate
investigative agency of all allegations of sexual abuse. In the past 12 months, there have not
been any allegations of sexual abuse occurring to a resident while she was 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 Operational Procedure A29 and are
aligned with the requirements of FDJJ 1919. A29 outlines the first responder duties and
other staff responses. Staff interviews confirmed that they are knowledgeable of their duties
as a first responder.
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 coordinated response is incorporated in the facility’s PREA Operational Procedure and
is aligned with FDJJ 1919. 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.
13
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:
Operational Procedure A29 addresses this standard and identifies the PREA Compliance
Manager as the staff member responsible for monitoring for retaliation against residents and
staff members who report sexual abuse or sexual harassment. FDJJ 1919 and facility
procedure require that if the retaliation conduct is identified, the monitoring would be
conducted for no less than 90 days. There have been no incidents of retaliation reported in the
past 12 months. While no incident of retaliation occurred, a review of documentation and
interviews reveal that precautions were taken to prevent the occurrence of retaliation
regarding the allegation of sexual abuse/harassment prior to the unsubstantiated findings of
the investigation.
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:
Segregated housing or isolation is not used. However, measures are taken to separate
residents for their safety by changing their assigned room or building or providing a single
14
room placement and keeping the residents separated to the extent possible by staff.
Documentation shows that during the investigation of the allegation of sexual abuse one
resident was moved from the general housing building to the LIFE House while the other
resident was housed in a room by herself until it was determined that the resident felt safe
from possible retaliation. When this occurred there was no disruption to the program
requirements. According to Operational Procedure A29, the Director/designee may
coordinate the re-location of a resident if it is determined to improve the safety of others or
the integrity of an investigation.
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:
A29 and FDJJ 1919 provide direction for this standard. Administrative investigations are
conducted by the DJJ Office of Inspector General (OIG) and criminal investigations are
conducted by the local law enforcement agency. The Florida Department of Children and
Families are also called when there is an allegation of sexual abuse and they may conduct
investigations. The policy and procedures direct staff to cooperate with the 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:
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)
15
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 allows for the victim to be informed that the investigation has been concluded. At
the conclusion of an OIG investigation, the victim or the victim’s parents or legal guardian
will be notified. At the conclusion of the investigations of the allegation that occurred at the
facility during this audit period, the resident was notified that the allegation was
unsubstantiated.
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:
Procedure A29 provides for disciplinary sanctions for staff to be up to and including
dismissal for violation of the facility’s zero-tolerance policy against sexual abuse and sexual
harassment. It states that the presumptive disciplinary sanction for staff who engages in
sexual abuse will be termination. 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:
A29 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. FDJJ 1919 requires that the contractor or volunteer is 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)
16
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:
Operating Procedures A29 and E21 address this standard. Residents found in violation of the
facility’s zero tolerance policy regarding sexual abuse, sexual assault, sexual misconduct or
sexual harassment against another resident will receive disciplinary sanctions after a formal
disciplinary process. The sanctions or consequences are provided in the resident handbook
and do not include isolation. The staff will complete a Change Behavior Report after an
incident. There have been no criminal or administrative findings of sexual abuse in the last 12
months.
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:
Operating Procedure A29 provides that residents who disclose prior sexual victimization or
who disclose previously perpetrating sexual abuse during an intake screening will be offered
a follow-up meeting with a medical or mental health practitioner within 14 days of the intake
screening. It also requires informed consent from residents 18 years of age and older before
reporting information about prior sexual victimization that did not occur at the facility. Staff
interviewed confirmed awareness of the policy and procedure.
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:
The Operating Procedure requires that treatment services to every victim will be provided at
no cost to the victim. It also states that access to the services will be timely and unimpeded
and based on the professional judgment of the medical and mental health staff. Interviews
with staff confirmed their knowledge of the procedure.
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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:
A29 addresses ongoing medical and mental health care for sexual abuse victims and abusers.
It also provides for the appropriate tests to be provided and that the facility will attempt to
obtain a mental health evaluation within 60 days of learning of resident-on-resident abusers
and offer treatment deemed appropriate by a mental health practitioner. Interviews with staff
confirmed their knowledge of the information.
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:
Operating Procedure A29 and FDJJ 1919 states that the sexual abuse incident review team
will include the PREA Compliance Manager, other upper-level management staff,
Department staff, and allow for input from line supervisors, investigators, and medical and
mental health staff. Interviews with staff revealed that the incident review process is in
place.
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 1919 and interviews with staff confirmed that DJJ collects incident-based, uniform and
aggregated data regarding allegations of sexual abuse at facilities under its direct control
using a standardized instrument and set of definitions. Policy requires the collection of
accurate, uniform data for every allegation of sexual assault. The agency provides DOJ with
data as requested.
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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 1919 addresses this standard. The statewide PREA Coordinator will review the collected
and aggregated data to assess and improve the effectiveness of the PREA related efforts and
initiatives. The Policy also states that an annual report will be prepared. A review of
documentation confirms this practice.
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:
According 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. A review of
documentation confirmed the practice.
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.
September 9, 2014
Auditor Signature Date
19

source: DJJ

report_type: PREA

program_name_raw: frances walker halfway house