facility_name: residential alternative for the mentally challenged

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Residential Alternative for the Mentally Challenged
Physical Address: 742 SW Greenville Hills Road, Greenville, FL 32331
Date report submitted: February 17, 2015
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: January 29, 2015
Facility Information
Facility Mailing Address: 742 SW Greenville Hills Road, Greenville, FL 32331
Telephone Number: (850) 948-1226
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: Ronald Matthews Title: Program Director
Email Address: rmatthews@twinoaksfl.org Telephone Number:
(850) 948-1226
Agency Information
Name of Agency: Twin Oaks Juvenile Development, Inc.
Governing Authority or Parent Agency: NA
Physical Address of Agency: 11939 NW SR 20, Bristol, FL 32321
Mailing Address: Same as Above
Telephone Number: (850) 643-1090
Agency Chief Executive Officer
Name: Donald B. Read Title: Chief Executive Officer
Telephone (850) 643-1090
Email Address: dread@twinoaksfl.org
Number:
Agency Wide PREA Coordinator
Name: Charles Chervanik Title: Chief Operating Officer
Email Address: cchervanik@twinoaksfl.org Telephone Number: ( 8 5 0 ) 6 4 3 - 1 0 9 0
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AUDIT FINDINGS
NARRATIVE:
The Residential Alternative for the Mentally Challenged (RAMC) is located in Greenville, Florida
and has a designed capacity of 54. The facility serves male juvenile offenders in the age range of 9-
18. Twin Oaks Juvenile Development, Inc. operates RAMC through a contract with the Florida
Department of Juvenile Justice (DJJ) to provide residential treatment services. The length of stay is 9-
12 months and the program serves low and moderate risk residents. The facility program and services
include education and vocational services; social services; case management, mental health; medical;
recreation; and transition planning.
Medical care is provided within the facility by the Director of Nursing and a Licensed Practical
Nurse; there is also a pool of six nurses that may be scheduled to work as needed. The contract
physician visits the facility at least weekly. On-site mental health services are provided by the Clinical
Director and four Therapists. The contract psychiatrist visits the facility at least every two weeks. The
education staff includes three teachers and a vocational instructor. Education strategies are designed
to meet the individual needs of the residents. Education courses include English, Math, Science, and
Social Studies; vocational training emphasizes culinary arts. Case Managers ensure coordinated
efforts for individualized treatment and facilitate transition planning. The direct care staff practice
engaged supervision of the residents in daily activities and during movement to and from activities and
services.
The facility is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).
The program is designed to serve adolescent males with developmental disabilities and requires each
youth meeting specific eligibility criteria for admission to the program. The behavior management
system is designed to meet the needs of this population and follow a reinforcement schedule that
supports the demonstration of the desired behaviors. Residents are considered for special events after
they meet specific requirements, including education trips, recreation trips, or community service
projects. Through a partnership between Twin Oaks Juvenile Development, Inc. and the Boys and
Girls Club of America, the facility operates a full service Boys and Girls Club that provide services
and activities comparable to those found in the community. Transition planning for the resident’s
return to the community may include continued membership in the Boys and Girls Club located in the
resident’s local community.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is housed on a spacious campus and consists of a main building that houses the
administrative area of offices, entrance lobby and the control room. The main building also contains
the cafeteria and kitchen; classrooms; medical clinic; and the RAM-C Cafe that serves as the setting
for the operations of the culinary arts vocational program. There are three dormitories and each
contains a day room area and offices. Located on the campus is also a building that houses the Boys
and Girls Club.
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Full bathrooms are located in each dormitory and they provide a reasonable amount of privacy for the
residents. The outside grounds contain a basketball court, ample space for additional recreation and
other activities, and an attractive gazebo.
SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in various parts of the facility at least six weeks
prior to the site visit. Photographs were taken of the various sites where the notices had been posted
and the photographs were electronically sent to the Auditor. An initial conference call was
conducted with identified staff from the facility and the parent agency, the statewide PREA
Coordinator, and this Auditor to discuss the audit process and data gathering process. The Pre-Audit
Questionnaire and the supporting documentation were uploaded to a flash drive, which was received
approximately four weeks prior to the on-site audit. During the review of the information on the
flash drive, communication was maintained with the facility and agency staff and additional
information was provided or clarified as requested. The Chief Operating Officer (COO) for Twin
Oaks Juvenile Development, Inc. serves as the agency’s PREA Coordinator.
The on-site audit was conducted January 29, 2015. Introductions were held with the Program
Director who served as the PREA Compliance Manager during this audit period and the Assistant
Program Director. Afterwards, a comprehensive tour of the facility was conducted by the Assistant
Program Director accompanied by the Program Director, COO and other agency staff. During the
tour, staff members were observed to be providing direct supervision and interacting with the
residents. Random staff, specialized staff and residents were interviewed during the on-site audit
process.
Additional information was provided upon request and in a timely manner while on-site. A close-out
meeting was held at the conclusion of the site visit and a summary of the audit findings was
provided.
Number of Standards Exceeded: 0
Number of Standards Met: 38
Number of Standards Not Met: 0
Number of Standards Not Applicable: 3
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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 facility adheres to the agency’s (Twin Oaks Juvenile Development, Inc.) Prison Rape
Elimination Act (PREA) Policy that provides guidelines for implementing the agency’s
approach to complying with the requirements of the PREA standards. The Policy provides for
a zero tolerance approach regarding all forms of sexual abuse and sexual harassment. It
contains definitions of the prohibited behaviors and sanctions for those who participate in such
behaviors. The agency’s PREA Policy and the facility procedures are aligned with the Florida
Department of Juvenile Justice PREA Policy (FDJJ 1919).
Standard 115.312 Contract With Other Entities for the Confinement of Residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
The facility does not contract with other facilities for the confinement of residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and practices provide for the implementation of a staffing plan with
adequate staffing levels to protect residents against sexual abuse and provides that the staffing
ratios are per the current program contract. According to the staffing plan and staff interviews
the ratios within the facility are 1:6 during the hours that residents are awake and 1:12 during
the sleeping hours. The ratios for the agency staffing plans include a smaller number of
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residents, based on the activity. The assessment of the staffing plan determines whether
adjustments are needed in accordance with the standard. The staffing plan details the
methodology that ensures adherence to the staffing ratios.
Members of the management team conduct unannounced rounds for the maintenance of a
safe environment. Policy and practice provide that staff members are prohibited from alerting
other staff regarding unannounced rounds occurring. Interviews with staff confirmed the
practice.
Standard 115.315 Limits to Cross-Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy prohibits cross-gender pat-down searches and also prohibits staff from
conducting cross-gender strip or cross-gender visual body cavity searches of residents. All
residents are able to shower, perform bodily functions, and change clothes without being
observed by staff of the opposite gender. Interviews with staff and residents confirmed this
practice.
The PREA Policy supports that staff shall not search or physically examine a transgender or
intersex resident to determine the resident’s genital status. In practice, female staff members
announce themselves when entering the dormitories. The PREA Policy directs that staff of
the opposite gender shall announce themselves when entering an area where residents may be
showering, performing bodily functions or changing clothes.
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:
Resources are available for the provision of support services for residents with disabilities
and residents who are limited English proficient to ensure that all residents benefit from and
participate in PREA education. Interpreter and other support services can be provided by
facility staff and Language Line Services through an agreement with the Florida Department
5
of Health. Resident education materials are accessible in dominant languages other than
English. A review of documentation and staff interviews confirmed that the resources are
available and that residents are not used as interpreters or readers.
.
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 and FDJJ 1919 address the components of this standard and provide for
background checks on all employees and contractors through a process that is used
statewide. A review of documentation and interviews with staff confirmed that prior to the
hiring of an employee or contractor, background checks are conducted as required.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
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. A camera system is used; however, there have not been any
upgrades or additional installation since the August 20, 2012 time frame.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy states that staff is expected to cooperate in investigations conducted by the
FDJJ Office of the Inspector General (OIG). Administrative investigations are conducted by
OIG and criminal investigations are conducted by the Florida Department of Children and
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Families and local law enforcement. The PREA Policy states that upon the arrival of law
enforcement investigators, a copy of the PREA Compliance Form will be provided to them
which contain the PREA standards requirements regarding investigations. There is an
Acknowledgement of PREA Protocol Procedures, signed by the facility Program Director
and a Lieutenant from the Madison County Sheriff’s Department stating receipt of the
protocols to be followed during an investigation.
The PREA Policy provides for forensic medical examinations to be completed at no
financial cost to the victim. The agency has a written Agreement with a Forensic Nurse
Specialist for the provision of forensic medical examinations and the Madison County
Memorial Hospital will be used for emergency medical services. There is evidence of efforts
to secure advocacy services from a rape crisis center. The facility has a Professional Services
Agreement with an agency staff member who is a Licensed Mental Health Counselor that
will be able to provide supportive services to residents as needed. There have been no
forensic examinations conducted during this audit period.
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 facility’s PREA Policy and FDJJ 1919 provide that staff report all allegations of sexual
abuse and sexual harassment and that the appropriate investigative entity be contacted when
allegations of sexual abuse are made. The Twin Oaks Juvenile Development, Inc. website
contains information regarding the referral of allegations for investigations of sexual abuse
and it has related information posted, which is accessible to the public. The website is very
informative and educational to the public and staff.
Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The comprehensive PREA Policy addresses employee training. Additionally, staff interviews
and a review of training documents show that employees participate in PREA training.
Supplementary training is provided or coordinated as needed.
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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 (PREA) 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:
A review of documentation and interviews with residents and staff confirm that residents
receive information about the contents of the PREA Policy, including how to report incidents
of sexual abuse or sexual harassment. According to the PREA Policy and additional
documentation, the facility will provide support services in accessible formats for residents
who are limited English proficient, deaf, visually impaired, or otherwise disabled. PREA
information is posted and readily available to the residents.
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 and the PREA Policy state 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 facility
settings.
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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:
A review of training documentation and staff interviews confirm that the specialized training
occurs for medical and mental health staff. The facility medical staff does 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:
Screening for the risk of sexual abuse victimization or sexual abusiveness toward other
residents is being conducted on each resident in accordance with the PREA Policy and FDJJ
1919. The initial screening is done during the intake process and the PREA Policy states that
the treatment teams should continually review the resident’s adjustment. Interviews with
residents and staff and a review of documentation support this information.
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 in
particular housing based solely on such identification or status. Housing and program
assignments will be made for each transgender or intersex resident on a case by case basis
and the resident’s view regarding safety will be seriously considered. According to the
PREA Policy, the facility prohibits considering gay, bisexual, transgender, or intersex
identification or status as an indicator of the likelihood of being sexually abusive.
9
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to the PREA Policy, there are internal ways a resident may report allegations of
sexual abuse; sexual harassment; retaliation for reporting; and staff neglect or other violations
that lead to abuse. A resident may complete a grievance form and place it in the Grievance
Box located in each dormitory; complete an Audience Request Form requesting to talk to a
specific staff member; talk to any staff member; and third parties may report allegations to
staff or through the Florida abuse hotline. Interviews with staff and residents and a review of
documentation support the practices.
PREA related information is posted in each dormitory. The abuse reporting hotline number is
posted and residents are provided access to a telephone to report allegations of sexual abuse
and sexual harassment. Interviews revealed that staff members are aware of their
responsibility to report sexual abuse and sexual harassment. They are also aware that they
may accept reports of sexual abuse and sexual harassment made verbally, in writing,
anonymously, and from third parties.
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 prohibits the use of an informal grievance process regarding allegations of
sexual abuse and sexual harassment. The facility considers resident grievances regarding
sexual abuse to be an allegation and when such a complaint is received, the procedures
regarding reporting allegations are initiated. Residents may place written allegations of
sexual abuse or sexual harassment in the Grievance Box. The PREA Policy indicates that
emergency grievances will be responded to immediately.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
10
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy requires the facility to provide the residents with access to outside victim
advocacy services. The facility is currently working with a rape crisis center representative
regarding the delivery of supportive services. Interviews with facility staff and the rape crisis
center representative confirm these efforts. A Professional Services Agreement exists with a
Licensed Mental Health Counselor, employed by Twin Oaks Juvenile Development, to
provide support services regarding an incident of sexual assault.
Residents are allowed to see their parents at visitation on Sundays and may talk to them at
least once a week by telephone. Attorneys or other legal representation may visit residents in a
confidential manner.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides guidelines regarding third-party reporting and the practice is that
staff responds to the receipt of third party reports. During the on-site audit a resident made a
third party allegation to this auditor during a random resident interview. This Auditor
informed the Program Director of the information received. Upon follow-up this Auditor
learned that that the allegation has been reported and referred for an investigation. The
agency website and the DJJ website provide the public with information regarding the
reporting of 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)
11
Auditor Comments:
According to the PREA Policy, staff members are to immediately report: any knowledge,
suspicion or information they receive regarding sexual abuse, sexual harassment, retaliation
against residents; or staff who report any incidents; or any staff neglect or violation of
responsibilities that may have contributed to an incident. Each staff interviewed was aware
of their reporting duties.
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 provides that when it is learned that a resident is subject to substantial risk
of imminent sexual abuse, immediate action is taken to protect the resident. There have been
no incidents in the last 12 months where the facility was required to take action in regards to
a resident being at 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:
The PREA Policy and FDJJ 1919 address this standard and provides that upon receipt of an
allegation that a resident was sexually abused while confined in another facility, the Program
Director will notify the Central Communications Center (CCC) and the Department of
Children and Families of the allegation. Additionally, the head of the other facility will be
notified. The notifications will be made within 72 hours of receipt of the allegation.
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 and FDJJ 1919 guide the staff response to this standard. The Policies
provide direction to staff in responding to allegations of sexual abuse; training has been
provided.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The agency’s institutional plan, Coordinated Response, is detailed in its guidance to staff
regarding steps to take in the event of an incident or allegation 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:
The PREA Policy provides protection against retaliation for residents and staff who report
allegations of sexual abuse or sexual harassment. There is a designated staff member
responsible for monitoring for the occurrence of retaliation. The Policy identifies areas to
monitor regarding possible retaliation of residents and staff.
13
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 facility does not use segregated housing; however, staff interviews revealed that
protective measures will be used to ensure the safety of the resident that can include
assigning the resident to another dormitory. The rooms in the dormitories vary from housing
one to four residents.
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 PREA Policy and FDJJ 1919 address this standard. Administrative investigations are
conducted by the DJJ OIG and criminal investigations are conducted by the Department of
Children and Families and local law enforcement. Both Policies direct facility staff to
cooperate with investigations. According to FDJJ 1919, an investigation is not terminated
solely because the source of the investigation recants the allegation. Substantiated allegations
of conduct that appear to be criminal are referred for prosecution.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
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.
14
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 and FDJJ 1919 provides the process for notifying residents following an
investigation of whether an allegation has been determined to be substantiated,
unsubstantiated, or unfounded.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides for disciplinary sanctions for staff to be up to and including
termination for violation of the sexual abuse and sexual harassment policies. The PREA
Policy requires that the violation be reported to local law enforcement and provides for
contacting relevant licensing bodies. In the past 12 months, no staff has been terminated or
has resigned for violating PREA related policies.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
An incident regarding sexual abuse by a contractor or volunteer will be reported as required,
including to relevant licensing bodies, according to the PREA Policy. The facility prohibits
future contact with residents in the case of any violation of the facility’s PREA related
policies. During the past 12 months, no contractor or volunteer has been reported to law
enforcement or any investigative entity for allegations of sexual abuse.
15
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides that any resident found in violation of that Policy may be subject
to disciplinary action, following a formal process. The resident may be transferred to another
facility following an administrative or criminal finding of resident-on-resident sexual abuse.
During the past 12 months there have been no incidents of resident-on-resident sexual abuse.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to the PREA Policy, residents who disclose a history of sexual abuse or who
disclose previously perpetrating sexual abuse will be offered a follow-up meeting with a
medical or mental health practitioner within 14 days of the intake screening. Staff
interviewed confirmed awareness of the policy and the requirements of the standard.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to the PREA Policy, timely and unimpeded access to emergency medical
treatment and crisis intervention services for victims of sexual abuse will be provided. The
nature and scope of the services are determined by medical and mental health practitioners
according to their professional judgment.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
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 staff interviews and a review of
documentation, the standard of health care is consistent with the community level of care.
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy provides information regarding staff conducting incident reviews. The
Policy details the requirements of the standard and states that the incident review will occur
within 30 days of the conclusion of the investigation. The incident review team has been
identified. Staff interviews indicated familiarity with the role of the incident review team
regarding incidents of sexual abuse. A process is in place which reviews all significant
incidences occurring within the facility.
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 agency’s PREA Policy requires the collection of accurate, uniform data for every
allegation of sexual abuse. The agency uses a system called TRENDSTAT for their facilities
to collect, analyze and submit monthly data to the corporate leadership team. The agency has
developed a data collection instrument that includes pertinent data.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
17
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy and FDJJ 1919 provide for analyzing the data to identify trends and/or
problem areas and to develop corrective actions where indicated. The Policies require the
review of data with the goal of improving the effectiveness of the agencies’ PREA initiatives
in the areas of prevention; protection and response policies; practices; and training.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The PREA Policy requires that data is collected and securely retained for 10 years, unless
otherwise required by law. The aggregated PREA data is reviewed and all personal
identifiers are removed. Twin Oaks Juvenile Development, Inc. has a report posted on its
website.
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.
February 17, 2015
Auditor Signature Date
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