summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY REPORT
JUVENILE FACILITIES
Name of Facility: Brevard Regional Juvenile Detention Center
Physical Address: 5225 DeWitt Avenue, Cocoa, FL 32927
Date report submitted: November 10, 2014
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: August 6-7, 2014
Facility Information
Facility Mailing Address: Same as Physical Address
Telephone Number: 321-690-3400
The Facility is: Military County Federal
Private for profit Municipal X State
Private not for profit
Facility Type: X Detention Correction Other:
Name of PREA Compliance Manager: Vickie Dyanne Alves Title: Superintendent
Email Address: dyanne.alves@djj.state.fl.us Telephone Number:
321-690-3400
Agency Information
Name of Agency: Florida Department of Juvenile Justice (DJJ)
Governing Authority or Parent Agency: NA
Physical Address: 2737 Centerview Drive, Tallahassee, FL 32399
Mailing Address: NA
Telephone Number: 850-717-2533
Agency Chief Executive Officer
Name: Christy Daly Title: DJJ Secretary
Telephone 850-413-7143
Email Address: Christy.Daly@djj.state.fl.us
Number:
Agency Wide PREA Coordinator
Name: Gene McMahon Title: Program Admin./Statewide PREA Coord.
Email Address: Gene.McMahon@djj.state.fl.us Telephone Number: 8 5 0 - 1 7 1 - 2 5 3 3
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AUDIT FINDINGS
NARRATIVE:
The Brevard Regional Juvenile Detention Center (BRJDC) is located in Cocoa, Florida and is
operated by the Florida Department of Juvenile Justice (DJJ). It is a secure detention facility that
serves female and male juvenile offenders between the ages of 12 and 19. Residents are detained by
the courts pending adjudication, disposition or placement in a commitment facility. The primary
length of stay is approximately 10 days. The facility capacity is 40. Eight hundred thirty-two residents
have been admitted to the BRJDC in the past 12 months.
Fifty-six staff members have been employed at the facility during the past year. Medical and mental
health services are provided by staff on-site. Medical services are provided by a facility Registered
Nurse and other contract medical staff. The contract medical staff includes a physician, Advanced
Registered Nurse Practitioner (ARNP), Licensed Practical Nurse and a medical assistant. The
Physician and the ARNP visit the facility at least weekly. Mental health services are also provided
through a contract and include a psychiatrist who visits the facility at least weekly, a qualified mental
health professional, and a part-time mental health worker. Education services are provided at the
facility by certified teachers through the Brevard County School District.
The services provided at the facility include mental health, medical, education; and substance abuse.
The mental health services include counseling, screenings, and crisis intervention and stabilization.
Residents participate in daily structured programming and recreation activities. Religious services are
provided and residents may attend on a voluntary basis. The programs and services provided at the
facility are aligned with its mission statement, “To increase public safety by reducing juvenile
delinquency through effective prevention, intervention and treatment services that strengthen families
and turn around the lives of troubled youth.”
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is located in one building and contains three living units or mods as they are called by
staff. The building consists of administrative offices; control room which is located in the front of the
building at the entrance; medical office; medical examination room; dining room; kitchen;
conference room; classrooms; three holding rooms; intake offices; three mods; a multi-purpose room
known as the Sunshine Room; and storage and utility closets.
Each mod has a day room area contained in the living unit where residents may assemble. One mod
is used to provide housing for the medium size to larger males and one is used for smaller males and
all females. The third mod is not currently being used as a housing unit but is used as a part of
programming activity space. The rooms in the vacant mod are being painted and included with
themed bedding to match the pictures painted on the walls of the room and outside of the room over
the doors. The plan is that these rooms will be available to residents who earn them through
identified positive behavior and by meeting additional criteria established by the facility. The facility
grounds provide for outside recreation activities, when the weather permits.
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SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in various parts of the facility prior to the site visit.
Photographs were taken of the various sites where the notices had been posted and the photographs
were electronically sent to this Auditor, noting their locations. A telephone conversation was held
with the Superintendent who also serves as the Compliance Manager and the PREA Compliance
Team to review the PREA audit processes. The Pre-Audit Questionnaire and the supporting
documentation were uploaded to a flash drive, which was received by the Auditor prior to the on-
site audit. After reviewing the information, notes were sent to the Superintendent to seek clarity of
information and to note the additional information needed. In response to the issues noted,
additional information was provided and discussed during the on-site audit.
The on-site audit was conducted August 6-7, 2014. An entrance meeting was held with the
Superintendent and the PREA Compliance Team and after the meeting a comprehensive tour of the
facility was conducted by the Assistant Superintendent. During the tour, staff members were
observed to be providing direct supervision to the residents. Random staff, specialized staff and
residents were interviewed during the on-site audit process. The interviews of both staff and
residents revealed how well both groups have been educated regarding PREA issues. All staff
interviewed expressed awareness of their duties and responsibilities as they relate to the safety of the
residents and PREA compliance. The residents interviewed demonstrated their knowledge of what
PREA means and how to report sexual assault and sexual harassment.
The information for the audit process was presented in an organized manner on the flash drive and
during the on-site audit. A close-out meeting was held at the conclusion of the on-site audit with the
Superintendent and the PREA Compliance Team and a summary of the audit findings was provided.
Two standards, 115.315 and 115.351, were not met during the on-site audit and required a Corrective
Action Plan as noted in the preliminary report dated September 2, 2014. The Corrective Action Plan
to address the standards was implemented as agreed upon and the standards have been met. The
details of the applied corrective actions are explained within this report under each standard.
Number of Standards Exceeded: 0
Number of Standards Met: 39
Number of Standards Not Met: 0
Number of Standards Not Applicable: 2
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Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The Brevard Regional Juvenile Detention Center (BRJDC) PREA Policy is inclusive of the
Florida Department of Juvenile Justice Policy, 1919 (FDJJ 1919) requirements and it contains
the facility’s operational procedures. The policy provides guidelines for implementing the
agency’s approach to complying with the requirements of the PREA standards including, zero
tolerance toward all forms of sexual abuse and sexual harassment. The policy contains
definitions of the prohibited behaviors and sanctions for those who participate in such
behaviors. Additionally, the Policy identifies the statewide PREA Coordinator; names the
Superintendent as the PREA Compliance Manager; and identifies the members of the BRJDC
PREA Compliance Team.
Standard 115.312 Contract With Other Entities for the Confinement of Residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
The BRJDC does not contract with other agencies for the confinement of residents. The State
of Florida does not contract with other entities for the confinement of youth in detention.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility’s staffing requirements are incorporated and detailed in the PREA Policy. The
Policy provides for the implementation of the described staffing plan with adequate staffing
levels to protect residents against sexual abuse. A review of the Policy and interviews with
staff revealed that staffing requirements are maintained on each shift. The facility reports no
deviations from the staffing plan in the past 12 months. The annual assessment of the staffing
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has been conducted by the Statewide PREA Coordinator to determine whether adjustments
are needed in accordance with the standard. The assessment shows that the staffing plan
addresses all components of the facility’s physical plant.
The Superintendent and the Assistant Superintendent document unannounced rounds of the
facility for the maintenance of a safe environment. A review of the Unannounced PREA
Review Form and staff interviews confirmed the practice of visits conducted by the
intermediate and higher level staffs.
Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for same gender pat-down searches absent exigent circumstances.
The Policy also states that staff shall not conduct a strip search, except in exigent
circumstances and that body cavity searches will be conducted by trained medical personnel
in an emergency room. There have been no cross gender pat-down, strip or body cavity
searches of residents during this audit period. All staff interviewed said that the facility
practice is that no cross-gender searches are conducted. Interviews with residents confirm the
practice. Staff and resident interviews also confirmed that staff members of the opposite
gender announce themselves when entering the mod, according to policy.
The PREA Policy states that staff will not search a transgender or intersex resident to
determine the resident’s genital status. Security staff has received training on conducting
cross-gender pat-down searches and on conducting searches of transgender and intersex
residents; the training is documented. Residents are provided with a reasonable amount of
privacy during shower time due to the installation of shower curtains.
Standard 115.316 Residents With Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has staff members that are bilingual and a list of those staff members is placed in
the control room and the intake area. According to the PREA Policy and staff interviews,
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assistance will be provided from the education and mental health units for assistance with
providing or accessing support services for residents with disabilities and those who are
limited English proficient so they may benefit from and participate in PREA education. The
education unit has the capability to access translators and other special services, as needed.
The facility may utilize a TTY system for residents who may be hearing impaired. The
PREA Policy states that the facility will not rely on resident interpreters, resident readers or
any kind of resident assistance except when a delay in obtaining interpreter services would
jeopardize a resident’s safety or an investigation and such cases must be documented.
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for annual background checks on all employees and a process
that is aligned with the standard. Applicants and employees are asked verbally or in writing
regarding previous misconduct. A review of documentation and interviews with staff
confirmed that prior to the hiring of an employee or contractor, background checks are
conducted.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
In addition to direct supervision, the facility utilizes a secondary monitoring system. A
camera system that enables staff to observe activities and areas on various screens is used.
The primary viewing area is the control room where there is constant monitoring. The
Superintendent, Assistant Superintendent and Lieutenant have access to desktop monitoring
of activities from their offices. Cameras are strategically placed inside and outside of the
facility. There are 54 cameras and the video monitoring system will be modified by adding
color as the black and white cameras go down. A review of camera activity is conducted by
the administrative staff and the Supervisors at least three hours per week. Records are
maintained that document each review.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
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X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The BRJDC PREA Policy addresses this standard. Victim advocacy services have been
obtained with Sexual Assault Victim Services-Brevard. The services include but are not
limited to crisis intervention, advocacy, accompaniment, and community referrals. The
advocacy agency’s rape crisis center is staffed with Sexual Assault Nurse Examiners and
forensic medical examinations are provided at no cost to the victim. A representative from the
Sexual Assault Victim Services was interviewed by telephone and she confirmed the
availability of the provision of services. According to staff interviews and a review of
documentation, residents who experience sexual abuse will also have access to forensic
medical services provided by qualified medical practitioners at the local hospital that the
facility currently uses for other services. There have been no forensic medical examinations
conducted on a BRJDC resident in the last 12 months.
According to the facility’s PREA Policy and FDJJ 1919, the facility is not responsible for
conducting administrative or criminal investigations. The DJJ Office of the Inspector General
(OIG) is responsible for conducting administrative investigations; the Florida Department of
Children and Families (DCF) is responsible for conducting allegations of child abuse; and the
local law enforcement agency, Brevard County Sheriff’s Office, is responsible for conducting
criminal investigations.
Standard 115. 322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 identify the agencies that will conduct the criminal and
administrative investigations. Policy instructs the facility staff to cooperate with the OIG
investigations. Facility policy ensures that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment. During the past 12
months, there were no allegations of sexual abuse or sexual harassment that required an
administrative or criminal investigation.
Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
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Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for the PREA training. The staff training is comprehensive and
covers the key areas referenced in the standard: zero tolerance policy; sexual abuse and
sexual harassment prevention, detection, response, and reporting; resident’s rights to be free
of sexual abuse and sexual harassment; dynamics of sexual harassment and sexual assault;
avoiding inappropriate relationships with residents; and detecting and responding to signs of
threatened and actual sexual abuse. A review of the training documentation and the results of
staff interviews confirm that training occurs.
Standard 115. 332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy contains information regarding the training of volunteers and contractors
who have contact with residents. Receipt of the training is documented and it contains a
review of the agency’s zero tolerance policy.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy requires that residents receive information about the facility’s zero-
tolerance policy and how to report incidents or suspicions of sexual abuse or sexual
harassment. The facility reports that in the past 12 months 347 residents received the
information. During intake residents are provided a review and copy the fact sheet/brochure
about the prevention of sexual abuse and sexual harassment and the facility’s zero tolerance
of any form of sexual abuse or sexual harassment. The discussion and the material used also
contain the hotline number to the Sexual Assault Victim Services/Rape Crisis Center.
Additionally, the residents are provided a brochure from the Sexual Assault Victim Services
that includes general information and specific information regarding the advocacy services
provided by the agency.
The residents view a comprehensive education video regarding PREA related issues and they
have the opportunity to discuss the video with staff, at least two days or sooner following
intake. Thereafter, the video is reviewed and discussed with the residents on a regular basis.
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Staff and resident interviews and a review of documentation confirm that the residents
receive the education regarding PREA during the intake process; receive additional
information at least two days after intake; and regularly receive refresher information during
their stay in the facility. Support services in accessible formats for residents who are limited
English proficient, deaf, visually impaired, or otherwise disabled is provided by facility staff
and community resources accessible through the education or mental health units.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 states that staff in the OIG will be trained on the related policies and procedures
regarding the handling of sexual misconduct incidents and reports. Training is provided to
investigative staff regarding conducting investigations in the DJJ settings.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility provided documentation showing that medical and mental health staff members
have received on-line training through the National Institute of Corrections and/or the
National Commission on Correctional Health Care. The facility nurses do not conduct
forensic medical examinations.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy addresses this standard. The Screening for Vulnerability to Victimization
and Sexually Aggressive Behavior instrument is completed on each resident. Staff and
resident interviews and a review of documentation confirm that screening for risk of sexual
abuse victimization or sexual abusiveness toward other residents is being conducted.
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Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy prohibits placing gay, bisexual, transgender, or intersex residents into
confinement based solely on such identification or status. Housing and program assignments
require determinations on each transgender or intersex resident on a case by case basis. The
facility prohibits considering gay, bisexual, transgender, or intersex identification or status as
an indicator of likelihood of being sexually abusive. There have been no residents placed in
isolation in the last 12 months because he or she was at risk of sexual victimization.
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
There are internal ways a resident may report allegations of sexual abuse; sexual harassment;
retaliation for reporting; and staff neglect or other violation(s) that led to abuse. A resident
may file a written grievance and give it to a Supervisor or place it in the locked box; talk to
any staff member; and third parties may report allegations to staff. The DJJ has developed a
process and policy for resident reporting via the hotline number. The facility has provided
training to both staff and residents regarding the policy and procedures.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy states that a resident may request to file an emergency grievance with a
Supervisor or place a completed grievance form in the locked box located in the Sunshine
Room, which is a multi-purpose area accessible to the residents. The locked box is checked
every two hours by the shift supervisor and the grievance is responded to within two hours of
receipt of the grievance. There have been no complaints relating to sexual abuse or sexual
harassment received in the past 12 months.
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Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy supports that the facility provides the residents with access to outside victim
advocacy services. Documentation was provided by the facility that shows that advocacy and
support services are provided by Sexual Assault Victim Services. A brochure is provided by
the facility to each resident during the intake process regarding the advocacy services. Related
PREA information, along with the advocacy service hotline number, is provided in the
facility’s Youth Safety Brochure. The brochures are reviewed with and given to each resident.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility’s PREA Policy provides information regarding third-party reporting of sexual
abuse. The Florida DJJ website contains information, available to the public, on how to
report sexual abuse. Two brochures, “Prison Rape Elimination Act: Parents & Visitors Third
Party Reporting” and “The Sexual Assault Victim Services” contain information on how to
report sexual abuse and is available to the public in the lobby of the facility.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to the PREA Policy and the Florida Administrative Code Rule 63F-11, all staff
members are required to report any allegation of sexual misconduct or youth-on-youth
sexual activity to the Central Communications Center (CCC). The Policy further states that
staff is prohibited from revealing any related information to anyone other than those persons
making treatment, investigation, security, or management decisions. Policy goes on to say
that staff members are to immediately report any knowledge, suspicion or information they
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receive regarding sexual abuse and sexual harassment; retaliation against residents or staff
who report any incidents; or any staff neglect or violation of responsibilities that may have
contributed to an incident or retaliation. This information should be reported to the CCC,
Department of Children and Families Abuse Registry, and local law enforcement. Staff
interviews support this information.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy addresses this standard and provides that when the facility learns that a
resident is subject to substantial risk of imminent sexual abuse, it takes immediate action to
protect the resident. There have been no incidents in the last 12 months where the agency or
the facility took any action in regards to a resident being in substantial risk of imminent
sexual abuse. Policy guides the response to this standard if it becomes necessary.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility’s PREA Policy addresses this standard. Upon receiving an allegation that a
resident was sexually abused while confined in another facility, the Superintendent will
notify the head of that facility as soon as possible but no later than 72 hours and document
the notification. In the past 12 months, there have not been any allegations of sexual abuse
occurring to a resident while he or she was in another facility.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
The PREA Policy provides a detailed account of first responder duties and responses. There
have been no allegations that a resident was sexually abused within the last 12 months. Staff
interviews confirmed that they are knowledgeable of their duties as a first responder.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The coordinated response is incorporated in the PREA Policy and is aligned with FDJJ 1919.
Interviews with staff support that an institutional plan has been developed and that they are
familiar with it. The plan coordinates the actions to be taken among facility first responders
and other staff in response to an incident of sexual abuse.
Standard 115.366 Preservation of Ability to Protect Residents from Contact with Abusers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable. The Brevard County Juvenile Detention Center does not
maintain any collective bargaining agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The comprehensive PREA Policy addresses protection against retaliation. The Assistant
Superintendent has been identified as the staff member designated with monitoring for
possible retaliation. If the conduct is identified the monitoring would be conducted for no less
than 90 days. There have been no incidents or allegations of sexual abuse within the last 12
months.
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Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides that if post allegation protective custody is used, its use shall be
subject to the requirements of PREA Standard 115.342 and that residents will not be denied
the identified programs and services. Policy also states that transporting a resident to another
facility may be a viable option. There have been no allegations of sexual abuse or sexual
harassment during the last 12 months and not a need for post allegation protective custody.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility’s PREA Policy and operational procedures and FDJJ 1919 address this standard.
Administrative investigations are conducted by the DJJ Office of Inspector General and
criminal investigations are conducted by the local law enforcement agency. The Florida
Department of Children and Families are also called when there is an allegation of sexual
abuse. Both Policies direct facility staff to cooperate with the investigations.
According to FDJJ 1919, an investigation is not terminated solely because the source of the
investigation recants the allegation. Substantiated allegations of conduct that appears to be
criminal are referred for prosecution.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The OIG, responsible for administrative investigations, imposes a standard of a preponderance
of the evidence for determining whether allegations are substantiated.
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Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides the process for notifying residents, following an investigation, of
whether an allegation has been determined to be substantiated, unsubstantiated, or
unfounded. There has not been an allegation of sexual abuse in the past 12 months.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for disciplinary sanctions for staff to be up to and including
termination for violation of the PREA Policy of zero-tolerance against sexual abuse and
sexual harassment. The policy requires that the violation be reported to local law
enforcement. In the past 12 months, no staff has been terminated or has resigned for
violating the facility PREA and related policies.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy addresses the corrective actions regarding any contractor or volunteer
engaging in sexual abuse of residents. They will be reported to local law enforcement unless
the activity was clearly not criminal and to relevant licensing bodies. The Policy requires the
facility to prohibit the contractor or volunteer from entering the facility in the case of any
violation of the facility’s PREA and related policies. During the past 12 months, no contractor
or volunteer has been reported to law enforcement or any investigative agency for allegations
of sexual abuse.
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
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X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy addresses this standard. Any resident found in violation of the facility’s
zero tolerance policy regarding sexual abuse, sexual assault, sexual misconduct or sexual
harassment against another resident will receive disciplinary sanctions after a formal
disciplinary process. If the disciplinary sanction results in the isolation of the resident, policy
requires that the resident receives the required daily visits, programming and services. The
Policy also states that the facility may discipline a resident for sexual contact with staff only
upon finding that the staff did not consent to such contact. There has been no incident of
resident-on-resident sexual abuse in the past 12 months.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy states that residents who disclose a history of sexual abuse or who disclose
previously perpetrating sexual abuse during an intake screening will be offered a follow-up
meeting with a medical or mental health practitioner within 24 hours of the intake screening.
Staff interviewed confirmed awareness of the policy and the requirements of the standard.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy requires timely access to emergency medical treatment, crisis intervention
services, and victim advocacy services for victims of sexual abuse. Treatment services will
be provided to every victim. The nature and scope of the services are determined by medical
and mental health practitioners according to their professional judgment.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
16
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for ongoing medical and mental health care for sexual abuse
victims. It also provides for medical and mental health evaluations and appropriate treatment
in accordance with the standard. According to the Policy, the resident victim will be
provided medical and mental health care that are consistent with the community level of
care, which was confirmed by observations and staff interviews.
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy addresses this standard. There have not been any criminal investigations
conducted at the facility in the last 12 months; however, the policies will serve as the guide
for staff in conducting sexual abuse incident reviews. A process has been in place for
conducting significant incidents. The incident review team has been identified.
Standard 115.387 Data collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy, FDJJ 1919 and interviews with staff confirmed that DJJ collects incident-
based, uniform and aggregated data regarding allegations of sexual abuse at facilities under
its direct control using a standardized instrument and set of definitions. Policy requires the
collection of accurate, uniform data for every allegation of sexual assault. The agency
provides DOJ with data as requested.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
17
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 and the PREA Policy address this standard. The statewide PREA Coordinator will
review the collected and aggregated data to assess and improve the effectiveness of the PREA
related efforts and initiatives. The Policy also states that an annual report will be prepared. A
review of documentation confirms this practice.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to the PREA Policy and FDJJ 1919, it is required that data is collected and
securely retained for 10 years. The aggregated PREA data is reviewed and all personal
identifiers are removed. A review of documentation confirmed the practice.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
November 10, 2014
Auditor Signature Date
18

program_name_raw: brevard detention center


state: FL

facility_name: Brevard Juvenile Detention Center

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Brevard Group Treatment Home
Physical Address: 3905 Grissom Parkway, Cocoa, FL 32926
Date report submitted: September 11, 2014
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: August 12-13, 2014
Facility Information
Facility Mailing Address: Same as Physical Address
Telephone Number: 321-637-1866, ext.221
The Facility is: Military County Federal
Private for profit Municipal State
X Private not for profit
Facility Type: Detention Correction X Other: Residential
Name of PREA Compliance Manager: Joseph M. Nixon Title: Administrator
Email Address: Joseph.Nixon@aspirehp.org Telephone Number:
321-637-1866, ext. 221
Agency Information
Name of Agency: Aspire Health Partners
Governing Authority or Parent Agency: NA
Physical Address: 5151 Adanson Street, Orlando, FL 32804
Mailing Address: Same as Above
Telephone Number: 407-245-0045
Agency Chief Executive Officer:
Name: Dick Jacobs Title: CEO
Telephone 407-245-0045
Email Address: Dick.Jacobs@aspirehp.org
Number:
Agency Wide PREA Coordinator
Name: Joseph Nixon Title: Administrator DJJ
Email Address: Joseph.Nixon@aspireHP.org Telephone Number: 3 2 1 - 6 3 7 - 1 8 6 6 , e x t . 2 2 1
1
AUDIT FINDINGS
NARRATIVE:
The Brevard Group Treatment Home is located in Coca, Florida and is operated by Aspire Health
Partners through a contract with the Florida Department of Juvenile Justice (DJJ). It is a
low/moderate risk residential treatment facility that serves male juvenile offenders between the ages
of 12 and 15. The facility capacity is 30 and 63 residents were admitted to the facility in the past 12
months. The length of stay is three to six months for residents classified as low risk and six to nine
months for those classified as moderate risk. The Brevard Group Treatment Home program and
services include: individual, group and family counseling; anger management sessions; life skills
activities; and recreation activities.
Thirty-seven staff members have been employed at the facility during the past 12 months. Medical
services are provided on-site by a full-time Registered Nurse and a full-time Licensed Practical
Nurse. An Advanced Registered Nurse Practitioner visits the facility weekly. A contract physician is
on-site at least weekly and on-call medical services are provided to the facility. The mental health
staff includes the Clinical Manager; two Senior Counselors; and a Case Manager. A contract
psychiatrist is on-site at least weekly and provides on-call services. Education and related support
services are provided to the facility through the Brevard County School District with on-site certified
personnel. The education courses focus on English, Math, Science, Social Studies and one elective
course.
The program has a behavior management system that includes the use of achievement levels and a
weekly point system. There is also an opportunity for residents to participate in community services
and outdoor education and activities at various places in the local area. A resident’s involvement in
community service projects and other off campus activities is based on his achievement level or phase
in the program, current behaviors, and risk status.
DESCRIPTION OF FACILITY CHARACTERISTICS:
There are two buildings that contain the program. The main building has a small foyer at the entrance
with a check-in/out desk for visitors and the Secretary’s office is adjacent to this area. This front
section also contains the Administrator’s office and other offices. Beyond the front section of the
building are the classrooms; computer laboratory/conference room; offices; kitchen; and dining area. A
second building serves as the housing unit and it includes the medical office, which also serves as the
examination room; another office; large dayroom; staff work station; small day room for special
activities; and storage closet. The small dayroom is known as the “Man Cave” where residents engage
in special activities and privileges that they have earned through the behavior management system. The
bathroom and the configuration of the showers provide residents with a reasonable amount of privacy.
The grounds of the facility provide space for outside large muscle and other activities.
2
SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in the buildings prior to the site visit. Photographs
were taken of the posted notices and the photographs were electronically sent to the Auditor, noting
their locations. There was communication between the Administrator, who also serves as the PREA
Compliance Manager, and the Auditor to review the PREA audit processes. The Pre-Audit
Questionnaire, facility policies and supporting documentation were uploaded to a flash drive, which
was received by the Auditor prior to the on-site audit. After reviewing the information, notes were
sent to the Administrator to seek clarity of information and to note the additional documents needed.
In response to the issues noted, additional information was provided and discussed during the site
visit and corrective actions were taken to provide clarity and address the issues identified.
The on-site audit was conducted August 12-13, 2014. An entrance meeting was held with the
Administrator and the Compliance Coordinator of Aspire Health Partners. After the meeting a
comprehensive tour of the facility was conducted by the Administrator, accompanied by the
Compliance Coordinator. During the tour, staff members were observed to be providing direct
supervision to the residents. Random staff, specialized staff and residents were interviewed during
the on-site audit process. The interviews of both staff and residents showed their awareness and
knowledge of PREA. The staff members interviewed were aware of the related policies, the
facility’s operational procedures and understood their role in ensuring PREA compliance through
maintaining the safety of the residents. Interviews with the residents revealed their knowledge of
what PREA means and that they understand how to report sexual assault and sexual harassment. At
the conclusion of the on-site audit, a summary of the findings were provided in a close-out meeting
with the Administrator.
Number of Standards Exceeded: 0
Number of Standards Met: 39
Number of Standards Not Met: 0
Number of Standards Not Applicable: 2
3
Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The Brevard Group Treatment Home has a comprehensive document, Operating Procedure
A04, which outlines the facility’s approach to preventing, detecting and responding to sexual
abuse and sexual harassment. The Operating Procedure is aligned with the Florida
Department of Juvenile Justice PREA Policy 1919 (FDJJ 1919). Operating Procedure A04
and FDJJ 1919 contain definitions of the prohibited behaviors and sanctions for those who
participate in such behaviors. The facility Administrator serves as the PREA Compliance
Manager.
Standard 115.312 Contract With Other Entities for the Confinement of Residents
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
The facility does not contract with other agencies for the confinement of residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
In accordance with Operating Procedure A04, the DJJ PREA Coordinator in consultation
with the Administrator completed an assessment which included a review of staffing,
deployment of cameras, and other related areas. The staffing plan is in accordance with the
4
current contract with DJJ and Operating Procedure E01. The facility and DJJ are
cooperatively working together regarding staffing, through identifying and hiring additional
staff, which will be in accordance with the standard. Hold-over staff members are identified
for the shifts and a call-in process is in place to provide for the staffing ratios prescribed in
the standard.
The Operating Procedure provides for unannounced visits to deter sexual abuse. The
unannounced rounds are conducted by the Administrator; Program Managers; Program
Supervisors; the Director from another Aspire Health Partners juvenile residential facility;
and the Compliance Coordinator. A review of documentation and staff interviews revealed
that unannounced rounds occur.
Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 prohibits staff from searching a transgender or intersex resident to
determine the resident’s genital status. Cross-gender strip and cross-gender pat-down
searches are also prohibited according to Operating Procedures A04 and E04. The viewing of
residents by opposite gender staff while they are showering, changing clothes, and
performing bodily functions is not permitted, unless there are exigent circumstances.
There have been no cross-gender pat-down, strip or body cavity searches of residents during
this audit period. All staff interviewed said that the facility policy and practice are that cross-
gender searches are prohibited. The residents interviewed confirmed that no cross-gender
searches occur. Operating Procedure A04 requires staff of the opposite sex to announce their
presence when entering a housing area or area where residents may be showering, changing
clothes or performing bodily functions. A sign is posted and interviews with residents and
staff confirm this practice.
Standard 115.316 Residents With Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
5
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operating Procedure A04 provides that the facility will not rely on resident interpreters,
resident readers or any kind of resident assistance except when a delay in obtaining
interpreter services would jeopardize a resident’s safety or an investigation. Based on a
review of the documentation and staff interviews, the facility provides residents with sign
language and other interpreter services.
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility’s and DJJ policies and procedures provide for a background checks system that
applies to all prospective and current employees. A review of the Operating Procedure and
other documentation and interviews with staff revealed that applicants and employees are
asked about previous misconduct and that background checks are conducted.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
A camera system is used for monitoring activities in support of the direct supervision
provided by staff. Additional cameras were added in the housing area, some offices and
areas in the administration building. The system enables staff to observe activities in various
areas. Radios are used for staff communications within and outside of the buildings.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
6
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
A Memorandum of Understanding exists with Sexual Assault Victim Services (SAVS) which
also includes the rape crisis center that is staffed with sexual assault nurse examiners. When
requested, a qualified staff member from the agency will provide services that include:
accompanying the victim through the forensic medical examination process and investigatory
interviews; crisis intervention; information and referrals; and emotional support. The
provision of services to be provided was confirmed through a representative of the advocacy
agency. The facility’s Operating Procedure and a SAVS document provide that forensic
medical examinations will be provided at no cost to the victim. There has not been a need for
a forensic medical examination during this audit period.
According to FDJJ 1919, the facility is not responsible for conducting administrative or
criminal investigations. The DJJ Office of the Inspector General (OIG) is responsible for
conducting administrative investigations; the Florida Department of Children and Families
(DCF) is responsible for conducting allegations of child abuse; and the local law enforcement
agency, Brevard County Sheriff’s Office, is responsible for conducting criminal
investigations.
Standard 115. 322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 and FDJJ 1919 identify the agencies that will conduct the
criminal and administrative investigations. Both documents instruct the facility staff to
cooperate with the investigations and provide that an administrative or criminal investigation
is completed for all allegations of sexual abuse and sexual harassment. During the past 12
months, there were no allegations of sexual abuse or sexual harassment. The facility’s agency
website contains information regarding PREA investigations and contains a link to the DJJ
website that provides the required information.
Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
7
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 provides for the PREA training. The staff training includes the
key elements of the standard. A review of the training documentation and interviews with
staff confirm that the training is provided and the subject matter is aligned with the standard.
Standard 115. 332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 and FDJJ 1919 require that volunteers and contractors be trained
on their responsibilities regarding sexual misconduct prevention, detection, and response.
The policies and procedures also require that staff complete training as outlined in the
Florida Administrative Code, Rule 63-H. A review of documentation and interviews
confirmed that the training occurs for volunteers and contractors.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 requires that all residents receive information about the facility’s
zero-tolerance policy and how to report incidents or suspicions of sexual abuse or sexual
harassment. Residents receive comprehensive education regarding PREA and periodic
refreshers through a review of the information. A signed acknowledgement statement by the
resident of having received the training is maintained. PREA education will be provided
through accessible formats for residents who are limited English proficient, deaf, visually
impaired, or otherwise disabled. Interviews with staff, residents and a review of
documentation confirmed the practice.
8
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 states that staff in the OIG will be trained on the related policies and procedures
regarding the handling of sexual misconduct incidents and reports. An e-mail response
document from the Brevard County Sheriff’s Office indicated responsibility within the
county’s jurisdiction. It also provided that the Brevard County Sheriff’s Office Investigators
receive advanced training in sex crimes, domestic violence, and interviews and interrogations,
in addition to the mandatory training for law enforcement certification.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy A04 addresses this standard. Documentation shows that the medical and mental health
staff members have completed on-line specialized training through the National Commission
on Correctional Healthcare and the National Institute of Corrections. The facility nurses do
not conduct forensic medical examinations.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 contains a section that outlines the process of screening for risk
of victimization and abusiveness and the information to be obtained. The Screening for
9
Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB) instrument is
completed on each resident. Staff and resident interviews and a review of documentation
confirmed that the screening is being conducted using the objective instrument.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 provides for the use of the information from the VSAB to assist
in determining housing and other program assignments. It also prohibits placing gay,
bisexual, transgender, or intersex residents into confinement based solely on such
identification or status. Housing and program assignments require determinations on each
transgender or intersex resident on a case by case basis. The facility prohibits considering
gay, bisexual, transgender, or intersex identification or status as an indicator of likelihood of
being sexually abusive. There have been no residents isolated in the last 12 months because
he was at risk of sexual victimization.
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
There are internal ways a resident may report allegations of sexual abuse; sexual harassment;
retaliation for reporting; and staff neglect or other violation(s) that led to abuse. A resident
may talk to any staff member; complete a complaint/grievance form and place it in the locked
grievance box; the DJJ hotline numbers are available and accessible; and third parties may
report allegations to the facility or use the hotline numbers. A dedicated phone and a hotline
number are provided in the computer lab/conference room in the main building, accessible to
all residents, to call the rape crisis center hotline to report sexual assault. Information
regarding reporting is available in brochures, printed in two other dominant languages, and in
the Youth Handbook.
10
.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has an administrative procedure for dealing with resident grievances. Operational
Procedure A04 and the Youth Handbook contain information regarding the grievance system.
A locked box is posted in the housing building accessible to the residents and
complaint/grievance forms are also available in the building. The residents are directed to
complete a grievance form and put it in the box and management staff checks the box. The
Operational Procedure states that the resident will not be referred to the staff member who is
the subject of the complaint. The Operational Procedure also states that there is no time limit
for a resident to submit a grievance regarding an allegation of sexual misconduct. There were
no emergency grievances alleging a substantial risk of imminent sexual abuse filed in the past
12 months.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 states that all of the residents shall have access to outside victim
advocacy services. A Memorandum of Understanding has been obtained with Sexual Assault
Victim Services. The information about the advocacy services is explained to the resident
during the intake process and it is accessible to the residents. A dedicated phone is provided in
the computer lab/conference room for the resident to call the rape crisis center hotline number,
if needed.
The facility also has a MOU with trained staff through Aspire Health Partners to provide
support services as they relate to child abuse. The services include but are not limited to crisis
intervention; therapy; and education for staff and residents on preventing child abuse,
including sexual assault. Operational Procedure A04 and staff and resident interviews reveal
that residents have confidential access to their attorney or other legal representative and access
to their parents or legal guardians.
11
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility provides methods for third-party reporting of sexual abuse. The Parent
Handbook is provided to parents and legal guardians of residents regarding reporting sexual
abuse. Posters and brochures are located in areas of the facility accessible to the public.
PREA information is available on the facility’s website and there is a link to the DJJ website
regarding the reporting of sexual abuse or sexual harassment on behalf of a resident.
Operational Procedure A04 provides for third party assistance to a resident in filing a
grievance alleging sexual abuse.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 and FDJJ 1919 require staff to report any allegation of sexual
misconduct or resident-on-resident sexual activity to the Central Communications Center.
The Procedure states that staff members are prohibited from revealing any related
information to anyone other than those who are involved in treatment, investigation and
other security and management decisions. Policy and procedures require that staff members
are to immediately report any knowledge, suspicion or information they receive regarding
sexual misconduct; retaliation against residents or staff who report any incidents; any staff
neglect or violation of responsibilities that may have contributed to an incident or retaliation.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
12
Auditor Comments:
According to A04, when staff learns that a resident is subject to substantial risk of imminent
sexual abuse, immediate action must be taken to protect the resident. The facility reports that
there have been no incidents in the last 12 months where the facility took any action in
regards to a resident being in substantial risk of imminent sexual abuse.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to A04, upon receiving an allegation that a resident was sexually abused while
confined in another facility, the Administrator will notify the head of that facility or the
appropriate office as soon as possible but no later than 72 hours after receiving the
allegation. The Operational Procedure and FDJJ 1919 require notifying the appropriate
investigative agency of all allegations of sexual abuse. In the past 12 months, there have not
been any allegations of sexual abuse occurring to a resident while he was in another facility.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The staff first responder duties are incorporated in Operational Procedure A04 and are
aligned with the requirements of FDJJ 1919. A04 outlines the first responder duties and
other staff responses. Staff interviews confirmed that they are knowledgeable of their duties
as a first responder.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
13
Auditor Comments:
The coordinated response is incorporated in Operational Procedure A04 and is aligned with
FDJJ 1919. Interviews with staff revealed that they are familiar with the institutional plan.
The plan coordinates the actions to be taken among facility first responders and other staff in
response to an incident of sexual abuse.
Standard 115.366 Preservation of Ability to Protect Residents from Contact with Abusers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable. The facility does not maintain any collective bargaining
agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 identifies the PREA Compliance Manager as the staff member
responsible for monitoring for retaliation against residents and staff members who report
sexual abuse or sexual harassment. There have been no allegations of sexual abuse or sexual
harassment during this audit period. However, Operational Procedure A04 will provide
guidance to staff if there is a need for staff or resident protection against retaliation.
Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
14
Auditor Comments:
Operational Procedure A04 provides that the Administrator or his designee may coordinate
the re-location of a resident if it is determined to improve the safety of others or the integrity
of the investigation. Segregated housing or isolation is not used at this facility. However,
measures may be taken to separate residents for their safety by changing their assigned
room, arranging for the resident to sleep in the large dayroom or open bay as it is called at
the facility, and keeping a resident separated to the extent possible by staff.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 and FDJJ 1919 provide direction for this standard.
Administrative investigations are conducted by OIG and criminal investigations will be
conducted by the Brevard County Sheriff’s Office. The Florida Department of Children and
Families will also be called when there is an allegation of sexual abuse and they may
conduct investigations. The Operational Procedure and FDJJ 1919 direct staff to cooperate
with the investigations.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The OIG, responsible for administrative investigations, imposes a standard of a preponderance
of the evidence for determining whether allegations are substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
15
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 allows for the victim to be informed that the investigation has been concluded. At
the conclusion of an OIG investigation, the victim or the victim’s parents or legal guardian
will be notified.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 provides for disciplinary sanctions for staff to be up to and
including dismissal for violation of the facility’s zero-tolerance policy against sexual abuse
and sexual harassment. It states that the presumptive disciplinary sanction for staff who
engages in sexual abuse will be termination. In the past 12 months, no staff has been
terminated or has resigned for violating any PREA related policies.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Operational Procedure A04 and FDJJ 1919, any contractor or volunteer
engaging in sexual abuse of residents will be subject to referral to local law enforcement
regarding criminal charges and to relevant licensing bodies. FDJJ 1919 states that the
contractor or volunteer is prohibited from having contact with residents. During the past 12
months, no contractor or volunteer has been reported to law enforcement or any investigative
agency for allegations of sexual abuse.
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
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X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operating Procedure A04 addresses this standard. Residents found in violation of the
facility’s zero tolerance policy regarding sexual abuse, sexual assault, sexual misconduct or
sexual harassment against another resident will receive disciplinary sanctions after a formal
disciplinary process. The rule violations and the sanctions or consequences for such behavior
are provided in the Youth Handbook. The consequences or sanctions do not include isolation.
There have been no criminal or administrative investigations of sexual abuse during the last
12 months.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 provides that residents who disclose prior sexual victimization or
who disclose previously perpetrating sexual abuse during an intake screening will be offered
a follow-up meeting with a medical or mental health practitioner within 14 days of the intake
screening. Staff interviewed confirmed awareness of the policy and procedure.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 requires timely and unimpeded access to emergency medical
treatment services for victims of sexual abuse. It also states that access to the services will be
based on the professional judgment of the medical and mental health staff. Interviews with
staff confirmed their knowledge of the process.
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Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Operational Procedure A04 requires ongoing medical and mental health care for sexual
abuse victims and abusers and that the appropriate tests be provided. The Procedure states
that the facility will attempt to obtain a mental health evaluation within 60 days of learning
of resident-on-resident abusers and offer treatment deemed appropriate by a mental health
practitioner. Interviews with staff confirmed their knowledge of the information.
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
There have been no criminal or administrative investigations of sexual abuse in the past 12
months; however, Operational Procedure A04 requires a review of every sexual abuse
allegation within 30 days of the conclusion of the investigation. The Operational Procedure
also identifies the incident review team and others who may provide input to the process.
Standard 115.387 Data collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 and interviews with staff confirmed that DJJ collects incident-based, uniform and
aggregated data regarding allegations of sexual abuse at facilities under its direct control
using a standardized instrument and set of definitions. Operational Procedure A04 states that
the PREA Compliance Manager is responsible for gathering PREA related data being stored
at the facility and on the DJJ website. FDJJ 1919 requires the collection of accurate, uniform
data for every allegation of sexual assault. The DJJ provides DOJ with data as requested.
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Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to FDJJ 1919, the DJJ PREA Coordinator will review the collected and aggregated
data to assess and improve the effectiveness of the PREA related efforts and initiatives. The
Policy also states that an annual report will be prepared. An examination of the DJJ document,
PREA Incident Reports, confirms the data gathering and review.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According FDJJ 1919, it is required that data is collected and securely retained for 10 years.
The aggregated PREA data is reviewed and all personal identifiers are removed.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
September 11, 2014
Auditor Signature Date
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source: DJJ

report_type: PREA

program_name_raw: brevard group treatment home