state: FL

facility_name: Crestview Youth Academy

summary: PREA - Year 1 Cycle 5

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Crestview Youth Academy
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 05/02/2026
Auditor Certification
The contents of this report are accurate to the best of my knowledge.
No conflict of interest exists with respect to my ability to conduct an audit of the
agency under review.
I have not included in the final report any personally identifiable information (PII)
about any inmate/resident/detainee or staff member, except where the names of
administrative personnel are specifically requested in the report template.
Auditor Full Name as Signed: Shirley Turner Date of Signature: 05/02/2026
AUDITOR INFORMATION
Auditor name: Turner, Shirley
Email: shirleyturner3199@comcast.net
Start Date of On- 03/18/2026
Site Audit:
End Date of On-Site 03/19/2026
Audit:
FACILITY INFORMATION
Facility name: Crestview Youth Academy
Facility physical 4449 Straightline Road , Crestview , Florida - 32539
address:
Facility mailing 4449 Straight Line Rd, Crestview, Florida - 32539
address:
Primary Contact
Name: Orvando Freeman
Email Address: orvando.freeman@youthopportunity.com
Telephone Number: 9044140550
Superintendent/Director/Administrator
Name: Orvando Freeman
Email Address: orvando.freeman@youthopportunity.com
Telephone Number: 9044140550
Facility PREA Compliance Manager
Name: Orvando Freeman
Email Address: orvando.freeman@youthopportunity.com
Telephone Number: 904-414-0550
Facility Health Service Administrator On-Site
Name: Chelsea McKinney
Email Address: Chelsea.McKinney@youthopportuity.com
Telephone Number: 850 683 3908 ext4210
Facility Characteristics
Designed facility capacity: 56
Current population of facility: 55
Average daily population for the past 12 45
months:
Has the facility been over capacity at any No
point in the past 12 months?
What is the facility’s population Men/boys
designation?
Age range of population: 13-19
Facility security levels/resident custody Moderate
levels:
Number of staff currently employed at the 60
facility who may have contact with
residents:
Number of individual contractors who have 0
contact with residents, currently
authorized to enter the facility:
Number of volunteers who have contact 64
with residents, currently authorized to
enter the facility:
AGENCY INFORMATION
Name of agency: Youth Opportunity Investments, LLC.
Governing authority
or parent agency (if
applicable):
Physical Address: 701 94th Avenue North , Suite 100, St. Petersburg , Florida - 33702
Mailing Address:
Telephone number:
Agency Chief Executive Officer Information:
Name:
Email Address:
Telephone Number:
Agency-Wide PREA Coordinator Information
Name: Joseph Nixon Email Address: joseph.nixon@youthopportunity.com
Facility AUDIT FINDINGS
Summary of Audit Findings
The OAS automatically populates the number and list of Standards exceeded, the number of
Standards met, and the number and list of Standards not met.
Auditor Note: In general, no standards should be found to be "Not Applicable" or "NA." A
compliance determination must be made for each standard. In rare instances where an auditor
determines that a standard is not applicable, the auditor should select "Meets Standard” and
include a comprehensive discussion as to why the standard is not applicable to the facility being
audited.
Number of standards exceeded:
0
Number of standards met:
43
Number of standards not met:
0
POST-AUDIT REPORTING INFORMATION
Please note: Question numbers may not appear sequentially as some questions are
omitted from the report and used solely for internal reporting purposes.
GENERAL AUDIT INFORMATION
On-site Audit Dates
1. Start date of the onsite portion of the 2026-03-18
audit:
2. End date of the onsite portion of the 2026-03-19
audit:
Outreach
10. Did you attempt to communicate Sel eYcetse . d:
with community-based organization(s)
or victim advocates who provide Un sNeole . cted:
services to this facility and/or who may
have insight into relevant conditions in
the facility?
a. Identify the community-based Emerald Coast Children's Advocacy Center -
organization(s) or victim advocates with Niceville, FL
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 56
15. Average daily population for the past 45
12 months:
16. Number of inmate/resident/detainee 2
housing units:
17. Does the facility ever hold youthful Un sYeelse .c ted:
inmates or youthful/juvenile detainees?
Un sNeole . cted:
Sel eNcotte dA:p plicable for the facility type audited
(i.e., Community Confinement Facility or
Juvenile Facility) .
Audited Facility Population Characteristics on Day One of the Onsite
Portion of the Audit
Inmates/Residents/Detainees Population Characteristics on Day One of the Onsite Portion
of the Audit
23. Enter the total number of inmates/ 51
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
25. Enter the total number of inmates/ 0
residents/detainees with a physical
disability in the facility as of the first
day of the onsite portion of the audit:
26. Enter the total number of inmates/ 14
residents/detainees with a cognitive or
functional disability (including
intellectual disability, psychiatric
disability, or speech disability) in the
facility as of the first day of the onsite
portion of the audit:
27. Enter the total number of inmates/ 0
residents/detainees who are Blind or
have low vision (visually impaired) in the
facility as of the first day of the onsite
portion of the audit:
28. Enter the total number of inmates/ 0
residents/detainees who are Deaf or
hard-of-hearing in the facility as of the
first day of the onsite portion of the
audit:
29. Enter the total number of inmates/ 0
residents/detainees who are Limited
English Proficient (LEP) in the facility as
of the first day of the onsite portion of
the audit:
30. Enter the total number of inmates/ 0
residents/detainees who identify as
lesbian, gay, or bisexual in the facility as
of the first day of the onsite portion of
the audit:
31. Enter the total number of inmates/ 0
residents/detainees who identify as
transgender or intersex in the facility as
of the first day of the onsite portion of
the audit:
32. Enter the total number of inmates/ 0
residents/detainees who reported sexual
abuse in the facility as of the first day of
the onsite portion of the audit:
33. Enter the total number of inmates/ 0
residents/detainees who disclosed prior
sexual victimization during risk
screening in the facility as of the first
day of the onsite portion of the audit:
34. Enter the total number of inmates/ 0
residents/detainees who were ever
placed in segregated housing/isolation
for risk of sexual victimization in the
facility as of the first day of the onsite
portion of the audit:
35. Provide any additional comments No text provided.
regarding the population characteristics
of inmates/residents/detainees in the
facility as of the first day of the onsite
portion of the audit (e.g., groups not
tracked, issues with identifying certain
populations):
Staff, Volunteers, and Contractors Population Characteristics on Day One of the Onsite
Portion of the Audit
36. Enter the total number of STAFF, 64
including both full- and part-time staff,
employed by the facility as of the first
day of the onsite portion of the audit:
37. Enter the total number of 0
VOLUNTEERS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
38. Enter the total number of 7
CONTRACTORS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
39. Provide any additional comments No text provided.
regarding the population characteristics
of staff, volunteers, and contractors who
were in the facility as of the first day of
the onsite portion of the audit:
INTERVIEWS
Inmate/Resident/Detainee Interviews
Random Inmate/Resident/Detainee Interviews
40. Enter the total number of RANDOM 16
INMATES/RESIDENTS/DETAINEES who
were interviewed:
41. Select which characteristics you Sel eAcgtee .d :
considered when you selected RANDOM
INMATE/RESIDENT/DETAINEE Sel eRcatceed .:
interviewees: (select all that apply)
Sel eEcthtendic: ity (e.g., Hispanic, Non-Hispanic) .
Sel eLcetnegdt:h of time in the facility .
Sel eHcotuesdi:n g assignment .
Un sGeelencdteerd . :
Un sOetlheecrt .e d:
Un sNeolencet .e d:
42. How did you ensure your sample of Reviewed the population sheet and randomly
RANDOM INMATE/RESIDENT/DETAINEE selected names from each living unit
interviewees was geographically considering age, race, ethnicity, length of
diverse? time in the facility and targeting the sub-
groups of the vulnerable categories. Observed
and spoke with residents during the
comprehensive site review to double check
for balance of the random selections. Also,
conferred with staff regarding the overall
population and the random selections to get
additional background information as deemed
necessary to get the most geographically
diverse sample.
43. Were you able to conduct the Sel eYcetse . d:
minimum number of random inmate/
resident/detainee interviews? Un sNeole . cted:
44. Provide any additional comments No text provided.
regarding selecting or interviewing
random inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews,
barriers to ensuring representation):
Targeted Inmate/Resident/Detainee Interviews
45. Enter the total number of TARGETED 5
INMATES/RESIDENTS/DETAINEES who
were interviewed:
As stated in the PREA Auditor Handbook, the breakdown of targeted interviews is intended to
guide auditors in interviewing the appropriate cross-section of inmates/residents/detainees who
are the most vulnerable to sexual abuse and sexual harassment. When completing questions
regarding targeted inmate/resident/detainee interviews below, remember that an interview with
one inmate/resident/detainee may satisfy multiple targeted interview requirements. These
questions are asking about the number of interviews conducted using the targeted inmate/
resident/detainee protocols. For example, if an auditor interviews an inmate who has a physical
disability, is being held in segregated housing due to risk of sexual victimization, and disclosed
prior sexual victimization, that interview would be included in the totals for each of those
questions. Therefore, in most cases, the sum of all the following responses to the targeted
inmate/resident/detainee interview categories will exceed the total number of targeted inmates/
residents/detainees who were interviewed. If a particular targeted population is not applicable in
the audited facility, enter "0".
47. Enter the total number of interviews 0
conducted with inmates/residents/
detainees with a physical disability using
the "Disabled and Limited English
Proficient Inmates" protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Conferred with staff, reviewed resident files,
to determine if this population exists in and observed population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
48. Enter the total number of interviews 5
conducted with inmates/residents/
detainees with a cognitive or functional
disability (including intellectual
disability, psychiatric disability, or
speech disability) using the "Disabled
and Limited English Proficient Inmates"
protocol:
49. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Blind or have low
vision (i.e., visually impaired) using the
"Disabled and Limited English Proficient
Inmates" protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Conferred with staff, reviewed resident files,
to determine if this population exists in and observed population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
50. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Deaf or hard-of-
hearing using the "Disabled and Limited
English Proficient Inmates" protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Conferred with staff, reviewed resident files,
to determine if this population exists in and observed population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
51. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Limited English
Proficient (LEP) using the "Disabled and
Limited English Proficient Inmates"
protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Conferred with staff and reviewed resident
to determine if this population exists in files.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
52. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as lesbian, gay,
or bisexual using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Conferred with staff and reviewed resident
to determine if this population exists in files.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
53. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as transgender
or intersex using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Conferred with staff and reviewed resident
to determine if this population exists in files.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
54. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who reported sexual abuse in
this facility using the "Inmates who
Reported a Sexual Abuse" protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Conferred with staff and reviewed resident
to determine if this population exists in files.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
55. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who disclosed prior sexual
victimization during risk screening using
the "Inmates who Disclosed Sexual
Victimization during Risk Screening"
protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Conferred with staff and reviewed resident
to determine if this population exists in files.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
56. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are or were ever placed
in segregated housing/isolation for risk
of sexual victimization using the
"Inmates Placed in Segregated Housing
(for Risk of Sexual Victimization/Who
Allege to have Suffered Sexual Abuse)"
protocol:
a. Select why you were unable to Sel eFactceildit:y said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees. .
Un sTehlee cintemda: tes/residents/detainees in this
targeted category declined to be interviewed. .
b. Discuss your corroboration strategies Isolation is not used in this facility.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
57. Provide any additional comments No text provided.
regarding selecting or interviewing
targeted inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews):
Staff, Volunteer, and Contractor Interviews
Random Staff Interviews
58. Enter the total number of RANDOM 12
STAFF who were interviewed:
59. Select which characteristics you Sel eLcetnegdt:h of tenure in the facility .
considered when you selected RANDOM
STAFF interviewees: (select all that Sel eSchtieftd a: ssignment .
apply)
Sel eWcoterkd :a ssignment .
Sel eRcatnekd :( or equivalent) .
Un sOetlheecrt e(de:. g., gender, race, ethnicity,
languages spoken) .
Un sNeolencet .e d:
60. Were you able to conduct the Sel eYcetse . d:
minimum number of RANDOM STAFF
interviews? Un sNeole . cted:
61. Provide any additional comments No text provided.
regarding selecting or interviewing
random staff (e.g., any populations you
oversampled, barriers to completing
interviews, barriers to ensuring
representation):
Specialized Staff, Volunteers, and Contractor Interviews
Staff in some facilities may be responsible for more than one of the specialized staff duties.
Therefore, more than one interview protocol may apply to an interview with a single staff
member and that information would satisfy multiple specialized staff interview requirements.
62. Enter the total number of staff in a 9
SPECIALIZED STAFF role who were
interviewed (excluding volunteers and
contractors):
63. Were you able to interview the Sel eYcetse . d:
Agency Head?
Un sNeole . cted:
64. Were you able to interview the Sel eYcetse . d:
Warden/Facility Director/Superintendent
or their designee? Un sNeole . cted:
65. Were you able to interview the PREA Sel eYcetse . d:
Coordinator?
Un sNeole . cted:
66. Were you able to interview the PREA Sel eYcetse . d:
Compliance Manager?
Un sNeole . cted:
Un sNeAle (cNteAd i:f the agency is a single facility
agency or is otherwise not required to have a
PREA Compliance Manager per the Standards) .
67. Select which SPECIALIZED STAFF Sel eAcgteendc: y contract administrator .
roles were interviewed as part of this
audit from the list below: (select all that Sel eInctteerdm: ediate or higher-level facility staff
apply) responsible for conducting and documenting
unannounced rounds to identify and deter
staff sexual abuse and sexual harassment .
Un sLeinleec stetadff: who supervise youthful inmates
(if applicable) .
Un sEedlueccatetido:n and program staff who work with
youthful inmates (if applicable) .
Sel eMcetdedic:a l staff .
Sel eMcetnedta: l health staff .
Un sNeolenc-mteedd: ical staff involved in cross-gender
strip or visual searches .
Sel eAcdtmedin: istrative (human resources) staff .
Un sSeelxeucatel dA:s sault Forensic Examiner (SAFE) or
Sexual Assault Nurse Examiner (SANE) staff .
Sel eIncvteedst:i gative staff responsible for
conducting administrative investigations .
Un sInevleecstteigda: tive staff responsible for
conducting criminal investigations .
Sel eSctateffd w: ho perform screening for risk of
victimization and abusiveness .
Un sSetaleffc twehdo: supervise inmates in segregated
housing/residents in isolation .
Sel eSctateffd o: n the sexual abuse incident review
team .
Sel eDcetseidg:n ated staff member charged with
monitoring retaliation .
Un sFeirlsetc rteesdp: onders, both security and non-
security staff .
Sel eIncttaekde: staff .
Un sOetlheecrt .e d:
68. Did you interview VOLUNTEERS who Un sYeelse .c ted:
may have contact with inmates/
residents/detainees in this facility? Sel eNcot .e d:
69. Did you interview CONTRACTORS Sel eYcetse . d:
who may have contact with inmates/
residents/detainees in this facility? Un sNeole . cted:
a. Enter the total number of 2
CONTRACTORS who were interviewed:
b. Select which specialized CONTRACTOR Un sSeelceucrtietdy/:d etention .
role(s) were interviewed as part of this
audit from the list below: (select all that Sel eEcdtuecda:t ion/programming .
apply)
Un sMeeledcicteadl/:d ental .
Un sFeoloedc tseedr:v ice .
Un sMealeinctteenda: nce/construction .
Un sOetlheecrt .e d:
70. Provide any additional comments No text provided.
regarding selecting or interviewing
specialized staff.
SITE REVIEW AND DOCUMENTATION SAMPLING
Site Review
PREA Standard 115.401 (h) states, "The auditor shall have access to, and shall observe, all areas
of the audited facilities." In order to meet the requirements in this Standard, the site review
portion of the onsite audit must include a thorough examination of the entire facility. The site
review is not a casual tour of the facility. It is an active, inquiring process that includes talking
with staff and inmates to determine whether, and the extent to which, the audited facility's
practices demonstrate compliance with the Standards. Note: As you are conducting the site
review, you must document your tests of critical functions, important information gathered
through observations, and any issues identified with facility practices. The information you
collect through the site review is a crucial part of the evidence you will analyze as part of your
compliance determinations and will be needed to complete your audit report, including the Post-
Audit Reporting Information.
71. Did you have access to all areas of Sel eYcetse . d:
the facility?
Un sNeole . cted:
Was the site review an active, inquiring process that included the following:
72. Observations of all facility practices Sel eYcetse . d:
in accordance with the site review
component of the audit instrument (e.g., Un sNeole . cted:
signage, supervision practices, cross-
gender viewing and searches)?
73. Tests of all critical functions in the Sel eYcetse . d:
facility in accordance with the site
review component of the audit Un sNeole . cted:
instrument (e.g., risk screening process,
access to outside emotional support
services, interpretation services)?
74. Informal conversations with inmates/ Sel eYcetse . d:
residents/detainees during the site
review (encouraged, not required)? Un sNeole . cted:
75. Informal conversations with staff Sel eYcetse . d:
during the site review (encouraged, not
required)? Un sNeole . cted:
76. Provide any additional comments No text provided.
regarding the site review (e.g., access to
areas in the facility, observations, tests
of critical functions, or informal
conversations).
Documentation Sampling
Where there is a collection of records to review-such as staff, contractor, and volunteer training
records; background check records; supervisory rounds logs; risk screening and intake
processing records; inmate education records; medical files; and investigative files-auditors must
self-select for review a representative sample of each type of record.
77. In addition to the proof Sel eYcetse . d:
documentation selected by the agency
or facility and provided to you, did you Un sNeole . cted:
also conduct an auditor-selected
sampling of documentation?
78. Provide any additional comments No text provided.
regarding selecting additional
documentation (e.g., any documentation
you oversampled, barriers to selecting
additional documentation, etc.).
SEXUAL ABUSE AND SEXUAL HARASSMENT ALLEGATIONS AND
INVESTIGATIONS IN THIS FACILITY
Sexual Abuse and Sexual Harassment Allegations and Investigations
Overview
Remember the number of allegations should be based on a review of all sources of allegations
(e.g., hotline, third-party, grievances) and should not be based solely on the number of
investigations conducted. Note: For question brevity, we use the term “inmate” in the following
questions. Auditors should provide information on inmate, resident, or detainee sexual abuse
allegations and investigations, as applicable to the facility type being audited.
79. Total number of SEXUAL ABUSE allegations and investigations overview during
the 12 months preceding the audit, by incident type:
Row name # of allegations
# of
# of that had both
sexual # of criminal
administrative criminal and
abuse investigations
investigations administrative
allegations
investigations
Inmate- 0 0 0 0
on-
inmate
sexual
abuse
Staff- 0 0 0 0
on-
inmate
sexual
abuse
Total 0 0 0 0
80. Total number of SEXUAL HARASSMENT allegations and investigations overview
during the 12 months preceding the audit, by incident type:
Row name # of allegations
# of sexual # of that had both
# of criminal
harassment administrative criminal and
investigations
allegations investigations administrative
investigations
Inmate-on- 0 0 0 0
inmate
sexual
harassment
Staff-on- 0 0 0 0
inmate
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Outcomes
Sexual Abuse Investigation Outcomes
Note: these counts should reflect where the investigation is currently (i.e., if a criminal
investigation was referred for prosecution and resulted in a conviction, that investigation
outcome should only appear in the count for “convicted.”) Do not double count. Additionally, for
question brevity, we use the term “inmate” in the following questions. Auditors should provide
information on inmate, resident, and detainee sexual abuse investigation files, as applicable to
the facility type being audited.
81. Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding
the audit:
Row name Referred Indicted/
Convicted/
Ongoing for Court Case Acquitted
Adjudicated
Prosecution Filed
Inmate-on- 0 0 0 0 0
inmate sexual
abuse
Staff-on- 0 0 0 0 0
inmate sexual
abuse
Total 0 0 0 0 0
82. Administrative SEXUAL ABUSE investigation outcomes during the 12 months
preceding the audit:
Row name Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 0 0
sexual abuse
Staff-on-inmate 0 0 0 0
sexual abuse
Total 0 0 0 0
Sexual Harassment Investigation Outcomes
Note: these counts should reflect where the investigation is currently. Do not double count.
Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors
should provide information on inmate, resident, and detainee sexual harassment investigation
files, as applicable to the facility type being audited.
83. Criminal SEXUAL HARASSMENT investigation outcomes during the 12 months
preceding the audit:
Row name Indicted/
Referred
Court Convicted/
Ongoing for Acquitted
Case Adjudicated
Prosecution
Filed
Inmate-on- 0 0 0 0 0
inmate sexual
harassment
Staff-on- 0 0 0 0 0
inmate sexual
harassment
Total 0 0 0 0 0
84. Administrative SEXUAL HARASSMENT investigation outcomes during the 12
months preceding the audit:
Row name Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 0 0
sexual
harassment
Staff-on-inmate 0 0 0 0
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Files Selected for
Review
Sexual Abuse Investigation Files Selected for Review
85. Enter the total number of SEXUAL 0
ABUSE investigation files reviewed/
sampled:
a. Explain why you were unable to There was no evidence of allegations of
review any sexual abuse investigation sexual abuse during this audit period.
files:
86. Did your selection of SEXUAL ABUSE Un sYeelse .c ted:
investigation files include a cross-
section of criminal and/or administrative Sel eNcot .e d:
investigations by findings/outcomes?
Un sNeAle (cNteAd i:f you were unable to review any
sexual abuse investigation files) .
Inmate-on-inmate sexual abuse investigation files
87. Enter the total number of INMATE- 0
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
88. Did your sample of INMATE-ON- Un sYeelse .c ted:
INMATE SEXUAL ABUSE investigation
files include criminal investigations? Sel eNcot .e d:
Un sNeAle (cNteAd i:f you were unable to review any
inmate-on-inmate sexual abuse investigation
files) .
89. Did your sample of INMATE-ON- Un sYeelse .c ted:
INMATE SEXUAL ABUSE investigation
files include administrative Sel eNcot .e d:
investigations?
Un sNeAle (cNteAd i:f you were unable to review any
inmate-on-inmate sexual abuse investigation
files) .
Staff-on-inmate sexual abuse investigation files
90. Enter the total number of STAFF-ON- 0
INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
91. Did your sample of STAFF-ON-INMATE Un sYeelse .c ted:
SEXUAL ABUSE investigation files
include criminal investigations? Sel eNcot .e d:
Un sNeAle (cNteAd i:f you were unable to review any
staff-on-inmate sexual abuse investigation
files) .
92. Did your sample of STAFF-ON-INMATE Un sYeelse .c ted:
SEXUAL ABUSE investigation files
include administrative investigations? Sel eNcot .e d:
Un sNeAle (cNteAd i:f you were unable to review any
staff-on-inmate sexual abuse investigation
files) .
Sexual Harassment Investigation Files Selected for Review
93. Enter the total number of SEXUAL 0
HARASSMENT investigation files
reviewed/sampled:
a. Explain why you were unable to There was no evidence of sexual harassment
review any sexual harassment during this audit period.
investigation files:
94. Did your selection of SEXUAL Un sYeelse .c ted:
HARASSMENT investigation files include
a cross-section of criminal and/or Sel eNcot .e d:
administrative investigations by
findings/outcomes?
Un sNeAle (cNteAd i:f you were unable to review any
sexual harassment investigation files) .
Inmate-on-inmate sexual harassment investigation files
95. Enter the total number of INMATE- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
96. Did your sample of INMATE-ON- Un sYeelse .c ted:
INMATE SEXUAL HARASSMENT files
include criminal investigations? Sel eNcot .e d:
Un sNeAle (cNteAd i:f you were unable to review any
inmate-on-inmate sexual harassment
investigation files) .
97. Did your sample of INMATE-ON- Un sYeelse .c ted:
INMATE SEXUAL HARASSMENT
investigation files include administrative Sel eNcot .e d:
investigations?
Un sNeAle (cNteAd i:f you were unable to review any
inmate-on-inmate sexual harassment
investigation files) .
Staff-on-inmate sexual harassment investigation files
98. Enter the total number of STAFF-ON- 0
INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
99. Did your sample of STAFF-ON-INMATE Un sYeelse .c ted:
SEXUAL HARASSMENT investigation files
include criminal investigations? Sel eNcot .e d:
Un sNeAle (cNteAd i:f you were unable to review any
staff-on-inmate sexual harassment
investigation files) .
100. Did your sample of STAFF-ON- Un sYeelse .c ted:
INMATE SEXUAL HARASSMENT
investigation files include administrative Sel eNcot .e d:
investigations?
Un sNeAle (cNteAd i:f you were unable to review any
staff-on-inmate sexual harassment
investigation files) .
101. Provide any additional comments No text provided.
regarding selecting and reviewing
sexual abuse and sexual harassment
investigation files.
SUPPORT STAFF INFORMATION
DOJ-certified PREA Auditors Support Staff
102. Did you receive assistance from any Un sYeelse .c ted:
DOJ-CERTIFIED PREA AUDITORS at any
point during this audit? REMEMBER: the Sel eNcot .e d:
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
Non-certified Support Staff
103. Did you receive assistance from any Sel eYcetse . d:
NON-CERTIFIED SUPPORT STAFF at any
point during this audit? REMEMBER: the Un sNeole . cted:
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
a. Enter the TOTAL NUMBER OF NON- 1
CERTIFIED SUPPORT who provided
assistance at any point during this audit:
AUDITING ARRANGEMENTS AND COMPENSATION
108. Who paid you to conduct this audit? Un sTehlee catuedd:it ed facility or its parent agency .
Un sMeyle scttaetde:/ territory or county government
employer (if you audit as part of a consortium
or circular auditing arrangement, select this
option) .
Sel eAc tthedir:d -party auditing entity (e.g.,
accreditation body, consulting firm) .
Un sOetlheectre . d:
Identify the name of the third-party Correctional Management and
auditing entity Communications Group, LLC
Standards
Auditor Overall Determination Definitions
• Exceeds Standard
(Substantially exceeds requirement of standard)
• Meets Standard
(substantial compliance; complies in all material ways with the stand for the relevant
review period)
• Does Not Meet Standard
(requires corrective actions)
Auditor Discussion Instructions
Auditor discussion, including the evidence relied upon in making the compliance or non-
compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions.
This discussion must also include corrective action recommendations where the facility does not
meet standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Zero tolerance of sexual abuse and sexual harassment; PREA
115.311
coordinator
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA Procedures
Facility Policy 5-19, Prison Rape Elimination Act (PREA)
Employee Handbook
PREA Pre-Audit Questionnaire (PAQ)
Organization Chart
Interviews:
PREA Coordinators
Superintendent/PREA Compliance Manager
Provision (a):
An agency shall have a written policy mandating zero tolerance toward all
forms of sexual abuse and sexual harassment and outlining the agency’s
approach to preventing, detecting, and responding to such conduct.
The Crestview Youth Academy is a Florida Department of Juvenile Justice (DJJ)
residential facility for juvenile offenders located in Orlando, Florida. The facility is
managed by Youth Opportunity Investments through a contract with DJJ. There is a
DJJ overarching PREA Policy, FDJJ 1919, Prison Rape Elimination Act Procedures, that
all state-run and contract facilities must adhere to and align their policies,
procedures, and practices with the DJJ PREA policy. Under the umbrella and through
the direction of policy FDJJ 1919 each state-run and contract facility must adhere to
the PREA standards and maintain PREA compliance. The Employee Handbook, p. 57,
also informs staff of prohibited behavior, including, "Employees are never to enter
into personal or sexual relationships with a resident or recently released youth."
A review of the written agency and facility policies and Employee Handbook
revealed alignment and mandated zero-tolerance toward all forms of sexual abuse
and sexual harassment in facilities, whether a state-run or a facility managed by a
private provider. Zero-tolerance of sexual abuse and sexual harassment of residents
is the focus of the PREA policies for both agencies. The preamble to FDJJ 1919
Procedures, p. 4, states, "All of the following procedures have been established in
alignment with the national standards to prevent, detect, and respond to prison
rape under the PREA Rape Elimination Act." Aligned with the FDJJ 1919 preamble,
facility policy 15.19, p. 1, provides the facility "has a zero tolerance for any acts of
sexual abuse, assault, misconduct or harassment. Sexual activity between staff,
volunteers or contracted personnel and youth, as well as between youth and youth
is prohibited and subject to both administrative and criminal disciplinary sanctions."
A review of the agency and facility policies, which are used together, individually,
and interchangeably, provide guidance to staff regarding the facility’s approach to
preventing, detecting, and responding to conduct that violates the zero-tolerance
approach regarding all forms of sexual abuse and sexual harassment. The policies,
aligned with the PAQ, outline how the facility staff and processes implement the
approach to preventing, detecting, and responding to sexual abuse and sexual
harassment. Both policies include the definitions of prohibited behaviors of sexual
abuse and sexual harassment. The policies also include sanctions for individuals
found to have participated in the prohibited behaviors. The policies include
descriptions of strategies and responses to reduce and prevent sexual abuse and
sexual harassment of residents including but not limited to staff training, resident
education, assessments and reassessments, and reporting methods and processes.
The identified policies also include responding to sexual abuse and sexual
harassment through community advocacy services and investigations. The
interviews with the facility's regional PREA Coordinator and the DJJ statewide PREA
Coordinator support the guidance of the overarching DJJ PREA policy and the
facility's supporting PREA policy.
Conclusion:
The review of documents, including the facility PAQ, and interviews, confirmed the
facility is compliant with the requirements of this provision.
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA
Coordinator with sufficient time and authority to develop, implement, and
oversee agency efforts to comply with the PREA standards in all of its
facilities.
The agency policy provides for the designation of a PREA Coordinator. The DJJ PREA
Coordinator manages the PREA implementation efforts statewide. The DJJ statewide
PREA Coordinator lends support and direction to all contract and State-run facilities
as determined from interviews, observations, review of documentation, and
continual communication between the auditor and the DJJ statewide PREA
Coordinator. DJJ Policy 1919 defines the role of the statewide PREA Coordinator in
the definitions on p. 2, "PREA Statewide Coordinator – Position responsible for
developing, implementing, and overseeing the Department’s efforts to comply with
the PREA standards in all its juvenile confinement facilities." The parent agency for
the facility has also designated the regional leadership staff as PREA Coordinator for
the programs in the State. The interviews revealed both PREA Coordinators have
knowledge of the standards, implementation of the standards, and audit processes.
Collaboration exists with the PREA Coordinators and superintendent. The interviews
and observations revealed the authority to serve as PREA Coordinators.
The PREA Coordinators have a rapport with each other and direct contact with the
superintendent regarding PREA related issues. The interview with the parent
agency's PREA Coordinator provided that he has the time and authority to develop,
implement, and oversee the efforts to comply with the PREA standards. Also,
according to the interview, the facility's efforts to comply with the PREA standards is
accomplished through teamwork among the staff, led by the superintendent. The
parent agency's PREA Coordinator reports directly to the Vice President of Florida
Programs. Informal conversations with random staff and superintendent confirmed
the PREA Coordinator provides support to the facility and support is provided by the
DJJ statewide PREA Coordinator.
The agency policy FDJJ 1919 provides for a statewide PREA Coordinator in upper
level management. The DJJ statewide PREA Coordinator is in direct contact with the
Assistant Secretary of the agency. He is responsible for managing PREA compliance
in the state-run and contract facilities statewide. He revealed that "his sole
responsibility is PREA compliance for the residential and detention facilities" and
feels he has enough time to manage those responsibilities. When asked, If he
identifies an issue with complying with a PREA standard, what actions/process
does he use to comply with the standard, he stated he has "an excellent working
relationship with all PREA Compliance Managers" and maintain open lines of
communication through email or they may call him anytime and he will always
respond. He further stated that he provides technical assistance, supporting
documentation, and training as needed to ensure all facilities are compliant. Also, as
a Certified PREA auditor, the DJJ statewide PREA Coordinator feels he has access to
many resources to assist with compliance. The DJJ statewide PREA Coordinator
collaborates with the superintendent and the facility's agency PREA Coordinator
regarding PREA related issues.
Conclusion:
The review of documents, including the facility PAQ, and interviews, confirmed the
facility is compliant with the requirements of this provision.
Provision (c):
Where an agency operates more than one facility, each facility shall
designate a PREA Compliance Manager with sufficient time and authority
to coordinate the facility’s efforts to comply with the PREA standards.
Youth Opportunity Investments, Incorporated operates more than one facility for the
Florida Department of Juvenile Justice and according to the PAQ, this facility has
designated a PREA Compliance Manager. Facility policy 5-19, p. 4, states, "The
Facility Administrator is the designated PREA Facility Compliance Manager and shall
ensure that all mandated requirements of this policy, the state, and the federal
government are met." The organization chart also identifies the facility
administrator (superintendent) as the PREA Compliance Manager, answering
directly to the regional supervisory staff member. The interview revealed sufficient
time to perform the duties in the role of PREA Compliance Manager and
observations and informal conversations with random staff revealed the authority
and staff cooperation.
Conclusion:
The review of documents, including the facility PAQ, and interviews, confirmed the
facility is compliant with the requirements of this provision.
115.312 Contracting with other entities for the confinement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA Procedures
Residential Providers Data Sheet
Provider Contract Language
PREA Audit Reports
PREA Pre-Audit Questionnaire (PAQ)
Interview:
Agency Contract Administrator
Provision (a):
A public agency that contracts for the confinement of its residents with
private agencies or other entities, including other government agencies,
shall include in any new contract or contract renewal the entity’s
obligation to adopt and comply with the PREA standards.
According to the PAQ, the agency has entered into or renewed a contract for the
confinement of residents on or after since the last PREA audit at this facility. The
public agency, Florida Department of Juvenile Justice, contracts for residential
services for juvenile offenders. Thirty-two providers maintain contracts, p. 3 contract
language, which provides for the adoption and compliance with the PREA standards.
The Residential Provider Data Sheet provides the agencies' names and
corresponding names of facilities, start date of contract, end date of contract, and
other information regarding each contractor. Agency policy FDJJ 1919, p.2, states,
"All new contracts, amended contracts, or contracts renewed after the effective
date of this policy shall include the contracting entity’s obligation to adopt and
comply with the PREA standards outlined in this policy, procedures, and any
subsequent administrative rule for any confinement services provided on behalf of
the Department."
Conclusion:
An examination of the documents, including the facility PAQ, and the interview
verify the facility's compliance with this provision.
Provision (b):
Any new contract or contract renewal shall provide for agency contract
monitoring to ensure that the contractor is complying with the PREA
standards.
According to the PAQ, all of the contracts with the 32 providers require the agency
to monitor the contractor's compliance with PREA standards. Contracts exist that
inform the providers of the requirements by the Florida Department of Juvenile
Justice (DJJ) to comply with the PREA Standards and participate in PREA audits. The
practice was also confirmed by completed PREA audit reports for this facility and
other contract facilities. According to FDJJ 1919, p.2, "Contracted providers will be
subject to PREA audits, including contract monitoring, to ensure compliance."
The interview with the agency contract administrator revealed, regarding
monitoring contracts, that monitoring is mandated for all contracts. She further
stated it is required for all contracts for private providers. She also provided that the
PREA coordinator is responsible for monitoring and provides a copy of the PREA
audits to her office. The interview confirmed the PREA compliance results have been
completed for each contract entered into an agreement in the past 12 months. The
DJJ agency contract administrator, in reference to the DJJ statewide PREA
Coordinator, provided that, "The PREA coordinator provides my office with an excel
document of each audit schedule for the three-year cycle and a copy of the
completed audit." She concluded she has a copy of each PREA audit conducted for
the last three years.
Conclusion:
An examination of the documents, including the facility PAQ, and the interview
verify the facility's compliance with this provision.
115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Staffing Plan
Annual Staffing Plan Assessment
PREA Unannounced Rounds
Interviews:
Superintendent
PREA Compliance Manager
Intermediate or Higher-Level Staff
PREA Coordinator
Agency Head Designee
Provision (a):
The agency shall ensure that each facility it operates shall develop,
implement, and document a staffing plan that provides for adequate levels
of staffing, and, where applicable, video monitoring, to protect residents
against sexual abuse. In calculating adequate staffing levels and
determining the need for video monitoring, facilities shall take into
consideration:
(1) Generally accepted juvenile detention and correctional/secure
residential practices;
(2) Any judicial findings of inadequacy;
(3) Any findings of inadequacy from Federal investigative agencies;
(4) Any findings of inadequacy from internal or external oversight bodies;
(5) All components of the facility’s physical plant (including “blind spots”
or areas where staff or residents may be isolated);
(6) The composition of the resident population;
(7) The number and placement of supervisory staff;
(8) Institution programs occurring on a particular shift;
(9) Any applicable State or local laws, regulations, or standards;
(10) The prevalence of substantiated and unsubstantiated incidents of
sexual abuse; and
(11) Any other relevant factors.
According to the PAQ, the facility ensures that it developed, implemented, and
documented a staffing plan that provides for adequate levels of staffing, and, where
applicable, video monitoring, to protect residents against sexual abuse. Since the
last PREA audit the average daily number of residents was 45 and the average daily
number of residents on which the staffing plan was predicated is 56.
The interview with the superintendent and review of contract section, revealed the
staffing ratio is listed in the contract between the provider ant the Department of
Juvenile Justice (DJJ). Additionally, he stated there is no obligation by law, regulation,
or judicial consent decree regarding the staffing ratios. The written staffing plan,
maintained by the superintendent, generally contains the elements outlined in the
standard and as applicable to this juvenile facility including any blind spots;
composition of the resident population; and programs occurring on a particular
shift. The superintendent shared that he checks for compliance with the staffing
plan through the review of staffing reports and review of unannounced rounds
reports completed by administrative staff. The PREA compliance manager/
superintendent discussed the components of the staffing plan as outlined on the
staffing plan document, including ratios; composition of population; physical plant;
and excessive absence. He described the resident population and programming on
particular shifts correlating to the number and placement of supervisory staff. The
facility is comprised of multiple co-located residential commitment programs
serving moderate risk male youth aged 13 to 21 who require behavioral/mental
health, substance abuse, and borderline intellectual functioning services.
The staffing plan addresses maintaining the staffing ratios and the staffing plan
outlines the staffing requirements. The facility’s staffing plan, internal controls, and
management ensures that the ratios of 1:8 (awake hours) and1:12 (sleeping hours)
are maintained, in accordance with the contract and assigned program services.
Direct supervision is provided to residents during the activities and program
services as observed by the auditor during the comprehensive site review and
subsequent walkthroughs. In addition to the direct care staff, facility practice
provides for other staff in a supportive role. Observations during the comprehensive
site review and subsequent walkthroughs and the interviews indicated the staffing
ratios are maintained. The camera system is located in the control room and is
constantly monitored by the control room operator assigned for each shift. Camera
monitors are also located in the superintendent's office.
The work schedules ensured the staffing ratios were met. The auditor observed the
staffing ratios met during the comprehensive site review where residents were in
classrooms and group and individual meetings. Each housing unit or dormitory has a
dayroom area and bathroom facilities are located on each dormitory. The staff line
of sight was observed to be adequate. The bathrooms provide a reasonable amount
of privacy for the residents. The facility does not use isolation.
The facility has signage which indicates where residents are not allowed; allowed
with staff supervision; or allowed to move in and out without direct supervision.
Staff presence is used for any identified blind spots. The facility has a total of 96
cameras that are located in admissions; cafeteria; kitchen; day rooms; classrooms;
laundry; outside perimeter; and recreation area. There are no cameras located in
the sleeping rooms and bathrooms and they cannot be viewed on camera as
observed from monitoring the cameras in the control room and superintendent's
office. Direct care staff were observed providing sight and sound supervision during
the onsite audit process and stated as practice during informal conversations with
random staff.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (b):
The agency shall comply with the staffing plan except during limited and
discrete exigent circumstances, and shall fully document deviations from
the plan during such circumstances.
The PAQ documents no deviations from the staffing ratios in the past 12 months.
According to the superintendent's interview, there were no instances of deviations
from the staffing plan and he knew to document the situation if it occurs. This
facility is a contract provider for residential services for the Department of Juvenile
Justice and the contract mandates the staffing ratios. A coordinated effort was
described by the superintendent for maintaining the staffing ratios through
meetings with the supervisors and assistant superintendent and annual review or
sooner if needed. The operations of the facility and staffing plan provide for
mandated holdovers when there is an unexpected absence as referenced in the
staffing plan.
Conclusion:
Based upon the review and analysis of the available evidence and the interview, the
facility is compliant with this provision.
Provision (c):
Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8
during resident waking hours and 1:16 during resident sleeping hours,
except during limited and discrete exigent circumstances, which shall be
fully documented. Only security staff shall be included in these ratios. Any
facility that, as of the date of publication of this final rule, is not already
obligated by law, regulation, or judicial consent decree to maintain the
staffing ratios set forth in this paragraph shall have until October 1, 2017,
to achieve compliance.
The facility’s staffing plan, internal controls, and management ensures that the
PREA ratios of 1:8 during the waking hours and 1:16 during the sleeping hours are
maintained. The internal staffing ratios, in accordance with the contract, are 1:8
during the waking hours and 1:12 during the sleeping hours. Direct supervision by
direct care staff was provided to residents during the daily activities and program
services observed by the auditor during the comprehensive site review and
subsequent walkthroughs. Observations and informal conversations with random
staff during the comprehensive site review and subsequent walkthroughs, and the
interviews indicated the staffing ratios are maintained. According to the PAQ and
superintendent, there were no deviations from the staffing plan in the past 12
months. According to the superintendent, the facility is not obligated by law,
regulation, or judicial consent decree to maintain staffing ratios. The ratios are
mandated in the contract.
Conclusion:
Based upon the review and analysis of the available evidence and the staff
interview and informal conversations with random staff, the facility is compliant with
this provision.
Provision (d):
Whenever necessary, but no less frequently than once each year, for each
facility the agency operates, in consultation with the PREA Compliance
Manager required by §115.311, the agency shall assess, determine, and
document whether adjustments are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this
section;
(2) Prevailing staffing patterns;
(3) The facility’s deployment of video monitoring systems and other
monitoring technologies; and
(4) The resources the facility has available to commit to ensure
adherence to the staffing plan.
According to the PAQ, at least once every year the facility, in collaboration with the
agency's PREA Coordinator, reviews the staffing plan to see whether adjustments
are needed to: (a) the staffing plan; (b) prevailing staffing patterns; (c) the
deployment of monitoring technology; or (d) the allocation of agency or facility
resources to commit to the staffing plan to ensure compliance with the staffing plan.
The staffing plan assessments were facilitated by the Florida Department of Juvenile
Justice (DJJ) statewide PREA Coordinator in conjunction with the facility's PREA
compliance manager. It was noted on the staffing plan assessment that, "The
facility's contracted ratios with FDJJ meet or exceed the required PREA ratios."
The Staffing Plan Assessments document reviews, but is not limited to, the following
areas: prevailing staffing patterns and review of staffing plan; electronic monitoring
system; and review of other areas related to adequate supervision. The Staffing Plan
Assessments cover the physical plant. It considers any adjustments that need to be
made by the construction and implementation of a corrective action plan where
indicated through findings or recommendations. The last annual staffing plan
assessment was completed on July 10, 2025 and there were no
recommendations. There were no problems noted with scheduling and the holdover
process was said to be in place and ensures adequate coverage. According to the
facility PREA compliance manager/superintendent, he was consulted regarding the
annual assessment of the staffing plan and the document shows a cooperative
assessment by the statewide PREA Coordinator and the PREA compliance manager/
superintendent.
Conclusion:
Based upon the review and analysis of the available evidence and the staff
interview, the facility is compliant with this provision.
Provision (e):
Each secure facility shall implement a policy and practice of having
intermediate-level or higher level supervisors conduct and document
unannounced rounds to identify and deter staff sexual abuse and sexual
harassment. Such policy and practice shall be implemented for night shifts
as well as day shifts. Each secure facility shall have a policy to prohibit
staff from alerting other staff members that these supervisory rounds are
occurring, unless such announcement is related to the legitimate
operational functions of the facility.
According to the PAQ: The facility requires that intermediate-level or higher-level
staff conduct unannounced rounds to identify and deter staff sexual abuse and
sexual harassment. The facility documents unannounced rounds. Over time, the
unannounced rounds cover all shifts. The facility prohibits staff from alerting other
staff of the conduct of such rounds. Facility policy 5-19, Rounds, p.6, states, "The
Facility Administrator, Assistant Facility Administrator, Clinical Director and shift
supervisors shall conduct unannounced rounds to identify and deter staff sexual
abuse and sexual harassment. The unannounced rounds should occur at least
weekly on all shifts and all areas of the facility and will be documented. Staff are
prohibited from alerting other staff of the supervisory round, unless it is related to
the legitimate operation functions of the facility. Staff alerting other staff shall
receive disciplinary sanctions."
The policy provides for the occurrence of unannounced rounds that are conducted
by management staff members and supervisors. A sample of the unannounced
rounds documents reviewed onsite demonstrate the rounds are made at various
times and cover all shifts. A dedicated form, PREA Unannounced Rounds, is used by
administrative staff and it includes the date, time, and considerations and
observations made. The form includes checking on the following but is not limited
to: residents' routine being followed; all youth accounted for; staff ratios;
appropriate staff positioning; and blind spots or areas outside of the cameras. Staff
may add additional narrative with an attached email to the form, if needed.
The interview with the intermediate or higher-level staff revealed he conducts
unannounced rounds and they are documented which were reviewed by the auditor.
Corresponding video footage along with a completed PREA Unannounced Rounds
Form were reviewed by the auditor. It was shared that staff doesn't know when he is
coming; he uses his keys and does not have to be buzzed in the building. The
unannounced rounds are conducted throughout the facility to identify and deter
sexual abuse and sexual harassment. Staff members are prohibited from alerting
other staff when the rounds are occurring in accordance with policy and the
interview.
Conclusion:
Based upon the review and analysis of the available evidence and the staff
interview, the facility is compliant with this provision.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 5-6, Contraband and Search Practices
Facility Policy 5-19, PREA
Sample of Search Forms
Training Curriculum on the Agency's Website (www.djj.state.fl.us/partners-providers-
staff/prison-rape-elimination-act-prea/implementation-tool)
Interviews:
Random Staff
Residents
Provision (a):
The facility shall not conduct cross-gender strip searches or cross-gender
visual body cavity searches (meaning a search of the anal or genital
opening) except in exigent circumstances or when performed by medical
practitioners.
According to the PAQ, the facility does not conduct cross-gender strip or cross-
gender visual body cavity searches of residents. Such searches are also prohibited
by agency policy FDJJ 1919, p. 8, "Staff shall not conduct opposite sex strip searches
or opposite sex frisk searches." Facility policy 5-06, p. 6, states, "The search is to be
conducted by a staff of the same sex as the youth. It is recommended that two staff
are present for the strip search. If this is not possible, the staff conducting the
search shall position themselves in view of the camera however, the youth shall
never be in camera view during a strip search. If the second staff person is not the
same sex as the youth being searched, the second staff shall place themselves in a
position where they can observe the staff member conducting the search but not
observe the youth being searched." There was no evidence among the sample of
search forms of cross-gender searches of any type occurring at the facility in the
last 12 months. The PAQ also shows there were no cross-gender strip or cross-
gender visual body cavity searches of residents.
The search procedures utilize two staff members when searching for contraband.
According to informal conversations with staff during the comprehensive site
review, the resident is taken to a private area by two staff of the same gender as
the resident. One staff member only observes the other staff member from a
distance as he is conducting the search. The staff member conducting the search
determines whether there is or is not any contraband. The searches are conducted
in a private area observed by the auditor during the comprehensive site review.
Sixteen residents were interviewed, all stated they and other residents were never
naked in full view of female staff.
Conclusion:
An examination of the relevant documents, PAQ, interviews. and observation,
confirmed the facility is compliant with this provision.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in
exigent circumstances.
Agency policy FDJJ 1919, p. 8, prohibits cross-gender pat-down searches which
states, "Staff shall not conduct opposite sex strip searches or opposite sex frisk
searches." Facility policy, 5-6, p. 9, states, "All searches shall conform to PREA
guidelines/policy. Staff shall not conduct cross gender (opposite gender) full body
visual searches or other searches except in exigent circumstances which are any set
of temporary and unforeseen circumstances that require immediate action in order
to combat a threat to the security or institutional orders of the facility."
The female random staff interviewed indicated they were restricted from conducting
cross-gender pat-down searches and there was always a male present to conduct
searches. The consensus was that males are always present to conduct searches as
needed. All 16 residents interviewed indicated a female had not conducted a pat-
down search of their body. All random staff interviewed confirmed awareness of the
policy regarding searches. No residents or random staff during informal
conversations during the comprehensive site review reported the occurrence of any
cross-gender pat-down searches. The evidence and PAQ shows cross-gender pat-
down searches have not occurred at the facility during the last 12 months.
Conclusion:
An examination of the relevant documents, PAQ, interviews. and observation,
confirmed the facility is compliant with the requirements of this provision.
Provision (c):
The facility shall document and justify all cross-gender strip searches,
cross-gender visual body cavity searches, and cross-gender pat-down
searches.
The agency policy FDJJ 1919 prohibits all cross-gender searches. According to
informal conversations with random staff during the comprehensive site review,
when searching for contraband the resident is taken to a private area by two staff of
the same gender as the resident. One staff member only observes the other staff
member from a distance as he is conducting the search. The resident is asked to
remove their outer garments, but not to remove their undergarments. The staff
member conducting the search determines whether there is or is not any
contraband. The pat-down or frisk searches are conducted by the same gender.
According to facility policy 5-6, p. 7, "All such searches circumstances will be
documented with the specific exigent circumstance in the log book." The interviews
with random staff and residents and the PAQ confirmed that no type of cross-gender
search was conducted during this audit period.
Conclusion:
A review of the documents, PAQ, interviews, and informal discussions with staff and
observation, confirmed that the facility is compliant with the requirements of this
provision.
Provision (d):
The facility shall implement policies and procedures that enable residents
to shower, perform bodily functions, and change clothing without
nonmedical staff of the opposite gender viewing their breasts, buttocks,
or genitalia, except in exigent circumstances or when such viewing is
incidental to routine cell checks. Such policies and procedures shall
require staff of the opposite gender to announce their presence when
entering a resident housing unit. In facilities (such as group homes) that
do not contain discrete housing units, staff of the opposite gender shall be
required to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions, or
changing clothing.
In accordance with agency policy FDJJ 1919, p. 8, "Youth must be allowed to shower,
perform bodily functions, and change clothing without nonmedical staff of the
opposite sex viewing their breasts, buttocks, or genitalia, except in exigent
circumstances or when such viewing is incidental to routine cell checks." This
practice was confirmed through interviews with residents and staff. None of the 16
residents interviewed reported ever having been naked in full view of the opposite
gender staff while showering, changing clothes, and performing bodily functions. All
12 random staff interviewed confirmed that residents are able to dress, shower, and
use the toilet without being viewed by staff of the opposite gender. The practice is
aligned with agency policy and facility policy 5-19, p.7, "The facility will ensure that
youth have access to shower, perform bodily functions, and change clothing without
non-medical staff of the opposite gender viewing their breasts, buttocks or genitalia,
except in exigent circumstances.
During the site review, the superintendent explained how hygiene practices
are conducted and the practice of residents entering the shower fully dressed and
exiting fully dressed in the clean clothing. The shower and toilet stalls do not allow
staff to get a view of the resident’s body due to stall doors and shower curtains.
Hygiene practices are performed with the expectations of reasonable privacy for
each resident. It was observed that residents have privacy during use of the
bathroom. The auditor's review of the camera monitors provided that cameras are
not placed in the resident's rooms or bathrooms and the cameras in the other part
of the living unit do not show residents when they are showering, using the toilet or
changing clothes.
Staff members of the opposite gender must announce their presence when entering
the residents’ housing units and signs are posted informing staff of the opposite
gender to announce. Whenever female staff enter an area at a time that youth
maybe showering, toileting, changing clothes, or in the privacy of their rooms, the
expectation is that female staff will announce their presence in accordance with
facility policy 5-19, p. 6. The 16 residents confirmed female staff announce
themselves upon entering their living units. The practice of opposite gender
announcements was confirmed by all residents and all 12 random staff interviews
affirmed females announcing their presence upon entering the living units. The
auditor also observed a sign posted outside of each living unit informing the reader
that all females must announce their presence. All random staff interviews
confirmed residents are able to dress, shower, and use the toilet without being
viewed by staff of the opposite gender. The evidence, including informal
conversations with random staff confirmed residents shower, perform bodily
functions, and change clothing without nonmedical staff of the opposite gender
viewing their buttocks or genitalia.
Conclusion:
A review of the documents, PAQ, interviews, and informal discussions with staff and
observations, confirmed that the facility is compliant with the requirements of this
provision.
Provision (e):
NA
Provision (f):
NA
Residents with disabilities and residents who are limited English
115.316
proficient
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19, PREA
Facility Policy 2-01, Admission and Orientation
Agency Policy FDJJ 1919, PREA
Interpreting Service Agreement Posted PREA Information
PREA Training Curriculum-Part II, Youth With Disabilities
Electronic Training Records
PREA Pre-Audit Questionnaire (PAQ)
Bilingual Posters
Resident Files
Interviews:
Agency Head Designee
Targeted Interviewees
Random Staff
Service Provider Representative
Provision (a):
The agency shall take appropriate steps to ensure that residents with
disabilities (including, for example, residents who are deaf or hard of
hearing, those who are blind or have low vision, or those who
have intellectual, psychiatric, or speech disabilities), have an equal
opportunity to participate in or benefit from all aspects of the agency’s
efforts to prevent, detect, and respond to sexual abuse and
sexual harassment. Such steps shall include, when necessary to ensure
effective communication with residents who are deaf or hard of hearing,
providing access to interpreters who can interpret effectively, accurately,
and impartially, both receptively and expressively, using any necessary
specialized vocabulary. In addition, the agency shall ensure that written
materials are provided in formats or through methods that ensure
effective communication with residents with disabilities, including
residents who have intellectual disabilities, limited reading skills, or who
are blind or have low vision. An agency is not required to take actions that
it can demonstrate would result in a fundamental alteration in the nature
of a service, program, or activity, or in undue financial and administrative
burdens, as those terms are used in regulations promulgated under title II
of the Americans With Disabilities Act, 28 CFR 35.164.
According to the PAQ, the agency has established procedures to provide disabled
residents equal opportunity to participate in or benefit from all aspects of the
facility’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment. Agency policy addresses the provision of support services for Limited
English Proficient and disabled residents by providing these residents the equal
opportunity to participate in or benefit from all aspects of the facility’s efforts to
prevent, detect, and respond to sexual abuse and sexual harassment.
Policy FDJJ 1919, pp. 10-11, states, "Facilities must ensure all youth with disabilities
(including, for example, youth who are deaf or hard of hearing, those who are blind
or have low vision, or those who have intellectual, developmental, psychiatric, or
speech disabilities), have an equal opportunity to participate in or benefit from all
aspects of the Department’s efforts to prevent, detect, and respond to sexual
misconduct." Facility policy 5-19, p.7, states, "The PREA Facility Compliance
Manager shall ensure that youth with disabilities, including youth who are deaf/hard
of hearing, blind/low vision, or those who have intellectual, developmental,
psychiatric, or speech disabilities, have an equal opportunity to participate in or
benefit from all aspects of the facilities efforts to prevent, detect, and respond to
sexual misconduct."
The parent agency's Interpreting Service Agreement for professional interpreting
services ensures the residents’ understanding of PREA and PREA-related
information. The Interpreting Service Agreement through American Sign Languages
Incorporated includes translation for many different languages and services for the
Deaf. Each resident has an equal opportunity to participate in or benefit from all
aspects of the facility’s efforts to prevent, detect and respond to sexual abuse and
sexual harassment as confirmed by the Interpreting Service Agreement and a
telephone conversation with a representative of American Sign Language Services,
Inc. The education unit also provides support services, through certified teachers
with the education background to modify/adapt information for all residents to
understand. Assistance may also be provided by the treatment staff to ensure all
residents’ understanding of the PREA information.
Posted PREA information is in English and Spanish and the PREA video is in English
and Spanish and may be accessed in other languages as needed. Additionally, the
facility has bilingual staff. Information may also be accessible in Creole and other
languages as needed through the Interpreting Service Agreement according to the
conversation with the service provider's representative, and interview with the
facility's agency head designee.
The agency's staff training curricula, PREA Training-Part II, pp. 11, contains a
section, Youth With Disabilities, where required services are discussed and disability
awareness is enhanced. The facility training officer and the electronic training
records confirmed staff's receipt of the online training. The agency head designee
confirmed access to accommodations for limited English proficient residents. The
facility's agency head designee provided that staff is made aware of the pending
arrival of residents and there is time to obtain the accommodations needed.
Additional resources include staff reading the information to the resident,
information with large print, use of magnifiers, according to informal conversation
with superintendent and observation.
There were no limited English proficient residents in the facility during the onsite
audit phase. There are two sides to the facility. One side are those residents who
require behavioral/mental health, substance abuse services and the other side
receives services for borderline intellectual functioning residents. There were five
targeted interviews conducted, the interviewees shared their experience when they
arrived at the facility. The residents confirmed they were told by staff: their right to
not be sexually abused or sexually harassed; how to report sexual abuse or sexual
harassment; and their right not to be punished for reporting sexual abuse or sexual
harassment.
Fifteen of 16 residents said they were provided the information about their rights
regarding PREA on the first day of arrival to the facility; one stated they were
provided the information on the second day. All 16 residents stated staff provided
information about the facility's rules against sexual abuse and sexual harassment,
as confirmed by the signed documents. The targeted interviewees confirmed the
information was explained by staff and provided in a way they understood. Although
some of the five targeted interviewees identified specific staff, all confirmed any
staff would help them understand things if they needed it, including information
about their rights concerning sexual abuse and sexual harassment and how to
report it. One targeted interviewee added, "Any staff will help; they don't judge."
Another added, "They will break it down for you." The review of 16 residents' files
contained signed acknowledgement statement of receipt of PREA education on the
same day of admission.
Conclusion:
Based upon the review and analysis of the evidence and interviews the facility is
compliant with this provision.
Provision (b):
The agency shall take reasonable steps to ensure meaningful access to all
aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment to residents who are limited
English proficient, including steps to provide interpreters who can
interpret effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary.
The documentation and interviews confirmed the availability of professional
interpreting services. Each resident has an equal opportunity to participate in or
benefit from all aspects of the facility’s efforts to prevent, detect and respond to
sexual abuse and sexual harassment, according to policy and informal conversation
with the superintendent/PREA compliance manager. PREA information is accessible
to residents in English and Spanish; Creole and other languages are accessible if
needed. The facility provides access to support services for preventing, detecting,
and responding to sexual abuse and sexual harassment to residents who are
Limited English Proficient, including taking steps to provide interpreters who can
interpret effectively, accurately, and impartially through the parent agency's
agreement with American Sign Language Services Incorporated which also include
spoken language interpreters.
Per agency policy FDJJ 1919, page 13, "The facility must also ensure meaningful
access to its efforts to prevent, detect, and respond to sexual misconduct to youth
who are limited English proficient, including steps to provide interpreters who can
interpret effectively, accurately, and impartially, both receptively and expressively,
using any necessary specialized vocabulary." Facility policy 5-19, 7-8 is aligned with
the agency policy. The intake staff is responsible for securing an interpreter during
the intake process; however, accessing interpreting services may be done by clinical
staff and shift supervisors as needed; services are available 24/7, confirmed by the
superintendent/PREA compliance manager. The agency's staff training curricula,
PREA Training-Part II, pp 11, contains a section, Youth With Disabilities, where
required services are discussed and disability awareness is strengthened. The
facility's electronic training records confirmed staff's receipt of the online training.
Five targeted interviews were conducted; the interviewees verbalized when they
arrived at the facility and stated they were told by staff: their right to not be
sexually abused or sexually harassed; how to report sexual abuse or sexual
harassment; and their right not to be punished for reporting sexual abuse or sexual
harassment. All residents said they were provided that information on the first day
of arrival at the facility. They stated staff explained the facility's rules against sexual
abuse and sexual harassment. The residents confirmed the information was
provided in a way they understood it. The targeted interviews revealed staff would
help the residents understand things if they needed it, including information about
their rights concerning sexual abuse and sexual harassment and how to report
it. Bilingual posters are on the walls in the living areas and other areas of the facility.
Posters are also graphic, colorful, and easy to read and/or understand.
Conclusion:
Based upon the review and analysis of the evidence, interviews and informal
conversations with the superintendent, the facility is compliant with this provision.
Provision (c):
The agency shall not rely on resident interpreters, resident readers, or
other types of resident assistants except in limited circumstances where
an extended delay in obtaining an effective interpreter could compromise
the resident’s safety, the performance of first-response duties under
§115.364, or the investigation of the resident’s allegations.
Agency policy FDJJ 1919 prohibits the use of resident readers and interpreters
except in limited circumstances where an extended delay in obtaining an interpreter
could compromise a resident’s safety; performance of first responder duties; or
investigation of allegations of sexual abuse or sexual harassment. This premise is
also indicated in the PAQ. Facility policy 2-01, p. 10, states, "Orientation will be
conducted in the youth’s language and will address program rules, expectations,
goals of the program and services applicable to the youth and will be conducted in a
manner that ensures individualized attention, thorough review of materials being
presented and assurance of special accommodations when needed to ensure a
youth’s understanding." The policy and practices and bilingual staff eliminate the
need for any assistance from residents. The interviews and documents, including
review of resident files, confirmed that the education and mental health staff
members have the capabilities to provide support services.
Informal conversations with random staff during the comprehensive site review,
confirmed residents are not used to relate PREA information to or from other
residents. Information regarding reporting allegations of sexual abuse and sexual
harassment is posted and accessible in both English and Spanish. The facility has
the resources available to get the PREA information translated and printed in the
additional languages as needed. Twelve random staff were interviewed; all stated
resident interpreters, resident readers, or other types of resident assistance to
assist disabled residents or residents with limited English proficiency will not be
used when the aforementioned residents make an allegation of sexual abuse or
sexual harassment and to the best of their knowledge, there has not been such an
occurrence.
Five targeted interviews were conducted, the interviewees articulated when they
arrived at the facility they were told by staff: their right to not be sexually abused or
sexually harassed; how to report sexual abuse or sexual harassment; and their right
not to be punished for reporting sexual abuse or sexual harassment. The 16
residents interviewed confirmed staff explained the facility's rules against sexual
abuse and sexual harassment. Additionally, the targeted residents confirmed the
information was provided in a way they understood it. The five targeted
interviewees confirmed staff would help them understand things if they needed it,
including information about their rights concerning sexual abuse and sexual
harassment and how to report it.
Conclusion:
Based upon the review and analysis of the evidence and interviews, the facility is
compliant with this provision.
115.317 Hiring and promotion decisions
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1800, Background Screening and Hiring Practice
Agency Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
Employee Handbook
PREA Pre-Audit Questionnaire (PAQ)
Criminal History Acknowledgement and PREA Compliance Form (IG/BSU-003)
Personnel Files
Interview:
Human Resources Staff
Provision (a):
The agency shall not hire or promote anyone who may have contact with
residents, and shall not enlist the services of any contractor who may
have contact with residents, who—(1) Has engaged in sexual abuse in a
prison, jail, lockup, community confinement facility, juvenile facility, or
other institution (as defined in 42 U.S.C. 1997); (2) Has been convicted of
engaging or attempting to engage in sexual activity in the community
facilitated by force, overt or implied threats of force, or coercion, or if the
victim did not consent or was unable to consent or refuse; or (3) Has been
civilly or administratively adjudicated to have engaged in the activity
described in paragraph (a)(2) of this section.
The PAQ affirms "the agency policy prohibits hiring or promoting anyone who may
have contact with residents, and prohibits enlisting the services of any contractor
who may have contact with residents, who:
• Has engaged in sexual abuse in a prison, jail, lockup, community confinement
facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997);
• Has been convicted of engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or coercion, or if
the victim did not consent or was unable to consent or refuse; or
• Has been civilly or administratively adjudicated to have engaged in the activity
described in paragraph (a)(2) of this section."
According to agency policy FDJJ 1919, page 16, "The Department does not hire,
promote, or contract with anyone who:
(a.) Has engaged in sexual abuse in a prison, jail, lockup, community confinement
facility, juvenile, facility, or other institution (as defined in 42 U.S.C 1997); (b.) Has
been convicted of engaging or attempting to engage in sexual activity in the
community facilitated by force, overt, or implied threats of force, or coercion, or if
the victim did not consent or was unable to consent or refuse; or (c.) Has been
civilly or administratively adjudicated to have engaged in the activity described in
(a.) and (b.)."
Agency policy FDJJ 1800, p. 2, states, "The Department does not hire, promote, or
contract with anyone who: i. Has engaged in sexual abuse in a prison, jail, lockup,
community confinement facility, juvenile, facility, or other institution (as defined in
42 U.S.C. 1997); ii. Has been convicted of engaging or attempting to engage in
sexual activity in the community facilitated by force, overt, or implied threats of
force, or coercion, or if the victim did not consent or was unable to consent or
refuse; iii. Has been civilly or administratively adjudicated to have engaged in the
activity described in ii above. The Department shall ask all applicants and
employees who may have contact with youth about previous misconduct in written
applications or interviews for hiring or promotions and in any interviews or written
self-evaluations conducted as part of review of current employees." Facility
policy 5-19, p. 14, mirrors the agency policy.
The agency form, Criminal History Acknowledgement and PREA Compliance Form,
provides that, "The Department shall ask all applicants and employees who may
have contact with youth about previous misconduct in written applications or
interviews for hiring or promotions and in any interviews or written self-evaluations
conducted as part of review of current employees." The form lists the three items
outlined in the standard provision and FDJJ 1919, page 16. The completed form is
part of the packet submitted to the Department of Juvenile Justice to secure a
criminal background check. Attached to the Criminal History Acknowledgement and
PREA Compliance Form is a list of offenses and accompanying statute number, that
will disqualify an applicant or current employee.
The procedures and practice was confirmed through a review of 15 personnel files
which included a sample of two volunteers and one contractor. The interview with
the human resources staff and a review of policies provided details about the hiring
process and completion of background checks. There was documentation of
completed background checks, showing the applicants were cleared to hire. The
personnel files included the completed background checks and hiring documents.
Background checks are obtained through the Florida Department of Juvenile Justice,
Background Screening Unit, and a local background check conducted by the sheriff's
office.
The review of the personnel files and policies and the interview verified the
routine completion of criminal background checks. All applicants are asked about
any prior misconduct involving any sexual activity as a part of the hiring process
and that specific form must be included in the paperwork for a background check to
be completed. The documentation, interview, and policies support the facility does
not hire or promote anyone who has engaged in sexual abuse or anyone who has
used or attempted to use force in the community to engage in sexual abuse.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision of the standard.
Provision (b):
The agency shall consider any incidents of sexual harassment in
determining whether to hire or promote anyone, or to enlist the services
of any contractor, who may have contact with residents.
According to the PAQ, agency policy requires the consideration of any incidents of
sexual harassment in determining whether to hire or promote anyone, or to enlist
the services of any contractor, who may have contact with residents. Agency policy
FDJJ 1919 supports that the facility does not hire or promote anyone who has been
civilly or administratively adjudicated or have been convicted of engaging in or
attempted to engage in sexual activity by any means. The interview was aligned
with the standard and the documentation shows the inquiries made during the
application process regarding previous misconduct.
The policies and interview collectively indicate that the facility considers any
incidents of sexual harassment in determining whether to hire or promote anyone,
or to enlist the services of any contractor or volunteer, who may have contact with
residents. No applicant will be considered for employment if a background check
reveals any history of inappropriate sexual behavior or arrest for inappropriate
sexual behavior. The policies, documented practices, and the interview supports
that the facility does not hire or promote anyone who has been civilly or
administratively adjudicated or have been convicted of engaging in or attempted to
engage in sexual activity by any means. The interview and the documentation
demonstrate the inquiries made during the application process regarding previous
sexual misconduct.
According to agency policy FDJJ, p. 16, "The Department does not hire, promote, or
contract with anyone who: a. Has engaged in sexual abuse in a prison, jail, lockup,
community confinement facility, juvenile, facility, or other institution (as defined in
42 U.S.C 1997); b. Has been convicted of engaging or attempting to engage in
sexual activity in the community facilitated by force, overt, or implied threats of
force, or coercion, or if the victim did not consent or was unable to consent or
refuse; or c. Has been civilly or administratively adjudicated to have engaged in the
activity described in a. and b. above."
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision of the standard.
Provision (c):
Before hiring new employees who may have contact with residents, the
agency shall: (1) Perform a criminal background records check; (2) Consult
any child abuse registry maintained by the State or locality in which the
employee would work; and (3) Consistent with Federal, State, and local
law, make its best efforts to contact all prior institutional employers for
information on substantiated allegations of sexual abuse or any
resignation during a pending investigation of an allegation of sexual
abuse.
According to the PAQ, Agency policy requires that before it hires any new employees
who may have contact with residents, it (a) conducts criminal background record
checks; (b) consults any child abuse registry maintained by the State or locality in
which the employee would work; and (c) consistent with Federal, State, and local
law, makes its best efforts to contact all prior institutional employers for information
on substantiated allegations of sexual abuse or any resignation during a pending
investigation of an allegation of sexual abuse.
Policy FDJJ 1800, p. 2, states, "Form IG/BSU-003 - The Criminal History
Acknowledgement and Prison Rape Elimination Act (PREA) compliance form is a
mandatory form that must be completed by Department and contract provider
applicants screened by Detention and Residential, to determine if the applicant has
a criminal offense(s) that would disqualify him or her from employment in a position
that has contact with youth or confidential youth records and to ensure compliance
with PREA standards." The form lists the three items outlined in the standard
provision and FDJJ 1919, page 16. The completed form is part of the packet
submitted to the Department of Juvenile Justice to secure a criminal background
check. Attached to the Criminal History Acknowledgement and PREA Compliance
Form (IG/BSU-003) is a list of offenses and accompanying statute number, that will
disqualify an applicant.
According to the PAQ, policy requires that a criminal background records check be
completed and applicable child abuse registries consulted before enlisting the
services of any contractor who may have contact with residents. The background
check process includes consulting a child abuse registry as confirmed during the
interview. Best efforts would be made to contact all prior institutional employers for
information of incidents or allegations of sexual abuse. The interview revealed the
resources used for the background checks include the Federal Bureau of
Investigations, Sheriff's Office, and the Sexual Offender Database System. The
interview confirmed the facility considers prior incidents of sexual harassment in
determining whether to hire or promote anyone or to enlist the services of any
contractor who may have contact with residents.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision of the standard.
Provisions (d):
The agency shall also perform a criminal background records check, and
consult applicable child abuse registries, before enlisting the services of
any contractor who may have contact with residents.
According to the PAQ, agency policy exists that requires a criminal background
records check be completed and applicable child abuse registries consulted before
enlisting the services of any contractor who may have contact with residents. The
background check process includes consulting a child abuse registry as confirmed
during the interview and is completed for employees, as well as contractors. The
review of the two contractors' files confirmed the same background check resources
as the regular employees. The interview revealed the resources used for the
background checks include the Federal Bureau of Investigations, local sheriff's
office, and the child abuse registry check through the Florida Department of
Children and Services. The interview confirmed the facility considers prior incidents
of sexual harassment in determining whether to hire or promote anyone or to enlist
the services of any contractor who may have contact with residents.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision of the standard.
Provision (e):
The agency shall either conduct criminal background records checks at
least every five years of current employees and contractors who may have
contact with residents or have in place a system for otherwise capturing
such information for current employees.
Policy FDJJ 1919, page 16, states, "The Department shall ask all applicants and staff
who may have contact with youth directly about previous misconduct in Section G
for all new hires, promotions, and all rescreenings every (5) years using form IG/
BSU-003 during the background screening process." Facility policy 1.130, page 2,
also provide for a five-year background check. The review of the personnel files
revealed initial background checks are conducted and background checks are
conducted every five years thereafter, in accordance with policy and the provision
of the standard. The interview, review of documentation and a review of the policies
provide details about the hiring process and completion of background checks. The
interview confirmed that the background check system for the five-year rescreen
included employees and contractors.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision of the standard.
Provision (f):
The agency shall also ask all applicants and employees who may have
contact with residents directly about previous misconduct described in
paragraph (a) of this section in written applications or interviews for
hiring or promotions and in any interviews or written self-evaluations
conducted as part of reviews of current employees. The agency shall also
impose upon employees a continuing affirmative duty to disclose any such
misconduct.
The form, Criminal History Acknowledgement and PREA Compliance Form is used to
ask the questions directly to the applicant and provides that, "The Department shall
ask all applicants and employees who may have contact with youth about previous
misconduct in written applications or interviews for hiring or promotions and in any
interviews or written self-evaluations conducted as part of review of current
employees." The form lists the three items outlined in the standard provision and
FDJJ 1919, page 16. The completed form is part of the packet submitted to the
Department of Juvenile Justice to secure a criminal background check. It is also used
annually for all staff and prior to a promotion. Attached to the Criminal History
Acknowledgement and PREA Compliance Form is a list of offenses and
accompanying statute number, that will disqualify an applicant or current employee.
According to the interview with the human resources staff and the sample of
personnel files reviewed, the Criminal History Acknowledgement and PREA
Compliance Form is used to disclose previous sexual misconduct for applicants and
current employees. The human resources staff confirmed new employees are
informed of their continuing affirmative duty to disclose any previous misconduct.
Conduct that may lead to suspension or termination is outlined in the Employee
Handbook (p. 23) and include such behavior as, "Failure to notify the Facility
Administrator immediately if you are arrested and/or charged with a misdemeanor
or felony." According to the human resources staff, he is notified electronically by
Department of Juvenile Justice (DJJ) if a staff member is arrested; DJJ has a
connection to law enforcement agencies.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision of the standard.
Provision (g):
Material omissions regarding such misconduct, or the provision of
materially false information, shall be grounds for termination.
The interview with the human resources staff revealed automatic electronic
notification through the Department of Juvenile Justice, Background Screening
Unit, if an employee is arrested and the identified charges. Additionally, FDJJ 1919,
page 16, requires that "Staff considered for promotion shall disclose any sexual
misconduct and material omission regarding such misconduct, or the provision of
materially false information shall be grounds for termination." The omission of
sexual misconduct information or providing false information is grounds for
termination in accordance with the policy.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision of the standard.
Provision (h):
Unless prohibited by law, the agency shall provide information on
substantiated allegations of sexual abuse or sexual harassment involving
a former employee upon receiving a request from an institutional
employer for whom such employee has applied to work.
The interview with the human resources staff revealed that when a former
employee applies for work at another institution, upon the request from that
institution, she will provide the requested information and "will talk with the
superintendent beforehand." According to policy FDJJ 1919, p. 17, "Unless prohibited
by law, the Department shall provide information on substantiated allegations of
sexual misconduct involving former staff upon receiving a request from any PREA
regulated employer for whom such staff has applied to work." There has been no
such request during the past 12 months.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision of the standard.
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
PREA PRE-Audit Questionnaire (PAQ)
Interviews:
Superintendent
Agency Head Designee
Provision (a):
If the agency designed or acquired any new facility or planned any
substantial expansion or modification of existing facilities, the agency
considered the effect of the design, acquisition, expansion, or modification
upon the agency’s ability to protect residents from sexual abuse.
There has not been a substantial expansion or modification to the facility since the
last PREA audit in 2023, according to the PAQ. The interviews with the
superintendent and agency head designee confirmed there have not been a
substantial expansion or modification since the last audit.
Conclusion:
Based on the PAQ, interviews, and observations, the facility is compliant with this
provision of the standard.
Provision (b):
If the agency installed or updated a video monitoring system, electronic
surveillance system, or other monitoring technology, the agency
considered how such technology may enhance the agency’s ability to
protect residents from sexual abuse.
According to the PAQ, the facility has installed or updated a video monitoring
system, electronic surveillance system, or other monitoring technology since the
last PREA audit in 2023. The interviews with the superintendent and agency head
designee confirmed cameras were installed in the recreation yard to increase the
safety of residents and staff by addressing blind spots and to provide for a more
clear line of sight, confirmed by observations of the auditor.
Conclusion:
Based on the PAQ, interviews, and observations, the facility is compliant with this
provision of the standard.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
PREA Compliance Form
Draft Memorandum of Understanding (MOU)
Advocacy Agency Website and Brochure
Interviews:
Random Staff
PREA Compliance Manager
Advocacy Agency Representative
Provision (a):
To the extent the facility is responsible for investigating allegations of
sexual abuse, the facility shall follow a uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for
administrative proceedings and criminal prosecutions.
The PAQ indicates the facility's parent agency is not responsible for conducting any
form of administrative or criminal sexual abuse investigations. The allegations of
sexual abuse are conducted by the Department of Children and Families (DCF) and
law enforcement. When an investigation is conducted in the facility by law
enforcement, the investigator is provided the protocol, PREA Compliance Form, by
the Department of Juvenile Justice/Office of Inspector General (DJJ/OIG). The PREA
Compliance Form is shared with local law enforcement investigators which outlines
the PREA standards that must be adhered to regarding an investigation of an
allegation of sexual abuse in a Department of Juvenile Justice (DJJ) facility. Facility
policy 5-19, p. 11, states, "Local law enforcement and the Department of Children
and Families (DCF) handle the investigation involving youth in Florida. Staff are
expected to cooperate with the investigation. The office of the Inspector General
(OIG) conducts administrative investigations, separate and apart from any criminal
investigations, to identify any misconduct by staff as related to Department
regulator guidance. Staff are expected to cooperate with the OIG investigation."
The 12 random staff interviewed collectively knew that the sexual abuse
investigations would be conducted by DCF, DJJ, and/or law enforcement. When
asked what they would do if they were the first person to be alerted that a resident
had allegedly been sexually abused, they collectively responded: call the
superintendent, supervisor, medical, and/or mental health staff; separate; call the
abuse reporting hotline.
Conclusion:
Based upon the review and analysis of the available evidence and interviews with
random staff, the facility is compliant with this provision.
Provision (b):
The protocol shall be developmentally appropriate for youth and, as
appropriate, shall be adapted from or otherwise based on the most recent
edition of the U.S. Department of Justice’s Office on Violence Against
Women publication, “A National Protocol for Sexual Assault Medical
Forensic Examinations, Adults/Adolescents,” or similarly comprehensive
and authoritative protocols developed after 2011.
Administrative investigations are conducted by the DJJ/OIG; allegations of sexual
abuse that are criminal in nature are investigated by DCF and law enforcement. The
facility or its parent agency does not conduct any type of investigations. The PREA
Compliance Form is shared with local law enforcement investigators which outlines
the PREA standards that must be adhered to regarding an investigation of an
allegation of sexual abuse in a DJJ state-run or contract facility.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (c):
The facility shall offer all residents who experience sexual abuse access to
forensic medical examinations whether on-site or at an outside facility,
without financial cost, where evidentiarily or medically appropriate. Such
examinations shall be performed by Sexual Assault Forensic Examiners
(SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible. If
SAFEs or SANEs cannot be made available, the examination can be
performed by other qualified medical practitioners. The facility shall
document its efforts to provide SAFEs or SANEs.
According to the PAQ: The facility offers all residents who experience sexual abuse
access to forensic medical examinations. The facility offers all residents who
experience sexual abuse access to forensic medical examinations at an outside
facility. Forensic medical examinations are offered without financial cost to the
victim. Where possible, examinations are conducted by Sexual Assault Forensic
Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs). When SANEs or
SAFEs are not available, a qualified medical practitioner performs forensic medical
examinations. The facility documents efforts to provide SANEs or SAFEs. According
to agency policy, FDJJ 1919, p. 10, resident victims of sexual abuse will, "Be
offered access to forensic medical examinations whether on-site or at an outside
facility, without financial cost, where evidentiarily or medically appropriate. Such
examinations shall be performed by Sexual Assault Forensic Examiners (SAFE) or
Sexual Assault Nurse Examiners (SANE) where possible. If a SAFE or SANE cannot be
made available, the examination can be performed by other qualified medical
practitioners." Agency policy FDJJ 1919 is aligned with the facility policy 5-19, p. 12.
The alleged victim will be provided forensic medical services at the Emerald Coast
Children's Advocacy Center (ECCAC) through the local hospital emergency room.
The forensic medical examination will be conducted by a Sexual Assault Nurse
Examiner (SANE) or a Sexual Assault Forensic Examiner (SAFE). The examination
and any follow-up treatment will be performed at no cost to the victim. The ECCAC
is a non-profit agency that provides free services to children in Okaloosa and Walton
counties who have experienced abuse or neglect. In addition to the forensic medical
examination, the facility offers therapy, crisis counseling, while coordinating with
law enforcement and Department of Children and Families to minimize trauma to
the youth by having the youth tell the story once in a single location.
An overview of services is provided on the agency's website and confirmed during
the interview with the advocacy agency representative. The MOU is in draft form for
review and application of signatures. The advocacy agency used in the past by the
facility has closed. The superintendent made temporary arrangements through DCF
for assistance in a referral for an advocate if there was a need. The abuse hotline
number provides a prompt to the caller if resources are needed. The auditor tested
the resource and the operator stated the call would be transferred to a counselor if
an advocate or other resource was requested. The advocacy agency representative
at ECCAC indicated that the lack of the signed document would not impede services
to a resident. There has not been a need for a forensic medical examination during
this audit period and there have not been allegations of abuse. The draft MOU,
policy, observation of posted DCF information, and interview with the ECCAC
representative confirmed that all residents have access to forensic medical
examinations.
The interview with the advocacy agency representative confirmed the availability of
SANE services upon notification by law enforcement. The examination and any
follow-up treatment will be performed at no cost to the victim which is supported by
policy FDJJ 1919, p. 10. The same policy and page also states, "Each facility will
attempt to maintain a Memorandum of Understanding (MOU) with a local rape crisis
center that has certified Sexual Assault Nurse Examiners or Sexual Assault Forensic
Examiners or maintain documentation that attempts were made to enter into an
MOU." The advocacy agency's brochure and website informs that the services
provided are free and confidential. In addition to the forensic medical examination,
the facility offers therapy, crisis counseling, accompaniment, information, and
referrals. The facility is in the process of getting the MOU signed, according to the
superintendent, due to the current MOU being with an advocacy agency that has
closed. The PAQ indicates there were no forensic medical examinations conducted
during the past 12 months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (d):
The facility shall attempt to make available to the victim a victim advocate
from a rape crisis center. If a rape crisis center is not available to provide
victim advocate services, the facility shall make available to provide these
services a qualified staff member from a community-based organization or
a qualified facility staff member. Agencies shall document efforts to secure
services from rape crisis centers. For the purpose of this standard, a rape
crisis center refers to an entity that provides intervention and related
assistance, such as the services specified in 42 U.S.C. 14043g(b)(2)(C), to
victims of sexual assault of all ages. The facility may utilize a rape crisis
center that is part of a governmental unit as long as the center is not part
of the criminal justice system (such as a law enforcement facility) and
offers a comparable level of confidentiality as a nongovernmental entity
that provides similar victim services.
According to the PAQ, the facility attempts to make a victim advocate from a rape
crisis center available to the victim, in person or by other means. These efforts are
documented by the draft MOU between the facility and advocacy agency and the
posted information in the facility. Policy FDJJ 1919, p.10 states, residents of sexual
abuse will, "Have access to a victim advocate from a rape crisis center or a qualified
staff member from a community-based organization or a qualified agency staff
member." The facility provides residents with access to outside victim advocates for
emotional support services related to sexual abuse, by providing, posting, and
making accessible mailing addresses and telephone numbers, including toll free
hotline numbers, according to observations and interview with the superintendent/
PREA compliance manager.
The Emerald Coast Children's Advocacy Center is not a part of the criminal justice
system and provides confidential services and take referrals made by the
Department of Children and Families (DCF) and law enforcement. The
superintendent/PREA compliance manager implied the referrals provided by DCF
and services offered by Emerald Coast Children's Center are aligned with the
standard which are reflected in the draft MOU that is pending signatures. According
to the superintendent, DCF was a temporary resourced for referral for services and
assistance in gaining advocacy services until the MOU can be signed. The interviews
with the advocacy agency representative and PREA superintendent/compliance
manager, and review of the draft MOU and posted information, collectively
confirmed the advocacy services include emotional support, accompaniment,
forensic medical examinations, and resources. According to the PAQ, there have
been no forensic medical examinations conducted during the past 12 months and
no allegations of sexual abuse.
Conclusion:
Based upon the review and analysis of the available evidence, the interviews, the
facility is compliant with this provision.
Provision (e):
As requested by the victim, the victim advocate, qualified facility staff
member, or qualified community-based organization staff member shall
accompany and support the victim through the forensic medical
examination process and investigatory interviews and shall provide
emotional support, crisis intervention, information, and referrals.
Victim advocacy services have been arranged and outlined in the daft MOU which is
pending signatures due to the closing of the advocacy agency where there was a
MOU in the past. Advocacy services are not impeded due to the lack of the formal
agreement, according to the advocacy agency representative. The Emerald Coast
Children's Advocacy Center works closely with the child welfare agency, DCF, and
law enforcement and accepts referrals from both. The victim advocacy facility
provides a range of programs and services, according to the superintendent/PREA
compliance manager, advocacy agency representative, and advocacy agency
website which include forensic medical examinations, accompaniment, referrals,
assigned advocate, and emotional support.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provisions (f):
To the extent the facility itself is not responsible for investigating
allegations of sexual abuse, the facility shall request that the
investigating facility follow the requirements of paragraphs (a) through (f)
of this section. (g): The requirements of paragraphs (a) through (f) of this
section shall also apply to:
(1) Any State entity outside of the facility that is responsible for
investigating allegations of sexual abuse in juvenile facilities; and
(2) Any Department of Justice component that is responsible for
investigating allegations of sexual abuse in juvenile facilities.
According to the PAQ, the facility or facility's parent agency is not responsible for
investigating administrative or criminal allegations of sexual abuse and relies on
another agency to conduct these investigations, the agency has requested that the
responsible agency follow the requirements of paragraphs §115.321 (a) through (e)
of the standards. The DJJ/OIG investigators conduct administrative investigations in
accordance with facility policy, and the PREA Standards as outlined on the PREA
Compliance Form. Investigations of allegations of sexual abuse or sexual
harassment that are criminal in nature are investigated by law enforcement and
DCF. The Compliance Form, which provides guidelines regarding PREA related
investigations, is provided to law enforcement through the OIG.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
115.322 Policies to ensure referrals of allegations for investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
PREA Pre-Audit Questionnaire (PAQ)
PREA Compliance Form
Agency Website
Interviews:
Investigative Staff
Agency Head Designee
Provision (a):
The agency shall ensure that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment.
The agency/facility ensures an administrative or criminal investigation is completed
for all allegations of sexual abuse and sexual harassment in State-run and contract
facilities, as supported by agency policy and the facility response on the PAQ.
Agency policy, FDJJ 1919, p. 14, states, "The Department does not conduct criminal
investigations for youth-related sexual abuse reports. Local law enforcement
agencies and the Department of Children and Families (DCF) handle such
investigations involving youth in Florida. The Department conducts administrative
investigations and management reviews, separate and apart from any criminal
investigations, to identify any misconduct by staff as related to Department
regulatory guidance." Facility policy 15-19, p.11, is aligned with the agency policy.
The interviews with12 random staff supported that all allegations of sexual abuse
and sexual harassment are to be reported and all verbal reports must be
documented. The interview with the facility's agency head designee revealed that
an administrative or criminal investigation is completed for all allegations of sexual
abuse and sexual harassment. The facility's agency head designee confirmed there
are no investigators within the facility or parent agency; allegations are investigated
by the Department of Juvenile Justice (DJJ) investigators, DCF, and/or law
enforcement. He described how the allegation would be reported through the abuse
hotline, DJJ Central Communications Center, and law enforcement if criminal in
nature.
The facility's PAQ reports no allegations of sexual abuse or sexual harassment. The
staff interviewed articulated how the allegations would be reported to all
investigative entities; DJJ/Office of Inspector General (OIG), DCF, and law
enforcement. The PREA Compliance Form is provided to investigators from law
enforcement agencies, through the OIG, to ensure proper protocol is followed when
conducting investigations of sexual abuse within the confinement setting.
The following is a segment of the PREA Compliance Form which is shared with law
enforcement investigators:
"According to DJJ policy, and to remain PREA compliant, all investigations conducted
by DJJ investigators concerning allegations of sexual abuse, will conform to the
following PREA Standards. It is the desire of DJJ that all assisting law enforcement
entities also adhere to the below listed requirements of 28 CFR 115.21, as are
applicable on a case by case basis.
PREA § 115.21 Evidence protocol and forensic medical examinations
· (a)To the extent the agency is responsible for investigating allegations of sexual
abuse; the agency shall follow a uniform evidence protocol that maximizes the
potential for obtaining usable physical evidence for administrative proceedings and
criminal prosecutions.
· (b) The protocol shall be developmentally appropriate for youth where applicable,
and, as appropriate, shall be adapted from or otherwise based on the most recent
edition of the U.S. Department of Justice’s Office on Violence Against Women
publication, “A National Protocol for Sexual Assault Medical Forensic Examinations,
Adults/Adolescents,” or similarly comprehensive and authoritative protocols
developed after 2011.
· (c) The agency shall offer all victims of sexual abuse access to forensic medical
examinations, whether on-site or at an outside facility, without financial cost, where
evidentiarily or medically appropriate. Such examinations shall be performed by
Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse Examiners
(SANEs) where possible. If SAFEs or SANEs cannot be made available, the
examination can be performed by other qualified medical practitioners. The agency
shall document its efforts to provide SAFEs or SANEs.
· (d) The agency shall attempt to make available to the victim a victim advocate
from a rape crisis center. If a rape crisis center is not available to provide victim
advocate services, the agency shall make available to provide these services a
qualified staff member from a community-based organization, or a qualified agency
staff member. Agencies shall document efforts to secure services from rape crisis
centers. For the purpose of this standard, a rape crisis center refers to an entity that
provides intervention and related assistance, such as the services specified in
42U.S.C. 14043g(b)(2)(C), to victims of sexual assault of all ages. The agency may
utilize a rape crisis center that is part of a governmental unit as long as the center is
not part of the criminal justice system (such as a law enforcement agency) and
offers a comparable level of confidentiality as a nongovernmental entity that
provides similar victim services.
· (e) As requested by the victim, the victim advocate, qualified agency staff
member, or qualified community-based organization staff member shall accompany
and support the victim through the forensic medical examination process and
investigatory interviews and shall provide emotional support, crisis intervention,
information, and referrals.
If you have any questions or concerns please contact the FDJJ Office of Inspector
General at (850) 921-6344."
Conclusion:
Based upon the review and analysis of the available evidence and the interview with
the facility's agency designee, the facility is compliant with this provision.
Provisions (b):
The facility shall have in place a policy to ensure that allegations of sexual
abuse or sexual harassment are referred for investigation to an facility
with the legal authority to conduct criminal investigations, unless the
allegation does not involve potentially criminal behavior. The facility shall
publish such policy on its website or, if it does not have one, make the
policy available through other means. The facility shall document all such
referrals.
According to the PAQ, the agency’s policy regarding the referral of allegations of
sexual abuse or sexual harassment for a criminal investigation is published on the
agency website or made publicly available via other means. The PAQ also states,
the agency documents all referrals of allegations of sexual abuse or sexual
harassment for criminal investigation. The agency has an overarching PREA policy,
FDJJ 1919, that requires allegations of sexual abuse or sexual harassment be
referred for an investigation to an investigative entity that has the legal authority to
conduct criminal investigations which include the Department of Children and
Families and law enforcement. All State-run and contract facilities must adhere to
agency policy FDJJ 1919. The agency, Department of Juvenile Justice, does not
conduct criminal investigations; only administrative investigations and management
reviews. All allegations are documented on a dedicated incident report form and all
investigations are documented. Pages 14-15 of policy FDJJ 1919 provide the
following, in support of this provision:
"1. The Department does not conduct criminal investigations for youth-related
sexual abuse reports. Local law enforcement agencies and the Department of
Children and Families handle such investigations involving youth in Florida. The
Department conducts administrative investigations and management reviews,
separate and apart from any criminal investigations, to identify any misconduct by
staff as related to Department regulatory guidance. Staff are expected to cooperate
with Office of the Inspector General (OIG) investigations.
2. The OIG staff will be trained on Department policies and procedures related to
the handling of sexual misconduct incidents and reports.
3. The Department will ensure administrative investigations and reviews are
completed for all allegations of sexual misconduct and all administrative
investigations by the OIG shall follow OIG guidelines governing PREA investigations.
4. The Department and/or agency being audited shall demonstrate that it has
attempted to gain compliance from local law enforcement that conducts criminal
investigations of sexual abuse with requirements (a) through (e) of standard 28
C.F.R. Part 115.321."
The DJJ agency's website contains the overarching PREA policy which contains
directives regarding investigations that describes investigative responsibilities of
both the agency and the separate investigative entities. The agency head designee
confirmed allegations are reported to the investigative entities by the
superintendent or designee or other staff. The agency's investigative staff provided
there are "several policies that require all allegations of sexual abuse or sexual
harassment be investigated. All reports to CCC or review and assigned within 24
hours." The agency has policies that guide agency investigators in conducting
investigations and the responsibilities of the other investigate entities.
Conclusion:
Based upon the review and analysis of the available evidence and interviews with
the agency head designee and investigative staff, the facility is compliant with this
provision.
Provision (c):
If a separate entity is responsible for conducting criminal investigations,
such publication shall describe the responsibilities of both the facility and
the investigating entity.
According to the PAQ, such publication describes the responsibilities of both the
agency and the investigative entity when a separate entity is responsible for
conducting criminal investigations. Policy FDJJ 1919, indicating which investigative
entities conduct investigations and the type, and reporting information is posted on
the agency's website, accessible to the public. Policies, investigation reports, and
interviews confirmed allegations of sexual abuse and sexual harassment are
investigated. Administrative investigations are conducted by DJJ/OIG trained
investigators. Allegations that are criminal in nature are referred to law
enforcement and DCF. The PREA Compliance Form is provided to investigators from
law enforcement agencies, through the OIG, to ensure proper protocol is followed
when conducting investigations of sexual abuse within the confinement setting. The
bulk of the contents of the PREA Compliance Form is provided in Provision (a).
Conclusion:
Based upon the review and analysis of the available evidence, including the DJJ
website PREA-related content, the facility is compliant with this provision.
115.331 Employee training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Training Curricula
Course Participant Training Roster
Interviews:
Random Staff
Provision (a):
The agency shall train all employees who may have contact with residents
on:
(1) Its zero-tolerance policy for sexual abuse and sexual harassment;
(2) How to fulfill their responsibilities under agency sexual abuse and
sexual harassment prevention, detection, reporting, and response policies
and procedures;
(3) Residents’ right to be free from sexual abuse and sexual harassment;
(4) The right of residents and employees to be free from retaliation for
reporting sexual abuse and sexual harassment;
(5) The dynamics of sexual abuse and sexual harassment in juvenile
facilities;
(6) The common reactions of juvenile victims of sexual abuse and sexual
harassment;
(7) How to detect and respond to signs of threatened and actual sexual
abuse and how to distinguish between consensual sexual contact and
sexual abuse between residents;
(8) How to avoid inappropriate relationships with residents;
(9) How to communicate effectively and professionally with residents,
including lesbian, gay, bisexual, transgender, intersex, or gender
nonconforming residents;
(10) How to comply with relevant laws related to mandatory reporting of
sexual abuse to outside authorities; and
(11) Relevant laws regarding the applicable age of consent.
According to the PAQ, the agency trains all employees who may have contact with
residents on the agency's zero-tolerance policy for sexual abuse and sexual
harassment. Policy FDJJ 1919, p. 17, addresses PREA related training for staff. The
12 random staff interviewed were generally familiar with the PREA information
regarding primary components of preventing, detecting and responding to sexual
abuse or sexual harassment. The facility policy, 5-19, p.4, provides that the PREA
compliance manager has, "Responsibility for ensuring all PREA training is conducted
as required at the facility, and that all of the staff have been properly trained on
PREA prior to their interaction with youth at the facility."
The agency developed specific PREA training curriculum, Part One and Part Two, that
address the following: (1) Its zero-tolerance policy for sexual abuse and sexual
harassment; (2) How to fulfill their responsibilities under agency sexual abuse and
sexual harassment prevention, detection, reporting, and response policies and
procedures; (3) Residents’ right to be free from sexual abuse and sexual
harassment; (4) The right of residents and employees to be free from retaliation for
reporting sexual abuse and sexual harassment; (5) The dynamics of sexual abuse
and sexual harassment in juvenile facilities; (6) The common reactions of juvenile
victims of sexual abuse and sexual harassment; (7) How to detect and respond to
signs of threatened and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents; (8) How to avoid
inappropriate relationships with residents; (9) How to communicate effectively and
professionally with residents, including lesbian, gay, bisexual, transgender, intersex,
or gender nonconforming residents; (10) How to comply with relevant laws related
to mandatory reporting of sexual abuse to outside authorities; and (11) Relevant
laws regarding the applicable age of consent.
It was determined that PREA related training is provided to all staff as indicated
through a review of the policies and training documents and the results of the
interviews with 12 random staff and informal conversations with other staff and the
superintendent/PREA compliance manager. Initial training is provided upon hire and
policy FDJJ 1919, page 17, requires a formal refresher to occur every two years;
however, interviews and informal conversations with random staff, training records,
and PAQ indicate that PREA refreshers occur annually. Facility policy 15-19, p.15,
requires refresher training to occur annually. The training records, PAQ, and
interviews with random staff reflect the initial and refresher training occurs annually.
PREA training occurs online and in-person. Ten of the 12 random staff members
interviewed reported having completed PREA related training or a refresher in 2026;
and two reported receiving training in 2025. The initial training and refresher are
based on the employee's hire date; the electronic training records reflect the
varying dates.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (b):
Such training shall be tailored to the unique needs and attributes of
residents of juvenile facilities and to the gender of the residents at the
employee’s facility. The employee shall receive additional training if the
employee is reassigned from a facility that houses only male residents to
a facility that houses only female residents, or vice versa.
The facility houses males only and the training considers the needs of the
population served as indicated by the training curricula and interviews. The policies
and interviews support training being tailored to the needs and attributes of the
population served. A review of the training curricula and informal conversation with
staff indicate the agency curricula is adaptable to meet the needs of the makeup of
the population served within each facility. All staff within the facility are provided
PREA training as appropriate according to the training curricula and PAQ; all staff
hired receive the PREA training specifically for the facility. The employee will receive
additional training if the employee is reassigned from a facility that houses only
female residents, according to informal conversation with the superintendent/PREA
compliance manager, who, according to policy is responsible for staff PREA training.
Conclusion:
Based upon the review and analysis of the available evidence and informal
conversation with the superintendent/PREA compliance manager, the facility is
compliant with this provision.
Provision (c):
All current employees who have not received such training shall be trained
within one year of the effective date of the PREA standards, and the
agency shall provide each employee with refresher training every two
years to ensure that all employees know the agency’s current sexual
abuse and sexual harassment policies and procedures. In years in which
an employee does not receive refresher training, the agency shall provide
refresher information on current sexual abuse and sexual harassment
policies.
Initial training is provided immediately after hire and policy FDJJ 1919, page 17,
requires a formal refresher to occur every two years; however, informal
conversations with random staff, and PAQ indicate that PREA refreshers occur
annually. Facility policy 1-8, Pre-Service Training, p.1, states, "Prior to being in the
presence of youth and before initiation of on the job training (OJT), staff must
complete Child Abuse Recognition, Reporting, and Prevention; CPR/First Aid/AED;
Emergency Procedures; Facility Operating Procedures; PREA, Professionalism,
Interpersonal Communication, and Ethics to include Standards of Conduct; Right
Interactions (RI); and Suicide Awareness and Prevention." According to the PAQ,
between trainings the agency provides employees who may have contact with
residents with refresher information about current policies regarding sexual abuse
and harassment through policy review during staff meetings, in accordance with
policy FDJJ 1919.
Staff interviews and documentation supported that refresher training was conducted
annually. All random staff interviewed indicated training was provided as required.
Staff were not allowed to work with residents until the PREA and other training was
completed, according to informal conversations with random staff and the
superintendent/PREA compliance manager. The informal conversations with random
staff and superintendent and training records indicated refresher training occurs at
least annually. Informal conversations with random staff also provided that refresher
trainings may be provided in staff meetings and shift briefings.
Conclusion:
Based upon the review and analysis of the available evidence and informal
conversation with the superintendent/PREA compliance manager and random staff,
the facility is compliant with this provision.
Provision (d):
The agency shall document, through employee signature or electronic
verification that employees understand the training they have received.
The PREA training reviewed was documented electronically and verified through 12
random staff interviews and informal communication with the superintendent who is
responsible for PREA training for staff. Electronic training records and certificates
are used to document completion of staff training. The sample of electronic training
records reviewed contained the staff member's name, attempt date, and an
indication whether the training was completed. The agency policy FDJJ 1919, p.17,
requires the documentation or electronic verification of receipt of PREA training. A
sample of 13 electronic Individual Training Reports were reviewed and contained
documented PREA training, including refresher training.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Training Curriculum
Training Records
Interviews:
Contractors
Provision (a):
The agency shall ensure that all volunteers and contractors who have
contact with residents have been trained on their responsibilities under
the agency’s sexual abuse and sexual harassment prevention, detection,
and response policies and procedures.
According to the PAQ, all volunteers and contractors who have contact with
residents have been trained on their responsibilities under the agency’s policies and
procedures regarding sexual abuse and sexual harassment prevention, detection,
and response. Agency policy FDJJ 1919, p.18, states, "All volunteers and contracted
providers in Residential and Detention facilities who have contact with youth must
be trained on their responsibilities under the Department’s sexual misconduct
prevention, detection, and response policy and procedures." The facility
policy, 5-19, p.15, provides that contractors and volunteers who have contact with
residents shall be trained on their responsibilities regarding PREA.
The PAQ provides that there are no contractors and volunteers; however, the
education staff, contract physician, and contract psychiatrist were identified as
contractors. The as agency for the education unit has a direct contract with the
Department of Juvenile Justice (DJJ), who ensures their PREA training is provided.
Two contractors within the education unit were interviewed; the facility does not
have volunteers that have contact with residents as provided in the PAQ and
confirmed by the superintendent. Documentation from the education contractor was
received confirming the PREA education provided. A review of the DJJ training
curriculum and interviews with two contractors confirmed the training occurs. The
contractors confirmed they had received training in their responsibilities regarding
sexual abuse and sexual harassment prevention, detection and response, per the
agency's policy and training curriculum. The interviews with the two contractors
also confirmed information received regarding the agency's zero-tolerance
regarding sexual abuse and sexual harassment.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with the provision of this standard.
Provision (b):
The level and type of training provided to volunteers and contractors shall
be based on the services they provide and level of contact they have with
residents, but all volunteers and contractors who have contact with
residents shall be notified of the agency’s zero-tolerance policy regarding
sexual abuse and sexual harassment and informed how to report such
incidents.
The interviews and review of documentation revealed the PREA training informs the
participants of their role in reporting allegations of sexual abuse and sexual
harassment. The interviews with the two contractors confirmed they are informed of
their responsibilities regarding sexual abuse prevention, detection, and response to
an allegation of sexual abuse or sexual harassment. The seven page curriculum is
designed for specialized staff that serves as contractors. The agency's zero-
tolerance policy FDJJ 1919 is reviewed within the training, according to the
interviews. The zero-tolerance policy is also posted on the agency's website and
may be downloaded.
The PREA training was provided online to the contractors, confirmed by interviews
and training curriculum. The contractors collectively provided the training included
an overview of PREA; how and when to report; pointed out the posted PREA
information; and reviewed zero-tolerance policy. The initial online training contains
cognitive post-tests and participation is documented electronically. Both volunteers
shared they are comfortable in reporting allegations of sexual abuse and sexual
harassment if the need arises.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with the provision of this standard.
Provision (c):
The agency shall maintain documentation confirming that volunteers and
contractors understand the training they have received.
The training evidence and interviews confirmed the receipt and awareness of
training by contractors. The interviews indicated the contractors understood the
training received. The DJJ initial online training curriculum for volunteers and
contractors contains cognitive post-tests and participation is documented
electronically.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with the provision of this standard.
115.333 Resident education
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
VRI-Video Remote Interpreting Agreement
Youth and Parent Program Handbook
New Youth Orientation Checklist
Youth Acknowledgement and Notification of PREA
PREA Education Sign-In Sheets
Multi-lingual PREA Brochures
Multi-lingual Posted PREA Information
Interviews:
Residents
Intake Staff
Provisions (a):
During the intake process, residents shall receive information explaining,
in an age- appropriate fashion, the facility’s zero tolerance
policy regarding sexual abuse and sexual harassment and how to report
incidents or suspicions of sexual abuse or sexual harassment.
According to the PAQ: Residents receive information at the time of intake about the
zero-tolerance policy and how to report incidents or suspicions of sexual abuse or
sexual harassment. The information is provided in an age appropriate fashion. There
were 46 residents admitted in the past 12 months who received
comprehensive age-appropriate education on their rights to be free from sexual
abuse and sexual harassment, from retaliation for reporting such incidents, and on
agency policies and procedures for responding to such incidents within 10 days of
intake. Agency policy FDJJ 1919, p. 18, states the following:
"1. During intake, all youth will be provided with information on the agency’s zero-
tolerance policy regarding sexual misconduct, including how to report incidents or
suspicions of sexual misconduct.
2. Special accommodations shall be made to ensure all written information about
sexual misconduct policies, including how to report sexual misconduct, is conveyed
verbally to youth with limited reading skills or who are visually impaired, deaf, or
otherwise disabled.
3. Within 10 days of intake, the facility shall provide comprehensive education to
youth (either in-person or via video) regarding 1) youths’ rights to be free from
sexual misconduct, 2) youths’ rights to be free from retaliation for reporting such
misconduct, and 3) the facility’s sexual misconduct response policies and
procedures. Refresher information will be readily available to all youth at all
facilities. The facility will retain documentation of youth participation in said training
classes."
The evidence shows residents received PREA-related information at the time of
intake, including the zero-tolerance policy of the facility, and how to report
allegations of sexual abuse and sexual harassment. The policy provides that all
residents admitted receive PREA education. Residents received directions on how to
report allegations of sexual abuse and sexual harassment; and the right to be free
from retaliation for reporting, according to the 16 residents interviewed, intake staff
interviewed, and a sample of 16 acknowledgement statements signed by residents.
The interviews with the 16 residents revealed they have a clear understanding of
the aforementioned and the various ways of how to report allegations of sexual
abuse and sexual harassment. The responses from residents on how they were
provided the information included: staff explained; provided a packet; provided a
Youth and Parent Program Handbook; saw the PREA video; read some papers or had
them read to him; and/or saw the information posted on the walls. The Youth and
Parent Program Handbook, pp.44-45, provides information on how to report
allegations of sexual abuse, including the abuse reporting hotline number.
The intake staff interview and the review of a sample of 16 resident files containing
acknowledgement statements confirmed residents are provided with information
about the agency's zero-tolerance policy and how to report incidents or suspicions
of sexual abuse and sexual harassment, at intake. It was also stated that the intake
process is managed by the youth's assigned Case Manager and they verbally
explain the PREA information and provide written information as well. The following
questions were asked of residents directly by the auditor, "When you came here,
were you told about: a. Your right to not be sexually abused or sexually harassed? b.
How to report sexual abuse or sexual harassment? c. Your right not to be punished
for reporting sexual abuse or sexual harassment?" The 16 residents interviewed
indicated the information was provided. When asked directly how long after coming
to the facility did they get the information, one answered on the second day of
admission; 15 answered on the same day of admission. Youth Acknowledgement
and Notification of Prison Rape Elimination Act (PREA) sheets were reviewed with
the youth by the intake staff, according to the interviews and signatures of residents
and intake staff on the 16 documents reviewed that contained the aforementioned
and other pertinent PREA information. All Youth Acknowledgement and Notification
of PREA sheets indicated the the PREA education sessions were conducted on the
same day of admission as stated by the intake staff.
The parent agency's overarching VRI-Video Remote Interpreting Agreement with
American Sign Languages Services, Incorporated, provides for language interpreter
services, access to certified American Sign Language providers, and specialized
interpreters for Deaf and Hard-of-Hearing residents, as confirmed by the service
provider's representative regarding professional interpreting services and American
Sign Language services. The education unit also provides support services,
especially through certified teachers with the educational background to modify/
adapt information for all residents to understand. Assistance may also be provided
by the treatment staff to ensure all residents’ understanding of the PREA
information. Posted PREA information and brochures are in English, French, and
Spanish. According to the VRI-Video Remote Interpreting Agreement and the
representative, translators for various spoken languages are available. The PREA
video is in English and Spanish and is accessible in other languages as needed.
There were no new admissions during the onsite audit phase. No interpretation
services were needed during the onsite audit phase and there was no evidence of
use during this audit period. The intake staff conducted a walkthrough of the intake
process and the paths taken by the youth during the intake process. The New Youth
Orientation Checklist is activated and completed for each new admission and must
be a part of the resident's file. This required document ensures current residents
have been provided information about the agency's zero-tolerance policy and how
to report incidents or suspicions of sexual abuse and sexual harassment.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, the facility is compliant with this provision.
Provision (b):
Within 10 days of intake, the facility shall provide comprehensive age-
appropriate education to residents either in person or through
video regarding their rights to be free from sexual abuse and sexual
harassment and to be free from retaliation for reporting such incidents,
and regarding facility policies and procedures for responding to such
incidents.
According to the PAQ, there were 56 youth admitted to the facility in the past 12
months who received comprehensive age-appropriate education on their rights to
be free from sexual abuse and sexual harassment, from retaliation for reporting
such incidents, and on agency policies and procedures for responding to such
incidents within 10 days of intake. A review of the education materials indicated the
information provided to the residents was age-appropriate. It was revealed that the
review of PREA information is conducted during group sessions as a rotating topic
among treatment topics covered in House Meeting Notes. it was recommended that
additional emphasis be placed on the identification and purpose of the advocacy
facility and the services provided and that it be rotated in the meetings at closer
intervals which has been adopted. The superintendent is in the process of the
review and obtaining the appropriate signature from the advocacy agency which is
a more direct service to the residents in providing advocacy services. The gap being
filled by the Department of Children and Services through the prompt on the hotline
for community resources, is only temporary until the Memorandum of
Understanding is formally in place with the Emerald Coast Children's Advocacy
Center because the previous facility used has been closed. The Emerald Coast
Children's Advocacy Center take referrals from DCF and law enforcement.
Once the review of the PREA information is completed, the resident signs the
acknowledgement form indicating the review of its content. The intake staff
revealed the youth are made aware of this information on the first day of arrival to
the facility and the review of 16 acknowledgement statements indicated same. The
residents initially sign acknowledgement statements (Youth Acknowledgement and
Notification of PREA) which represent receipt of the PREA information provided at
intake; the 16 documents reviewed were signed on the day of admission and House
Meetings Minutes document extended PREA education within 10 days of admission.
The PREA video is also shown within 10 days of intake or during the intake process.
The intake staff indicated there is a verbal review of the PREA information sheet
with all residents that address the following: a. The right to not be sexually abused
or sexually harassed; b. How to report sexual abuse or sexual harassment; c. The
right not to be punished for reporting sexual abuse or sexual harassment. The
resident interviews support the interview with the intake staff.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, the facility is compliant with this provision.
Provision (c):
Current residents who have not received such education shall be educated
within one year of the effective date of the PREA standards, and shall
receive education upon transfer to a different facility to the extent that
the policies and procedures of the resident’s new facility differ from those
of the previous facility.
All residents have received PREA education as evidenced by the the review of
the resident files, 16 resident interviews, intake staff interview, informal
conversations with random residents, and the PAQ. According to policy FDJJ 1919,
p.18, "During intake, all youth will be provided with information on the agency’s
zero-tolerance policy regarding sexual misconduct, including how to report incidents
or suspicions of sexual misconduct." The facility reports that 56 youth were
admitted to the facility during the past 12 months and that all participated in PREA
education sessions. Formal interviews and informal conversations with residents and
interview with intake staff and review of documentation, including the PAQ, support
that all youth admitted to the facility received PREA education during the intake
process.
Acknowledgement statements, Youth Acknowledgement and Notification of PREA,
and the interviews indicated general PREA education is provided and the corrective
action supplemented the general education by providing customized information
regarding outside advocacy services which has been noted on the New Youth
Orientation Checklist and emphasized during the PREA education sessions during
intake and specifically included more regularly in House Meetings, especially
providing the new information regarding how to access advocacy services and the
agency that provides them. There are training acknowledgement forms used for
PREA education during intake and the subsequent group sessions are noted on the
House Meeting Notes Form with an accompanying roster. All residents received the
initial PREA education during the intake process and the comprehensive education
at least 10 days after admission to the facility.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, the facility is compliant with this provision.
Provision (d):
The facility shall provide resident 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.
According to PAQ: Resident PREA education is available in formats accessible to all
residents, including those who are limited English proficient. Resident PREA
education is available in formats accessible to all residents, including those who are
deaf. Resident PREA education is available in formats accessible to all residents,
including those who are visually impaired. Resident PREA education is available in
formats accessible to all residents, including those who are otherwise disabled.
Resident PREA education is available in formats accessible to all residents, including
those who have limited reading skills. All in accordance with agency policy FDJJ
1919, p. 18. The facility has the capability to provide the PREA education in formats
accessible to all residents including those who may be hearing impaired; Deaf; have
intellectual, psychiatric and speech disabilities; low vision; blind; limited
reading,limited English proficient, and based on the individual need of the resident,
per the policy.
The education staff provides services through certified teachers with the
educational background to modify/adapt information for all residents to understand.
The education unit is a resource for accessibility and supportive services; the
mental health and case management units may assist in ensuring residents
understand the PREA information. The facility has bilingual staff as well as access to
the translation of languages upon request through VRI-Video Remote Interpreting
Agreement with American Sign Languages Services, Incorporated which provides for
language interpreter services, access to certified American Sign Language
providers, and specialized interpreters for Deaf and Hard-of-Hearing residents, as
confirmed by the service provider's representative regarding professional
interpreting and American Sign Language services. A representative of the service
provider confirmed the availability of translating services, including services for the
Deaf. The PREA videos are available in English and Spanish and other languages are
accessible to the facility. Posted and other printed PREA information is in English,
Spanish, and French.
The 12 random staff interviews revealed a practice of residents not used as
translators or readers for other residents. There was a collective awareness of the
availability of bilingual staff and/or arrangements for translating services. The
facility has knowledge of the youth’s arrival to the facility prior to the admission
date. This time period provides for the identified staff to make plans to
accommodate the special needs of residents. The special arrangements are
coordinated by treatment team staff in collaboration with the superintendent. PREA
posters, information sheets, and brochures are collectively available in English,
French, and Spanish, and there is access to other languages when indicated. Five
targeted interviewees confirmed receiving information on how to report; their right
not to be sexually abused, and the right not to be punished if they reported an
allegation. They also revealed staff verbally explained the PREA information to
them.
Conclusion:
Based upon the review and analysis of the available evidence, and interviews, the
facility is compliant with this provision.
Provision (e):
The facility shall maintain documentation of resident participation in these
education sessions.
The PAQ acknowledges the facility maintains documentation of resident
participation in PREA education sessions. Signed acknowledgement statements
(Youth Acknowledgement and Notification of PREA) and House Meeting Notes were
reviewed which supported the residents’ involvement in PREA education sessions;
initial and subsequent education sessions. PREA-related topics are a mainstay in
house meetings as noted on the House Meeting Notes document.
The residents’ interviews revealed their participation in PREA education sessions.
The residents were aware of how to report allegations of sexual abuse and sexual
harassment and that they would not be punished for reporting such. There were
documented refresher PREA education sessions conducted on the living units which
included all residents due to the results of the resident interviews and seven out of
16 not being able to readily articulate information regarding advocacy services. The
refresher education sessions provided enhanced information and the participants
utilized a sign-in roster, which contained the handwritten names of the participants,
confirming the implementation of the corrective action during the onsite audit
phase. Confirmation was also obtained from informal conversations with random
residents during a subsequent walkthrough.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
informal conversations with random residents, the facility is compliant with this
provision.
Provision (f):
In addition to providing such education, the facility shall ensure that key
information is continuously and readily available or visible to residents
through posters, resident handbooks, or other written formats.
The PAQ acknowledged, the facility ensures that key information about the agency's
PREA policies is continuously and readily available or visible through posters,
resident handbooks, or other written formats. The PREA education materials
provided residents information on how to report allegations of sexual harassment
and sexual abuse. PREA information is posted and provided to residents to assist in
eliminating incidents of sexual abuse and sexual harassment. The posted and other
printed materials provided information on sexual abuse and sexual harassment;
steps victims may take; advocacy services, and reporting information. Each resident
is provided a Youth and Parent Program Handbook and an orientation packet which
also contains PREA information. PREA-related information was observed posted or
displayed throughout the facility.
PREA signage is placed at varying eye levels and are colorful and/or graphic with
consistent messages. The signage in the dormitories are placed at a level for
reading while standing or seated as tested by the auditor. Civil Immigration
information is also posted. The interviews with the residents revealed they know
where to find information on the wall if they need it. Informal conversations with
random residents also revealed the PREA information is always on the wall and they
can obtain the information if they need to. The interviews with 16 residents
confirmed the PREA audit notices had been up for awhile. PREA information is
located in the housing area; common areas for staff, residents, contractors, and
visitors; lobby; and offices.
The interviews with the residents revealed the need for a refresher education
session focusing on the advocacy services available to victims of sexual abuse to
ensure the residents’ clear and un-contradicted understanding of the information.
Seven of 16 residents interviewed did not have a clear understanding of the
information provided regarding advocacy services. The corrective action of
conducting a refresher PREA education session regarding the victim advocacy
services was implemented during the onsite audit phase. The mental health staff
conducted the refresher education session and documentation of the refresher was
recorded on the a training sign-in roster and it contained the handwritten name of
each participant. The document showed the refresher education session included
the PREA education topic of advocacy services which included how to currently
access services and a review the location of the posted information and an overview
of advocacy services. The documentation and informal conversations with the
superintendent and random residents confirmed the occurrence of the refresher
PREA education sessions; the superintendent indicated the residents, overall, have
a better understanding regarding advocacy services.
The corrective action taken during onsite audit phase supported compliance of the
provision because it immediately eliminated the nonconformity with the current
population and provided for improved comprehensive education sessions about
advocacy services for incoming youth. Immediately addressing the issue through
the refresher education sessions mitigated the risk of what delaying the corrective
action may have caused. The corrective action immediately addressed the issue and
also provided for enhancing the information provided during future PREA education
sessions by adding, more frequently, a specific review of advocacy services in the
rotation of PREA topics during the House Meetings.
Conclusion:
Based upon the review and analysis of the available evidence, interviews,
implementation of corrective action, and informal conversations with the
superintendent and random residents, the facility is compliant with this provision.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Pre-Audit Questionnaire (PAQ)
Interview:
Superintendent
Provision (a):
In addition to the general training provided to all employees pursuant to
§115.331, the agency shall ensure that, to the extent the agency itself
conducts sexual abuse investigations, its investigators have received
training in conducting such investigations in confinement settings.
The PAQ provides there are no trained investigators; the facility does not conduct
administrative or criminal sexual abuse investigations; and that the provision is not
applicable. The superintendent confirmed this premise. Allegations of sexual abuse
are investigated by the Florida Department of Children and Families and law
enforcement.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (b):
Specialized training shall include techniques for interviewing juvenile
sexual abuse victims, proper use of Miranda and Garrity warnings, sexual
abuse evidence collection in confinement settings, and the criteria and
evidence required to substantiate a case for administrative action or
prosecution referral.
Allegations that are criminal in nature are investigated by the Florida Department of
Children and Families and law enforcement. The Florida Department of Juvenile
Justice conducts administrative investigations. General PREA training is required in
addition to the specialized training regarding conducting administrative
investigations. The facility and its parent agency do not conduct administrative or
criminal sexual abuse investigations.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (c):
The agency shall maintain documentation that agency investigators have
completed the required specialized training in conducting sexual abuse
investigations.
The facility staff does not conduct administrative or criminal sexual abuse
investigations; there are no trained investigators in the facility or its parent agency.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
115.335 Specialized training: Medical and mental health care
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Training Curricula
Training Records
Interviews:
Medical Staff
Mental Health Staff
Provision (a):
The agency shall ensure that all full- and part-time medical and mental
health care practitioners who work regularly in its facilities have been
trained in:
(1) How to detect and assess signs of sexual abuse and sexual
harassment;
(2) How to preserve physical evidence of sexual abuse;
(3) How to respond effectively and professionally to juvenile victims of
sexual abuse and sexual harassment; and
(4) How and to whom to report allegations or suspicions of sexual abuse
and sexual harassment.
According to the PAQ, a policy exists regarding the training of medical and mental
health practitioners who work regularly in its facilities. Medical and mental health
staff members receive the regular PREA training as well as the specialized training
provided through the Florida Department of Juvenile Justice (DJJ). Electronic training
logs and interviews document regular PREA training and the specialized training for
medical and mental health staff members. The contract facility also provides
training specifically for medical staff regarding the DJJ healthcare system. Policy FDJJ
1919, page 17, provides, "All full and part-time medical and mental health care
practitioners who work in Residential or Detention facilities, whether employed by
DJJ, contracted by DJJ, or contracted by DJJ providers, will be expected to complete
the PREA medical mental health training available in SkillPro. This specialized
training will include the following:
a. How to detect and assess signs of sexual abuse;
b. How to preserve physical evidence of sexual abuse;
c. How to respond effectively and professionally to juvenile victims of sexual abuse;
and
d. How and to whom to report allegations or suspicions of sexual abuse."
The medical and mental health staffs interviewed confirmed that all clinicians in
their respective areas have taken the online specialized training on the DJJ
electronic training platform. The reviewed training curricula consists of three
modules entitled, Mental Health and Medical Professionals, and collectively cover
detection and signs of sexual abuse; preservation of evidence; effective professional
response; and reporting; documented by the training curricula and interviews of the
mental health and medical staff. The electronic training records document receipt of
the training.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
training records, the facility is compliant with this provision.
Provision (b):
If medical staff employed by the agency conduct forensic examinations,
such medical staff shall receive the appropriate training to conduct such
examinations.
Forensic examinations are not conducted at the facility, as verified by medical staff.
Conclusion:
Based upon the review and analysis of the available evidence and interview, the
facility is compliant with this provision.
Provision (c):
The agency shall maintain documentation that medical and mental health
practitioners have received the training referenced in this standard either
from the agency or elsewhere.
The PAQ provides the facility maintains documentation showing that medical and
mental health practitioners have completed the required training. Electronic training
records were reviewed which confirmed the training occurs and the interviews
supported the training occurs. Informal conversations with other clinical staff also
confirmed the participation in the training. The reviewed documentation is
maintained in DJJ's learning and management system, and the documents may be
downloaded.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (d):
Medical and mental health care practitioners shall also receive the
training mandated for employees under Standard 115.331 or for
contractors and volunteers under Standard 115.332, depending upon the
practitioner’s status at the agency.
The electronic training records reviewed demonstrated that medical and mental
health staffs completed the general training that is provided for all employees as
indicated by training documentation, interviews, and informal conversations with
other mental health and medical staff.
Conclusion:
Based upon the review and analysis of the available, interviews, and informal
conversations, the facility is compliant with this provision.
115.341 Obtaining information from residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919. PREA
PREA Pre-audit Questionnaire (PAQ)
Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB) Instrument
Interviews:
Random Residents
Staff Responsible for Screening for Risk of Victimization and Abusiveness
PREA Coordinator
PREA Compliance Manager
Provision (a):
The policy provides that upon arrival or within 72 hours of the resident’s
arrival at the facility and periodically throughout a resident’s confinement,
the agency shall obtain and use information about each resident’s
personal history and behavior to reduce the risk of sexual abuse by or
upon a resident.
According to the PAQ and agency FDJJ 1919, p. 4, each youth admitted to the facility
will be screened during the intake process for risk of victimization prior to room
assignment, for sexual vulnerabilities or acting out with sexually aggressive
behavior. The instrument used to screen for vulnerability to victimization and
sexually aggressive behavior is the VSAB. Information may also be obtained from
the parent/guardian and through review of the court packet, according to the staff
responsible for the risk screening (risk screener). A review of 16 completed VSABs
and interviews with 16 residents, revealed the VSABs are completed by case
management staff on the same day of admission. The number of residents that
entered the facility was 56. The interview with the risk screener revealed that
"every youth" admitted to the facility, received a risk screening through the
administration of the VSAB, on the same day of arrival to the facility. The 16 files
indicated the VSAB was administered on the same day of admission.
The interview with the risk screener revealed a formal reassessment, using the
VSAB, is completed where there is new information (including an allegation of
sexual abuse) and every 30 days as long the resident is scored in the vulnerable
category. Nine out of 16 residents indicated the completion of a re-screening; one
could not remember; one was not sure; and five indicated they had not received a
re-screening. Policy FDJJ 1919, p. 5, provides that the treatment team continually
review the resident's assignment during the treatment team case review process.
Re-screens utilizing the VSAB was evident during the review of the resident files.
The risk screener provided a walkthrough of the process for administering the VSAB
and described a method of taking the time to build a rapport with the youth in an
effort to make the youth feel comfortable and as they open up, let them know that
he is already a little familiar with them. The interview revealed that research is
completed on the youth prior to his arrival to the facility, including interviewing
parents/guardian. The administration of the VSAB is done in the confidential setting
of an office. The risk screener provided that the youth and parents are asked
questions directly from the VSAB. The youth is interviewed during the intake
process to obtain information about his personal history and behavior as indicated
from a review of 16 VSABs and interviews with the residents. During the interviews
with 16 residents, 15 responses indicated administration of the VSAB on the first
day of arrival, one response revealed it was the second day after arrival. Informal
conversations with additional residents revealed familiarity with the questions on
the VSAB. All residents have an assigned Case Manager and Therapist they meet
with regularly.
Conclusion:
Based on the review of documentation and staff and resident interviews,
and informal conversations with residents, the facility is compliant with this
provision.
Provision (b):
Such assessments shall be conducted using an objective screening
instrument.
The PAQ confirms an objective screening instrument is used to obtain the
information required by the standard, including but not limited to prior sexual
victimization or abusiveness; self-identification; current charges and offense history;
disabilities; and a resident’s concern regarding his/her own safety. The instrument,
VSAB, is tabulated based on the information received where identified responses
can identify any special needs and safety concerns. Assessments are conducted
through the use of the VSAB containing verifiable items that collectively provide a
presumptive determination of risk for victimization or abusiveness. The
determination of the VSAB as an objective screening instrument is based on there
being clear, pre-determined, and measurable criteria or objectives and it measures
what it is intended to measure. The VSAB is administered by treatment/program
staff consistently, the same trained group, which also assists in minimizing
subjective interpretation and bias.
Conclusion:
Based on the review of documentation and interviews with mental health staff, the
facility is compliant with this provision.
Provision (c):
At a minimum, the facility shall attempt to ascertain information about:
(1) Prior sexual victimization or abusiveness;
(2) Any gender nonconforming appearance or manner or identification as
lesbian, gay, bisexual, transgender, or intersex, and whether the resident
may therefore be vulnerable to sexual abuse;
(3) Current charges and offense history;
(4) Age;
(5) Level of emotional and cognitive development;
(6) Physical size and stature;
(7) Mental illness or mental disabilities;
(8) Intellectual or developmental disabilities;
(9) Physical disabilities;
(10) The residents’ own perception of vulnerability; and
(11) Any other specific information about individual residents that may
indicate heightened needs for supervision, additional safety precautions,
or separation from certain other residents.
The auditor reviewed the screening instrument, VSAB, and determined the items
required by this provision of the standard are included within the VSAB. The
interview with the risk screener confirmed awareness of the elements of the risk
screening instrument. Sixteen resident interviews also confirmed the administration
of the screening instrument and the general inquiries made as collectively stated:
how you identify, age, if you feel safe, age; and/or if you been in trouble before. The
interviews revealed the practice is that the instrument is administered the first day
of the youth’s admission to the facility. The interviews with residents and risk
screener and review of documentation revealed the practice of the risk screening
being conducted as required and in accordance with policy. The review of the VSAB
and interview with the risk screener confirmed the information obtained from the
VSAB includes but is not limited to the following:
· Prior sexual victimization or abusiveness;
· Resident’s own perception of vulnerability;
· Current charges and offense history;
· Self-identification of resident;
· Intellectual or developmental disabilities;
· Physical disabilities;
· Mental illness or mental disabilities;
· Level of emotional and cognitive
development;
· Confirmation of size and stature;
· Confirmation of Age.
The VSAB contains additional specific information that may indicate heightened
needs for supervision, additional safety precautions, or separation from certain
other residents. There is a question regarding whether or not it is the youth's first
time in a Department of Juvenile Justice facility and another about the youth's
experience in a secure facility. Questions also seek information regarding the social
skills of the youth including their own perception about getting along with others,
feelings about being in groups, and feelings about being with people they do not
know. The interview with the risk screener revealed familiarity with the VSAB and its
measurement of risk factors for vulnerability and and aggressive behavior.
Conclusion:
Based on the review of documentation and interview with the risk screener and
residents, the facility is compliant with this provision.
Provision (d):
This information shall be ascertained through conversations with the
resident during the intake process and medical and mental health
screenings; during classification assessments; and by reviewing court
records, case files, facility behavioral records, and other relevant
documentation from the resident’s files.
The information to complete the risk screening instrument is gleaned from various
sources. Information in determining the risk for victimization or abusiveness is
obtained through interviewing the residents. Additional information to complete the
screening instrument includes review of the court packet and interviews with a
parent/guardian, according to a review of the resident files. The facility staff is
aware of pending admissions and treatment staff has the opportunity to review the
electronic record in an effort to preliminarily prepare for the needs prior to their
arrival. Additional assessments are completed after the youth is admitted to the
facility to obtain supportive information for treatment planning and keeping the
youth safe. The review of the16 resident files confirmed data gathering from various
sources, including parents/guardians and court records.
The resident interviews provided that in addition to meeting with their Case
Manager, Therapist, and Nurse during the intake process and a description of the
meetings was provided. The assessments are completed in private, according to
informal conversations with residents. The risk screener provided a walkthrough of
the process for the assessments and portions of assessments completed or
reviewed by medical and mental health staff and described a method of taking the
time to build a rapport with the youth in an effort to make the youth feel
comfortable; this is done in the confidential setting of an office.
Conclusion:
Based on the review of documentation and interview with the risk screener and
residents, and informal conversations with additional residents, the facility is
compliant with this provision.
Provision (e):
The agency shall implement appropriate controls on the dissemination
within the facility of responses to questions asked pursuant to this
standard in order to ensure that sensitive information is not exploited to
the resident’s detriment by staff or other residents.
The auditor observed appropriate controls taken to ensure that sensitive information
is protected and not exploited by maintaining the files securely in locked file
cabinets in locked offices or rooms when unoccupied. The key to the offices are in
the key control system with limited staff access. Electronic information is password
protected with limited and identified staff access. The risk screener addressed the
management of sensitive information and the access by mental health and case
management staff. The facility's regional PREA coordinator and PREA compliance
manager confirmed the treatment staff have been identified as having access to the
VSAB. Confidentiality is a component of staff training and addressed by policy.
Informal conversations with additional medical and mental health staff and the
interview with the risk screener confirmed use of the control measures regarding
hard copy and electronic records.
Conclusion:
Based upon the review and analysis of the available evidence, interview with risk
screener, and informal conversations with additional treatment staff, the facility is
compliant with this provision.
115.342 Placement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-audit Questionnaire (PAQ)
Vulnerability to Sexual Victimization and Sexually Aggressive Behavior (VSAB)
Instrument
Admission Classification Form
Resident Files
Interviews:
Staff Responsible for Risk Screening (Risk Screener)
PREA Compliance Manager/Superintendent
Random Staff
Medical Staff
Mental Health Staff
Provision (a):
The agency shall use all information obtained pursuant to §115.341 and
subsequently to make housing, bed, program, education, and work
assignments for residents with the goal of keeping all residents safe and
free from sexual abuse.
The PAQ and agency policy, FDJJ 1919, provide that information obtained from
administration of the VSAB is utilized to make placement decisions in all service
areas for residents with the goal of keeping them safe. Facility policy 5-19, p. 6,
provides, "The results of the youth’s VSAB screening shall be used in making room
assignment to ensure vulnerable youth are not assigned a roommate believed to
pose a risk." The interviews with the PREA compliance manager and risk screener
collectively indicated the screening information is used to inform staff of information
based on the need to know. The PREA compliance manager and risk screener
revealed the information from the VSAB is used in determining housing
assignments, shower schedules, and guiding treatment needs.
A classification meeting is held for each resident and re-classification meetings are
held on a regular basis and/or as needed. The initial classification and re-
classification meetings consider housing based on the alert status from the VSAB or
new information, security criteria, medical criteria, mental health criteria, and takes
into account additional information according to the documented meeting on the
Admission Classification Form (ACF). The staff in attendance sign the form; the
reviewed form was signed by the Case Manager, Therapist, Medical, Education,
living unit representative, and administrator/designee. The classification meeting
may assist with program assignments and in identifying treatment and any special
services. The ACF is reviewed and discussed in treatment team meetings to ensure
appropriate assignments for general as well as at-risk placements in the services
areas of education, housing, bed, program, and housekeeping chores. It is also
documented when a resident is re-classified due to a recommended room change.
The review of a sample of 16 files confirmed multi-source information gathering in
completion of the VSABs and ACFs.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (b):
Residents may be isolated from others only as a last resort when
less restrictive measures are inadequate to keep them and other residents
safe, and then only until an alternative means of keeping all residents safe
can be arranged. During any period of isolation, agencies shall not deny
residents daily large-muscle exercise and any legally required educational
programming or special education services. Residents in isolation shall
receive daily visits from a medical or mental health care clinician.
Residents shall also have access to other programs and work
opportunities to the extent possible.
According to overarching agency policy FDJJ 1919, pp. 5-6, a resident would only be
placed in isolation as a last resort for protection and it would only be until other
arrangements could be made to keep the resident safe. The superintendent's
interview was aligned with agency policy. If in protective custody, the agency policy
also provides that residents will receive services which include education, medical
and mental health services. According to the clinicians, isolation is not used in the
facility; if it happens residents would be seen at least daily. The agency practice is
that isolation is not used; a brief period of separation from the population, referred
to as controlled observation may be used for a brief cooling-off period, according to
agency policy. There was no evidence of the use of protective custody in the facility.
Informal conversations with random staff also revealed that isolation is not used as
protective custody regarding an allegation of sexual abuse. Random staff and
superintendent interviews collectively indicated that protective measures would be
taken immediately when a resident is at risk of sexual abuse by separating residents
to different dorms and alerting supervisors and other staff.
During the comprehensive site review and during the onsite audit period, all rooms
were empty during the day and residents were involved in program activities. There
were not any residents at risk of sexual victimization placed in isolation in the past
year, noted in the PAQ and no indication of such through the interviews with the
superintendent/PREA compliance manager, mental health staff, medical staff, and
16 residents; and review of the sample of 16 of resident files.
Conclusion:
Based upon the review and analysis of the available evidence and interviews with
the risk screener, residents, PREA compliance manager, the facility is compliant with
this provision.
Provision (c):
Not Applicable (NA)
Provision (d):
NA
Provision (e):
NA
Provision (f):
NA
Provision (g):
NA
Provision (h):
If a resident is isolated pursuant to paragraph (b) of this section, the
facility shall clearly document:
(1) The basis for the facility’s concern for the resident’s safety; and
(2) The reason why no alternative means of separation can be arranged.
From a review of 16 resident files of residents, staff interviews, informal
conversations with random staff, and the PAQ, there were no residents at-risk of
sexual victimization who were held in isolation in the past 12 months.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (i):
Every 30 days, the facility shall afford each resident described in
paragraph (h) of this section a review to determine whether there is a
continuing need for separation from the general population.
According to the PAQ and the staff interviews, isolation is not used in this facility. No
residents at risk of sexual victimization were placed in isolation in the 12 months
preceding the audit based on a review of a sample of resident files (16), medical
and mental health staff interviews, and informal conversations with staff. Protective
measures do not include isolation of youth from the general population or routine
activities. Instead, the resident may be placed in a different dorm or room,
according to random staff interviews.
Conclusion:
Based upon the review and analysis of the available evidence and random staff
interviews, the facility is compliant with this provision.
115.351 Resident reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
Florida Administrative Code, Rule 63F-11 PREA
PREA Pre-Audit Questionnaire (PAQ)
Youth and Parent Program Handbook
General Counsel Memorandum
Grievance Form
Request to Speak Form
Sick Call Form
Posted PREA Information
Interviews:
Random Staff
Residents
PREA Compliance Manager
Provision (a):
The agency shall provide multiple internal ways for residents to privately
report sexual abuse and sexual harassment, retaliation by other residents
or staff for reporting sexual abuse and sexual harassment, and staff
neglect or violation of responsibilities that may have contributed to such
incidents.
According to the PAQ: The agency has established procedures allowing for multiple
internal ways for residents to report privately to agency officials about sexual abuse
and sexual harassment; retaliation by other residents or staff for reporting sexual
abuse and sexual harassment; and staff neglect or violation of responsibilities that
may have contributed to such incidents. The agency and facility policies and
practices provide for internal ways a resident may report allegations of sexual abuse
and sexual harassment, including how they can privately report sexual abuse and
sexual harassment; retaliation for reporting; and staff neglect or violations of
responsibilities that may have contributed to such.
Facility policy 5-19, p. 7, provides that residents shall be provided multiple ways to
privately report sexual misconduct, retaliation for reporting sexual misconduct, and
staff neglect or violation of responsibilities. The residents can report by writing the
allegation on a Grievance Form, Request to Speak Form, and/or a Sick Call Request
Form; and/or telling a trusted staff member. Sixteen residents were interviewed and
collectively stated the methods of reporting, aligned with policy, included tell staff,
complete a Grievance or Request to Speak form; use the hotline . Twelve random
staff were interviewed and collectively responded that a resident may make a report
in writing, tell staff directly, or utilize the hotline.
The policies, posted information, and Youth and Parent Program Handbook provide
that residents may report allegations of sexual abuse or sexual harassment by
telephone through the 24-hour Florida abuse reporting hotline. Telephones are
accessible to residents for reporting allegations of sexual abuse and sexual
harassment. Staff members are required by agency policy to make the use of the
telephone accessible for residents to report allegations of sexual abuse and sexual
harassment, and staff neglect or violation of responsibilities that may have
contributed to such incidents. This premise is supported by the agency policy FDJJ
1919. Additionally, the policy provides that residents 18 years and over may call
Central Communications Center and the Florida abuse reporting hotline is available
as an outside reporting method.
Policy, posters, and the Youth and Parent Program Handbook collectively provide the
telephone numbers and instructions for reporting allegations and/or receipt of
follow-up information as a result of sexual abuse or sexual harassment. The posters
are at varying eye levels and a Handbook is provided to each resident. In addition to
accessing a telephone, residents are also informed in the PREA education sessions,
determined from the interviews, that they may tell staff; submit a complaint in
writing including the use of a Grievance Form or Request to Speak Form; or use the
hotline regarding allegations of sexual abuse or sexual harassment. The random
staff interviews collectively revealed residents may use a telephone, submit a
complaint in writing, or talk to staff to privately report sexual abuse and sexual
harassment.
The auditor observed that residents have access to writing materials and locked
receptacle, accessible to all residents for reporting allegations of sexual abuse and
sexual harassment. The written allegations may also be given to staff as determined
from the informal conversations with residents during the comprehensive site
review. If a Grievance Form is used to make a written allegation of sexual abuse, the
reporting procedures will be implemented in accordance with policy. Staff members
receive information on how to report allegations of sexual abuse or sexual
harassment through policies and procedures, training, and staff meetings.
Florida Administrative Code, Chapter 63-F, established by the Department of
Juvenile Justice, governs the mandatory, rapid reporting of incidents within juvenile
facilities to ensure safety, security, and proper care. Florida Statute 39.201 is a
mandatory reporting law that requires anyone to immediately report the suspicion
of child abuse, abandonment, or neglect to the Department of Children and Families
(DCF). The abuse reporting hotline is managed by DCF. The PREA education
materials provide residents information on how to report allegations of sexual
harassment and sexual abuse
Observations revealed the signage was posted announcing occurrence of the PREA
audit in the places initially identified initially; the signs were colorful and easy to
read and were accessible to residents, staff, contractors, and visitors. PREA related
signage had a consistent message regarding general information and how to report
and were in both English and Spanish at varying eye level. Signs were also reported
regarding advocacy services and civil immigration. The content of the posted
information and how they were posted made them age-appropriate. The information
provided by the signage was not obscured, unreadable by graffiti, or missing due to
damage. The content of the posted information was aligned with the Youth and
Parent Program Handbook and policies.
Residents are able to write and receive mail as indicated by the interviews with the
13 residents and informal conversations with additional residents and staff during
the comprehensive site review. The Youth and Parent Program Handbook outlines
the procedures for incoming and outgoing mail, telephone calls, and visitation. All
16 residents interviewed stated they have someone on the outside they have
contact with that do not work at the facility to report sexual abuse or sexual
harassment if they needed to. The residents either stated family or identified a
family member they had outside contact with and they were aware of visitation and
telephone call days. The residents' files were observed to be maintained in a
confidential manner, primarily electronically, password protected. Paper documents
are maintained secure in lockable cabinets inside lockable offices within a key
control system with limited access.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (b):
The agency shall also 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 sexual abuse and sexual harassment to agency officials,
allowing the resident to remain anonymous upon request. Residents
detained solely for civil immigration purposes shall be provided
information on how to contact relevant consular officials and relevant
officials at the Department of Homeland Security.
The State abuse reporting hotline may be used by residents and staff to report
allegations of sexual abuse and sexual harassment. Florida Statute 39.201 is a
mandatory reporting law that requires anyone to immediately report the suspicion
of child abuse, abandonment, or neglect to the Department of Children and Families
(DCF). The abuse reporting hotline is managed by DCF and was established and
mandated by another Florida law, Protection of Vulnerable Persons Act. Agency
policy FDJJ 1919 requires residents' access to telephones to report allegations of
sexual abuse or sexual harassment.
The interviews with 16 residents revealed four of them stating one of the ways they
would report an allegation of sexual abuse or sexual harassment is through the
abuse reporting hotline. Telephones are accessible to all staff and are made
accessible to residents by staff, according to informal conversations with residents
and random staff during the comprehensive site review. According to the Youth and
Parent Program Handbook, p.44, the message to the resident is to call the Florida
abuse reporting hotline if they feel they have been the victim of any form of abuse
or neglect and the number is provided. The Handbook also provides, "Please let
staff know if you need to make a report to the abuse hotline, and they will ensure
that you have unimpeded access to make the call. This means that you do not have
to obtain permission. Also, staff cannot determine whether you feel you have been
abused."
According to the interviews with residents, all 16 had someone on the outside they
could report to about sexual abuse or sexual harassment if they needed to. The 16
residents interviewed were aware they could make a report anonymously about
sexual abuse or sexual harassment by leaving their name off of a help request form
or note; use of the hotline; and/or tell staff directly. The PREA compliance manager
explained the availability and accessibility of the Florida abuse reporting hotline
which is managed by DCF, independent of the Department of Juvenile Justice. The
Florida abuse reporting hotline is communicated to all residents of all ages as an
outside agency for reporting allegations of sexual abuse and sexual harassment.
The PREA compliance manager confirmed that per policy if a resident requests to
use the hotline, staff has to get the resident to a telephone. He further stated the
resident may remain anonymous upon request, and must be given access to a
telephone in the privacy of an office. The hotline is manned 24/7 with operator
assistance and that notification to the investigative entities is also made by the
hotline operator. Reporting information was observed posted in offices and in the
living areas and the offices were observed where calls to the hotline could be made
in private.
The Youth and Parent Program Program Handbook informs residents of the abuse
reporting hotline number and instructions of how to use it. The Youth and Family
Program Handbook provides the number to call if a resident is 18 years or older;
however, DCF remains the external reporting option for all residents and access is
available and communicated to residents 18 and over independent of the CCC
option. The abuse reporting hotline was tested by the auditor and the routing of the
call was explained by the operator. The caller is informed electronically that they
may remain anonymous upon request, prior to actually reporting the allegation. An
allegation may also be reported in Spanish by following the recorded prompt on the
hotline.
The reports of sexual abuse or sexual harassment are referred for an investigation
per established protocol to the appropriate investigative entity. The facility does not
detain residents solely for civil immigration purposes according to the General
Counsel Memorandum, from the agency's legal department.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (c):
Staff shall accept reports made verbally, in writing, anonymously, and
from third-parties and shall promptly document any verbal reports.
According to the overarching agency policy, FDJJ 1919, "Florida Administrative Code
Rule 63F-11, Central Communications Center (CCC), requires that any allegation of
sexual misconduct or youth-on-youth sexual activity be reported to the CCC. The
person making the report shall provide basic information such as the date and time
of the incident, where the incident occurred, the supervising staff, and who may be
involved." The interviews with the 12 random staff confirmed the methods available
to residents for reporting allegations of sexual abuse and sexual harassment. Staff
members are required to accept reports made directly to them, anonymously, or
through a third-party.
The resident interviews revealed awareness of reporting either in person, in writing,
by telephone, or through a third-party and that someone else could make a report
for them so they would not have to give their name. The residents were also aware
that reports could be made anonymously, in writing, tell staff or someone else, and/
or the hotline. The 16 residents interviewed indicated they could make a report of
sexual abuse or sexual harassment in person or in writing and that someone else
could make a report for them so they would not have to give their name.
Conclusion:
Based upon the review and analysis of the available evidence and
interviews, the facility is compliant with this provision.
Provision (d):
The facility shall provide residents with access to tools necessary to make
a written report.
According to the PAQ, the facility provides residents with access to tools to make
written reports of sexual abuse or sexual harassment, retaliation by other residents
or staff for reporting sexual abuse and sexual harassment, and staff neglect or
violation of responsibilities that may have contributed to such incidents. During the
comprehensive site review, the auditor observed the accessibility of writing utensils,
including the help request forms, for the residents, necessary to make a written
report.
Interviews with the residents revealed writing materials are available for residents
to complete PREA/Grievance and other forms or write notes to report allegations of
sexual abuse or sexual harassment. Each resident is provided a Youth and Parent
Program Handbook which contains information regarding reporting by a written
method. The PREA compliance manager confirmed the posted forms and
accessibility to pens or pencils through staff on the living units and in the
classrooms. The residents interviewed could articulate how written communication
is conducted; letters are allowed outgoing and incoming, managed by case
management staff.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (e):
The agency shall provide a method for staff to privately report sexual
abuse and sexual harassment of residents.
According to the PAQ, the agency has established procedures for staff to privately
report sexual abuse and sexual harassment of residents and they are informed of
this through staff meetings, training, policy, Florida statutes, and the Florida
Administrative Code. There is a toll free number on the agency website for staff to
report suspected inappropriate or illegal conduct in a confidential manner.
The 12 random staff interviews revealed ways for reporting allegations privately
which are accessible to all staff: State abuse hotline; Central Communications
Center hotline; in writing; talk directly to supervisor or management staff; or call the
police. According to informal conversations with random staff during the
comprehensive site review, the responses mirrored those provided in the formal
interviews.
Conclusion:
Based upon the review and analysis of the available evidence, informal
conversations, and interviews, the facility is compliant with this provision.
115.352 Exhaustion of administrative remedies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy, FDJJ 1919, PREA
PREA Pre-Audit Questionnaire
Provision (a):
An agency shall be exempt from this standard if it does not have
administrative procedures to address resident grievances regarding
sexual abuse.
According to the PAQ, the agency does not have an administrative procedure for
dealing with resident grievances regarding sexual abuse. The grievance process is
not used for PREA-related allegations; they are immediately reported in accordance
with the agency policy regarding reporting allegations of sexual abuse and sexual
harassment. Agency policy, FDJJ 1919, p.10, provides, "Any allegation(s) of sexual
misconduct are immediately reported and converted to investigations that are
outside the agency and are not considered by the agency to be grievances."
Conclusion:
Based on the agency policy and informal conversation with the statewide PREA
Coordinator, the standard is not applicable to this facility.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Draft Memorandum of Understanding (MOU)
Posted/Printed Information
Interviews:
Residents
Superintendent/PREA Compliance Manager
Advocacy Agency Representative
Residents
Provision (a):
The facility shall provide residents with access to outside victim advocates
for emotional support services related to sexual abuse, by providing
posting, or otherwise making accessible mailing addresses and telephone
numbers, including toll free hotline numbers where available, of local,
State, or national victim advocacy or rape crisis organizations, and, for
persons detained solely for civil immigration purposes, immigrant services
agencies. The facility shall enable reasonable communication between
residents and these organizations and agencies, in as confidential a
manner as possible.
According to the PAQ: The facility provides residents with access to outside victim
advocates for emotional support services related to sexual abuse. The facility
provides residents with access to such services by giving residents (by providing,
posting, or otherwise making accessible) mailing addresses and telephone numbers
(including toll-free hotline numbers where available) for local, State, or national
victim advocacy or rape crisis organizations. The facility provides residents (by
providing, posting, or otherwise making accessible) with access to such services by
giving residents mailing addresses and telephone numbers (including toll-free
hotline numbers where available) for immigrant services agencies for persons
detained solely for civil immigration purposes. The facility provides residents with
access to such services by enabling reasonable communication between residents
and these organizations in as confidential a manner as possible.
Policy FDJJ 1919, p. 15, states, "Youth shall have access to outside victim advocates
for emotional support services related to sexual misconduct. The facility shall post,
provide, or otherwise make accessible mailing addresses and telephone numbers
(including hotline numbers) of local, state, or national victim advocacy or rape crisis
organizations."
Seven of the 16 resident interviews revealed residents required a refresher
regarding victim advocacy services due to those residents not verbalizing a clear
understanding of advocacy services. Nine of 16 residents interviewed collectively
knew there were advocacy services available on the outside; identified one and/or
two of the services offered; how the services may be accessed; numbers are free to
call; when the calls may be made; and confidentiality of services.
The refresher education sessions were conducted in the living units during the
onsite audit phase. The refresher education sessions focused on advocacy services
and were conducted by mental health staff. The documentation of the PREA
refresher education was provided to the auditor on on the sign-in roster of the
participants and informal conversations with residents confirmed the
implementation of the corrective action. The refresher education session was
conducted with all residents in the facility, ensuring that all residents were provided
current and concise information. Specific information regarding advocacy services
will be rotated more frequently in the House Meetings. PREA information is a
consistently discussed during the House Meetings as noted in the review of House
Meeting Notes; advocacy services, specifically, will be reviewed on a more frequent
basis, confirmed by the superintendent.
Help request forms (Grievance, Sick Call, Request to Speak) are maintained in the
dorms and the residents have access to pencils in the dorms and classrooms. The
Grievance and Sick Call forms may be used to write an allegation and place it in a
locked box and the Request to Speak form identifies specific staff the resident would
like to talk to. The draft MOU between the facility and Emerald Coast Children's
Advocacy Center is in the review process as confirmed by the superintendent due to
the closure of the previous advocacy agency where a MOU existed. The telephone
interview with the representative of the victim advocacy agency confirmed the
services to be provided when needed, as stated, such as 24/7 hotline; resources;
confidentiality; emotional support; medical intervention and services of a Sexually
Assault Nurse Examiner; and accompaniment.
PREA information is posted and provided to residents to assist in eliminating
incidents of sexual abuse and sexual harassment. The posted and other printed
materials provide information on sexual abuse and sexual harassment; steps victims
may take; and reporting information. Each resident is provided a Youth and Parent
Program Handbook and an orientation packet which also contains PREA information.
PREA-related information was observed posted or displayed throughout the facility.
PREA signage is placed at eye levels that may be read standing or seated and are
colorful and/or graphic with consistent messages. Signage is posted in both English
and Spanish.
The interviews with the residents and informal conversation with residents revealed
they know where to find information on the wall if they need it. Formal interviews
and informal conversations with residents revealed they initially learned about the
PREA audit either by the signs on the walls or were informed by staff. PREA
information is located in the housing areas; common areas for residents,
contractors, and visitors; lobby; and offices. The interviews confirmed the PREA
audit notices had been on the walls for awhile. The residents may ask any staff to
use the telephone at any time or request for their Case Manager or Therapist to
make the call for them or on their behalf to report an allegation of sexual abuse or
sexual harassment, per informal conversations with residents and random staff
during the comprehensive site review. The Department of Children and Family
Services will assist the facility/resident in obtaining advocacy services as needed
during the gap in the process of getting the MOU reviewed and signed; DCF contact
information is posted, accessible to residents and staff.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility meets this provision.
Provision (b):
The facility shall inform residents, prior to giving them access, of the
extent to which such communications will be monitored and the extent to
which reports of abuse will be forwarded to authorities in accordance with
mandatory reporting laws.
According to the PAQ: The facility informs residents, prior to giving them access to
outside support services, the extent to which such communications will be
monitored. The facility informs residents, prior to giving them access to outside
support services, of the mandatory reporting rules governing privacy,
confidentiality, and/or privilege that apply to disclosures of sexual abuse made to
outside victim advocates, including any limits to confidentiality under relevant
Federal, State, or local law.
Per policy FDJJ 1919, p. 8, "Youth shall have access to outside victim advocates for
emotional support services related to sexual misconduct. The facility shall post,
provide, or otherwise make accessible mailing addresses and telephone numbers
(including hotline numbers) of local, state, or national victim advocacy or rape crisis
organizations. Youth and victim advocate communications shall be
confidential. Youth shall have unimpeded access and means, including written, to
submit or report sexual abuse allegations."
Nine of the 16 residents interviewed, revealed conversations with people from the
advocacy agency would be kept confidential. Policy, facility staff interviews, and the
initial education and refresher education sessions provided that there would be
adherence to confidentiality measures and this information is shared with residents
during PREA education sessions and reminders through printed and posted
materials. The draft MOU contains information about the limitation of confidentiality.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility meets this provision.
Provision (c):
The facility shall maintain or attempt to enter into memoranda of
understanding or other agreements with community service providers that
are able to provide residents with confidential emotional support services
related to sexual abuse. The facility shall maintain copies of agreements
or documentation showing attempts to enter into such agreements.
The PAQ confirms the following: The agency or facility maintains memorandum of
understanding or other agreements with community service providers that are able
to provide residents with emotional support services related to sexual abuse. The
agency or facility has entered into a MOU with a community service provider that is
able to provide such services. The agency maintains documentation of attempts to
enter into such agreements.
The provision of advocacy services includes but not limited to emotional support;
forensic medical examination; and accompaniment through the forensic medical
examination and investigative interview as confirmed during the interview with the
advocacy agency representative. The draft MOU speaks to confidentiality. The
review of the draft MOU also revealed the advocacy agency provides confidential
emotional support.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility meets this provision.
Provision (d):
The facility shall also provide residents with reasonable and confidential
access to their attorneys or other legal representation and reasonable
access to parents or legal guardians.
According to the PAQ, The facility provides residents with reasonable and
confidential access to their attorneys or other legal representation and the facility
provides residents with reasonable access to parents or legal guardians. Per policy
FDJJ 1919, p.9, "Youth shall have reasonable and confidential access to their
attorney or other legal representation, their parents, or legal guardians for reporting
of sexual allegations. Youth shall have unimpeded access and means, including
written, to submit or report sexual allegations." The Student and Parent Handbook
provides information regarding visitation (pp. 41-42), mail (p. 38),and telephone
privileges (p. 40).
Telephone calls and visitation are conducted weekly, according to the resident
interviews; family day is conducted quarterly. Case Managers ensure the
opportunity for incoming and outgoing mail. The residents have reasonable and
confidential access to attorneys and court workers and reasonable access to their
parents/legal guardians which was supported by the interviews, policy, and Youth
and Parent Program Handbook. The residents were able to identify the days for
telephone calls and visitation. The residents are allowed to send and receive mail.
All residents interviewed stated communication opportunities occur. The rules
regarding written, verbal, and in-person communication provide opportunities for a
resident to have contact with someone on the outside to report to regarding
allegations of sexual abuse or sexual harassment if needed, this premise was also
supported by the resident interviews and informal conversations with random
residents.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility meets this provision.
115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19, PREA
PREA Pre-audit Questionnaire (PAQ)
Posted PREA Information
Agency Website
Interviews:
Random Staff
Residents
Standard 115.354:
The agency shall establish a method to receive third-party reports of
sexual abuse and sexual harassment and shall distribute publicly
information on how to report sexual abuse and sexual harassment on
behalf of a resident.
According to the PAQ, the agency provides a method to receive third-party
reports of allegations of resident sexual abuse and sexual harassment and publicly
distributes information on how to report such on behalf of a resident. Facility policy
5-19, p. 9, states, "The facility shall receive third-party reports of sexual abuse and
sexual harassment and shall distribute publicly information on how to report sexual
abuse and sexual harassment on behalf of a youth. This will be accomplished via
posters placed in administration building, visitation area, dorms and classrooms."
The auditor observed posted information, including brochures, within the lobby,
cafeteria, classrooms, and living units which provided that allegations may be
reported by a third party through the abuse registry hotline, Florida Department of
Juvenile Justice (DJJ) Central Communications Center, and by contacting law
enforcement. The same information was also observed posted on the DJJ agency
website. The toll free telephone numbers are provided for the hotline on the posted
information as well as on the website.
Facility policy 5-19, p.7, provides. "The facility shall provide youth with access to
tools necessary to make a written report and staff shall accept reports made
verbally, in writing, anonymously, and from third parties." The posted information
within the facility and on the website informs that a third-party may report an
allegation through the hotline numbers provided or to law enforcement. The 12
random staff members interviewed were aware that third-party reporting of sexual
abuse or sexual harassment may be received by staff and reported. The random
staff members also provided the verbal reports received must be documented
immediately.
All 16 residents interviewed indicated knowing someone who did not work at the
facility that they have contact with and could report an allegation to and that person
could make the report for them if needed. The residents collectively identified the
methods within the facility in which they may make a direct or third-party report
such as complete a grievance form or other help request form for reporting the
allegation, report to staff, or utilize the abuse reporting hotline number. A person
outside of the facility may report allegations of sexual abuse and may make a report
for a resident, also confirmed by the residents during the interviews.
The auditor observed the PREA audit notices posted throughout the facility including
lobby (administrative area), living areas, classrooms, and visitation area. The
advocacy agency information is posted in the living areas .The observed signage
was consistent in messaging and could be read from a standing or sitting
position. The PREA-related signage was accessible to residents, staff, contractors,
and visitors. The auditor tested the reporting method of the use of the hotline by a
third-party. The operator confirmed the allegation would be accepted and routed for
an investigation. The abuse reporting hotline is managed by the Florida Department
of Children and Families. The resident interviews and informal conversations with
residents revealed the reporting information is always posted on the walls within the
facility. The auditor reviewed the third-party reporting mechanism for consent or
eligibility restrictions and found none.
Conclusion:
Based upon the review and analysis of the available evidence, observations, and
interviews, the facility is compliant.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
Florida Statute 39.201
Pre-Audit Questionnaire (PAQ)
Interviews:
Random Staff
Superintendent/PREA Compliance Manager
Medical Staff
Mental Health Staff
Provision (a):
The agency shall require all staff to report immediately and according to
agency policy any knowledge, suspicion, or information they receive
regarding an incident of sexual abuse or sexual harassment that occurred
in a facility, whether or not it is part of the agency; retaliation against
residents or staff who reported such an incident; and any staff neglect or
violation of responsibilities that may have contributed to an incident or
retaliation.
The PAQ states all staff are required to immediately report and in accordance with
policy the following: (1. Any knowledge, suspicion, or information they receive
regarding an incident of sexual abuse or sexual harassment that occurred in a
facility, whether or not it is part of the agency. (2. Any retaliation against
residents or staff who reported such an incident. (3. Any staff neglect or violation of
responsibilities that may have contributed to an incident or retaliation.
Agency policy FDJJ 1919, p.10, states, "Florida Administrative Code Rule 63F-11,
Central Communications Center (CCC), requires any allegation of sexual misconduct
or youth-on-youth sexual activity be reported to the CCC." The Florida
Administrative Code Rule 63F-11 establishes the requirements for reporting serious
incidents involving youth in the care of DJJ or its providers. It requires reporting
serious incidents immediately and within two hours. Facility policy 5-19, p.7, states,
"All allegations of sexual misconduct or youth-on-youth sexual activity shall be
reported to the CCC within 2 hours."
Twelve random staff were interviewed, all responded affirmatively that the facility
requires all staff to report any knowledge, suspicion, or information regarding an
incident or sexual harassment that occurred in a facility; retaliation against
residents or staff who reported such an incident; and any staff neglect or violation of
responsibilities that may have contributed to an incident or retaliation. All random
staff interviewed, revealed the policy for reporting and information related to
resident sexual abuse is to inform a supervisor and/or management who will make
the telephone call to report the allegation to the appropriate investigative entities.
Conclusion:
Based on the the evidence provided and interviews, the facility is compliant with
this provision.
Provision (b):
The agency shall also require all staff to comply with any applicable
mandatory child abuse reporting laws.
The PAQ affirms the facility requires all staff to comply with the applicable
mandatory reporting laws. The policies support that all staff report any knowledge,
suspicion, information, or receipt of information regarding an incident or allegation
of sexual abuse, sexual harassment or incidents of retaliation and according to
mandatory reporting laws. Staff members are deemed as mandated reporters by
the State of Florida. Policy provides guidance to staff on reporting allegations of
sexual abuse and sexual harassment. Florida Statute Chapter 29, Section 201
addresses mandatory reports of child abuse, abandonment, or neglect; mandatory
reports of death; and central abuse hotline. The 12 random staff interviewed
identified the occurrence of their last PREA training and that it included how to
comply with relevant laws related to mandatory reporting of sexual abuse to outside
authorities.
Conclusion:
Based on the the evidence provided and interviews with random staff, the facility is
compliant with this provision.
Provision (c):
Apart from reporting to designated supervisors or officials and designated
State or local services agencies, staff shall be prohibited from revealing
any information related to a sexual abuse report to anyone other than to
the extent necessary, as specified in agency policy, to make treatment,
investigation, and other security and management decisions.
Agency policy FDJJ 1919, p.10, states, "Florida Administrative Code Rule 63F-11,
Central Communications Center (CCC), requires that any allegation of sexual
misconduct or youth-on-youth sexual activity be reported to the CCC. The person
making the report shall provide basic information such as the date and time of the
incident, where the incident occurred, the supervising staff, and who may be
involved. The CCC will make appropriate notification to senior DJJ management who
will in turn make subsequent notification to management overseeing the facility
where the alleged abuse occurred. Other than making appropriate notification
through Department channels, staff should take no further actions other than those
directed by law enforcement or first responders." Facility policy 5-19, p. 8, states,
"Staff is prohibited from revealing any information related to a sexual misconduct
report to anyone than to the extent necessary to make treatment, investigation, and
other security and management decisions."
Florida Administrative Code Chapter 63F-11 is managed by the Department of
Juvenile Justice and established the Central Communications Center (CCC) for
reporting significant incidents within two hours. Staff PREA training addresses
confidentiality of information and the conditions for providing information. The
policies collectively indicate that after allegations have been appropriately reported,
staff shall keep the information confidential regarding what was reported except
when necessary regarding the investigation and treatment and management
decisions.
Conclusion:
Based on the the evidence provided and interviews, the is compliant with this
provision.
Provision (d):
(1) Medical and mental health practitioners shall be required to report
sexual abuse to designated supervisors and officials pursuant to
paragraph (a) of this section, as well as to the designated State or local
services agency where required by mandatory reporting laws. (2) Such
practitioners shall be required to inform residents at the initiation of
services of their duty to report and the limitations of confidentiality.
According to the PAQ, medical and mental health practitioners are required to
report sexual abuse to designated supervisors and officials pursuant to paragraph
(a) of this section as well as to the designated State or local services agency where
required by mandatory reporting laws and medical and mental health practitioners
are required to inform residents of their duty to report, and the limitations of
confidentiality, at the initiation of services.
According to policy 5-19, p. 5, "Medical, case managers and mental health
practitioners are required to report sexual misconduct to designated supervisors
and Department officials, the CCC, law enforcement if criminal in nature, and the
Abuse Registry. Said practitioners must inform residents at the initiation of services
of their duty to report and the limitation of confidentiality." FDJJ 1919, p. 11,
provides, "Any staff, contractor(s), or volunteer(s) who receives a report of a sexual
misconduct or possible sexual misconduct must ensure that it is reported to the
Department of Children and Families Florida Abuse Hotline, local law enforcement if
criminal in nature, and the CCC."
The clinical staff interviewed indicated that residents are informed at the initiation
of services of the limitations of confidentiality and the duty of staff to report. The
clinical staff revealed they are mandated reporters and required by the State to
report allegations received regarding sexual abuse and sexual harassment, in
accordance with facility policies and State requirements. The interviews with clinical
staff revealed no awareness of an allegation sexual abuse or sexual harassment
during this audit period. Florida Statute 39.201 includes that caregivers or other
persons responsible for the child's welfare must report the knowledge or suspicion
of abuse. The clinicians confirmed they are required to report any knowledge,
suspicion, or information regarding an incident of sexual abuse or sexual
harassment to a designated supervisor or official immediately upon learning about
it. Both clinicians acknowledged informing residents of the limitations of
confidentiality and their duty to report.
Conclusion:
Based on the the evidence provided and interviews with medical and mental health
staff, the facility is compliant with this provision.
Provision (e):
(1) Upon receiving any allegation of sexual abuse, the facility head or his or her
designee shall promptly report the allegation to the appropriate agency office and
to the alleged victim’s parents or legal guardians, unless the facility has official
documentation showing the parents or legal guardians should not be notified. (2) If
the alleged victim is under the guardianship of the child welfare system, the report
shall be made to the alleged victim’s caseworker instead of the parents or legal
guardians. (3) If a juvenile court retains jurisdiction over the alleged victim, the
facility head or designee shall also report the allegation to the juvenile’s attorney or
other legal representative of record within 14 days of receiving the allegation.
According to the PAQ: (1) Upon receiving any allegation of sexual abuse, the facility
head or designee promptly reports the allegation to the appropriate office. Upon
receiving any allegation of sexual abuse, the facility head or designee promptly
report the allegation to the alleged victim’s parents or legal guardians unless the
facility has official documentation showing the parents or legal guardians should not
be notified. (2) If the alleged victim is under the guardianship of the child welfare
system, the facility head or designee promptly report the allegation to the alleged
victim’s caseworker instead of the parents or legal guardians. (3) If a juvenile court
retains jurisdiction over the alleged victim, the facility head or designee also reports
the allegation to the juvenile’s attorney or other legal representative of record
within 14 days of receiving the allegation.
Facility policy 5-19, p.10, states, "The Facility Administrator, or designee, shall notify
the alleged victim’s parents or legal guardians; unless there is official
documentation show the parents or legal guardians should not be notified." Agency
policy FDJJ 1919, p.11, states, "All verbal reports shall be documented promptly and
reported accordingly." The review of the investigation reports demonstrates the
allegation were reported promptly, within the mandated two-hour period, to the
investigative entities, including the DJJ Central Communications Center (CCC).
The interview with the superintendent/PREA compliance manager confirmed that a
resident’s case worker rather than a parent would be notified where indicated by
the resident being under the guardianship of the Florida Department of Children and
Families and the attorney of record would be notified within 14 days. He also
indicated he notifies the CCC; parent agency regional manager; law enforcement;
Department of Children and Families (DCF); parents/legal guardians; and DCF case
worker when the DCF guardianship is known. Additionally the superintendent/PREA
compliance manager revealed allegations are expected to be reported as soon as
possible and within the two-hour time period, according to policy and Florida
statute.
Conclusion:
Based on the the evidence provided and interviews, the facility was compliant with
this provision.
Provision (f):
The facility shall report all allegations of sexual abuse and sexual
harassment, including third-party and anonymous reports, to the facility’s
designated investigators.
The PAQ provides that the facility reports all allegations of sexual abuse and sexual
harassment, including third-party and anonymous reports, to the appropriate
investigative entity. According to facility policy 15-19, p., 8 "Reports can be received
verbally, in writing, anonymously and from third parties. Supervisor shall ensure
that it is reported to the Abuse Registry, local law enforcement, if criminal in nature,
the CCC and to the PREA Facility Compliance Manager." Agency policy FDJJ 1919, p.
11, states, "Any staff, contractor(s), or volunteer(s) who receives a report of a
sexual misconduct or possible sexual misconduct must ensure that it is reported to
the Department of Children and Families Florida Abuse Hotline, local law
enforcement if criminal in nature, and the CCC. Reports can be received verbally, in
writing, anonymously, and from third parties."
The policies, review of investigation reports, and interviews provide for all
allegations to be reported and include the Central Communications Center (CCC).
Administrative investigations are conducted by a Department of Juvenile Justice (DJJ)
investigator. Allegations that are criminal in nature are referred for investigation to
local law enforcement. Third-party and anonymous reports received must be
reported and documented by staff as confirmed through interviews and review of
policies. The interviews with the superintendent/PREA compliance manager
confirmed that all allegations are reported to the DJJ Central Communications Center
and the investigative entities.
Conclusion:
Based on the review of evidence and interview with the superintendent, the facility
is compliant with this provision.
115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy 1919, PREA
PREA PRE-Audit Questionnaire (PAQ)
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
Safety Plan
Interviews:
Superintendent
Random Staff
Agency Head Designee
Residents
Provision (a):
When an agency learns that a resident is subject to a substantial risk of
imminent sexual abuse, it shall take immediate action to protect the
resident.
According to the PAQ, staff is required to protect the residents through
implementing immediate protective measures when there is awareness the resident
is subject to a substantial risk of imminent sexual abuse. During the past 12
months, it was not determined that a resident was subject to substantial risk of
imminent sexual abuse, according to the PAQ. Agency policy FDJJ 1919, p.11, states,
"If staff learns that a youth is subject to a substantial risk of imminent sexual
misconduct, they shall take immediate action to protect the youth from further
harm or threat. Also, if staff learns a youth poses a substantial risk of sexually
abusing other youth in the facility, they shall take immediate action to protect other
youth from further harm or threat."
Administration of the risk screening instrument, VSAB, provides information that
assists and guide staff in keeping residents safe through housing and program
assignments. During the intake process, residents are asked about how they feel
about their safety as part of the inquiries by staff completing the VSAB, as
determined from the resident interviews and a review of 16 resident files. The
Trauma-Informed Individualized Safety Plan which assists staff in keeping residents
safe. Inquiries on the Trauma-Informed Individualized Safety Plan include but are not
limited to: ways staff will know when resident is upset; trauma reminders or
triggers; warning signs for when resident is losing control; things that help resident
control emotions; and identification of a safe space where the resident may feel
comfortable.
The interviews with staff summarily revealed protective measures will be
implemented as soon as possible and include separating youth, contacting
supervisors, and contacting superintendent. The facility's agency head designee
shared that all staff are required to take immediate action, separate the residents
involved, alert supervisors, and document the situation. The superintendent shared
that immediate action is required and the vulnerable resident should be removed
from the threat and to another living unit or room. Twelve random staff were
interviewed and the priority was separating the residents; followed by alerting
supervisor and other staff; all responded action would be taken immediately.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
115.363 Reporting to other confinement facilities
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 15-19, PREA
PREA Pre-Audit Questionnaire (PAQ)
Interviews:
Superintendent
Agency Head Designee
Provisions (a):
Upon receiving an allegation that a resident was sexually abused while
confined at another facility, the head of the facility that received the
allegation shall notify the head of the facility or appropriate office of the
agency where the alleged abuse occurred and shall also notify the
appropriate investigative agency.
According to the PAQ, the agency has a policy requiring that, upon receiving an
allegation that a resident was sexually abused while confined at another facility, the
head of the facility must notify the head of the facility or appropriate office of the
agency or facility where sexual abuse is alleged to have occurred. Policy FDJJ 1919,
p 12, is aligned with the provision and states, "Upon receiving an allegation that a
youth was sexually abused while confined at another facility, the head of the facility
that received the allegation shall notify the head of the facility where the alleged
abuse occurred and shall also notify the CCC, the Florida Abuse Hotline, and
local law enforcement." The facility has not received an allegation that a resident
was abused while confined at another facility, in accordance with the PAQ and
interview with the superintendent.
Conclusion:
Based upon the information received and interview with the superintendent, the
facility is compliant with this provision.
Provision (b):
Such notification shall be provided as soon as possible, but no later than
72 hours after receiving the allegation.
The notification shall be made immediately in accordance with policy. Page 11 of
agency policy FDJJ 1919 states, "All staff, contractors, and volunteers are required to
immediately report any knowledge, suspicion, or information received regarding any
incident of sexual misconduct which has occurred in a facility." Facility policy 5-19,
p.10, states, "Upon receiving an allegation that a youth was sexually abused while
confined at another facility, the Facility Administrator, or designee, of the facility
that received the allegation will notify the head of the facility where the alleged
abuse occurred as soon as possible, but no later than 72 hours." The was no
evidence the facility received any such notifications during this audit period and the
superintendent confirms this premise.
Conclusion:
Based upon the information received and interview with the superintendent, the
facility is compliant with this provision.
Provision (c):
The agency shall document that it has provided such notification.
The PAQ provides that the facility will document that it provided such notification
within 72 hours of receiving the allegation. However, no allegations were received
during this audit period. According to policy 5-19, p.10, "Upon receiving an
allegation that a youth was sexually abused while confined at another facility, the
Facility Administrator, or designee, of the facility that received the allegation will
notify the head of the facility where the alleged abuse occurred as soon as possible,
but no later than 72 hours. The facility documents that it has provided required
notification." An incident report would document the notification which must be
completed when reporting an allegation of sexual abuse or sexual harassment.
Conclusion:
Based upon the information received, the facility is compliant with this provision.
Provision (d):
The facility head or agency office that receives such notification shall
ensure that the allegation is investigated in accordance with these
standards.
In the past 12 months, there were no allegations of sexual abuse occurring at
another facility received by this facility, as stated in the PAQ. According to policy
15-19, p.11, "The Facility Administrator will also notify the appropriate investigative
agency. All allegations received from other agencies or facilities are investigated in
accordance with the PREA standards." Page 12 of agency policy FDJJ 1919, states,
"the head of the facility that received the allegation shall notify the head of the
facility where the alleged abuse occurred and shall also notify the CCC, the Florida
Abuse Hotline, and local law enforcement."
According to the superintendent, the allegation would be reported according to
policy which includes notifying the Central Communications Center (CCC) where
investigations are generated and the abuse reporting hotline. The facility's agency
head designee's responses were aligned with the superintendent; appropriate
notifications would be made. This occurrence has not happened during this audit
period, according to the superintendent and the PAQ.
Conclusion:
Based on the information received and interviews with superintendent and agency
head designee, the facility is compliant with this provision.
115.364 Staff first responder duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Interviews:
Random Staff
Provision (a):
Upon learning of an allegation that a resident was sexually abused, the
first staff member to respond to the report shall be required to: (1)
Separate the alleged victim and abuser; (2) Preserve and protect any
crime scene until appropriate steps can be taken to collect any evidence;
(3) If the abuse occurred within a time period that still allows for the
collection of physical evidence, request that the alleged victim not take
any actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating,
defecating, smoking, drinking, or eating; and (4) If the abuse occurred
within a time period that still allows for the collection of physical
evidence, ensure that the alleged abuser does not take any actions that
could destroy physical evidence, including, as appropriate, washing,
brushing teeth, changing clothes, urinating, defecating, smoking,
drinking, or eating.
The PAQ provides that the agency has a first responder policy for allegations of
sexual abuse. Agency policy FDJJ 1919, pp., 12-13, provides the following guidance
to staff:
"1. Upon discovery of an incident defined as sexual abuse, staff members are
responsible for taking immediate actions to ensure the safety of the victim and
notifying appropriate law enforcement and medical personnel. These actions
include, but are not limited to, identifying and separating victim(s), suspect(s), and
making every attempt to preserve evidence.
2. It is essential that the garments/clothing worn by those involved and the scenes
where alleged act(s) occurred be protected to ensure that evidence is not further
contaminated. This means simply securing any evidence until the arrival of law
enforcement. Securing is defined as keeping control over the evidence or scene and
documenting any access to or deviation regarding access to that evidence. Staff
shall not move, touch, or alter the evidence in any way. Staff shall not discuss any
facts of the incidents with anyone except those directly involved in response or
investigation of the incident. All of this information is reportable to law enforcement
and subsequent investigators.
3. Upon receipt of notice that any sexual abuse has occurred in the last 72 hours,
whether informed by the victim or a third party, take the following actions:
a. If the incident is reported by the victim:
i. Ensure the victim is safe, has no further contact with the alleged subject (youth
or staff), and if medical staff is available, take the victim to medical staff.
ii. Do not question the youth, other than to obtain basic information such as the
date and time of the incident, where the incident occurred, the
supervising staff, and who may be involved. Do not request youth to write a
statement.
iii. Immediately preserve the area where the incident allegedly occurred, including
ensuring that bedding, clothing, or related material are not disposed of
or cleaned up by staff, and keep those materials secure or free from contamination
by anyone else until instructed to do differently by law enforcement.
iv. Immediately notify the facility management.
v. Immediately notify law enforcement (911).
vi. Immediately contact the DCF Florida Abuse Hotline.
vii. Notify the CCC within two (2) hours of the incident or learning of the incident.
viii. Do not discuss the facts of the incident with anyone except those directly
involved in response or investigation of the incident.
ix. If the suspect is in the care and custody of the facility, do not notify them of
the victim’s report, but take adequate steps to ensure the safety of other
youth, and report suspect or subject information to law enforcement upon their
arrival.
x. Cooperate fully with law enforcement.
xi. Within seven (7) days of the reported event, the youth’s VSAB shall be
reviewed and updated by the youth’s case manager or the facility mental
health provider.
b. Upon receipt of notice that any sexual abuse occurred longer than 72 hours
ago, whether informed by the victim or a third party, take the following
actions:
i. Ensure the victim is safe, has no further contact with the alleged subject (youth
or staff), and if medical staff is available, take the victim to medical
staff.
ii. Do not question the youth, other than to obtain basic information such as the
date and time of the incident, where the incident occurred, the
supervising staff, and who may be involved. Do not request youth to write a
statement.
iii. Immediately notify the facility management.
iv. Immediately notify law enforcement (911).
v. Immediately contact the DCF Florida Abuse Hotline.
vi. Notify the CCC within two (2) hours of the incident or learning of the incident.
vii. Do not discuss the facts of the incident with anyone except those directly
involved in response or investigation of the incident.
viii. Cooperate fully with law enforcement.
ix. If the subject is in the care and custody of the facility, do not notify them of the
victim’s report, but take adequate steps to ensure the safety of other youth,
and report suspect or subject information to law enforcement upon their arrival.
x. Within seven (7) days of the reported event, the youth’s VSAB shall be reviewed
and updated by the youth’s case manager or the facility mental health
provider.
4.The facility staff shall notify the alleged victim’s parents or legal guardians; unless
there is official documentation showing the parents or legal guardians shall
not be notified. If the youth is under the custody of DCF, the caseworker shall be
notified.
5. If a juvenile court retains jurisdiction over the alleged victim, the youth’s attorney
or other legal representative of record shall be notified of the allegation
within 14 days of receiving the allegation. Youth over 18 years of age must provide
informed consent prior to any notifications."
According to the PAQ, there were no allegations of sexual abuse that were reported
for this audit period. The agency policy contains the elements of the standard,
which are to be followed in an investigation. The interviews with random staff
confirmed awareness of first responder duties and indicated the PREA training they
had been provided. Policy provides that the alleged victim was re-screened utilizing
the instrument, Screening for Vulnerability to Victimization and Sexually Aggressive
Behavior and that notifications be made in accordance with policy.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (b):
If the first staff responder is not a security staff member, the responder
shall be required to request that the alleged victim not take any actions
that could destroy physical evidence, and then notify security staff.
According to the PAQ, policy requires that if the first staff responder is not a security
staff member, that responder shall be required to request that the alleged victim
not take any actions that could destroy physical evidence. Agency policy FDJJ 1919
considers all staff security staff as they all receive the required training. The policy,
p. 12, provides that "1. Upon discovery of an incident defined as sexual abuse, staff
members are responsible for taking immediate actions to ensure the safety of the
victim and notifying appropriate law enforcement and medical personnel. These
actions include, but are not limited to, identifying and separating victim(s),
suspect(s), and making every attempt to preserve evidence. 2. It is essential that
the garments/clothing worn by those involved and the scenes where alleged act(s)
occurred be protected to ensure that evidence is not further contaminated. This
means simply securing any evidence until the arrival of law enforcement. Securing
is defined as keeping control over the evidence or scene and documenting any
access to or deviation regarding access to that evidence. Staff shall not move,
touch, or alter the evidence in any way."
The interview responses from the 12 random staff interviewed revealed their
knowledge of the first responder's duties. Their responses to the question regarding
their actions as the first person to be alerted that a resident had allegedly been the
victim of sexual abuse, collectively included the following: immediately alert
supervisor and other staff; call the hotline and CCC; separate; and secure the scene.
There were no allegations of sexual abuse or sexual harassment during this audit
period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Coordinated Response Plan
Interview:
Superintendent
Provision (a):
The facility shall develop a written institutional plan to coordinate actions
taken in response to an incident of sexual abuse among staff first
responders, medical and mental health practitioners, investigators, and
facility leadership.
The PAQ indicates the facility has developed a written institutional plan to
coordinate actions taken in response to an incident of sexual abuse among staff first
responders, medical and mental health practitioners, investigators, and facility
leadership." The agency policy FDJJ 1919, p.14, provides that each residential and
detention facility personnel develop a written plan in response to an incident of
sexual abuse. The facility has a written institutional plan, Coordinated Response
Plan, to be implemented in the event of an allegation or incident of sexual abuse.
The facility's written plan outlines the actions of the identified staff members such
as the first responder; medical; mental health; supervisors; and management. It
includes the coordination of actions of employee first responders, medical and
mental health practitioners, investigators, and facility leadership in response to an
incident of sexual abuse. The written Coordinated Response Plan contains a system
that provides the staff with clear actions to be taken including management,
medical and mental health staff, investigators. Staff members are directed to follow
the steps outlined and to utilize the document in addressing an allegation/incident
of sexual abuse. The interview with the superintendent indicated familiarity
regarding the response to an allegation of sexual abuse. He identified the steps staff
will take and the reporting and contact requirements.
Conclusion:
Based upon the review and analysis of the available evidence and interview, the
facility is compliant with this standard.
Preservation of ability to protect residents from contact with
115.366
abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Pre-Audit Questionnaire (PAQ)
Interview:
Agency Head Designee
Provision(a):
Neither the agency nor any other governmental entity responsible for
collective bargaining on the agency’s behalf shall enter into or renew any
collective bargaining agreement or other agreements that limits the
agency’s ability to remove alleged staff sexual abusers form contact
with residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is warranted.
According to the facility's agency head designee's interview, the agency does not
have any collective bargaining agreements.
Provision (b):
NA
Conclusion:
Based on the PAQ and interview, the facility is compliant with this standard.
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
Pre-Audit Questionnaire (PAQ)
Youth Acknowledgement and Notification of PREA
Interviews:
Retaliation Monitor/PREA Compliance Manager/Superintendent
Agency Head Designee
Provision (a):
The agency shall establish a policy to protect all residents and staff who
report sexual abuse or sexual harassment or cooperate with sexual abuse
or sexual harassment investigations from retaliation by other residents or
staff and shall designate which staff members or departments are charged
with monitoring retaliation.
The PAQ provides that the agency has a policy to protect all residents and staff who
report sexual abuse or sexual harassment or cooperate with sexual abuse or sexual
harassment investigations from retaliation by other residents or staff. According to
agency policy FDJJ 1919, p. 12, "Youth, staff, contractor(s), or volunteer(s) who have
reported sexual misconduct shall be provided protection against retaliation.
Accommodations will include housing changes and removal of alleged staff or youth
from contact with victims. Emotional support services for youth or staff who fear
retaliation for reporting or cooperating with investigations will be available."
The facility policy, 5-19, p.1, states the PREA compliance manager has the,
"Responsibility for ensuring confidentiality of reported information and monitoring
any retaliation that may happen as a result of a reported incident." The retaliation
monitor enlists the assistance of the Therapists in conducting retaliation monitoring
through their constant contact with the residents as confirmed by the retaliation
monitor's interview.
The information on the Youth Acknowledgement and Notification of PREA form is
reviewed with the youth during the intake process. The document includes bullets to
be discussed with the resident and includes, "The facility shall provide residents
with access to outside victim advocates for emotional support services related to
sexual abuse."
The policies, acknowledgement form, and interviews support protecting residents
and staff who report sexual abuse or sexual harassment, or cooperate with sexual
abuse or sexual harassment investigations from retaliation by other residents, or
staff. Isolation is not used for residents who have allegedly suffered sexual abuse
according to informal conversations with staff.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (b):
The agency shall employ multiple protection measures, such as housing
changes or transfers for resident victims or abusers, removal of alleged
staff or resident abusers from contact with victims, and emotional support
services for residents or staff that fear retaliation for reporting sexual
abuse or sexual harassment or for cooperating with investigations.
According to policy FDJJ 1919, p.12, "Accommodations will include housing changes
and removal of alleged staff or youth from contact with victims. Emotional support
services for youth or staff who fear retaliation for reporting or cooperating with
investigations will be available. The facility policy, p. 1, is aligned with the agency
policy, "Such protective measures may include housing changes or transfers for
resident victims or abusers, removal of alleged staff or resident abusers from
contact with victims, and emotional support services for residents or staff who fear
retaliation for reporting sexual abuse or sexual harassment or for cooperating with
investigations." Additionally, facility policy 5-19, p. 9, states the following: "Youth
and staff who have reported sexual misconduct or cooperate with sexual
misconduct investigations shall be provided protection against retaliation.
a. Accommodations will include housing changes and removal of alleged staff or
youth from contact with victims.
b. Emotional support services for youth or staff that fears retaliation for reporting or
cooperating with investigations will be available.
c. The director or designee will monitor for possible retaliation.
1. Designated staff will monitor the conduct/treatment of residents/staff who
reported sexual abuse to see if there are any changes that may suggest possible
retaliation for 90 days.
2. Designated staff will monitor the conduct/treatment of residents/staff who were
reported to have suffered sexual abuse to see if there are any changes that may
suggest possible retaliation for 90 days.
3. The facility will extend such monitoring beyond the 90 days if the initial
monitoring indicates a continuing need.
4. The facility will act promptly to remedy any such retaliation."
Protective measures were generally identified during the interviews and aligned
with the policies. According to the facility agency head designee, residents and staff
are protected from retaliation for sexual abuse or sexual harassment. He stated that
protective measures include housing and program separation; following
recommendations made by human resources regarding staff; apply disciplinary
sanctions with staff, up to termination; and conducting retaliation monitoring. The
superintendent/retaliation monitor also conveyed that separation would be key in
protecting both residents and staff from retaliation. Some of the different measures
that would be taken to protect residents and staff include change in housing
assignment; remove the staff from contact with resident; talk to associates; monitor
interactions; and changes shifts or assigned dormitories; and review cameras daily.
The retaliation monitor also stated that contact would be initiated with residents
who have reported sexual abuse and he would explain why he is checking in with
him.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (c):
For at least 90 days following a report of sexual abuse, the agency shall
monitor the conduct or treatment of residents or staff who reported the
sexual abuse and of residents who were reported to have suffered sexual
abuse to see if there are changes that may suggest possible retaliation by
residents or staff, and shall act promptly to remedy any such retaliation.
Items the agency should monitor include any resident disciplinary reports,
housing, or program changes, or negative performance reviews or
reassignments of staff. The agency shall continue such monitoring beyond
90 days if the initial monitoring indicates a continuing need.
The PAQ confirmed the facility monitors the conduct or treatment of residents or
staff who reported sexual abuse and of residents who were reported to have
suffered sexual abuse to see if there are any changes that may suggest possible
retaliation by residents or staff. Additionally the PAQ indicates retaliation monitoring
for at least 90 days, or longer if indicated, and that the facility acts promptly to
remedy any such retaliation.
Agency policy FDJJ 1919, p.12, states, "The facility shall continue such monitoring
beyond 90 days if the initial monitoring indicates a continuing need. The obligation
to monitor terminates if the allegation is determined to be unfounded."
According to facility policy 5-19, p.9, states, "1. Designated staff will monitor the
conduct/treatment of residents/staff who reported sexual abuse to see if there are
any changes that may suggest possible retaliation for 90 days. 2. Designated staff
will monitor the conduct/treatment of residents/staff who were reported to have
suffered sexual abuse to see if there are any changes that may suggest possible
retaliation for 90 days. 3. The facility will extend such monitoring beyond the 90
days if the initial monitoring indicates a continuing need. 4. The facility will act
promptly to remedy any such retaliation."
The interview with staff regarding retaliation monitoring revealed the following
would be monitored to detect possible retaliation: interactions between residents
and staff and residents and residents; behavior point cards; and daily camera
footage. He also confirmed retaliation monitoring surrounding reporting of sexual
abuse would last for 90 days; however, if retaliation was suspected the monitoring
would last until the resident was released from the facility. There were no
allegations of sexual abuse during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (d):
In the case of residents, such monitoring shall also include periodic status
checks.
According to agency facility policy FDJJ 19 19, p. 12, provides for status checks. The
retaliation monitor stated that contact would be initiated with residents who have
reported sexual abuse and he would explain why he is checking in with him.
Additionally, he would periodically check-in with the resident's Therapist as part of
the status checks. The interview with the retaliation monitor also indicated
monitoring for at least 30 days or until the resident is released, if indicated. There
was no evidence of an allegation of sexual abuse or sexual harassment during this
audit period and as confirmed by the superintendent/retaliation monitor/PREA
compliance manager.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (e):
If any other individual who cooperates with an investigation expresses a
fear of retaliation, the agency shall take appropriate measures to protect
that individual against retaliation.
The PAQ confirms that If any other individual who cooperates with an investigation
expresses a fear of retaliation, the facility takes appropriate measures to protect
that individual against retaliation.
The interview with the superintendent revealed that the different measures that will
be taken to protect residents and staff from retaliation include separate which
applies to youth and staff. He also stated the measures taken if retaliation is
suspected include removing staff from any contact with resident. According to the
agency head designee, any individual who cooperated with an investigation and
expressed fear of retaliation will be treated the same; separation measures will be
implemented, situation monitored closely, consultation with human resources, and/
or disciplinary measures implemented for the retaliator and up to termination.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
115.368 Post-allegation protective custody
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Resident Files
Interviews:
Superintendent
Medical Staff
Mental Health Staff
Provision (a):
The use of segregated housing to protect a resident who is alleged to have
suffered sexual abuse shall be subject to the requirements of §115.342.
According to the PAQ, there is a policy that residents who allege to have suffered
sexual abuse may only be placed in isolation as a last resort if less restrictive
measures are inadequate to keep them and other residents safe, and only until an
alternative means of keeping all residents safe can be arranged. However, the
practice is that segregated housing is not used in this facility. Observations and the
interviews revealed that segregated housing is not used in the facility to protect
residents who alleged to have suffered sexual abuse. The agency does include in
policy FDJJ 1919, p. 6, guidance to staff regarding segregated housing if it is ever
implemented:
"Youth may be isolated from others only as a last resort when less-restrictive
measures are inadequate to keep them and other youth safe, and then only until an
alternative means of keeping all youth safe can be arranged.
a. The facility shall clearly document the basis for the facility’s concern for the
youth’s safety and the reason no alternative means of separation can be
arranged.
b. Youth in isolation shall not be denied large-muscle exercise and educational
programming.
c. Youth in isolation shall receive daily visits from medical and mental health
practitioners."
The interviews with mental health and medical staff revealed that segregated
housing is not used as protective custody regarding residents who alleged sexual
abuse. The superintendent confirmed isolation is not used. The auditor did not
observe any segregated housing area during the comprehensive site review. A
review of a sample of 12 resident files and informal conversations with staff did not
reveal the use of isolation.
Conclusion:
Based upon the review of policy, PAQ, and resident files, interviews, informal
conversations, and observations, the facility is compliant with this standard.
115.371 Criminal and administrative agency investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ Policy 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Agency Investigations Reports
Interviews:
Superintendent/PREA Compliance Manager
Investigative Staff
Provision (a):
When the agency conducts its own investigations into allegations of
sexual abuse and sexual harassment, it shall do so promptly, thoroughly,
and objectively for all allegations, including third-party and anonymous
reports.
According to the PAQ, the agency has a policy related to criminal and administrative
agency investigations. Agency policy, FDJJ Policy 1919, p. 14, provides that
the agency investigates all allegations of sexual abuse and sexual harassment. The
facility and its parent agency do not conduct any investigations of sexual abuse or
sexual harassment. The investigations that are criminal in nature are investigated
by the Florida Department of Children and Families (DCF) and law enforcement.
The administrative investigations/management reviews are conducted by the
investigators with the Florida Department of Juvenile Justice (DJJ), Office of the
Inspector General (OIG). Based on the policy and interviews, trained investigators
conduct administrative investigations/management reviews. Allegations that are
criminal in nature are referred to law enforcement and DCF. According to the
investigative staff, "On the date we get the report we assign the report or reach out
to local law enforcement. If local law enforcement is not going to conduct a criminal
investigation, we begin the investigation the day that it is received."
Once the investigation is completed by OIG, a management review is conducted
reviewing the actions taken and the findings of the assigned investigator. According
to the investigative staff, cases are assigned to an investigator within 24 hours and
"we do not begin our investigation until Local LE has completed their investigation,
or we are notified that they have determined it is not criminal and are not going to
investigate." The investigative staff described the investigative process: "We start
with reviewing the allegation and determining if it could be criminal and then we
would contact local law enforcement and assist in any way they need. If not
criminal, then we start with the case plan and go from there. We gather all
evidence, interview all residents and staff, and utilize the video, any bystanders
would be interviewed. We then determine if it meets the preponderance of the
evidence protocol and then make a final determination. We then go to the next step
which is to determine staff action or lack of action contributed to the incident. This
includes looking at earlier videos to see if there was any indication that this could
have been prevented."
The steps in the investigation process, noted by the investigative staff, indicate the
allegations are investigated promptly; thoroughly; include interviews, findings and
notes with each encounter by the investigative entity; and actions taken. The
interview also revealed that anonymous or third-party reports of sexual abuse and
sexual harassment would be handled the same way as other investigations. There
were no allegations of sexual abuse or sexual harassment during this audit period
as stated in the PAQ, confirmed by the DJJ statewide PREA Coordinator, facility
superintendent, and review of 16 resident files, and grievance forms.
Conclusion:
Based upon the review and analysis of the available evidence and interviews,
the facility is compliant with this provision.
Provision (b):
Where sexual abuse is alleged, the agency shall use investigators who
have received special training in sexual abuse investigations involving
juvenile victims pursuant to §115.334.
The agency's investigative staff is trained through the Department of Juvenile
Justice as supported by the PAQ. The DJJ/OIG follows protocols in conducting
administrative investigations and the investigators received training on the related
agency policies and specialized training regarding conducting investigations in
confinement settings. The interview with the investigative staff revealed that
investigators receive online mandatory training. He also described training for new
staff that includes procedures for conducting PREA investigations, establish
timelines for investigation activities, and learn how to develop a case file that is
used prior to conducting any investigations. He further stated, "we train staff to be
victim centered during the interview process. If the youth is a victim of sexual abuse
and has been interviewed by local law enforcement we will review the investigation
and may not have to interview the victim. We do administrative investigation and
are not required to do the Miranda warning. We cover it, however we train all DJJ
staff and vendors to secure the scene and victim and abuser and wait on local law
enforcement to collect the evidence. If we respond prior to local law enforcement,
our staff are trained on how to secure the scene, separate the victim and abuser
and secure the victim and abuser from destroying evidence. we use the
preponderance of the evidence and train staff on the more likely that it happened
than it didn’t happen. 51%."
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (c):
Investigators shall gather and preserve direct and circumstantial
evidence, including any available physical and DNA evidence and any
available electronic monitoring data; shall interview alleged victims,
suspected perpetrators, and witnesses; and shall review prior complaints
and reports of sexual abuse involving the suspected perpetrator.
According to the PAQ, investigators gather and preserve direct and circumstantial
evidence, including any available physical and DNA evidence and any available
electronic monitoring data; interview alleged victims, suspected perpetrators, and
witnesses; review prior reports and complaints of sexual abuse involving the
suspected perpetrator. The Investigator gathers direct and circumstantial
evidence that includes but is not limited to video, clothing, witness statements;
listen to any related telephone calls; and logs. Law enforcement and a qualified
medical practitioner are responsible for collecting direct physical and DNA evidence,
in accordance with the interview with the investigative staff.
The interview with the investigative staff continued: "The first step in any
investigation begins with a case plan which includes all areas that will be part of the
investigations which include videos, telephone calls, interviews, gathering
documents, and any other evidence that is going to be used. We also plan for the
administrative review of policies, procedures, staffing etc. for additional information.
As I indicated we start with reviewing the allegation and determining if it could be
criminal and then we would contact local law enforcement and assist in any way
they need. If not criminal, then we start with the case plan and go from there. We
gather all evidence, interview all residents and staff, and utilize the video, any
bystanders would be interviewed. We then determine if it meets the preponderance
of the evidence protocol and make a final determination. We then go to the next
step which is to determine if staff action of lack of action contributed to the
incident. This includes looking at earlier videos to see if there was any indication
that this could have been prevented."
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (d):
The agency shall not terminate an investigation solely because the source
of the allegation recants the allegation.
The interview with the investigative staff confirmed that an investigation is not
terminated if the source recants the allegation. Agency policy FDJJ 1919, p.14,
provides that "The Department will ensure administrative investigations and reviews
are completed for all allegations of sexual misconduct and all administrative
investigations by the OIG shall follow OIG guidelines governing PREA investigations.
The interview with investigative staff and agency policy p. are aligned with the
confirmation in the PAQ that the agency does not terminate an investigation solely
because the source of the allegation recants the allegation.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (e):
When the quality of evidence appears to support criminal prosecution, the
agency shall conduct compelled interviews only after consulting with
prosecutors as to whether compelled interviews may be an obstacle for
subsequent criminal prosecution.
The agency investigators do not conduct compelled interviews. According to the
Department of Juvenile Justice investigative staff, "We do not have authority to
notify local prosecutor; however, we encourage the local law enforcement to work
with the local prosecutors. The IG or FDJJ Secretary could forward information to
state law enforcement."
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (f):
The credibility of an alleged victim, suspect, or witness shall be assessed
on an individual basis and shall not be determined by the person’s status
as resident or staff. No agency shall require a resident who alleges sexual
abuse to submit to a polygraph examination or other truth-telling device
as a condition for proceeding with the investigation of such an allegation.
Regarding credibility assessment, the investigative staff revealed they review the
past history, compare statements with videos and documentation, and consider
corroboration with the other interviews. Summarily, the credibility of an alleged
victim, suspect, or witness is assessed on an individual basis and is not determined
by the person’s status as a resident or staff. No resident who alleges sexual abuse
will be subjected to a polygraph examination or other truth telling device as a
condition for proceeding with the investigation of the allegation, in accordance with
the interview of investigative staff.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (g): Administrative Investigations:
(1) Shall include an effort to determine whether staff actions or failures to
act contributed to the abuse. (2) Shall be documented in written reports
that include a description of the physical and testimonial evidence, the
reasoning behind credibility assessments, and investigative facts and
findings.
The interview with the investigative staff revealed the investigation determines if
staff action of lack of action contributed to the incident. According to the interview
with investigative staff, there would be a review of all evidence and information.
"We look at policies and procedures that may have not been followed. We look at
previous camera footage for the same time period to see if there is a pattern." It
was also shared that staffing would be reviewed especially in the area where the
allegation occurred.
The investigations are documented in written reports as confirmed by the auditor
through the review of agency investigative reports for other sites. The reports
included: videos, audio recordings, witness statements, medical information, mental
health information, summary document, and everything that was generated in the
investigation including handwritten notes. The report may also include results of a
forensic medical examination where indicated, according to the investigative staff
interview.
The previously reviewed investigation reports contained the facts and findings as
processed by the investigators, based on a preponderance of the evidence, The
reports contained a description of any testimonial evidence. They reflected
consideration for consistency in the interviews with the alleged victims, alleged
perpetrators, and any witnesses. The previously reviewed reports also contained
evidence of corroboration in the "update" section of the reports regarding additional
interviews, additional information, or where information provided was confirmed.
The reports identified the person type whether youth or staff and the involvement
type such as victim, subject, reporting person. The reports did not indicate the
interviews of the staff, subject, or reporting person were weighted differently.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (h):
Criminal investigations shall be documented in a written report that
contains a description of physical, testimonial, and documentary evidence
and attaches copies of all documentary evidence where feasible.
The administrative investigation report reviewed by the auditor identified the case
number assigned by law enforcement and that a report had been completed which
noted the findings and their justification. The report also contained a case number
assigned by the DCF and the findings and reasoning for the findings and any
recommendations for services. According to the interview with investigative staff, in
some cases they are not able to get very much from the law enforcement and in
other cases they get the complete file.
Conclusion:
Based upon the review and analysis of the available evidence and interviews,
the facility is compliant with this provision.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be
referred for prosecution.
The DJJ investigators do not conduct criminal investigations. It is the responsibility of
law enforcement personnel to refer cases for prosecution. There were no allegations
of sexual abuse or sexual harassment during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (j):
The agency shall retain all written reports referenced in paragraphs (g)
and (h) of this section for as long as the alleged abuser is incarcerated or
employed by the agency, plus five years, unless the abuse was committed
by a juvenile resident and applicable law requires a shorter period of
retention.
The written investigative reports are maintained for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years, according to the PAQ.
Additionally, there were no allegations of sexual abuse or sexual harassment during
this audit period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
Provision (k):
The departure of the alleged abuser or victim from the employment or
control of the facility or agency shall not provide a basis for terminating
an investigation.
The investigative interview confirmed that upon the start of an investigation, it will
not end until the investigation has been completed. The departure of the alleged
abuser or victim from the employment or control of the facility will not terminate the
investigation.
Conclusion:
Based upon the review and analysis of the available evidence and interviews,
the facility is compliant with this provision.
Provision (m):
When outside agencies investigate sexual abuse, the facility shall
cooperate with outside investigators and shall endeavor to remain
informed about the progress of the investigation.
According to agency policy FDJJ 1919, p. 11, "Staff will fully cooperate with any law
enforcement investigation of sexual abuse." The interviews supported the agency
policy and provided the following: Investigative Staff--"We offer any assistance they
request. We make certain that the facility cooperates with the local investigators
and we aid the investigators in making staff and resident available to be
interviewed. Agency policy and interviews indicate that staff cooperates with
investigators and that the agency/facility is kept informed of the progress of an
investigation." Superintendent/PREA compliance manager--"The facility stays in
contact with DCF, DJJ, and law enforcement until the case is closed." Facility's
regional PREA Coordinator--The facility "must depend on law enforcement and DJJ to
keep informed about investigations."
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
facility is compliant with this provision.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Agency Investigation Reports
Interview:
Investigative Staff
Provision (a):
The agency shall impose no standard higher than a preponderance of the
evidence in determining whether allegations of sexual abuse or sexual
harassment are substantiated.
According to the PAQ, the agency imposes a standard of a preponderance of the
evidence or a lower standard of proof for determining whether allegations of sexual
abuse or sexual harassment are substantiated. The policy and practice of the
Department of Juvenile Justice, Office of Inspector General, responsible for
administrative investigations, impose a standard of a preponderance of the
evidence for determining whether allegations are substantiated, according to the
interview with investigative staff and a review of agency investigation reports from
other sites.
Conclusion:
Based upon the review and analysis of the evidence and the interview, the facility is
compliant with the standard.
115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Agency Investigation Reports
Agency Notification Letter
Interviews:
Superintendent
Investigative Staff
Statewide PREA Coordinator
Provision (a):
Following an investigation into a resident’s allegation of sexual abuse
suffered in an agency facility, the agency shall inform the resident as to
whether the allegation has been determined to be substantiated,
unsubstantiated, or unfounded.
According to the PAQ, the agency has a policy requiring that any resident who
makes an allegation that he or she suffered sexual abuse in an agency facility is
informed, verbally or in writing, as to whether the allegation has been determined to
be substantiated, unsubstantiated, or unfounded following an investigation by the
agency. Page 15 of the agency's PREA policy, FDJJ 1919, addresses the resident
being informed when the investigation is completed and that the notification of the
outcome of the investigation to the resident be documented.
The interviews revealed knowledge of the policy requirement. The investigative staff
indicated that at the conclusion of the investigations the IG’s office sends a letter to
the resident and/or the parents with the outcome of the investigation. The
superintendent also confirmed through the interview the resident would be notified
at the end of the investigation of the findings and that policy exists regarding such.
The superintendent revealed there have not been any allegations of sexual abuse or
sexual harassment during this audit period.
Conclusion:
The interviews and review of Policy and other documentation confirmed the facility
is compliant with this provision.
Provision (b):
If the agency did not conduct the investigation, it shall request the
relevant information from the investigative agency in order to inform the
resident.
The PAQ provides that if an outside entity conducts the investigation, the agency
requests the relevant information from the investigative entity in order to inform the
resident of the outcome of the investigation. The information contained in the
administrative investigation report demonstrates that information is shared when
investigations are conducted by an outside agency and the same would occur if the
allegation had been one of sexual abuse or if the investigations had determined the
allegation was one of sexual abuse. The agency investigation reports previously
reviewed for other sites, document that law enforcement and the Department of
Children and Families (DCF) were called as a result of an allegation of sexual abuse
or sexual harassment and the results of those investigations are documented in an
investigation report completed by the Department of Juvenile Justice, Office of the
Inspector General, and the case numbers were provided. The investigation reports
documented contact with the investigative entities.
According to the interview with the superintendent, the facility remains abreast of
the involvement of the investigative entities by staying in contact with them.
Findings are shared when conducted by an outside agency as determined by the
investigation report and interview with the superintendent and investigative
staff. Informal conversations with the DJJ statewide PREA Coordinator revealed he
monitors allegations and investigations and communicates with agency
investigators regarding communication with law enforcement and DCF. The DJJ PREA
Coordinator assists in keeping the superintendent informed on investigations
conducted by DJJ, DCF, and law enforcement personnel.
Conclusion:
The interviews and review of Policy and other documentation confirmed the facility
is compliant with this provision.
Provision (c):
Following a resident’s allegation that a staff member has committed
sexual abuse against the resident, the agency shall subsequently inform
the resident (unless the agency has determined that the allegation is
unfounded) whenever:
(1) The staff member is no longer posted within the resident’s unit;
(2) The staff member is no longer employed at the facility;
(3) The agency learns that the staff member has been indicted on a
charge related to sexual abuse within the facility; or
(4) The agency learns that the staff member has been convicted on a
charge related to sexual abuse within the facility.
The FDJJ 1919 policy, pp. 15-16, requires that following a resident’s allegation that a
staff member committed sexual abuse against the resident, the resident will be
informed, in writing, of the following, unless it has been determined that the
allegation is unfounded, "whenever:
a. The staff member is no longer posted within the resident’s housing unit;
b. The staff member is no longer employed at the facility;
c. The staff member has been indicted on a charge related to sexual abuse in the
facility;
d. The staff member has been convicted on a charge related to sexual abuse in the
facility."
Conclusion:
The interviews and review of Policy and other documentation confirmed the facility
is compliant with this provision.
Provision (d):
Following a resident’s allegation that he or she has been sexually abused
by another resident, the agency shall subsequently inform the alleged
victim whenever:
(1) The agency learns that the alleged abuser has been indicted on a
charge related to sexual abuse within the facility; or
(2) The agency learns that the alleged abuser has been convicted on a
charge related to sexual abuse within the facility.
Policy provides that following a resident’s allegation that he has been sexually
abused by another resident the alleged victim shall be informed, in writing,
whenever:
a. The alleged abuser is criminally charged related to the sexual abuse.
b. The alleged abuser is adjudicated on a charge related to sexual abuse within the
facility.
Conclusion:
The interviews and review of Policy and other documentation confirmed the facility
is compliant with this provision.
Provision (e):
All such notifications or attempted notifications shall be documented.
The policy provides that the notifications to the resident be documented. According
to the agency policy, FDJJ 1919, page 16, "All such notifications or attempted
notifications shall be documented." The Office of Inspector General or notification to
residents of the outcome of investigations of sexual abuse allegations collaborates
with the superintendent and regional DJJ staff to inform the resident of the
classifications. The reviewed notification letter from another agency facility,
contains the resident's name, date, allegation, summarization of the findings of
substantiated, unsubstantiated, or unfounded.
Conclusion:
The interviews and review of policy and other documentation confirmed the facility
is compliant with this provision.
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Interviews:
Superintendent/PREA Compliance Manager
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including
termination for violating agency sexual abuse or sexual harassment
policies.
Agency policy, FDJJ 1919, p. 2 provides, "Failure to comply with the requirements
contained in this policy and procedures may result in disciplinary action up to and
including dismissal." The interviews also support that staff be subject to disciplinary
sanctions up to and including termination for violating sexual abuse or sexual
harassment policies. According to the PAQ, staff is subject to disciplinary sanctions
up to and including termination for violating agency sexual abuse or sexual
harassment policies.
Conclusion:
Based upon the review of documentation and the interview, the facility is compliant
with this provision.
Provision (b):
Termination shall be the presumptive disciplinary sanction for staff who
has engaged in sexual abuse.
Termination is the presumptive disciplinary sanction for staff who has engaged in
sexual abuse with a resident, according to agency policy FDJJ 1919, p. 2. Per the
PAQ, there was no staff member from the facility that was terminated for violating
agency sexual abuse policy.
Conclusion:
Based upon the review of documentation and the interview, the facility is compliant
with this provision.
Provision (c):
Disciplinary sanctions for violations of agency policies relating to sexual
abuse or sexual harassment shall be commensurate with the nature and
circumstances of the acts committed, the staff member’s disciplinary
history, and the sanctions imposed for comparable offenses by other staff
with similar histories.
According to the PAQ, disciplinary sanctions for violations of policies relating to
sexual abuse or sexual harassment (other than engaging in sexual abuse) will be
commensurate with the act committed, the staff member’s disciplinary history, and
the similar history of other staff, in accordance with policy. Also, in the past 12
months, the number of staff from the facility who have been disciplined for violation
of agency sexual abuse or sexual harassment policies (other than actually engaging
in sexual abuse) was zero, according to the PAQ and informal conversation with the
superintendent.
Conclusion:
Based upon the review of documentation, the facility is compliant with this
provision.
Provision (d):
All terminations for violations of agency sexual abuse or sexual
harassment policies, or resignations by staff who would have been
terminated if not for their resignation, shall be reported to law
enforcement agencies, unless the activity was clearly not criminal, and to
any relevant licensing bodies.
Agency policy provides that terminations for violations of the facility’s sexual abuse
or sexual harassment policies or resignations by staff that would have been
terminated if not for their resignation, will be reported to law enforcement, unless
the activity is clearly not criminal. In addition, such will be reported to law
enforcement and relevant licensing bodies. According to the PAQ no staff member
has been terminated for violating the facility’s sexual abuse policy during this audit
period.
Conclusion:
Based upon the review of documentation and interview, the facility is compliant
with this provision.
115.377 Corrective action for contractors and volunteers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Training Curriculum
Interviews:
Superintendent
Contractors
Provision (a):
Any contractor or volunteer who engages in sexual abuse shall be
prohibited from contact with residents and shall be reported to law
enforcement agencies, unless the activity was clearly not criminal, and to
relevant licensing bodies.
According to agency FDJJ 1919, page 1, "DJJ has zero tolerance for any acts of sexual
abuse, assault, misconduct or harassment. Sexual activity between staff and
juveniles, volunteers or contract personnel and juveniles, and juvenile and
juvenile is prohibited and subject to administrative and criminal disciplinary
sanctions." Policy and the interview with the superintendent provide for contractors
and volunteers who engage in sexual abuse with a resident to be reported to law
enforcement and to relevant licensing bodies. He further stated, their services
would no longer be utilized and at present, there are no volunteers at the facility.
Documentation and interviews with two contractors confirmed the facility provides
contractors a clear understanding that sexual misconduct with a resident is
prohibited. Any contractor who violates the agency’s sexual abuse or sexual
harassment policies is prohibited from contact with residents, according to the
interview with the superintendent. During this audit period, there have been no
allegations of sexual abuse or sexual harassment regarding a contractor. The facility
does not have any volunteers.
Conclusion:
The review of the documentation, as well as interviews, confirmed the facility is in
compliance with the requirements of this provision.
Provision (b):
The facility shall take appropriate remedial measures, and shall consider
whether to prohibit further contact with residents, in the case of any other
violation of agency sexual abuse or sexual harassment policies by a
contractor or volunteer.
The facility will take the appropriate remedial measures and prohibit further contact
with residents in the case of any other violation of the sexual abuse and sexual
harassment policies by a contractor or volunteer and consider whether to prohibit
further contact with residents, according to the agency policy. According to the
superintendent, the services of the contractor or volunteer would no longer be
needed. In the past 12 months, no contractors were reported for allegations of
sexual abuse or sexual harassment.
The contractors interviewed indicated that PREA related training included the
facility's zero-tolerance policy on sexual abuse and sexual harassment. The
interviews with the contractors confirmed the facility provides a clear understanding
that sexual misconduct with a resident is prohibited. Any contractor or volunteer
who violates the agency’s sexual abuse or sexual harassment policies is prohibited
from contact with residents. There have been no allegations of sexual abuse or
sexual harassment involving contracting and volunteers during the last 12 months,
according to the PAQ and the superintendent.
Conclusion:
The review of documentation, including the facility PAQ, as well as interviews,
confirmed the facility is in compliant with tthis provision.
115.378 Interventions and disciplinary sanctions for residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
Youth and Parent Program Handbook
PREA Pre-Audit Questionnaire (PAQ)
Interviews:
Superintendent
Medical Staff
Mental Health Staff
Provision (a):
A resident may be subject to disciplinary sanctions only pursuant to a
formal disciplinary process following an administrative finding that the
resident engaged in resident-on-resident sexual abuse or following a
criminal finding of guilt for resident-on-resident sexual abuse.
According to the PAQ, residents are subject to disciplinary sanctions only after
formal proceedings regarding resident-on-resident sexual abuse. Facility policy
15-19, p. 14, states, "A youth may receive disciplinary sanctions following an
administrative finding that the youth engaged in youth-on-youth sexual abuse or
following a criminal finding of guilt for youth-on-youth sexual abuse." Residents
found in violation of facility rules are subject to sanctions pursuant to the
administrative process.
The consequences will be administered through the administrative process,
encompassing the behavior management system which includes level
advancement, loss of points/privileges, and additional consequences, as detailed in
the Youth and Parent Program Handbook, pp. 19-13. Allegations of sexual abuse are
referred for an investigation to the appropriate investigative entities and a resident
may be placed in the regional juvenile detention center, per the interview with the
superintendent. There were no allegations of sexual abuse or sexual harassment
during this audit period.
Conclusion:
Based on the review of documentation and the interview with the superintendent,
the facility is compliant with this provision.
Provision (b):
Any disciplinary sanctions shall be commensurate with the nature and
circumstances of the abuse committed, the resident’s disciplinary history,
and the sanctions imposed for comparable offenses by other residents
with similar histories. In the event a disciplinary sanction results in the
isolation of a resident, agencies shall not deny the resident daily large-
muscle exercise or access to any legally required educational
programming or special education services. Residents in isolation shall
receive daily visits from a medical or mental health care clinician.
Residents shall also have access to other programs and work
opportunities to the extent possible.
According to the interview with the superintendent where there is an investigative
finding of a substantiated allegation of sexual abuse, the resident will be moved to
the regional juvenile detention center. He also revealed, PREA related violations
may result in charges filed and the resident placed in detention based on the
circumstances of the incident. An administrative finding will garner sanctions
through the behavior management system which could mean a loss in level or
reduction in points/privileges, detailed in the Youth and Parent Handbook, pp. 10-13.
Additionally, Allegations of sexual abuse are referred for an investigation to the
appropriate investigative entities. Isolation is not used as a disciplinary sanction or
as protective custody, in accordance with the interviews.
Conclusion:
Based on the review of documentation and the interview with the superintendent,
the facility is compliant with this provision.
Provision (c):
The disciplinary process shall consider whether a resident’s mental
disabilities or mental illness contributed to his or her behavior when
determining what type of sanction, if any, should be imposed.
Disciplinary and other processes consider whether a resident’s mental disabilities or
mental illness contributed to the resident’s behavior regarding the application of
disciplinary measures. The interview with the superintendent also revealed that the
residents mental health issues and disciplinary history will be considered and
sanctions will be commensurate with the nature and circumstances of other
residents, based on the findings of an administrative investigation.
Conclusion:
Based on the review of documentation and the interview with the superintendent,
the facility is compliant with this provision.
Provision (d):
If the facility offers therapy, counseling, or other interventions designed
to address and correct underlying reasons or motivations for the abuse,
the facility shall consider whether to offer the offending resident
participation in such interventions. The agency may require participation
in such interventions as a condition of access to any rewards-based
behavior management system or other behavior-based incentives, but not
as a condition to access to general programming or education.
The facility would consider whether to offer the offending resident intervention
services designed to address and correct underlying reasons or motivations for the
abuse participation, based on the interview with mental health staff. The facility
would not require participation in such interventions as a condition for participation
in the behavior management system or to access general programming or
education as determined from the interview. Observations and the interview with
mental health staff revealed the mental health unit is equipped to develop
treatment planning and interventions to address underlying reasons or motivations
for the abuse with alleged victims and offending residents.
Conclusion:
Based on the review of documentation and interview with mental health staff, the
facility is compliant with the provision.
Provision (e):
The agency may discipline a resident for sexual contact with staff only
upon a finding that the staff member did not consent to such contact.
Policy provides that a resident may be disciplined for sexual contact with staff only
upon a finding that the staff member did not consent to such contact. According to
the facility policy 5-19, p. 15, The facility may discipline a youth for sexual contact
with staff only upon a finding that the staff member did not consent to such
contact." There was no evidence of a disciplinary action regarding such occurrence.
Conclusion:
Based on the review of documentation and interview with mental health staff and
the superintendent, the facility is compliant with the provision.
Provision (f):
For the purpose of disciplinary action, a report of sexual abuse made in
good faith based upon a reasonable belief that the alleged conduct
occurred shall not constitute falsely reporting an incident or lying, even if
an investigation does not establish evidence sufficient to substantiate the
allegation.
A report of sexual abuse made in good faith based on the belief that the alleged
incident occurred does not constitute falsely reporting an incident or lying, even if
an investigation does not establish evidence sufficient to substantiate the
allegation, in accordance with agency policy FDJJ 1919, p. 12. Additionally, anyone
reporting in good faith will be immune from any civil or criminal liability. Specifically,
the policy states, ". . . any person who knowingly and willfully makes a false report
to the Florida Abuse Hotline or counsels another to make a false report is guilty of a
third-degree felony in accordance with Chapter 39.205, Florida Statutes. This
Statute outlines the penalties for failing to report, obstructing the reporting of, or
knowingly making false reports of child abuse, abandonment, or neglect. Facility
policy 5-19, p.8, is aligned with agency policy FDJJ 1919 and the Statute, "Youth and
staff shall be advised that any person who knowingly and willfully makes a false
report to the Abuse Registry or counsels another to make a false report is guilty of a
third degree felony. Anyone reporting in good faith shall be immune from any civil or
criminal liability." There was no evidence of false reports made during this audit
period.
Conclusion:
Based on the review of documentation and interviews, the facility is compliant with
the standard.
Provision (g):
An agency may, in its discretion, prohibit all sexual activity between
residents and may discipline residents for such activity. An agency may
not, however, deem such activity to constitute sexual abuse if it
determines that the activity is not coerced.
According to facility policy 5-19, p. 1, "Sexual activity between staff, volunteers or
contracted personnel and youth, as well as between youth and youth is prohibited
and subject to both administrative and criminal disciplinary sanctions. Agency and
facility policies provide that referrals are made to the investigative entities and
court processes occur after determination the sexual activity was coerced.
Conclusion:
Based on the review of documentation and interviews, the facility is compliant with
the standard.
115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Facility Policy 5-19, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Medical Staff
Mental Health Staff
Staff Responsible for Risk Screening (Risk Screener)
Provision (a):
If the screening pursuant to §115.341 indicates that a resident has
experienced prior sexual victimization, whether it occurred in an
institutional setting or in the community, staff shall ensure that the
resident is offered a follow-up meeting with a medical or mental health
practitioner within 14 days of the intake screening.
Agency policy FDJJ 1919, page 8, provides that, "If the youth discloses prior sexual
victimization or staff, based on intake screening information, suspects or discovers
the youth has perpetrated sexual abuse, whether it occurred in a facility setting or
in the community, then staff shall ensure the youth is referred for medical and
mental health services within 14 days of the intake screening." Facility policy 5-19,
page 5, provides for the same regarding the revelation during the risk screening
that a resident experienced prior sexual victimization. The interview with the risk
screener, corroboration with other staff, and review of a sample of 16 VSABs (risk
screenings), revealed there was no such disclosure during the risk screening in the
past year.
According to the risk screener, the information may be addressed immediately with
mental health staff, who administers the VSAB screening instrument, or later and
within 14 days. The interview with the risk screener revealed that all relevant
information is shared with the mental health and medical staff. The risk screener
described sharing information and alerting each other if the risk screening indicates
any prior sexual victimization. There was no targeted interviewee during this audit
period.
Conclusion:
Based upon the review and analysis of the available evidence and the interview
with risk screener, the facility is compliant with this provision.
Provision (b):
If the screening pursuant to §115.341 indicates that a resident has
previously perpetrated sexual abuse, whether it occurred in an
institutional setting or in the community, staff shall ensure that the
resident is offered a follow-up meeting with a mental health practitioner
within 14 days of the intake screening.
Policy and practice provide that a resident be referred to mental health or medical
staff within 14 days if identified as having been a victim or perpetrator of sexual
abuse. Facility policy 2-01, p. 8, states, "Youth, who identify prior sexual
victimization or perpetrated sexual abuse, or prior youth-on-youth abuse, shall be
referred to an appropriate medical and mental health professional. If referred, staff
shall ensure that the youth is seen within fourteen (14) days." Agency policy FDJJ
1919, p. 8, provides that, "If the youth discloses prior sexual victimization or staff,
based on intake screening information, suspects or discovers the youth has
perpetrated sexual abuse, whether it occurred in a facility setting or in the
community, then staff shall ensure the youth is referred for medical and mental
health services within 14 days of the intake screening." The interview with the risk
screener revealed when the issues are identified upon admission, they may be
addressed the same day, due to mental health staff meeting with the youth on the
same day of admission. A related follow-up meeting may be scheduled by mental
health staff directly due to regular scheduled sessions with an assigned Therapist.
Conclusion:
Based upon the review and analysis of the available evidence and the interview with
risk screener, the facility is compliant with this provision.
Provision (c):
Any information related to sexual victimization or abusiveness that
occurred in an institutional setting shall be strictly limited to medical and
mental health practitioners and other staff, as necessary, to inform
treatment plans and security and management decisions, including
housing, bed, work, education, and program assignments, or as otherwise
required by Federal, State, or local law.
According to the PAQ, information related to sexual victimization or abusiveness
that occurred in an institutional setting is strictly limited to medical and mental
health practitioners. The facility and agency policies support that no information is
to be shared with staff other that medical and mental health practitioners unless it
is required for security and management decisions regarding sexual abuse history.
Agency policy FDJJ 1919, p.8, states, "Information gathered from screenings related
to sexual victimization or abusiveness shall be strictly limited to medical and
mental health practitioners and other staff, as required by Department policy and
Federal, State, or local law, to guide treatment plans and security and management
decisions, including housing, bed, work, education, and program assignments."
Facility policy 5-19 mirrors the same directive to staff and also includes on p.5, All
sensitive information shall be on a need-to-know basis and shall not be exploited to
the youth’s detriment by staff or other youth."
The interviews confirmed that information related to sexual victimization or
abusiveness that occurred in an institutional setting is limited to clinical and
treatment staff and to other staff, based on their need to know, to make effective
management decisions. During the onsite review, the files were observed to be
maintained in a secure manner in locked cabinets and drawers in the lockable
rooms/offices.
Medical has the keys to the clinic and mental health to their offices through the
facilities key control system with restricted access. Electronic records are password
protected and the agency has a private network which is also password protected
with limited and identified access. The user must have prior management approval
prior to accessing the site. Informal conversations with staff during the
comprehensive site review revealed that clinical staff solely have access to the
clinical records; other staff will be provided information, based on their need to
know. Observations and informal conversations with staff during the comprehensive
site review confirmed that hard copies and electronic files are maintained secure.
Conclusion:
Based upon the review and analysis of the available evidence and the interview with
risk screener, the facility is compliant with this provision.
Provision (d):
Medical and mental health practitioners shall obtain informed consent
from residents before reporting information about prior sexual
victimization that did not occur in an institutional setting, unless the
resident is under the age of 18.
According to the PAQ, medical and mental health practitioners obtain informed
consent from residents before reporting information about prior sexual victimization
that did not occur in an institutional setting, unless the resident is under the age
of 18. Agency policy FDJJ 1919, p. 8, addresses informed consent being obtained for
residents 18 years or over prior to clinical personnel reporting information disclosed
about prior sexual victimization that did not occur in an institutional setting. The
mental health and medical staff interviewed expressed an understanding of the use
of informed consent for residents 18 years or over regarding allegations of sexual
abuse. They understand they are mandated reporters regarding residents under 18
years old. The use of informed consent will be documented in the case notes for
mental health staff and in the nurse's notes for medical staff.
Conclusion:
Based upon the review and analysis of the available evidence and interviews with
medical and mental health staff, the facility is compliant with this provision.
115.382 Access to emergency medical and mental health services
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919. PREA
Facility Policy 5-19, PREA
Facility Policy 1-06, Incident Reporting (CCC)
PREA Pre-Audit Questionnaire (PAQ)
Youth and Parent Program Handbook
Coordinated Response Plan
Interviews:
Mental Health Staff
Medical Staff
Random Staff
Provision (a):
Resident victims of sexual abuse shall receive timely, unimpeded access to
emergency medical treatment and crisis intervention services, the nature
and scope of which are determined by medical and mental health
practitioners according to their professional judgment.
The PAQ, interviews, and agency policy FDJJ 1919, pp. 9-10, support the victim will
receive timely and unimpeded access to emergency medical treatment and crisis
intervention services; and the nature and scope of the services are determined
according to the professional judgment of the practitioners. Residents are informed
of clinical services during the intake process in the time spent with medical staff and
mental health staff according to informal conversations with residents, review of
secondary materials, and Student Handbook. According to the Youth and
Parent Program Handbook, p. 37, "When the Nurse completes your physical
assessment she or he will also inform you of all health services and appropriate
procedures to access nursing services." The clinical staff maintain secondary
materials that document services provided and encounters with residents, as
evident in the files.
The alleged victim will be transported to the local hospital emergency room for a
forensic medical examination by a Sexual Assault Nurse Examiner (SAFE), Sexual
Assault Nurse Examiner (SANE), or other qualified medical practitioner if a SAFE or
SANE is not available, in accordance with agency policy FDJJ 1919, p. 10, and the
interview with medical staff, in response to an allegation of sexual abuse. According
to medical and mental health staff, residents will receive timely and unimpeded
access to emergency medical treatment and crisis intervention services. The clinical
staff defined timely as immediately and that they are on-call 24/7. Both clinical staff
interviews revealed the nature and scope of their services are determined by their
professional judgement. During the onsite audit phase, there was no resident in the
facility that reported an allegation of sexual abuse.
Conclusion:
Based on the evidence reviewed, interviews with clinical staff, informal
conversations with random residents and random staff, and observations, the
facility is compliant with this provision.
Provision (b):
If no qualified medical or mental health practitioners are on duty at the
time a report of recent abuse is made, staff first responders shall take
preliminary steps to protect the victim pursuant to §115.362 and shall
immediately notify the appropriate medical and mental health
practitioners.
The PAQ revealed, if no qualified medical or mental health practitioners are on duty
at the time a report of recent sexual abuse is made, direct care staff will take
preliminary steps to protect the victim pursuant to §115.362 and will immediately
notify the appropriate medical and mental health practitioners. The interviews with
clinical staff revealed residents have access to unimpeded access to emergency
services and that they are on call 24/7.
The policies and coordinated response plan provide guidance to staff in protecting
residents and for contacting the appropriate staff and agencies regarding
allegations or incidents of sexual abuse, including contacting treatment staff and
investigative entities. A review of the coordinated response plan and related
documentation and policies; observations of the interactions among residents and
staff during the comprehensive site review; and the staff interviews, indicated direct
care staff will take preliminary steps to protect victims and notify clinical staff as
soon as possible.
Conclusion:
Based on the evidence reviewed, interviews with clinical staff and observations, the
facility is compliant with this provision.
Provision (c):
Resident victims of sexual abuse while incarcerated shall be offered timely
information about and timely access to emergency contraception and
sexually transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically appropriate.
According to facility policy 5-19, p.13, "Youth victims of sexual abuse shall be
offered timely information about and timely access to emergency contraception and
sexually transmitted infections prophylaxis, in accordance with professionally
accepted standards of care, where medically appropriate." This premise is also
aligned with agency policy FDJJ 1919 and the PAQ. The interview with medical staff
revealed that victims will be offered timely information about access to sexually
transmitted infections (STI) prophylaxis and the service will be provided at the
hospital. The medical staff also elaborated that testing for STIs is conducted at the
facility upon admission and the contract physician will prescribe medication as
indicated by the results of the tests. There were no allegations of sexual abuse
during this audit period.
Conclusion:
Based on the evidence reviewed, interviews with clinical staff and observations, the
facility is compliant with this provision.
Provision (d):
Treatment services shall be provided to the victim without financial cost
and regardless of whether the victim names the abuser or cooperates with
any investigation arising out of the incident.
Agency policy FDJJ 1919, p. 10, requires that a victim of sexual abuse "be offered
access to forensic medical examinations whether on-site or at an outside facility,
without financial cost, where evidentiarily or medically appropriate," as generally
confirmed in the PAQ. Agency and facility policies and informal conversation with
the superintendent provide that treatment services will be provided to the
victim without financial cost to the victim and regardless of whether the victim
names the abuser, or cooperate with any investigation arising out of the incident.
Conclusion:
Based on the evidence reviewed, informal conversation with the superintendent, the
facility is compliant with this provision.
Ongoing medical and mental health care for sexual abuse victims
115.383
and abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
Progress Notes
Screenings for Vulnerability to Victimization and Sexually Aggressive Behavior
(VSABs)
Interviews:
Medical Staff Mental Health Staff
Provision (a):
The facility shall offer medical and mental health evaluation and, as
appropriate, treatment to all residents who have been victimized by
sexual abuse in any prison, jail, lockup, or juvenile facility.
According to agency policy FDJJ 1919, page 8, "The facility shall offer medical and
mental health evaluations, and as appropriate, treatment to all youth who have
been victimized by sexual misconduct in any juvenile facility." The policy, PAQ, and
interviews with medical and mental health staff and the targeted interviewee
support that medical and mental health evaluation and treatment will be offered to
resident victims of sexual abuse, as appropriate. The interview with medical staff
revealed follow-up services would include following the orders provided by
the hospital and follow-up consultation with the facility's contract physician. The
interview with mental health staff revealed that follow-up services would also
include follow-up mental health services as indicated.
Conclusion:
Based upon the review and analysis of the available evidence, interviews with
medical and mental health staff, the facility is compliant with this provision.
Provision (b):
The evaluation and treatment of such victims shall include, as
appropriate, follow-up services, treatment plans, and, when necessary,
referrals for continued care following their transfer to, or placement in,
other facilities, or their release from custody.
Interviews and documentation of clinical encounters with residents confirmed on-
going medical and mental health care will be provided as appropriate and will
include but not be limited to treatment planning; evaluations, and clinical follow-up
and referrals as needed. Specialized treatment may also be provided by clinicians
on site and through contracted services within the professional judgement of the
clinician. According to agency policy, FDJJ 1919, pp. 8-9, "The facility shall offer
medical and mental health evaluations, and as appropriate, treatment to all youth
who have been victimized by sexual misconduct in any juvenile facility. The
evaluation and treatment of victims shall include, as appropriate, follow-up services,
treatment plans, and, when necessary, referrals for continued care following their
transfer to, or placement in, other facilities, or their release from custody." Based on
the interviews and informal conversations, the ongoing evaluation and treatment of
residents who have been victimized will include the appropriate follow-up services
such as crisis counseling, consultation with the facility's contract physician, and the
discharge orders from the hospital being followed.
Conclusion:
Based upon the review and analysis of the available evidence, interviews with
medical and mental health staff, and observations, the facility is compliant with this
provision.
Provision (c):
The facility shall provide such victims with medical and mental health
services consistent with the community level of care.
The review of agency policy and secondary documents such as Progress Notes,
VSABs, and Crisis Assessment, interviews, and observations revealed medical and
mental health services are consistent with the community level of care. Treatment
services may be provided by facility staff and contract services if needed and
determined within the scope of services by the clinician. The interviews, and
observations and informal conversations during the comprehensive site review,
underscored the treatment services at the facility are consistent with the
community level of care.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, informal
conversations, the facility is compliant with this provision.
Provision (d):
Resident victims of sexually abusive vaginal penetration while
incarcerated shall be offered pregnancy tests.
Only males are housed at this facility.
Provision (e):
If pregnancy results from conduct specified in paragraph (d) of this
section, such victims shall receive timely and comprehensive information
about and timely access to all lawful pregnancy-related medical services.
Only males are housed at this facility.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests
for sexually transmitted infections as medically appropriate.
The PAQ provides that resident victims of sexual abuse while in the facility are
offered tests for sexually transmitted infections as medically
appropriate. Additionally the facility policy mirrors the standard provision; according
to policy 5-19, p.13, "Youth victims of sexual abuse shall be offered tests for
sexually transmitted infections as medically appropriate." The interviews and
policies ensure that victims of sexual abuse will be provided tests for sexually
transmitted infections as medically appropriate. These services will be provided at
the hospital and may be provided at the facility if needed, according to medical
staff. Follow-up testing, post-test counseling, and health education may be done at
the facility.
Conclusion:
Based upon the review and analysis of the available evidence and the interviews,
the facility is compliant with this provision.
Provision (g):
Treatment services shall be provided to the victim without financial cost
and regardless of whether the victim names the abuser or cooperates with
any investigation arising out of the incident.
All treatment services will be provided at no cost to the victim and whether or not
the victim names the abuser of cooperates with the investigation, according to the
PAQ. Facility policy 5-19, p.12, provides, "The facility shall offer all youth who
experience sexual abuse access to forensic medical examinations whether on-site or
at an outside facility, without financial cost, where evidentiary or medically
appropriate.
Conclusion:
Based upon the review and analysis of the available evidence, the facility is
compliant with this provision.
Provision (h):
The facility shall attempt to conduct a mental health evaluation of all
known resident-on-resident abusers within 60 days of learning of such
abuse history and offer treatment when deemed appropriate by mental
health practitioners.
According to the PAQ, the facility attempts to conduct a mental health evaluation of
all known resident-on-resident abusers within 60 days of learning of such abuse
history and offers treatment when deemed appropriate by mental health
practitioners. A mental health evaluation and treatment will be offered to known
resident-on-resident abusers within 60 days according to mental health staff. The
facility is equipped to provide treatment when deemed appropriate by mental
health practitioners. According to mental health staff and documentation, there is
regular contact with facility and contract mental health professionals. The auditor
observed services provided by Therapists and Case Managers during the onsite
audit phase. residents.
Conclusion:
Based upon the review and analysis of the available evidence, interview with mental
health staff, and observations, the facility is compliant with this provision.
115.386 Sexual abuse incident reviews
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
PREA Pre-Audit Questionnaire (PAQ)
Interviews:
Superintendent/PREA Compliance Manager
Statewide PREA Coordinator
Incident Review Team Member
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion
of every sexual abuse investigation, including where the allegation has
not been substantiated, unless the allegation has been determined to be
unfounded.
According to the PAQ, "The facility conducts a sexual abuse incident review at the
conclusion of every criminal or administrative sexual abuse investigation, unless the
allegation has been determined to be unfounded." The facility is required to conduct
a sexual abuse incident review at the conclusion of an investigation, unless the
allegation was unfounded, in accordance with policy FDJJ 1919, p. 15. The policy
states, "The PREA Statewide Coordinator will conduct a sexual misconduct incident
review at the end of every sexual misconduct investigation or administrative review,
including those where the allegation has not been substantiated, unless the
allegation has been determined to be unfounded." There were no incident reviews
conducted during this audit period and no allegations of sexual abuse. The incident
review team member interviewed confirmed the meetings will be held.
Conclusion:
Based upon the review of policy and other documentation and interviews, the
facility is compliant with this provision.
Provision (b):
Such review shall ordinarily occur within 30 days of the conclusion of the
investigation.
Policy FDJJ 1919, p. 15, requires the incident review to occur within 30 days of the
conclusion of an investigation. The interview with the PREA compliance manager
supported that the incident review will occur 30 days after all investigations have
been completed, as prescribed by policy and stated in the PAQ. The administrative
review conducted by the Department of Juvenile Justice investigator does not begin
until the investigations of sexual abuse have been completed by the Department of
Children and Families and law enforcement. The incident reviews are facilitated by
the Department of Juvenile Justice statewide PREA Coordinator as stated in the
agency policy. The interviews confirmed the incident reviews will occur within 30
days.
Conclusion:
Based upon the review of policy and other documentation and interviews, the
facility is compliant with this provision.
Provision (c):
The incident review team shall include upper-level management officials,
with input from line supervisors, investigators, and medical or mental
health practitioners.
According to the PAQ, the sexual abuse incident review team includes upper-level
management officials and allows for input from line supervisors, investigators, and
medical or mental health practitioners. Policy FDJJ 1919, p. 15, provides the review
team includes the PREA compliance manager, Department program area staff,
upper-level management, with input from line supervisors, including medical and
mental health officials. The Office of Inspector General (OIG) "may participate when
the incident was investigated by the OIG." Facility policy , 5-19, p.11, states, "The
facility shall create a review team that consists of: PREA Facility Compliance
Manager; Florida Director; FDJJ Program Area Staff; Assistant Facility Administrator;
Medical official; Mental Health official; and OIG, if the incident was investigated by
the OIG. The facility policy is aligned with the overarching agency PREA policy. The
policies and interview with the incident review team member collectively identify
members of the incident review team. The statewide PREA Coordinator facilitates
the incident reviews and record the meeting minutes.
Conclusion:
Based upon the review of policy and other documentation and interviews, the
facility is compliant with this provision.
Provision (d):
The review team shall:
(1) Consider whether the allegation or investigation indicates a need to
change policy or practice to better prevent, detect, or respond to sexual
abuse;
(2) Consider whether the incident or allegation was motivated by race;
ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex
identification, status, or perceived status; or, gang affiliation; or was
motivated or otherwise caused by other group dynamics at the facility;
(3) Examine the area in the facility where the incident allegedly occurred
to assess whether physical barriers in the area may enable abuse.
(4) Assess the adequacy of staffing levels in that area during different
shifts;
(5) Assess whether monitoring technology should be deployed or
augmented to supplement supervision by staff; and
(6) Prepare a report of its findings, including but not necessarily limited to
determinations made pursuant to paragraphs (d)(1)-(d)(5) of this section,
and any recommendations for improvement and submit such report to the
facility head and PREA compliance manager.
According to the PAQ, the facility prepares a report of its findings from sexual abuse
incident reviews, including but not necessarily limited to determinations made
pursuant to paragraphs (d)(1)-(d)(5) of this section and any recommendations for
improvement, and submits such report to the facility head and PREA Compliance
Manager. The facility and agency policies outlined the requirements of the provision
for the areas to be assessed by the incident review team as shown above, aligned
with this provision. The interviews and review of policy confirmed the incident
review team has been charged with considering the factors identified in this
standard provision regarding the results of the investigations.
The incident review process will be documented by the statewide PREA Coordinator
and disseminated to the superintendent/PREA compliance manager and regional
Department of Juvenile Justice management staff. The written report also includes
any recommendations for improvement, according to informal conversation with the
superintendent/PREA compliance manager.
Conclusion:
Based upon the review of policy and other documentation and interview, the facility
is compliant with this provision.
Provision (e):
The facility shall implement the recommendations for improvement, or
shall document its reasons for not doing so.
The overarching PREA policy FDJJ1919, page 15 states, the "recommendations for
improvement from the report shall be implemented, or justification provided for not
implementing said recommendations." Policy also indicates the reasons for not
following recommendations are documented. The interview with the incident review
team member revealed familiarity with the policy requirements. The incident review
process allows for the assessment of the circumstances surrounding the incident. A
format for documenting the incident review process has been developed by the DJJ
statewide PREA Coordinator.
Conclusion:
Based upon the review of policy and other documentation and interviews, the
facility is compliant with this provision.
115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Agency Policy FDJJ 2020, Incident Operations Center CCC
CCC Data and PREA Allegation Data Report FY 24-25
PREA Pre-Audit Questionnaire (PAQ)
Annual Report
Interview:
Statewide PREA Coordinator
Provision (a):
The agency shall collect accurate, uniform data for every allegation of
sexual abuse at facilities under its direct control using a standardized
instrument and set of definitions.
Policy 1919, p. 19, provides for the collection of accurate and uniform data from the
database in the Central Communications Center (CCC) for every allegation of sexual
abuse from incident-based documents. The policy states, "The Department shall
collect uniform data in the CCC for every allegation of sexual misconduct at its
facilities, both state-operated and those with contracted providers." Per the policy,
Incident-based sexual misconduct data is aggregated at least annually as
documented in the data report for FY 24-25 for the state-run and contracted
facilities. Policy FDJJ 2020 contains a standardized set of definitions and provides
support for the collection of accurate and uniform data.
Conclusion:
Based upon the review and analysis of the documentation and the interview, the
facility is compliant with this provision of the standard.
Provision (b):
The agency shall aggregate the incident-based sexual abuse data at least
annually.
The agency aggregates the incident-based, uniform data regarding allegations of
sexual abuse and sexual harassment, at least annually, according to the PAQ,
interview, and policy FDJJ 1919, p.19. The aggregated data contributes to the
development of the annual report for the agency which is supported by the
reviewed data and policies. Evidence of the aggregated data is recorded on the CCC
Data and PREA Allegation Data report, FY 24-25. The agency collects the data and
completes an annual report with the compilation of data gleaned from the facilities
through the central reporting system as determined from the interview with the
statewide PREA Coordinator.
Conclusion:
Based upon the review and analysis of the documentation and the interview, the
facility is compliant with this provision of the standard.
Provision (c):
The incident-based data collected shall include, at a minimum, the data
necessary to answer all questions from the most recent version of the
Survey of Sexual Violence conducted by the Department of Justice.
The agency maintains incident-based data complete enough to complete the most
recent version of the instrument formerly identified as the Survey of Sexual Violence
and now identified as the Survey of Sexual Victimization. The premise was
confirmed by a review of the PREA-related data and Survey of Sexual Victimization.
Conclusion:
Based upon the review and analysis of the documentation, the facility is compliant
with this provision of the standard.
Provision (d):
The agency shall maintain, review, and collect data as needed from all
available incident-based documents, including reports, investigation files,
and sexual abuse incident reviews.
The data is collected and various types of data are identified and related documents
regarding PREA information as applicable. The facility policy requires that statistical
information is maintained for various service areas and occurrences, including major
incidents and medical and mental health emergencies. The agency collects and
maintains PREA-related data, through the CCC, for state-run and contract facilities
and aggregates the data. According to the statewide PREA Coordinator, the CCC is a
computer-based data system. Policy FDJJ 1919, p. 20, states, "the PREA Statewide
Coordinator will review data collected and aggregated in order to assess and
improve the effectiveness of the Department’s sexual misconduct prevention,
detection, and response policies, practices, and training. The incident reviews are
facilitated by the statewide PREA Coordinator and he also maintains the records.
Conclusion:
Based upon the review and analysis of the documentation and the interview, the
facility is compliant with this provision of the standard.
Provision (e):
The agency also shall obtain incident-based and aggregated data from
every private facility with which it contracts for the confinement of its
residents.
The agency collects and maintains data for state-run and contract facilities and
aggregates the data, documented on the CCC Data and PREA Allegation Data sheet
and intimated by the statewide PREA Coordinator. The information assist in the
culmination of the annual report. The data is collected from the contract facilities
and is included in the agency’s annual reports as evident by the review of the CCC
Data and PREA Allegation Data sheet and annual reports posted on the agency
website.
Conclusion:
Based upon the review and analysis of the documentation and the interview, the
facility is compliant with this provision of the standard.
Provision (f):
Upon request, the agency shall provide all such data from the previous
calendar year to the Department of Justice no later than June 30.
Upon request, the facility completes all such data from the previous calendar year
and submits to the Department of Justice in a timely manner based on the year of
the most recent version of the Survey of Sexual Victimization. According to the PAQ,
a request has not been received by the Department of Justice.
Conclusion:
Based upon the review and analysis of the documentation, the facility is compliant
with the provision of this standard.
115.388 Data review for corrective action
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Annual Reports
Interviews:
Statewide PREA Coordinator
Agency Head Designee
Provision (a):
The agency shall review data collected and aggregated pursuant to
§115.387 in order to assess and improve the effectiveness of its sexual
abuse prevention, detection, and response policies, practices, and
training, including:
(1) Identifying problem areas;
(2) Taking corrective action on an ongoing basis; and
(3) Preparing an annual report of its findings and corrective actions for
each facility, as well as this agency as a whole.
The PAQ confirms this provision occurs. The interviews with the parent agency's
agency head designee and Department of Juvenile Justice statewide (DJJ) PREA
Coordinator support the review of data and that it is used to improve the PREA
efforts for both agencies. The interviews and review of documentation revealed the
collection of various types of data, including PREA related information. According to
the statewide PREA Coordinator, data is collected through the DJJ Central
Communication Center (CCC) where information from all incidents is reported.
According to the facility's parent agency's head designee, Youth Opportunity
Investments corporate-level and management staff, review significant data
including PREA on a monthly basis. The parent agency/facility develops and
implements corrective as actions as needed to policy and/or staff training.
The statewide PREA Coordinator prepares an annual report complete with current
and previous PREA data from all residential and detention facilities operated and
contracted by DJJ. the data is managed by the DJJ statewide PREA Coordinator
gleaned from State-run and contracted facilities. The annual reports are made
available through the DJJ webpage. Data is reviewed to assess and improve the
effectiveness of prevention, detection and response within the agency as well as
individual facilities. The data is also primary to preparing annual reports.
Conclusion:
Based upon the review and analysis of the documentation and the
interviews, the facility is compliant with this standard.
Provisions (b):
Such report shall include a comparison of the current year’s data and
corrective actions with those from prior years and shall provide an
assessment of the agency’s progress in addressing sexual abuse.
According to the review of the annual report, the agency adheres to policy FDJJ
1919, pp. 19-20, in the preparation of the annual report. The policy provides the
following: "The Department’s PREA Statewide Coordinator will prepare an annual
report of sexual misconduct incidents, findings, and corrective actions for all
facilities, state and contracted, and the Department as a whole. The report will
include a comparison of the current year’s data and corrective actions with those
from prior years and shall provide an assessment of the agency’s progress in
addressing sexual misconduct. The report will be reviewed and approved by the
Secretary and be made readily available to the public through the agency’s
website." The annual report was reviewed on the website and it
contains comparison data references corrective actions.
Conclusion:
Based upon the review and analysis of the documentation, the facility is compliant
with this provision.
Provision (c):
The agency’s report shall be approved by the agency head and made
readily available to the public through its website or, if it does not have
one, through other means.
The agency website was reviewed and the annual reports for the agency have been
uploaded and are accessible to the public, in accordance with policy FDJJ 1919 and
the interviews. The agency head designee confirmed the overarching annual report
is prepared by the DJJ statewide PREA Coordinator for all the contract and state-run
facilities. He also confirmed that parent agency do PREA assessments annually and
share with staff. The annual report is approved by the DJJ agency head as confirmed
by the DJJ statewide PREA Coordinator. The reports were reviewed on the DJJ
website.
Conclusion:
Based upon the review and analysis of the documentation and interviews, the
agency is compliant with this standard.
Provision (d):
The agency may redact specific material from the reports when publication
would present a clear and specific threat to the safety and security of a
facility, but must indicate the nature of the material redacted.
According to the PAQ, the agency redacts material from the annual report for
publication, the redactions are limited to specific materials where publication would
present a clear and specific threat to the safety and security of the facility and the
agency indicates the nature of material redacted. The annual report is prepared by
the statewide PREA Coordinator for the agency and includes data from all state-run
and contract facilities within the agency. There are no personal identifiers in the
report and contains PREA related data in accordance with FDJJ 1919 policy.
According to the statewide PREA Coordinator, "Youth and staff personal identifying
information is not included in the annual report." The annual report contains PREA
related data that represents previous calendar years allowing for the comparison of
data. The overarching annual report for the agency is posted on the agency’s
website, accessible to the public, and contains no redactions. Materials are not
included in the report that would present a clear and specific threat to the safety
and security of the facility.
Conclusion:
Based upon the review and analysis of the documentation and interviews, the
agency is compliant with this provision.
115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1316, Records and Information Management
Annual Report
PREA Pre-Audit Questionnaire (PAQ)
Interviews:
Regional PREA Coordinator
DJJ Statewide PREA Coordinator
Provisions (a):
The facility shall ensure that data collected pursuant to §115.387 are
securely retained.
According to the PAQ, the facility/agency ensure that incident and aggregate data
are securely retained. Agency policy FDJJ 13.16, Records Information Management,
p.1., states, "The Florida Department of Juvenile Justice (DJJ) shall have formal
procedures for the management, storage and disposal of all its records regardless of
media format in accordance with the guidelines set forth by the Florida Department
of State." The statewide PREA Coordinator confirmed the data is securely retained
and that "electronic data may only be accessed with permissions." Additionally, data
is collected through the Central Communication Center (CCC) where information
from all incidents is reported, updated, and maintained. The regional PREA
coordinator for the parent agency of the facility also confirmed data is stored,
onsite, electronically [password protected] and hard copies are maintained in locked
cabinets in offices with locked doors within the key control system. The auditor
observed sensitive information stored in locked cabinets, in locked offices.
Conclusion:
Based upon the review and analysis of the documentation, interviews and
observations, the facility is compliant with this provision.
Provision (b):
The facility shall make all aggregated sexual abuse data, from facilities
under its direct control and private facilities with which it contracts,
readily available to the public at least annually through its website or, if it
does not have one, through other means.
The PAQ provides that the agency policy requires that aggregated sexual abuse
data from facilities under its direct control and private facilities with which it
contracts is made readily available to the public, at least annually, through its
website. According to policy FDJJ 1919, p.20, "The Department shall collect uniform
data in the CCC for every allegation of sexual misconduct at its facilities, both state-
operated and those with contracted providers. Incident-based sexual misconduct
data shall be aggregated at least annually." The annual report is available to the
public through the agency website and was reviewed by the auditor. Agency policy
FDJJ 1919, p. 19, states, "The Department's PREA Statewide Coordinator will prepare
an annual report of sexual misconduct incidents, findings, and corrective actions for
all facilities, state and contracted, and the Department as a whole."
Conclusion:
Based upon the review and analysis of the documentation, interview with the
statewide PREA Coordinator and observations, the facility is compliant with this
provision.
Provision (c):
Before making aggregated sexual abuse data publicly available, the
facility shall remove all personal identifiers.
Personal identifiers were removed from aggregated data before making the data
publicly available as determined by the review of annual reports. According to policy
FDJJ 1919, pp. 19-20, "Information that may present a clear and specific threat to
the safety and security of a facility may be redacted but must indicate the nature of
the information redacted." The DJJ statewide PREA Coordinator confirmed the
redaction of personal identifiers of residents and staff as evidenced by the auditor's
review of the publicly available data.
Conclusion:
Based upon the review and analysis of the documentation, informal conversation
with the statewide PREA Coordinator, and observations, the facility is compliant
with this provision.
Provision (d):
The facility shall maintain sexual abuse data collected pursuant
to §115.387 for at least 10 years after the date of its initial collection
unless Federal, State, or local law requires otherwise.
According to the PAQ, the agency maintains sexual abuse data collected pursuant
to §115.387 for at least 10 years after the date of initial collection, unless federal,
state, or local law requires otherwise. Policy FDJJ 1919, p.19, states, "Reports will be
maintained in accordance with State of Florida record retention schedules. All data
collected will be maintained for at least 10 years after the date of the initial
collection. The annual reports remain on the agency's website and may be
downloaded. The aggregated data is maintained with the Central Communications
Center (CCC).
Conclusion:
Based upon the review and analysis of the documentation, informal conversations
with the PREA Coordinators, and observations, the facility is compliant with this
provision.
115.401 Frequency and scope of audits
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
PREA Pre-Audit Questionnaire (PAQ)
PREA Audits, 2014-2023
Posted PREA Audit Notices
Provision (a):
During the three-year period starting on August 20, 2013, and during each
three-year period thereafter, the agency shall ensure that each facility
operated by the agency, or by a private organization on behalf of the
agency, is audited at least once.
The initial PREA audit was conducted in 2014 and each three-year period thereafter:
2017, 2020, 2023, and this current audit in 2026. FDJJ Policy 1919 requires all DJJ
facilities be audited every three years for compliance with the Prison Rape
Elimination Act. All audits were conducted by a certified PREA auditor.
Conclusion:
Based on the available evidence and informal conversations with the
superintendent/PREA compliance manager and statewide PREA Coordinator, the
facility is compliant with this provision.
Provision (b):
During each one-year period starting on August 20, 2013, the agency shall
ensure that at least one-third of each facility type operated by the agency,
or by a private organization on behalf of the agency, is audited.
During the prior three-year cycles, the agency ensured that each facility operated
by the agency, or by a private organization on behalf of the agency, was audited at
least once as evidenced by the PAQ, posted PREA audit reports for each three-year
period, and informal conversations with the superintendent/PREA Compliance
Manager and statewide PREA Coordinator. The FDJJ ensured the completion of PREA
audits for each state-run and contract facility as required, including this facility.
Conclusion:
Based on the available evidence and informal conversations with identified staff, the
facility is compliant with this provision.
Provision h:
The auditor shall have access to, and shall observe, all areas of the
facilities.
The comprehensive site review was provided to the superintendent who serves as
the PREA Compliance Manager. All areas of the facility were observed including
administrative area, living units and individual rooms, classrooms, cafeteria,
kitchen, laundry rooms, bathrooms, storage closets, control room, and recreation
area. The auditor also had the opportunity to re-visit areas without impediment
when conducting interviews, initiating informal conversations with residents and
staff, and/or completing additional observations.
Conclusion:
Based on the available evidence and informal conversations with staff and
residents, and observations, the facility is compliant with this provision.
Provision (i):
The auditor shall be permitted to request and receive copies of any
relevant documents (including electronically stored information).
The PAQ was completed in the online automated system and supporting
documentation was also uploaded in the system. The auditor was provided
additional information and documents onsite upon request and by email. During the
onsite and post audit phases, the superintendent/PREA compliance manager
provided additional information as requested. The auditor was able to review
electronically stored documents, including video footage, during the onsite audit
phase. The additional documents requested included personnel and resident files,
pertinent forms, training records, and video footage of an unannounced round.
Conclusion:
Based on the available evidence and informal conversations with staff, the facility is
compliant with this provision.
Provision (m):
The auditor shall be permitted to conduct private interviews with
residents.
The superintendent/PREA compliance manager and other facility staff were
cooperative in providing information and participating in or assisting in coordinating
the interviews with residents. The staff ensured that the interviews were conducted
in private with the residents and staff. Privacy was provided in a conference room,
behind a closed door, in the administrative area.
The written notices regarding the audit were observed posted within the facility and
specifically in the living units during the comprehensive site review. The notices
were colorful, easy to read, and printed in English and Spanish on the same posting.
The notices provided the general information and included instructions and auditor
contact information regarding how to provide confidential information to the auditor.
The facility has a process for confidential correspondence however no such
correspondence was received by the auditor. All residents randomly and specifically
selected agreed to be interviewed and there were no requests made by any
residents to speak with the auditor.
Conclusion:
Based on the available evidence and informal conversations with random staff, the
facility is compliant with this provision.
Provision (n):
Residents shall be permitted to send confidential information or
correspondence to the auditor in the same manner as if they were
communicating with legal counsel.
The PREA audit notices, provided by the auditor, were posted within the facility
including the living units. The notices provided the general information regarding
the scheduled audit and included instructions and auditor contact information
regarding how to provide confidential information to the auditor. The facility has a
process for confidential correspondence; however, no such correspondence was
received by the auditor. All residents interviewed, stated they were aware of the
occurrence of the audit either through the posted notice or through staff telling
them.
Conclusion:
Based on the available evidence and informal conversations with identified staff and
residents, the facility is compliant with this provision.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Previous PREA Audits
Agency Website
Interviews:
Superintendent/PREA Compliance Manager
Statewide PREA Coordinator
Provision (f):
The agency shall ensure that the auditor’s final report is published on the
agency’s website if it has one, or is otherwise made readily available to
the public.
The PREA reports are posted on the Department of Juvenile Justice (DJJ) website,
accessible to the public and may be downloaded. The facility and agency policies,
review of previous audit reports, and informal conversations with the
superintendent/PREA Compliance Manager, and DJJ statewide PREA
Coordinator confirmed the completion of PREA audits every required three-years
within the audit cycle. Previous audits were conducted and posted on the agency's
website in 2014, 2017, 2020, and 2023. Informal conversation with the statewide
PREA Coordinator and observations by the auditor confirmed the reports are posted
on the agency website. Each audit was conducted by a certified PREA auditor.
Conclusion:
Based on the available evidence and informal conversations with identified staff, the
facility is compliant with this provision.
Appendix: Provision Findings
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(a) coordinator
Does the agency have a written policy mandating zero tolerance yes
toward all forms of sexual abuse and sexual harassment?
Does the written policy outline the agency’s approach to yes
preventing, detecting, and responding to sexual abuse and sexual
harassment?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(b) coordinator
Has the agency employed or designated an agency-wide PREA yes
Coordinator?
Is the PREA Coordinator position in the upper-level of the agency yes
hierarchy?
Does the PREA Coordinator have sufficient time and authority to yes
develop, implement, and oversee agency efforts to comply with
the PREA standards in all of its facilities?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(c) coordinator
If this agency operates more than one facility, has each facility yes
designated a PREA compliance manager? (N/A if agency operates
only one facility.)
Does the PREA compliance manager have sufficient time and yes
authority to coordinate the facility’s efforts to comply with the
PREA standards? (N/A if agency operates only one facility.)
115.312
Contracting with other entities for the confinement of residents
(a)
If this agency is public and it contracts for the confinement of its yes
residents with private agencies or other entities including other
government agencies, has the agency included the entity’s
obligation to adopt and comply with the PREA standards in any
new contract or contract renewal signed on or after August 20,
2012? (N/A if the agency does not contract with private agencies
or other entities for the confinement of residents.)
115.312
Contracting with other entities for the confinement of residents
(b)
Does any new contract or contract renewal signed on or after yes
August 20, 2012 provide for agency contract monitoring to ensure
that the contractor is complying with the PREA standards? (N/A if
the agency does not contract with private agencies or other
entities for the confinement of residents OR the response to
115.312(a)-1 is "NO".)
115.313
Supervision and monitoring
(a)
Does the agency ensure that each facility has developed a staffing yes
plan that provides for adequate levels of staffing and, where
applicable, video monitoring, to protect residents against sexual
abuse?
Does the agency ensure that each facility has implemented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility has documented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
prevalence of substantiated and unsubstantiated incidents of
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Generally accepted juvenile detention and correctional/secure
residential practices?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
judicial findings of inadequacy?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from Federal investigative agencies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from internal or external oversight bodies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: All
components of the facility’s physical plant (including “blind-spots”
or areas where staff or residents may be isolated)?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
composition of the resident population?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
number and placement of supervisory staff?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Institution programs occurring on a particular shift?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
applicable State or local laws, regulations, or standards?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
other relevant factors?
115.313
Supervision and monitoring
(b)
Does the agency comply with the staffing plan except during yes
limited and discrete exigent circumstances?
In circumstances where the staffing plan is not complied with, na
does the facility fully document all deviations from the plan? (N/A
if no deviations from staffing plan.)
115.313
Supervision and monitoring
(c)
Does the facility maintain staff ratios of a minimum of 1:8 during yes
resident waking hours, except during limited and discrete exigent
circumstances? (N/A only until October 1, 2017.)
Does the facility maintain staff ratios of a minimum of 1:16 during yes
resident sleeping hours, except during limited and discrete
exigent circumstances? (N/A only until October 1, 2017.)
Does the facility fully document any limited and discrete exigent yes
circumstances during which the facility did not maintain staff
ratios? (N/A only until October 1, 2017.)
Does the facility ensure only security staff are included when yes
calculating these ratios? (N/A only until October 1, 2017.)
Is the facility obligated by law, regulation, or judicial consent yes
decree to maintain the staffing ratios set forth in this paragraph?
115.313
Supervision and monitoring
(d)
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The staffing plan established
pursuant to paragraph (a) of this section?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: Prevailing staffing patterns?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The facility’s deployment of
video monitoring systems and other monitoring technologies?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The resources the facility has
available to commit to ensure adherence to the staffing plan?
115.313
Supervision and monitoring
(e)
Has the facility implemented a policy and practice of having yes
intermediate-level or higher-level supervisors conduct and
document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? (N/A for non-secure facilities )
Is this policy and practice implemented for night shifts as well as yes
day shifts? (N/A for non-secure facilities )
Does the facility have a policy prohibiting staff from alerting other yes
staff members that these supervisory rounds are occurring, unless
such announcement is related to the legitimate operational
functions of the facility? (N/A for non-secure facilities )
115.315
Limits to cross-gender viewing and searches
(a)
Does the facility always refrain from conducting any cross-gender yes
strip or cross-gender visual body cavity searches, except in
exigent circumstances or by medical practitioners?
115.315
Limits to cross-gender viewing and searches
(b)
Does the facility always refrain from conducting cross-gender pat- yes
down searches in non-exigent circumstances?
115.315
Limits to cross-gender viewing and searches
(c)
Does the facility document and justify all cross-gender strip yes
searches and cross-gender visual body cavity searches?
Does the facility document all cross-gender pat-down searches? yes
115.315
Limits to cross-gender viewing and searches
(d)
Does the facility implement policies and procedures that enable yes
residents to shower, perform bodily functions, and change clothing
without nonmedical staff of the opposite gender viewing their
breasts, buttocks, or genitalia, except in exigent circumstances or
when such viewing is incidental to routine cell checks?
Does the facility require staff of the opposite gender to announce yes
their presence when entering a resident housing unit?
In facilities (such as group homes) that do not contain discrete na
housing units, does the facility require staff of the opposite gender
to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions,
or changing clothing? (N/A for facilities with discrete housing
units)
115.315
Limits to cross-gender viewing and searches
(e)
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.315
Limits to cross-gender viewing and searches
(f)
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.316 Residents with disabilities and residents who are limited
(a) English proficient
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are deaf or hard of hearing?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are blind or have low vision?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have intellectual disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have psychiatric disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have speech disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Other? (if "other," please explain in overall determination notes.)
Do such steps include, when necessary, ensuring effective yes
communication with residents who are deaf or hard of hearing?
Do such steps include, when necessary, providing access to yes
interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any
necessary specialized vocabulary?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
intellectual disabilities?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
limited reading skills?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Who are
blind or have low vision?
115.316 Residents with disabilities and residents who are limited
(b) English proficient
Does the agency take reasonable steps to ensure meaningful yes
access to all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment to residents
who are limited English proficient?
Do these steps include providing interpreters who can interpret yes
effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary?
115.316 Residents with disabilities and residents who are limited
(c) English proficient
Does the agency always refrain from relying on resident yes
interpreters, resident readers, or other types of resident assistants
except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s
safety, the performance of first-response duties under §115.364,
or the investigation of the resident’s allegations?
115.317
Hiring and promotion decisions
(a)
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has engaged in sexual
abuse in a prison, jail, lockup, community confinement facility,
juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been convicted of
engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or
coercion, or if the victim did not consent or was unable to consent
or refuse?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been civilly or
administratively adjudicated to have engaged in the activity
described in the bullet immediately above?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has
engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as
defined in 42 U.S.C. 1997)?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
convicted of engaging or attempting to engage in sexual activity
in the community facilitated by force, overt or implied threats of
force, or coercion, or if the victim did not consent or was unable to
consent or refuse?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
civilly or administratively adjudicated to have engaged in the
activity described in the two bullets immediately above?
115.317
Hiring and promotion decisions
(b)
Does the agency consider any incidents of sexual harassment in yes
determining whether to hire or promote anyone, or to enlist the
services of any contractor, who may have contact with residents?
115.317
Hiring and promotion decisions
(c)
Before hiring new employees who may have contact with yes
residents, does the agency: Perform a criminal background records
check?
Before hiring new employees who may have contact with yes
residents, does the agency: Consult any child abuse registry
maintained by the State or locality in which the employee would
work?
Before hiring new employees who may have contact with yes
residents, does the agency: Consistent with Federal, State, and
local law, make its best efforts to contact all prior institutional
employers for information on substantiated allegations of sexual
abuse or any resignation during a pending investigation of an
allegation of sexual abuse?
115.317
Hiring and promotion decisions
(d)
Does the agency perform a criminal background records check yes
before enlisting the services of any contractor who may have
contact with residents?
Does the agency consult applicable child abuse registries before yes
enlisting the services of any contractor who may have contact
with residents?
115.317
Hiring and promotion decisions
(e)
Does the agency either conduct criminal background records yes
checks at least every five years of current employees and
contractors who may have contact with residents or have in place
a system for otherwise capturing such information for current
employees?
115.317
Hiring and promotion decisions
(f)
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in written applications or
interviews for hiring or promotions?
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in any interviews or
written self-evaluations conducted as part of reviews of current
employees?
Does the agency impose upon employees a continuing affirmative yes
duty to disclose any such misconduct?
115.317
Hiring and promotion decisions
(g)
Does the agency consider material omissions regarding such yes
misconduct, or the provision of materially false information,
grounds for termination?
115.317
Hiring and promotion decisions
(h)
Unless prohibited by law, does the agency provide information on yes
substantiated allegations of sexual abuse or sexual harassment
involving a former employee upon receiving a request from an
institutional employer for whom such employee has applied to
work? (N/A if providing information on substantiated allegations of
sexual abuse or sexual harassment involving a former employee is
prohibited by law.)
115.318
Upgrades to facilities and technologies
(a)
If the agency designed or acquired any new facility or planned any na
substantial expansion or modification of existing facilities, did the
agency consider the effect of the design, acquisition, expansion,
or modification upon the agency’s ability to protect residents from
sexual abuse? (N/A if agency/facility has not acquired a new
facility or made a substantial expansion to existing facilities since
August 20, 2012, or since the last PREA audit, whichever is later.)
115.318
Upgrades to facilities and technologies
(b)
If the agency installed or updated a video monitoring system, yes
electronic surveillance system, or other monitoring technology,
did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if
agency/facility has not installed or updated a video monitoring
system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit,
whichever is later.)
115.321
Evidence protocol and forensic medical examinations
(a)
If the agency is responsible for investigating allegations of sexual na
abuse, does the agency follow a uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for
administrative proceedings and criminal prosecutions? (N/A if the
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
115.321 Evidence protocol and forensic medical examinations
(b)
Is this protocol developmentally appropriate for youth? (N/A if the na
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
Is this protocol, as appropriate, adapted from or otherwise based na
on the most recent edition of the U.S. Department of Justice’s
Office on Violence Against Women publication, “A National Protocol
for Sexual Assault Medical Forensic Examinations, Adults/
Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative
sexual abuse investigations. )
115.321
Evidence protocol and forensic medical examinations
(c)
Does the agency offer all residents who experience sexual abuse yes
access to forensic medical examinations, whether on-site or at an
outside facility, without financial cost, where evidentiarily or
medically appropriate?
Are such examinations performed by Sexual Assault Forensic yes
Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs)
where possible?
If SAFEs or SANEs cannot be made available, is the examination yes
performed by other qualified medical practitioners (they must
have been specifically trained to conduct sexual assault forensic
exams)?
Has the agency documented its efforts to provide SAFEs or yes
SANEs?
115.321
Evidence protocol and forensic medical examinations
(d)
Does the agency attempt to make available to the victim a victim yes
advocate from a rape crisis center?
If a rape crisis center is not available to provide victim advocate yes
services, does the agency make available to provide these
services a qualified staff member from a community-based
organization, or a qualified agency staff member?
Has the agency documented its efforts to secure services from yes
rape crisis centers?
115.321 Evidence protocol and forensic medical examinations
(e)
As requested by the victim, does the victim advocate, qualified yes
agency staff member, or qualified community-based organization
staff member accompany and support the victim through the
forensic medical examination process and investigatory
interviews?
As requested by the victim, does this person provide emotional yes
support, crisis intervention, information, and referrals?
115.321
Evidence protocol and forensic medical examinations
(f)
If the agency itself is not responsible for investigating allegations yes
of sexual abuse, has the agency requested that the investigating
entity follow the requirements of paragraphs (a) through (e) of this
section? (N/A if the agency is responsible for investigating
allegations of sexual abuse.)
115.321
Evidence protocol and forensic medical examinations
(h)
If the agency uses a qualified agency staff member or a qualified na
community-based staff member for the purposes of this section,
has the individual been screened for appropriateness to serve in
this role and received education concerning sexual assault and
forensic examination issues in general? (Check N/A if agency
attempts to make a victim advocate from a rape crisis center
available to victims per 115.321(d) above.)
115.322
Policies to ensure referrals of allegations for investigations
(a)
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual abuse?
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual
harassment?
115.322
Policies to ensure referrals of allegations for investigations
(b)
Does the agency have a policy in place to ensure that allegations yes
of sexual abuse or sexual harassment are referred for
investigation to an agency with the legal authority to conduct
criminal investigations, unless the allegation does not involve
potentially criminal behavior?
Has the agency published such policy on its website or, if it does yes
not have one, made the policy available through other means?
Does the agency document all such referrals? yes
115.322
Policies to ensure referrals of allegations for investigations
(c)
If a separate entity is responsible for conducting criminal yes
investigations, does such publication describe the responsibilities
of both the agency and the investigating entity? (N/A if the
agency/facility is responsible for criminal investigations. See
115.321(a))
115.331
Employee training
(a)
Does the agency train all employees who may have contact with yes
residents on: Its zero-tolerance policy for sexual abuse and sexual
harassment?
Does the agency train all employees who may have contact with yes
residents on: How to fulfill their responsibilities under agency
sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures?
Does the agency train all employees who may have contact with yes
residents on: Residents’ right to be free from sexual abuse and
sexual harassment
Does the agency train all employees who may have contact with yes
residents on: The right of residents and employees to be free from
retaliation for reporting sexual abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: The dynamics of sexual abuse and sexual
harassment in juvenile facilities?
Does the agency train all employees who may have contact with yes
residents on: The common reactions of juvenile victims of sexual
abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: How to detect and respond to signs of threatened
and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents?
Does the agency train all employees who may have contact with yes
residents on: How to avoid inappropriate relationships with
residents?
The subsection of this provision is no longer applicable to your na
compliance finding, please select N/A.
Does the agency train all employees who may have contact with yes
residents on: How to comply with relevant laws related to
mandatory reporting of sexual abuse to outside authorities?
Does the agency train all employees who may have contact with yes
residents on: Relevant laws regarding the applicable age of
consent?
115.331
Employee training
(b)
Is such training tailored to the unique needs and attributes of yes
residents of juvenile facilities?
Is such training tailored to the gender of the residents at the yes
employee’s facility?
Have employees received additional training if reassigned from a yes
facility that houses only male residents to a facility that houses
only female residents, or vice versa?
115.331
Employee training
(c)
Have all current employees who may have contact with residents yes
received such training?
Does the agency provide each employee with refresher training yes
every two years to ensure that all employees know the agency’s
current sexual abuse and sexual harassment policies and
procedures?
In years in which an employee does not receive refresher training, yes
does the agency provide refresher information on current sexual
abuse and sexual harassment policies?
115.331
Employee training
(d)
Does the agency document, through employee signature or yes
electronic verification, that employees understand the training
they have received?
115.332
Volunteer and contractor training
(a)
Has the agency ensured that all volunteers and contractors who yes
have contact with residents have been trained on their
responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and
procedures?
115.332
Volunteer and contractor training
(b)
Have all volunteers and contractors who have contact with yes
residents been notified of the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment and informed how
to report such incidents (the level and type of training provided to
volunteers and contractors shall be based on the services they
provide and level of contact they have with residents)?
115.332
Volunteer and contractor training
(c)
Does the agency maintain documentation confirming that yes
volunteers and contractors understand the training they have
received?
115.333
Resident education
(a)
During intake, do residents receive information explaining the yes
agency’s zero-tolerance policy regarding sexual abuse and sexual
harassment?
During intake, do residents receive information explaining how to yes
report incidents or suspicions of sexual abuse or sexual
harassment?
Is this information presented in an age-appropriate fashion? yes
115.333
Resident education
(b)
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from sexual abuse and
sexual harassment?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from retaliation for
reporting such incidents?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Agency policies and procedures for responding to
such incidents?
115.333
Resident education
(c)
Have all residents received such education? yes
Do residents receive education upon transfer to a different facility yes
to the extent that the policies and procedures of the resident’s
new facility differ from those of the previous facility?
115.333
Resident education
(d)
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are limited English proficient?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are deaf?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are visually impaired?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are otherwise disabled?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Have limited reading skills?
115.333
Resident education
(e)
Does the agency maintain documentation of resident participation yes
in these education sessions?
115.333
Resident education
(f)
In addition to providing such education, does the agency ensure yes
that key information is continuously and readily available or visible
to residents through posters, resident handbooks, or other written
formats?
115.334
Specialized training: Investigations
(a)
In addition to the general training provided to all employees na
pursuant to §115.331, does the agency ensure that, to the extent
the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such
investigations in confinement settings? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.334
Specialized training: Investigations
(b)
Does this specialized training include: Techniques for interviewing na
juvenile sexual abuse victims? (N/A if the agency does not conduct
any form of administrative or criminal sexual abuse investigations.
See 115.321(a).)
Does this specialized training include: Proper use of Miranda and na
Garrity warnings? (N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See
115.321(a).)
Does this specialized training include: Sexual abuse evidence na
collection in confinement settings? (N/A if the agency does not
conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
Does this specialized training include: The criteria and evidence na
required to substantiate a case for administrative action or
prosecution referral? (N/A if the agency does not conduct any form
of administrative or criminal sexual abuse investigations. See
115.321(a).)
115.334
Specialized training: Investigations
(c)
Does the agency maintain documentation that agency na
investigators have completed the required specialized training in
conducting sexual abuse investigations? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.335
Specialized training: Medical and mental health care
(a)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to detect and assess signs of sexual
abuse and sexual harassment? (N/A if the agency does not have
any full- or part-time medical or mental health care practitioners
who work regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to preserve physical evidence of sexual
abuse? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual
harassment? (N/A if the agency does not have any full- or part-
time medical or mental health care practitioners who work
regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How and to whom to report allegations or
suspicions of sexual abuse and sexual harassment? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(b)
If medical staff employed by the agency conduct forensic yes
examinations, do such medical staff receive appropriate training
to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams or the agency does not
employ medical staff.)
115.335
Specialized training: Medical and mental health care
(c)
Does the agency maintain documentation that medical and yes
mental health practitioners have received the training referenced
in this standard either from the agency or elsewhere? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(d)
Do medical and mental health care practitioners employed by the yes
agency also receive training mandated for employees by
§115.331? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Do medical and mental health care practitioners contracted by yes
and volunteering for the agency also receive training mandated
for contractors and volunteers by §115.332? (N/A if the agency
does not have any full- or part-time medical or mental health care
practitioners contracted by or volunteering for the agency.)
115.341
Obtaining information from residents
(a)
Within 72 hours of the resident’s arrival at the facility, does the yes
agency obtain and use information about each resident’s personal
history and behavior to reduce risk of sexual abuse by or upon a
resident?
Does the agency also obtain this information periodically yes
throughout a resident’s confinement?
115.341
Obtaining information from residents
(b)
Are all PREA screening assessments conducted using an objective yes
screening instrument?
115.341
Obtaining information from residents
(c)
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Prior sexual
victimization or abusiveness?
The subsection of this provision is no longer applicable to your na
compliance finding, please select N/A.
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Current
charges and offense history?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Age?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Level of
emotional and cognitive development?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical size
and stature?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Mental illness
or mental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Intellectual or
developmental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical
disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: The resident’s
own perception of vulnerability?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any other
specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or
separation from certain other residents?
115.341
Obtaining information from residents
(d)
Is this information ascertained: Through conversations with the yes
resident during the intake process and medical mental health
screenings?
Is this information ascertained: During classification assessments? yes
Is this information ascertained: By reviewing court records, case yes
files, facility behavioral records, and other relevant documentation
from the resident’s files?
115.341
Obtaining information from residents
(e)
Has the agency implemented appropriate controls on the yes
dissemination within the facility of responses to questions asked
pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or
other residents?
115.342
Placement of residents
(a)
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Housing Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Bed assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Work Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Education
Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Program Assignments?
115.342
Placement of residents
(b)
Are residents isolated from others only as a last resort when less yes
restrictive measures are inadequate to keep them and other
residents safe, and then only until an alternative means of
keeping all residents safe can be arranged?
During any period of isolation, does the agency always refrain yes
from denying residents daily large-muscle exercise?
During any period of isolation, does the agency always refrain yes
from denying residents any legally required educational
programming or special education services?
Do residents in isolation receive daily visits from a medical or yes
mental health care clinician?
Do residents also have access to other programs and work yes
opportunities to the extent possible?
115.342
Placement of residents
(c)
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(d)
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(e)
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(f)
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(g)
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(h)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The basis for the facility’s
concern for the resident’s safety? (N/A for h and i if facility doesn’t
use isolation?)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The reason why no alternative
means of separation can be arranged? (N/A for h and i if facility
doesn’t use isolation?)
115.342
Placement of residents
(i)
In the case of each resident who is isolated as a last resort when yes
less restrictive measures are inadequate to keep them and other
residents safe, does the facility afford a review to determine
whether there is a continuing need for separation from the general
population EVERY 30 DAYS?
115.351 Resident reporting
(a)
Does the agency provide multiple internal ways for residents to yes
privately report: Sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: 2. Retaliation by other residents or staff for
reporting sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: Staff neglect or violation of responsibilities that
may have contributed to such incidents?
115.351
Resident reporting
(b)
Does the agency also provide at least one way for residents to yes
report sexual abuse or sexual harassment to a public or private
entity or office that is not part of the agency?
Is that private entity or office able to receive and immediately yes
forward resident reports of sexual abuse and sexual harassment to
agency officials?
Does that private entity or office allow the resident to remain yes
anonymous upon request?
Are residents detained solely for civil immigration purposes yes
provided information on how to contact relevant consular officials
and relevant officials at the Department of Homeland Security to
report sexual abuse or harassment?
115.351
Resident reporting
(c)
Do staff members accept reports of sexual abuse and sexual yes
harassment made verbally, in writing, anonymously, and from
third parties?
Do staff members promptly document any verbal reports of sexual yes
abuse and sexual harassment?
115.351
Resident reporting
(d)
Does the facility provide residents with access to tools necessary yes
to make a written report?
115.351
Resident reporting
(e)
Does the agency provide a method for staff to privately report yes
sexual abuse and sexual harassment of residents?
115.352
Exhaustion of administrative remedies
(a)
Is the agency exempt from this standard? yes
NOTE: The agency is exempt ONLY if it does not have
administrative procedures to address resident grievances
regarding sexual abuse. This does not mean the agency is exempt
simply because a resident does not have to or is not ordinarily
expected to submit a grievance to report sexual abuse. This
means that as a matter of explicit policy, the agency does not
have an administrative remedies process to address sexual abuse.
115.352
Exhaustion of administrative remedies
(b)
Does the agency permit residents to submit a grievance regarding na
an allegation of sexual abuse without any type of time limits? (The
agency may apply otherwise-applicable time limits to any portion
of a grievance that does not allege an incident of sexual abuse.)
(N/A if agency is exempt from this standard.)
Does the agency always refrain from requiring an resident to use na
any informal grievance process, or to otherwise attempt to resolve
with staff, an alleged incident of sexual abuse? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(c)
Does the agency ensure that: A resident who alleges sexual abuse na
may submit a grievance without submitting it to a staff member
who is the subject of the complaint? (N/A if agency is exempt from
this standard.)
Does the agency ensure that: Such grievance is not referred to a na
staff member who is the subject of the complaint? (N/A if agency
is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(d)
Does the agency issue a final agency decision on the merits of any na
portion of a grievance alleging sexual abuse within 90 days of the
initial filing of the grievance? (Computation of the 90-day time
period does not include time consumed by residents in preparing
any administrative appeal.) (N/A if agency is exempt from this
standard.)
If the agency determines that the 90 day timeframe is insufficient na
to make an appropriate decision and claims an extension of time
(the maximum allowable extension of time to respond is 70 days
per 115.352(d)(3)) , does the agency notify the resident in writing
of any such extension and provide a date by which a decision will
be made? (N/A if agency is exempt from this standard.)
At any level of the administrative process, including the final level, na
if the resident does not receive a response within the time allotted
for reply, including any properly noticed extension, may a resident
consider the absence of a response to be a denial at that level?
(N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(e)
Are third parties, including fellow residents, staff members, family na
members, attorneys, and outside advocates, permitted to assist
residents in filing requests for administrative remedies relating to
allegations of sexual abuse? (N/A if agency is exempt from this
standard.)
Are those third parties also permitted to file such requests on na
behalf of residents? (If a third party, other than a parent or legal
guardian, files such a request on behalf of a resident, the facility
may require as a condition of processing the request that the
alleged victim agree to have the request filed on his or her behalf,
and may also require the alleged victim to personally pursue any
subsequent steps in the administrative remedy process.) (N/A if
agency is exempt from this standard.)
If the resident declines to have the request processed on his or na
her behalf, does the agency document the resident’s decision?
(N/A if agency is exempt from this standard.)
Is a parent or legal guardian of a juvenile allowed to file a na
grievance regarding allegations of sexual abuse, including
appeals, on behalf of such juvenile? (N/A if agency is exempt from
this standard.)
If a parent or legal guardian of a juvenile files a grievance (or an na
appeal) on behalf of a juvenile regarding allegations of sexual
abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her
behalf? (N/A if agency is exempt from this standard.)
115.352 Exhaustion of administrative remedies
(f)
Has the agency established procedures for the filing of an na
emergency grievance alleging that a resident is subject to a
substantial risk of imminent sexual abuse? (N/A if agency is
exempt from this standard.)
After receiving an emergency grievance alleging a resident is na
subject to a substantial risk of imminent sexual abuse, does the
agency immediately forward the grievance (or any portion thereof
that alleges the substantial risk of imminent sexual abuse) to a
level of review at which immediate corrective action may be
taken? (N/A if agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency provide an initial response within 48 hours? (N/A if
agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency issue a final agency decision within 5 calendar days?
(N/A if agency is exempt from this standard.)
Does the initial response and final agency decision document the na
agency’s determination whether the resident is in substantial risk
of imminent sexual abuse? (N/A if agency is exempt from this
standard.)
Does the initial response document the agency’s action(s) taken in na
response to the emergency grievance? (N/A if agency is exempt
from this standard.)
Does the agency’s final decision document the agency’s action(s) na
taken in response to the emergency grievance? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(g)
If the agency disciplines a resident for filing a grievance related to na
alleged sexual abuse, does it do so ONLY where the agency
demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.)
115.353 Resident access to outside confidential support services and
(a) legal representation
Does the facility provide residents with access to outside victim yes
advocates for emotional support services related to sexual abuse
by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll-free hotline
numbers where available, of local, State, or national victim
advocacy or rape crisis organizations?
Does the facility provide persons detained solely for civil yes
immigration purposes mailing addresses and telephone numbers,
including toll-free hotline numbers where available of local, State,
or national immigrant services agencies?
Does the facility enable reasonable communication between yes
residents and these organizations and agencies, in as confidential
a manner as possible?
115.353 Resident access to outside confidential support services and
(b) legal representation
Does the facility inform residents, prior to giving them access, of yes
the extent to which such communications will be monitored and
the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws?
115.353 Resident access to outside confidential support services and
(c) legal representation
Does the agency maintain or attempt to enter into memoranda of yes
understanding or other agreements with community service
providers that are able to provide residents with confidential
emotional support services related to sexual abuse?
Does the agency maintain copies of agreements or documentation yes
showing attempts to enter into such agreements?
115.353 Resident access to outside confidential support services and
(d) legal representation
Does the facility provide residents with reasonable and yes
confidential access to their attorneys or other legal
representation?
Does the facility provide residents with reasonable access to yes
parents or legal guardians?
115.354
Third-party reporting
(a)
Has the agency established a method to receive third-party yes
reports of sexual abuse and sexual harassment?
Has the agency distributed publicly information on how to report yes
sexual abuse and sexual harassment on behalf of a resident?
115.361
Staff and agency reporting duties
(a)
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding an incident of sexual abuse or
sexual harassment that occurred in a facility, whether or not it is
part of the agency?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding retaliation against residents or
staff who reported an incident of sexual abuse or sexual
harassment?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding any staff neglect or violation of
responsibilities that may have contributed to an incident of sexual
abuse or sexual harassment or retaliation?
115.361
Staff and agency reporting duties
(b)
Does the agency require all staff to comply with any applicable yes
mandatory child abuse reporting laws?
115.361
Staff and agency reporting duties
(c)
Apart from reporting to designated supervisors or officials and yes
designated State or local services agencies, are staff prohibited
from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency
policy, to make treatment, investigation, and other security and
management decisions?
115.361
Staff and agency reporting duties
(d)
Are medical and mental health practitioners required to report yes
sexual abuse to designated supervisors and officials pursuant to
paragraph (a) of this section as well as to the designated State or
local services agency where required by mandatory reporting
laws?
Are medical and mental health practitioners required to inform yes
residents of their duty to report, and the limitations of
confidentiality, at the initiation of services?
115.361
Staff and agency reporting duties
(e)
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
appropriate office?
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
alleged victim’s parents or legal guardians unless the facility has
official documentation showing the parents or legal guardians
should not be notified?
If the alleged victim is under the guardianship of the child welfare yes
system, does the facility head or his or her designee promptly
report the allegation to the alleged victim’s caseworker instead of
the parents or legal guardians? (N/A if the alleged victim is not
under the guardianship of the child welfare system.)
If a juvenile court retains jurisdiction over the alleged victim, does yes
the facility head or designee also report the allegation to the
juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation?
115.361
Staff and agency reporting duties
(f)
Does the facility report all allegations of sexual abuse and sexual yes
harassment, including third-party and anonymous reports, to the
facility’s designated investigators?
115.362
Agency protection duties
(a)
When the agency learns that a resident is subject to a substantial yes
risk of imminent sexual abuse, does it take immediate action to
protect the resident?
115.363
Reporting to other confinement facilities
(a)
Upon receiving an allegation that a resident was sexually abused yes
while confined at another facility, does the head of the facility that
received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse
occurred?
Does the head of the facility that received the allegation also yes
notify the appropriate investigative agency?
115.363
Reporting to other confinement facilities
(b)
Is such notification provided as soon as possible, but no later than yes
72 hours after receiving the allegation?
115.363
Reporting to other confinement facilities
(c)
Does the agency document that it has provided such notification? yes
115.363
Reporting to other confinement facilities
(d)
Does the facility head or agency office that receives such yes
notification ensure that the allegation is investigated in
accordance with these standards?
115.364
Staff first responder duties
(a)
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Separate the alleged victim and abuser?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Request that the alleged victim not take any actions
that could destroy physical evidence, including, as appropriate,
washing, brushing teeth, changing clothes, urinating, defecating,
smoking, drinking, or eating, if the abuse occurred within a time
period that still allows for the collection of physical evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating,
defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical
evidence?
115.364
Staff first responder duties
(b)
If the first staff responder is not a security staff member, is the yes
responder required to request that the alleged victim not take any
actions that could destroy physical evidence, and then notify
security staff?
115.365
Coordinated response
(a)
Has the facility developed a written institutional plan to coordinate yes
actions among staff first responders, medical and mental health
practitioners, investigators, and facility leadership taken in
response to an incident of sexual abuse?
115.366 Preservation of ability to protect residents from contact with
(a) abusers
Are both the agency and any other governmental entities yes
responsible for collective bargaining on the agency’s behalf
prohibited from entering into or renewing any collective
bargaining agreement or other agreement that limits the agency’s
ability to remove alleged staff sexual abusers from contact with
any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is
warranted?
115.367
Agency protection against retaliation
(a)
Has the agency established a policy to protect all residents and yes
staff who report sexual abuse or sexual harassment or cooperate
with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff?
Has the agency designated which staff members or departments yes
are charged with monitoring retaliation?
115.367
Agency protection against retaliation
(b)
Does the agency employ multiple protection measures for yes
residents or staff who fear retaliation for reporting sexual abuse or
sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers,
removal of alleged staff or resident abusers from contact with
victims, and emotional support services?
115.367
Agency protection against retaliation
(c)
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents or staff who reported the sexual abuse to
see if there are changes that may suggest possible retaliation by
residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents who were reported to have suffered sexual
abuse to see if there are changes that may suggest possible
retaliation by residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Act promptly to remedy any
such retaliation?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident housing
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident program
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Negative performance
reviews of staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Reassignments of
staff?
Does the agency continue such monitoring beyond 90 days if the yes
initial monitoring indicates a continuing need?
115.367
Agency protection against retaliation
(d)
In the case of residents, does such monitoring also include yes
periodic status checks?
115.367
Agency protection against retaliation
(e)
If any other individual who cooperates with an investigation yes
expresses a fear of retaliation, does the agency take appropriate
measures to protect that individual against retaliation?
115.368
Post-allegation protective custody
(a)
Is any and all use of segregated housing to protect a resident who yes
is alleged to have suffered sexual abuse subject to the
requirements of § 115.342?
115.371
Criminal and administrative agency investigations
(a)
When the agency conducts its own investigations into allegations yes
of sexual abuse and sexual harassment, does it do so promptly,
thoroughly, and objectively? (N/A if the agency does not conduct
any form of administrative or criminal investigations of sexual
abuse or harassment. See 115.321(a).)
Does the agency conduct such investigations for all allegations, yes
including third party and anonymous reports? (N/A if the agency
does not conduct any form of administrative or criminal
investigations of sexual abuse or harassment. See 115.321(a).)
115.371
Criminal and administrative agency investigations
(b)
Where sexual abuse is alleged, does the agency use investigators yes
who have received specialized training in sexual abuse
investigations involving juvenile victims as required by 115.334?
115.371
Criminal and administrative agency investigations
(c)
Do investigators gather and preserve direct and circumstantial yes
evidence, including any available physical and DNA evidence and
any available electronic monitoring data?
Do investigators interview alleged victims, suspected yes
perpetrators, and witnesses?
Do investigators review prior reports and complaints of sexual yes
abuse involving the suspected perpetrator?
115.371
Criminal and administrative agency investigations
(d)
Does the agency always refrain from terminating an investigation yes
solely because the source of the allegation recants the allegation?
115.371
Criminal and administrative agency investigations
(e)
When the quality of evidence appears to support criminal no
prosecution, does the agency conduct compelled interviews only
after consulting with prosecutors as to whether compelled
interviews may be an obstacle for subsequent criminal
prosecution?
115.371
Criminal and administrative agency investigations
(f)
Do agency investigators assess the credibility of an alleged victim, yes
suspect, or witness on an individual basis and not on the basis of
that individual’s status as resident or staff?
Does the agency investigate allegations of sexual abuse without yes
requiring a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition
for proceeding?
115.371
Criminal and administrative agency investigations
(g)
Do administrative investigations include an effort to determine yes
whether staff actions or failures to act contributed to the abuse?
Are administrative investigations documented in written reports yes
that include a description of the physical evidence and testimonial
evidence, the reasoning behind credibility assessments, and
investigative facts and findings?
115.371
Criminal and administrative agency investigations
(h)
Are criminal investigations documented in a written report that yes
contains a thorough description of the physical, testimonial, and
documentary evidence and attaches copies of all documentary
evidence where feasible?
115.371
Criminal and administrative agency investigations
(i)
Are all substantiated allegations of conduct that appears to be yes
criminal referred for prosecution?
115.371
Criminal and administrative agency investigations
(j)
Does the agency retain all written reports referenced in yes
115.371(g) and (h) for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years unless
the abuse was committed by a juvenile resident and applicable
law requires a shorter period of retention?
115.371
Criminal and administrative agency investigations
(k)
Does the agency ensure that the departure of an alleged abuser yes
or victim from the employment or control of the facility or agency
does not provide a basis for terminating an investigation?
115.371
Criminal and administrative agency investigations
(m)
When an outside entity investigates sexual abuse, does the facility yes
cooperate with outside investigators and endeavor to remain
informed about the progress of the investigation? (N/A if an
outside agency does not conduct administrative or criminal sexual
abuse investigations. See 115.321(a).)
115.372
Evidentiary standard for administrative investigations
(a)
Is it true that the agency does not impose a standard higher than yes
a preponderance of the evidence in determining whether
allegations of sexual abuse or sexual harassment are
substantiated?
115.373
Reporting to residents
(a)
Following an investigation into a resident’s allegation of sexual yes
abuse suffered in the facility, does the agency inform the resident
as to whether the allegation has been determined to be
substantiated, unsubstantiated, or unfounded?
115.373
Reporting to residents
(b)
If the agency did not conduct the investigation into a resident’s yes
allegation of sexual abuse in an agency facility, does the agency
request the relevant information from the investigative agency in
order to inform the resident? (N/A if the agency/facility is
responsible for conducting administrative and criminal
investigations.)
115.373
Reporting to residents
(c)
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer posted within the resident’s unit?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer employed at the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been indicted on a charge related to
sexual abuse in the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been convicted on a charge related to
sexual abuse within the facility?
115.373
Reporting to residents
(d)
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been indicted on a charge related to sexual abuse
within the facility?
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been convicted on a charge related to sexual abuse
within the facility?
115.373
Reporting to residents
(e)
Does the agency document all such notifications or attempted yes
notifications?
115.376
Disciplinary sanctions for staff
(a)
Are staff subject to disciplinary sanctions up to and including yes
termination for violating agency sexual abuse or sexual
harassment policies?
115.376
Disciplinary sanctions for staff
(b)
Is termination the presumptive disciplinary sanction for staff who yes
have engaged in sexual abuse?
115.376
Disciplinary sanctions for staff
(c)
Are disciplinary sanctions for violations of agency policies relating yes
to sexual abuse or sexual harassment (other than actually
engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s
disciplinary history, and the sanctions imposed for comparable
offenses by other staff with similar histories?
115.376
Disciplinary sanctions for staff
(d)
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to: Law
enforcement agencies, unless the activity was clearly not
criminal?
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to:
Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(a)
Is any contractor or volunteer who engages in sexual abuse yes
prohibited from contact with residents?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Law enforcement agencies (unless the activity was
clearly not criminal)?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(b)
In the case of any other violation of agency sexual abuse or sexual yes
harassment policies by a contractor or volunteer, does the facility
take appropriate remedial measures, and consider whether to
prohibit further contact with residents?
115.378
Interventions and disciplinary sanctions for residents
(a)
Following an administrative finding that a resident engaged in yes
resident-on-resident sexual abuse, or following a criminal finding
of guilt for resident-on-resident sexual abuse, may residents be
subject to disciplinary sanctions only pursuant to a formal
disciplinary process?
115.378
Interventions and disciplinary sanctions for residents
(b)
Are disciplinary sanctions commensurate with the nature and yes
circumstances of the abuse committed, the resident’s disciplinary
history, and the sanctions imposed for comparable offenses by
other residents with similar histories?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied daily
large-muscle exercise?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied access
to any legally required educational programming or special
education services?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident receives daily visits
from a medical or mental health care clinician?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the resident also have access to other programs
and work opportunities to the extent possible?
115.378 Interventions and disciplinary sanctions for residents
(c)
When determining what types of sanction, if any, should be yes
imposed, does the disciplinary process consider whether a
resident’s mental disabilities or mental illness contributed to his or
her behavior?
115.378
Interventions and disciplinary sanctions for residents
(d)
If the facility offers therapy, counseling, or other interventions yes
designed to address and correct underlying reasons or motivations
for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions?
If the agency requires participation in such interventions as a yes
condition of access to any rewards-based behavior management
system or other behavior-based incentives, does it always refrain
from requiring such participation as a condition to accessing
general programming or education?
115.378
Interventions and disciplinary sanctions for residents
(e)
Does the agency discipline a resident for sexual contact with staff yes
only upon a finding that the staff member did not consent to such
contact?
115.378
Interventions and disciplinary sanctions for residents
(f)
For the purpose of disciplinary action, does a report of sexual yes
abuse made in good faith based upon a reasonable belief that the
alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish
evidence sufficient to substantiate the allegation?
115.378
Interventions and disciplinary sanctions for residents
(g)
Does the agency always refrain from considering non-coercive yes
sexual activity between residents to be sexual abuse? (N/A if the
agency does not prohibit all sexual activity between residents.)
115.381
Medical and mental health screenings; history of sexual abuse
(a)
If the screening pursuant to § 115.341 indicates that a resident yes
has experienced prior sexual victimization, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a medical or
mental health practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(b)
If the screening pursuant to § 115.341 indicates that a resident yes
has previously perpetrated sexual abuse, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a mental health
practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(c)
Is any information related to sexual victimization or abusiveness yes
that occurred in an institutional setting strictly limited to medical
and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions,
including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local
law?
115.381
Medical and mental health screenings; history of sexual abuse
(d)
Do medical and mental health practitioners obtain informed yes
consent from residents before reporting information about prior
sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18?
115.382
Access to emergency medical and mental health services
(a)
Do resident victims of sexual abuse receive timely, unimpeded yes
access to emergency medical treatment and crisis intervention
services, the nature and scope of which are determined by
medical and mental health practitioners according to their
professional judgment?
115.382
Access to emergency medical and mental health services
(b)
If no qualified medical or mental health practitioners are on duty yes
at the time a report of recent sexual abuse is made, do staff first
responders take preliminary steps to protect the victim pursuant
to § 115.362?
Do staff first responders immediately notify the appropriate yes
medical and mental health practitioners?
115.382
Access to emergency medical and mental health services
(c)
Are resident victims of sexual abuse offered timely information yes
about and timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically
appropriate?
115.382
Access to emergency medical and mental health services
(d)
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(a) victims and abusers
Does the facility offer medical and mental health evaluation and, yes
as appropriate, treatment to all residents who have been
victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility?
115.383 Ongoing medical and mental health care for sexual abuse
(b) victims and abusers
Does the evaluation and treatment of such victims include, as yes
appropriate, follow-up services, treatment plans, and, when
necessary, referrals for continued care following their transfer to,
or placement in, other facilities, or their release from custody?
115.383 Ongoing medical and mental health care for sexual abuse
(c) victims and abusers
Does the facility provide such victims with medical and mental yes
health services consistent with the community level of care?
115.383 Ongoing medical and mental health care for sexual abuse
(d) victims and abusers
Are resident victims of sexually abusive vaginal penetration while na
incarcerated offered pregnancy tests? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(e) victims and abusers
If pregnancy results from the conduct described in paragraph § na
115.383(d), do such victims receive timely and comprehensive
information about and timely access to all lawful pregnancy-
related medical services? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(f) victims and abusers
Are resident victims of sexual abuse while incarcerated offered yes
tests for sexually transmitted infections as medically appropriate?
115.383 Ongoing medical and mental health care for sexual abuse
(g) victims and abusers
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(h) victims and abusers
Does the facility attempt to conduct a mental health evaluation of yes
all known resident-on-resident abusers within 60 days of learning
of such abuse history and offer treatment when deemed
appropriate by mental health practitioners?
115.386
Sexual abuse incident reviews
(a)
Does the facility conduct a sexual abuse incident review at the yes
conclusion of every sexual abuse investigation, including where
the allegation has not been substantiated, unless the allegation
has been determined to be unfounded?
115.386
Sexual abuse incident reviews
(b)
Does such review ordinarily occur within 30 days of the conclusion yes
of the investigation?
115.386
Sexual abuse incident reviews
(c)
Does the review team include upper-level management officials, yes
with input from line supervisors, investigators, and medical or
mental health practitioners?
115.386
Sexual abuse incident reviews
(d)
Does the review team: Consider whether the allegation or yes
investigation indicates a need to change policy or practice to
better prevent, detect, or respond to sexual abuse?
The subsection of this provision is no longer applicable to your na
compliance finding, please select N/A.
Does the review team: Examine the area in the facility where the yes
incident allegedly occurred to assess whether physical barriers in
the area may enable abuse?
Does the review team: Assess the adequacy of staffing levels in yes
that area during different shifts?
Does the review team: Assess whether monitoring technology yes
should be deployed or augmented to supplement supervision by
staff?
Does the review team: Prepare a report of its findings, including yes
but not necessarily limited to determinations made pursuant to §§
115.386(d)(1)-(d)(5), and any recommendations for improvement
and submit such report to the facility head and PREA compliance
manager?
115.386
Sexual abuse incident reviews
(e)
Does the facility implement the recommendations for yes
improvement, or document its reasons for not doing so?
115.387
Data collection
(a)
Does the agency collect accurate, uniform data for every yes
allegation of sexual abuse at facilities under its direct control
using a standardized instrument and set of definitions?
115.387
Data collection
(b)
Does the agency aggregate the incident-based sexual abuse data yes
at least annually?
115.387
Data collection
(c)
Does the incident-based data include, at a minimum, the data yes
necessary to answer all questions from the most recent version of
the Survey of Sexual Violence conducted by the Department of
Justice?
115.387
Data collection
(d)
Does the agency maintain, review, and collect data as needed yes
from all available incident-based documents, including reports,
investigation files, and sexual abuse incident reviews?
115.387
Data collection
(e)
Does the agency also obtain incident-based and aggregated data na
from every private facility with which it contracts for the
confinement of its residents? (N/A if agency does not contract for
the confinement of its residents.)
115.387
Data collection
(f)
Does the agency, upon request, provide all such data from the yes
previous calendar year to the Department of Justice no later than
June 30? (N/A if DOJ has not requested agency data.)
115.388
Data review for corrective action
(a)
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Identifying problem areas?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Taking corrective action on an
ongoing basis?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Preparing an annual report of
its findings and corrective actions for each facility, as well as the
agency as a whole?
115.388
Data review for corrective action
(b)
Does the agency’s annual report include a comparison of the yes
current year’s data and corrective actions with those from prior
years and provide an assessment of the agency’s progress in
addressing sexual abuse?
115.388
Data review for corrective action
(c)
Is the agency’s annual report approved by the agency head and yes
made readily available to the public through its website or, if it
does not have one, through other means?
115.388
Data review for corrective action
(d)
Does the agency indicate the nature of the material redacted yes
where it redacts specific material from the reports when
publication would present a clear and specific threat to the safety
and security of a facility?
115.389
Data storage, publication, and destruction
(a)
Does the agency ensure that data collected pursuant to § 115.387 yes
are securely retained?
115.389
Data storage, publication, and destruction
(b)
Does the agency make all aggregated sexual abuse data, from yes
facilities under its direct control and private facilities with which it
contracts, readily available to the public at least annually through
its website or, if it does not have one, through other means?
115.389
Data storage, publication, and destruction
(c)
Does the agency remove all personal identifiers before making yes
aggregated sexual abuse data publicly available?
115.389
Data storage, publication, and destruction
(d)
Does the agency maintain sexual abuse data collected pursuant to yes
§ 115.387 for at least 10 years after the date of the initial
collection, unless Federal, State, or local law requires otherwise?
115.401
Frequency and scope of audits
(a)
During the prior three-year audit period, did the agency ensure yes
that each facility operated by the agency, or by a private
organization on behalf of the agency, was audited at least once?
(Note: The response here is purely informational. A "no" response
does not impact overall compliance with this standard.)
115.401
Frequency and scope of audits
(b)
Is this the first year of the current audit cycle? (Note: a “no” yes
response does not impact overall compliance with this standard.)
If this is the second year of the current audit cycle, did the agency na
ensure that at least one-third of each facility type operated by the
agency, or by a private organization on behalf of the agency, was
audited during the first year of the current audit cycle? (N/A if this
is not the second year of the current audit cycle.)
If this is the third year of the current audit cycle, did the agency na
ensure that at least two-thirds of each facility type operated by
the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle?
(N/A if this is not the third year of the current audit cycle.)
115.401
Frequency and scope of audits
(h)
Did the auditor have access to, and the ability to observe, all yes
areas of the audited facility?
115.401
Frequency and scope of audits
(i)
Was the auditor permitted to request and receive copies of any yes
relevant documents (including electronically stored information)?
115.401
Frequency and scope of audits
(m)
Was the auditor permitted to conduct private interviews with yes
inmates, residents, and detainees?
115.401
Frequency and scope of audits
(n)
Were inmates, residents, and detainees permitted to send yes
confidential information or correspondence to the auditor in the
same manner as if they were communicating with legal counsel?
115.403
Audit contents and findings
(f)
The agency has published on its agency website, if it has one, or yes
has otherwise made publicly available, all Final Audit Reports. The
review period is for prior audits completed during the past three
years PRECEDING THIS AUDIT. The pendency of any agency
appeal pursuant to 28 C.F.R. § 115.405 does not excuse
noncompliance with this provision. (N/A if there have been no Final
Audit Reports issued in the past three years, or, in the case of
single facility agencies, there has never been a Final Audit Report
issued.)

source: DJJ

report_type: PREA

program_name_raw: Crestview Youth Academy

cycle: Year 1 Cycle 5