state: FL

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Okaloosa Youth Academy
Physical Address: 4455 Straight Line Road, Crestview, FL 32539
Date report submitted: December 17, 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: November 17-18, 2014
Facility Information
Facility Mailing Address: 4455 Straight Line Road, Crestview, FL 32539
Telephone Number: (850) 689-1984
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention X Correction Other:
Name of PREA Compliance Manager: Denny Skinner Title: QA Officer
Email Address: denny.skinner@uhsinc.com Telephone Number:
(850) 683-3900
Agency Information
Name of Agency: Gulf Coast Youth Services, Inc.
Governing Authority or Parent Agency: Universal Health Services
Physical Address of Agency: 1015 Mar Walt Drive, Fort Walton Beach, FL 32547
Mailing Address: Same as Above
Telephone Number: (850) 863-4160
Agency Chief Executive Officer
Name: Jeanette Jackson Title: Chief Executive Officer
Telephone (850) 863-4160
Email Address: jeanette.jackson@uhsinc.com
Number:
Agency Wide PREA Coordinator
Name: Denny Skinner Title: QA Officer
Email Address: denny.skinner@uhsinc.com Telephone Number: ( 8 5 0 ) 6 8 3 - 3 9 0 0
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AUDIT FINDINGS
NARRATIVE:
The Okaloosa Youth Academy, located in Crestview, Florida, is a 75 bed moderate risk residential
facility that houses male juvenile offenders in the age range of 10-19. The facility is operated by
Universal Health Services, Inc. through a contract with the Florida Department of Juvenile Justice
(DJJ). Thirty-five beds are allotted for youth who have been adjudicated as sex offenders. Forty beds
are allotted for adjudicated youth identified as moderate risk and 10 of those beds are for youth with
substance abuse issues. The average length of stay for the sex offender program and the substance
abuse program is 12-18 months and 6-9 months for the remaining youth. While in the facility
residents participate in programming that include education and vocational services; social services;
mental health services; substances abuse services; recreation; transition planning; and faith based
services provided by volunteers. Seventy-seven residents have been admitted to the facility in the past
12 months.
One hundred thirteen staff members have been employed at the facility during the past year. On-site
medical services, including an evaluation and screening for any medical needs, are provided by a full-
time Registered Nurse and two Licensed Practical Nurses. The contract physician visits the facility
weekly. Mental health services are provided on-site by the Treatment Coordinator and six Therapists,
with a contract psychiatrist visiting twice a month. The parent agency has a Director of Nursing and a
Designated Mental Health Authority on staff and they are accessible to the facility medical and
mental health personnel. Education services are provided by teachers through the Okaloosa County
School District. Case Managers ensure coordinated efforts for individualized treatment; transition
planning begins at the time of admission.
The Okaloosa Youth Academy program is accredited by the Commission on Accreditation of
Rehabilitation Facilities (CARF). The goals of the facility are to develop and broaden the skills of the
residents through therapeutic and rehabilitative programming enabling residents to meet their
individualized goals; and to assist residents in establishing and maintaining useful interactions and
relationships that transcend to a successful re-entry into the community.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is located approximately two miles south of Crestview, Florida in an area with other
adult and juvenile correctional facilities and a juvenile detention center. The program consists of an
administration building; housing units; a building that contains the kitchen and dining area on one
side and the education unit of four classrooms on the other. There is a vocational building where
instructors through Home Builders Institute conduct classes and hands-on activities in woodworking,
basic home maintenance and carpentry. A computer laboratory is also housed in the vocational
building. One of the housing units houses the colorfully themed painted Reward Area which consists
of the token store; game rooms; area to watch movies; library/quiet room; and a barber shop. There is
ample space on the outside grounds for an array of recreation and other activities.
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A dayroom is located in each housing unit along with showers, toilets, and a laundry room. The
bathrooms provide reasonable privacy for the residents. Each housing unit has a tranquility room that
contains books and a chalkboard. The facility grounds accommodate a chicken pen and several
chickens in a fenced area. Under staff guidance, the youth take responsibility in caring for the
chickens and gathering the eggs. The care of the chickens serves a therapeutic purpose as well as
educational and vocational opportunities for the residents. Youth Care Workers provide direct
supervision of residents in daily activities and movement to and from activities and services both
inside and outside of the facility.
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 this Auditor, noting their locations. An initial call
was made to the Program Director to discuss the process and for clarification of information. 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. After reviewing the information
on the flash drive, a written response was sent to the PREA Coordinator and followed up with a
telephone call. Additional information was provided or clarified as requested. The parent agency’s
Quality Assurance (QA) Officer serves as the PREA Coordinator.
The on-site audit was conducted November 17-18, 2014. An entrance meeting was held with the
Program Director, Assistant Program Director and the QA Officer/PREA Coordinator. After the
meeting a comprehensive tour of the facility was conducted by the Program Director and the
Assistant Program Director. During the tour, staff members were observed to be directly supervising
the residents. Random staff, specialized staff and residents were interviewed during the on-site audit
process.
While on-site, additional information for the audit process was provided in a prompt manner. A
close-out meeting was held at the conclusion of the on-site audit and a summary of the audit findings
was provided to the Program Director and the PREA Coordinator.
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 facility has various policies that provide guidelines for implementing the agency’s
approach to complying with the requirements of the PREA standards. Policy 13.00 states a
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. The Florida Department of Juvenile Justice Policy 1919 (FDJJ 1919) is also used
and adhered to for support of the PREA standards.
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:
Policy 9.010 provides for the implementation of a staffing plan with adequate staffing levels
to protect residents against sexual abuse and that the ratios are aligned with the program
contract. The facility reported no deviations from the current staffing plan in the past 12
months. The annual assessment of the staffing plan and other areas has been conducted to
determine whether adjustments are needed in accordance with the standard. A review of the
staffing has been documented through the completion of the Staffing Plan Assessment form.
Unannounced rounds of the facility for the maintenance of a safe environment are conducted
and documented by appropriate staff. Staff interviews and a review of documentation
confirmed the practice of unannounced rounds.
Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
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Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 9.100 prohibits cross gender pat-down searches and there have been no cross gender
pat-down searches during this audit period. The Policy also prohibits staff from conducting
cross-gender strip or cross-gender visual body cavity searches of residents and none have
been conducted during this audit period. Policies 13.09 and FDJJ 1919 have been
implemented that provide for residents to shower, perform bodily functions, and change
clothes without being observed by staff of the opposite gender. Interviews with staff and
residents confirm the aforementioned practices. Policy 13.11 states that staff shall not search
a transgender or intersex resident to determine the resident’s genital status. The related
training and reviews have been provided.
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:
Policy 1.150 addresses support that provide residents with disabilities and residents who are
limited English proficient with various services so that they may benefit from and participate
in PREA education. Resident education materials are available in dominant languages other
than English. Policy 1.150 ensures that the facility will not rely on resident interpreters. The
policy contains information regarding the resources to be used and how they will be
accessed. A review of documentation and staff interviews confirmed that outside resources
would be used to assist residents.
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:
Policy 1.130, FDJJ 1800 and 1919 provides for background checks on all employees and
contractors through a process that is aligned with the standard. 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)
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Does Not Meet Standard (requires corrective action)
Auditor Comments:
A secondary monitoring system is used in addition to direct staff supervision. A camera
system that enables staff to observe activities and areas on multiple screens is used. There are
a total of 96 cameras within and outside of the facility. Additional cameras were added in the
administration building and in an outside area to aid in the observation of residents. The
Program Director has access to the camera system by desktop monitoring of activities from
his office.
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:
Policy 13.18 addresses this standard and states that staff will cooperate in investigations
conducted by the FDJJ Office of the Inspector General (OIG) for administrative
investigations and with the Florida Department of Children and Families and local law
enforcement regarding criminal investigations. Policy 13.13 provides for forensic medical
examinations to be completed at no financial cost to the victim. There have been no forensic
examinations in the last 12 months. The facility has a Memorandum of Understanding
(MOU) with the Shelter House, Inc. in Fort Walton Beach, Florida which provides victim
advocacy services that include accompaniment to forensic examinations and training for
staff and residents.
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:
Policy 13.27 and FDJJ 1919 provide that staff report all allegations of sexual abuse and
sexual harassment. The appropriate investigative entity will be contacted regarding reporting
and any subsequent investigation. There has been one allegation from a resident during the
past 12 months. The allegation was reported as required and investigated by the Okaloosa
County Sheriff’s Office, the Department of Children and Families the DJJ OIG. According
to the summation at the end of the report by the Sheriff’s Office, the case was closed due to
no independent witnesses; no further leads to follow; and conflicting statements. The
Department of Children and Families closed the case as unsubstantiated. The DJJ website
contains information regarding the referral of allegations for investigations of sexual abuse.
The facility posts related information in the visitation area which is accessible to the public.
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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:
FDJJ 1919 provides for the PREA training of all staff. The facility staff received the DJJ
training and the facility has conducted refresher training in the key areas referenced in the
standard. Documentation of staff participating in training is maintained.
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:
Policy 13.04 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:
Documentation and interviews with residents and staff confirm that residents receive
information about the facility’s zero-tolerance policy and how to report incidents or
suspicions of sexual abuse or sexual harassment. In the past 12 months, approximately 77
residents received the information. Documentation of residents’ signatures is maintained to
support that residents received the PREA education. Through resources identified in policy,
the facility will provide support services in accessible formats for residents who are limited
English proficient, deaf, visually impaired, or otherwise disabled.
Standard 115.334 Specialized Training: Investigations
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:
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:
Policy 13.15 addresses PREA training for medical and mental health staff. A review of
documentation and staff interviews confirm the specialized training. 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:
Policies 13.01 and FDJJ 1919 address this standard. A review of documentation and staff
and resident interviews confirm that screening for risk of sexual abuse victimization or
sexual abusiveness toward other residents is being conducted on each resident. The initial
screening is done during the intake process and Policy states that residents receive
reassessments periodically.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility prohibits placing gay, bisexual, transgender, or intersex residents into
confinement based solely on such identification or status. According to Policy 13.02 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
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identification or status as an indicator of likelihood of being sexually abusive. Isolation is not
used at this facility and there have been no residents placed in isolation because of
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:
According to Policy 13.22 and staff and resident interviews, 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 file a grievance; complete a
Youth Special Request Form where a resident seeks to talk to specific staff; write a note; talk
to any staff member; and third parties may report allegations to staff. The grievance and other
written requests may be placed in the locked box located in the housing units.
PREA related information is posted in each housing unit. Residents are provided access to a
telephone to report allegations of sexual abuse and sexual harassment to the abuse reporting
hotline. The hotline number is also accessible from any office phone in the administration
building. Interviews revealed that staff members are aware of their responsibility to report
sexual abuse and sexual harassment. They are also aware that they are to accept reports of
sexual abuse and sexual harassment made verbally, in writing, anonymously, and from third
parties in accordance with Policies 13.22 and FDJJ 1919.
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:
Policies 13.21 and 3.08 provide guidance regarding the grievance process and information is
contained in the resident handbook. Residents may put a completed grievance form in the
locked grievance box located in each housing unit. Policy prohibits the use of an informal
grievance process regarding allegations of sexual abuse and sexual harassment. The facility
reports that there have been no grievances submitted relating to sexual abuse or sexual
harassment received 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)
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Auditor Comments:
Policy 13.23 requires the facility to provide the residents with access to outside victim
advocacy services. The documented MOU provides for services that will be delivered by a
local victim advocacy agency. A telephone conversation with the representative from the
victim advocacy agency, Shelter House, Inc., confirmed that victim services will be provided
to the facility when requested and that no services have been requested.
Residents are allowed to see their parents at visitation on the weekends and they are also
allowed to make weekly phone calls. Attorneys or other legal representation may visit the
facility and may visit 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:
Policy 13.14 provides guidelines regarding third-party reporting. The DJJ website provides
the public with information regarding third-party reporting of abuse. Parents receive
information about reporting incidents of sexual abuse through information posted in the
visitation area. Staff and resident interviews were aligned with this information.
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 Policy 1.07 and Florida Statute 39.201, all staff members are mandated
reporters. They are to immediately report any knowledge, suspicion or information they
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. 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:
Policy 13.12 addresses this standard and provides that when the agency or facility staff
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
10
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:
According to Policy 13.26, upon receiving an allegation that a resident was sexually abused
while confined in another facility, the Program Director/designee will notify the Central
Communications Center (CCC) of the allegation within 72 hours. The CCC notifies the
facility of which the allegation was made. Staff interviews confirmed knowledge of the
policy and procedure.
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:
Policy 13.20 addresses the first responder duties and provides an account of first responder
duties and responses. There has been one allegation by a resident regarding sexual abuse
within the last 12 months which was reported as required. The allegations were investigated
and determined to be unsubstantiated. Staff training and a refresher have been provided,
including the duties of the 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:
A review of the written document, PREA Institutional Plan, and interviews with staff
confirm that a coordinated response plan has been developed. The plan coordinates the
actions to be taken among staff including first responders, leadership, medical and mental
health 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)
11
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:
Policy 13.19 addresses protection against retaliation for residents and staff who report
allegations of sexual abuse or sexual harassment. The Program Director, Assistant Program
Director and shift supervisors have been identified as the staff members designated with
monitoring for possible retaliation. If the conduct is identified the Policy states that the
monitoring is ongoing. Policy 13.19 also instructs staff on reporting incidents of 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)
Auditor Comments:
Policy 13.29 addresses this standard and covers the requirements of how protective measures
are implemented. The protective measures do not include the isolation of residents; however,
the resident may be transferred to another room and/or housing unit. The resident will be
separated from potential abusers, according to the policy and staff interviews.
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:
Policy 13.18 and FDJJ 1919 address this standard. Administrative investigations are
conducted by the DJJ Office of Inspector General and criminal investigations are conducted
12
by the Department of Children and Families and local law enforcement. Both Policies direct
facility staff to cooperate with the investigations. Policy also provides that 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:
Policy 13.28 supports that a standard of the preponderance of the evidence is used for
determining if 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)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 13.18 and FDJJ 1919 provide 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:
Policy 13.17 and FDJJ 1919 provide for disciplinary sanctions for staff to be up to and
including termination for violation of the sexual abuse and sexual harassment policies. The
policies require 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)
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Auditor Comments:
Policy 13.16 and FDJJ 1919 address the corrective actions regarding any contractor or
volunteer engaging in sexual abuse of residents. The incident will be reported as required as
well as relevant licensing bodies. The policies require the facility to take remedial measures
and prohibit future contact with residents in the case of any violation of the facility’s PREA
related policies by contractors or volunteers. During the past 12 months, no contractor or
volunteer has been reported to law enforcement or any investigative entity for allegations of
sexual abuse.
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:
Policy 13.24 addresses this standard. Any resident found in violation of the facility’s zero
tolerance policy against sexual abuse may be subject to disciplinary action, following a
disciplinary 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:
Policy 13.05 states that 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:
Policies 13.05 and 13.06 provide that timely 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.
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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:
Policy 13.05 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,
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:
Policy 13.25 addresses this standard. The policy will serve as the guide for staff in
conducting incident reviews. The incident review team has been identified. Staff interviews
indicated that the role of the incident review team is understood.
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:
Policy 13.30 and FDJJ 1919 require the collection of accurate, uniform data for every
allegation of sexual assault. DJJ has developed a data collection instrument that includes the
required data.
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:
Policy 13.30 and FDJJ 1919 address this standard. The Policies require the review of data for
corrective action towards improving the effectiveness of the agencies’ prevention, protection
and response policies, practices, and training.
15
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:
Policies 13.30 and FDJJ 1919 address this standard and require 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.
December 17, 2014
Auditor Signature Date
16

source: DJJ


facility_name: Okaloosa Youth Academy

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Okaloosa Youth Development Center
Physical Address: 4449 Straight Line Road, Crestview, FL 32539
Date report submitted: December 15, 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: November 19-20, 2014
Facility Information
Facility Mailing Address: 4455 Straight Line Road, Crestview, FL 32539
Telephone Number: (850) 689-1984
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention X Correction Other:
Name of PREA Compliance Manager: Denny Skinner Title: QA Officer
Email Address: denny.skinner@uhsinc.com Telephone Number:
(850) 683-3900
Agency Information
Name of Agency: Gulf Coast Youth Services, Inc.
Governing Authority or Parent Agency: Universal Health Services
Physical Address of Agency: 1015 Marwalt Drive, Fort Walton Beach, FL
3M2a5il4in7g Address: Same as Above
Telephone Number: (850) 863-4160
Agency Chief Executive Officer
Name: Jeanette Jackson Title: Chief Executive Officer
Telephone (850) 863-4160
Email Address: jeanette.jackson@uhsinc.com
Number:
Agency Wide PREA Coordinator
Name: Denny Skinner Title: QA Officer
Email Address: denny.skinner@uhsinc.com Telephone Number: ( 8 5 0 ) 6 8 3 - 3 9 0 0
1
AUDIT FINDINGS
NARRATIVE:
The Okaloosa Youth Development Center is located in Crestview, Florida and is a 49-bed facility for
male juvenile offenders in the age range of 13-19. The facility is operated by Universal Health
Services, Inc. through a contract with the Florida Department of Juvenile Justice (DJJ) to provide
treatment services for committed youth. The length of stay is from three to 12 months. While in the
facility residents participate in programming that include education and vocational services; social
services; mental health services; recreation; and transition planning.
Eighty-four staff members have been employed at the facility during the past year. On-site medical
care is provided by one Registered Nurse and two Licensed Practical Nurses. The contract physician
visits the facility weekly. Mental health services are provided on-site by the Treatment Coordinator
and four Therapists, with a contract psychiatrist visiting the facility at least every two week. The
parent agency has a Director of Nursing and a Designated Mental Health Authority on staff and they
are accessible to the facility medical and mental health personnel. Education services are provided by
teachers through the Okaloosa County School District. Case Managers ensure coordinated efforts for
individualized treatment ant transition planning begins at the time of admission.
The Okaloosa Youth Development Center is accredited by the Commission on Accreditation of
Rehabilitation Facilities (CARF). The facility serves low to moderate and high risk residents.
Twenty-four of the program beds are allocated for residents with a borderline IQ of 70-79 and 25
beds are for developmentally disabled residents with an IQ of 60-69 and are high risk. An
individualized performance plan is developed for each resident by a multi-disciplinary treatment
team.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is located approximately two miles south of Crestview, Florida in an area with other
adult and juvenile correctional facilities and a juvenile detention center. The program consists of one
main building where the front of it contains the entrance lobby; control room; administrative offices;
and the medical area. The building also contains two housing units with a dayroom in each,
classrooms, and additional offices. Each of the living units also houses a Reward Area which is
painted and designed in a very colorful manner and includes a token store; game rooms; areas to
watch movies; and a library/quiet room.
There is a kitchen and dining room area where the two groups eat separately. Bathrooms are located
in each housing unit and they provide a reasonable amount of privacy for the residents. Youth Care
Workers provide direct supervision of residents in daily activities and movement to and from
activities and services.
2
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 this Auditor, noting their locations. An initial call
was made to the Program Director to discuss the audit process and data gathering. 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 PREA Coordinator and additional information
was provided or clarified as requested. The parent agency’s Quality Assurance (QA) Officer serves
as the PREA Coordinator.
The on-site audit was conducted November 19-20, 2014. On the first day of the on-site audit an
entrance meeting was held with the Program Director. After the meeting a comprehensive tour of the
facility was conducted by the Program Director. During the tour, staff members were observed to be
directly supervising the residents. Random staff, specialized staff and residents were interviewed
during the on-site audit process.
While on-site, additional information for the audit process was provided in a prompt manner. A
close-out meeting was held at the conclusion of the on-site audit and a summary of the audit findings
was provided to the Program Director.
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 facility has various policies that provide guidelines for implementing the agency’s
approach to complying with the requirements of the PREA standards. Policy 13.00 states a
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. The Florida Department of Juvenile Justice Policy 1919 (FDJJ 1919) is also used
and adhered to for support of the PREA standards.
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:
Policy 9.010 addresses this standard and provide for the implementation of a staffing plan
with adequate staffing levels to protect residents against sexual abuse and that the ratios are
per the current program contract. The facility reported no deviations from the current staffing
plan in the past 12 months. The annual assessment of the staffing plan and other areas has
been conducted to determine whether adjustments are needed in accordance with the
standard. A review of staffing is documented through the completion of the Staffing Plan
4
Assessment form. Unannounced rounds of the facility for the maintenance of a safe
environment are conducted and documented by appropriate staff. Staff interviews 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:
Policy 9.100 prohibits cross gender pat-down searches and there have been no cross gender
pat-down searches during this audit period. The Policy also prohibits staff from conducting
cross-gender strip or cross-gender visual body cavity searches of residents and none have
been conducted during this audit period. Policies 13.09 and FDJJ 1919 have been
implemented that provide for residents to shower, perform bodily functions, and change
clothes without being observed by staff of the opposite gender. Interviews with staff and
residents confirm the aforementioned practices.
Policy 13.11 states that staff shall not search or physically examine a transgender or intersex
resident to determine the resident’s genital status. The related training and reviews have been
provided. Policy 13.10 addresses opposite gender staff announcing their presence when
entering an area where residents may be showering, changing clothes or performing bodily
functions.
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:
Policy 1.150 addresses support services for residents with disabilities and residents who are
limited English proficient so that they may benefit from and participate in PREA education.
Resident education materials are available in dominant languages other than English. Policy
1.150 provides that the facility will not rely on resident interpreters. The policy contains
information regarding the resources to be used and how they will be accessed. A review of
documentation and staff interviews confirmed that outside resources would be used to assist
residents.
5
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:
Policy 1.130, FDJJ 1800 and FDJJ 1919 provide for background checks on all employees
and contractors through a process that is aligned with the standard. 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)
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 staff supervision, a camera system is used that enables observation of
activities and areas on multiple screens. There are a total of 32 cameras that are strategically
placed and the camera software has been updated. The Program Director has access to the
camera system by desktop monitoring of activities from his office.
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:
Policy 13.18 addresses this standard and states that staff will cooperate in investigations
conducted by the FDJJ Office of the Inspector General (OIG) for administrative
investigations and with the Florida Department of Children and Families and local law
enforcement regarding criminal investigations. Policy 13.13 provides for forensic medical
examinations to be completed and at no financial cost to the victim. A review of
documentation and staff interviews confirm that forensic examinations will be conducted by
qualified medical practitioners and that staff cooperate with investigations.
6
The facility has a Memorandum of Understanding (MOU) with the Shelter House, Inc. in
Fort Walton Beach, Florida which provides victim advocacy services that include
accompaniment to forensic examinations when requested and training for staff and residents.
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:
Policy 13.27 and FDJJ 1919 provide that staff report all allegations of sexual abuse and
sexual harassment. The appropriate investigative entity will be contacted when allegations of
sexual abuse are made. There has been one allegation from a resident at this facility during
the past 12 months. The allegation was reported and was investigated by the Office of the
Inspector General. The investigative report shows that the allegations were unsubstantiated.
The DJJ website contains information regarding the referral of allegations for investigations
of sexual abuse. The facility posts related information in the visitation area which is
accessible to the public.
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:
FDJJ 1919 provides for the PREA training of all staff. The facility staff received the DJJ
training and the facility has conducted refresher training in the key areas referenced in the
standard. Documentation of staff participating in training is maintained.
Standard 115.332 Volunteer and Contractor 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:
Policy 13.04 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:
Policies 13.00, 1.150 and FDJJ 1919 address this standard. A review of documentation and
interviews with residents and staff confirm that residents receive information about the
facility’s zero-tolerance policy and how to report incidents or suspicions of sexual abuse or
sexual harassment. In the past 12 months, approximately 61 residents received the
information. Through resources identified in policy, the facility will provide support services
in accessible formats for residents who are limited English proficient, deaf, visually
impaired, or otherwise disabled.
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.
8
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 13.15 addresses PREA training for medical and mental health staff. A review of
documentation and staff interviews confirm the specialized training. 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:
Policies 13.01 and FDJJ 1919 address this standard. The screening for risk of sexual abuse
victimization or sexual abusiveness toward other residents is being conducted on each
resident. The initial screening is done during the intake process and Policy states that
residents receive reassessments periodically. Interviews with residents and staff and a review
of documentation confirmed that the screening is conducted.
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:
Policy 13.02 prohibits placing gay, bisexual, transgender, or intersex residents into
confinement based solely on such identification or status. Additionally, housing and program
assignments require determinations on each transgender or intersex resident on a case by
case basis. According to the Policy, 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 because of victimization.
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 Policies 13.22 and FDJJ 1919 and staff and resident interviews, 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 file a
grievance; complete a Youth Special Request Form where a resident identifies specific staff
he would like to talk to; write a note; talk to any staff member; and third parties may report
allegations to staff. The grievance may be placed in the locked box located in the housing
units.
PREA related information is posted in each housing unit. Residents are provided access to a
telephone to report allegations of sexual abuse and sexual harassment to the abuse reporting
hotline. The hotline number is also accessible from any office phone in the administration
area of the building. Interviews revealed that staff members are aware of their responsibility
to report sexual abuse and sexual harassment. They are also aware that they are to accept
reports of sexual abuse and sexual harassment made verbally, in writing, anonymously, and
from third parties in accordance with Policies 13.22 and FDJJ 1919.
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:
Policies 3.08 and 13.21 provide guidance about the grievance process and information is
contained in the resident handbook. Residents may put a completed grievance form in the
locked grievance box located in each housing unit. Policy prohibits the use of an informal
grievance process regarding allegations of sexual abuse and sexual harassment. The facility
reports that there have been no grievances submitted relating to sexual abuse or sexual
harassment received in the past 12 months.
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:
Policy 13.23 requires the facility to provide the residents with access to outside victim
advocacy services. The facility has a MOU with Shelter House, Inc. that provides for services
to the victim by the advocacy agency. A telephone conversation with the representative from
the victim advocacy agency confirmed that victim services will be provided. No services have
been requested.
Residents are allowed to see their parents at visitation on the weekends and they are also
allowed to make weekly phone calls. 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:
Policy 13.14 provides guidelines regarding third-party reporting. The DJJ website provides
the public with information regarding third-party reporting of abuse. Parents receive
information about reporting incidents of sexual abuse through information posted in the
visitation area.
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 Policy 1.07, DJJ 1919 and Florida Statute 39.201, all staff members are
mandated reporters. Staffs are to immediately report any knowledge, suspicion or
information they 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. Staff interviews support the policies.
11
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:
Policy 13.12 addresses this standard and provides that when the agency or facility staffs
learn that a resident is subject to substantial risk of imminent sexual abuse, immediate action
is taken to protect the resident. The facility reports that 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.
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 Policy 13.26, upon receiving an allegation that a resident was sexually abused
while confined in another facility, the Program Director/designee will notify the Central
Communications Center (CCC) of the allegation within 72 hours. The CCC notifies the
facility of which the allegation was made. Staff interviews confirmed knowledge of the
policy and procedure.
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:
Policy 13.20 and FDJJ address the first responder duties and provides an account of first
responder duties and responses. There has been one allegation by a resident regarding sexual
abuse within the last 12 months which was reported as required. The allegations were
investigated and the case closed as unsubstantiated. Initial staff training and refresher
training have been provided to staff.
12
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 PREA Institutional Plan documents the actions to be taken among staff in response to an
incident of sexual abuse. The Plan includes first responders, leadership, medical, and mental
health staffs.
Standard 115.366 Preservation of Ability to Protect Residents from Contact with 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)
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:
Policy 13.19 addresses protection against retaliation for residents and staff who report
allegations of sexual abuse or sexual harassment. The Program Director, Assistant Program
Director and shift supervisors have been identified as the staff members designated with
monitoring for possible retaliation. If the conduct is identified the Policy states that the
monitoring is ongoing. Policy 13.19 also instructs staff to report incidents of retaliation.
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:
Policy 13.29 addresses this standard and covers the requirements of how protective measures
are implemented. The protective measures do not include the isolation of residents; however,
the resident may be transferred to another room and/or housing unit. The resident will be
separated from potential abusers, according to the policy and staff interviews.
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:
Policy 13.18 and FDJJ 1919 address this standard. Administrative investigations are
conducted by the DJJ Office of Inspector General and criminal investigations are conducted
by the Department of Children and Families and local law enforcement. 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 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:
Policy 13.28 supports that a standard of the preponderance of the evidence is used for
determining if 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:
Policy 13.18 and FDJJ 1919 guide staff regarding the process for notifying residents as a
result of an investigation, of whether an allegation has been determined to be substantiated,
unsubstantiated, or unfounded. Staff confirmed awareness of the policy.
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:
Policy 13.17 and FDJJ 1919 provide for disciplinary sanctions for staff to be up to and
including termination for violation of the sexual abuse and sexual harassment policies. The
policies require 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:
Policy 13.16 and FDJJ 1919 address the standard, indicating that an incident regarding sexual
abuse by a contractor or volunteer will be reported as required as well as relevant licensing
bodies. The policies require the facility to take remedial measures and prohibit 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:
Policy 13.24 addresses this standard. Any resident found in violation of the facility’s zero
tolerance policy against sexual abuse may be subject to disciplinary action, following a
disciplinary process. The resident may be transferred to another facility following an
administrative or criminal finding 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:
Policy 13.05 states that 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:
Policies 13.05 and 13.06 address this standard. Timely 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.
16
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:
Policy 13.05 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,
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:
Policy 13.25 addresses this standard. The policy will serve as the guide for staff in
conducting incident reviews. The incident review team has been identified. Staff interviews
indicated that the role of the incident review team is understood.
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:
Policy 13.30 and FDJJ 1919 require the collection of accurate, uniform data for every
allegation of sexual assault. DJJ has developed a data collection instrument that includes the
required 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:
Policies 13.30 and FDJJ 1919 support this standard. The Policies require the review of data
for corrective action towards improving the effectiveness of the agencies’ 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:
Policies 13.30 and FDJJ 1919 require 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.
December 15, 2014
Auditor Signature Date
18

report_type: PREA

program_name_raw: okaloosa youth development center


summary: PREA - Year 1 Cycle 4

raw_content:
Program: Okaloosa Youth Academy
Report Type: PREA
Fiscal Year:
Status:
PDF URL: https://www.djj.state.fl.us/content/download/706130/file/Florida_Okaloosa Youth Academy_year1cycle4.pdf?version=1

program_name_raw: Okaloosa Youth Academy

cycle: Year 1 Cycle 4


summary: SPEP - FY15-16

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Okaloosa Youth Academy
Gulf Coast Youth Services, Inc.
(Contract Provider)
4445 Straightline Road
Crestview, Florida 32539
Primary Service: Seven Challenges
SPEP Review Date(s): July 13-17, 2015
Florida Department of Juvenile Justice
Report Date(s): 11/4/2015
Introduction
The Standardized Program Evaluation Protocol (SPEP) is an assessment tool derived from
meta-analytic research on the effectiveness of juvenile justice interventions. The tool is
designed to compare existing intervention services, as implemented in the field, to the
characteristics of the most effective intervention services found in the research.
The SPEP scoring system allows service providers to identify specific areas in which program
improvements can be made to their existing Primary Services. These improvements can be
expected to increase the effectiveness of those Primary Services in the reduction of recidivism
for youth receiving the Primary Service. A separate SPEP evaluation is conducted, at the time
of the program’s Quality Improvement Review, for each Primary Service provided by the
program.
This report provides two types of SPEP scores: a Basic Score, equivalent to the number of
points received, and a Program Optimization Score (POS) that is equivalent to the maximum
number of possible points that could be received based on the SPEP domains under the control
of the program. The Basic Score compares the Primary Service being evaluated to other
intervention services found in the research to be effective, regardless of service type. It is meant
as a reference to the expected overall recidivism reduction when compared to other Primary
Services of any Type.
A Program Optimization Percentage (POP) rate is derived from the Basic Score and Program
Optimization Score. The POP rate is a percentage score that indicates where the rate of
effectiveness of the Primary Service is when compared to its potential effectiveness if optimized
to match the characteristics of similar Primary Services found to be most effective in the
research. The POP rate is likely more meaningful to service providers as it represents how
close the program’s Primary Service is to its potential for that Primary Service Type. For
example, a POP rate of 55% would indicate that the program’s Primary Service is operating at
55% of its potential effectiveness for recidivism reduction that has been found for a similar
Primary Service Type with research evidence of effectiveness.
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Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report
Program Name: Okaloosa Youth Academy QI Program Code: 1160
Provider Name: Gulf Coast Youth Services, Inc. Contract Number: R2073
Location: Okaloosa County / Circuit: 1 Number of Beds: 60
Review Date(s): July 13-17, 2015 Lead Reviewer Code: 128
Persons Interviewed
Program Director Corporate QI/QA staff 2 # Program Supervisors
DJJ Monitor 3 # Case Managers 5 # Youth
DHA or designee 4 # Clinical Staff # Other (listed by title):
DMHCA or designee 2 # Healthcare Staff
Documents Reviewed
Written Protocol/Manual Logbooks 5 # Personnel Records
Fidelity Monitoring Documents Program Schedules 5 # Training Records/CORE
Internal Corrective Action Reports Supplemental Contracts 3 # Youth Records (Closed)
Staff Evaluations Table of Organization 5 # Youth Records (Open)
Accreditation Reports Youth Handbook # Other:
Contract Monitoring Reports 5 # Health Records
Contract Scope of Services 5 # MH/SA Records
Observations During Review
Group/Session of Primary Service(s)
Program Activities
Recreation
Social Skill Modeling by Staff
Staff Interactions with Youth
Staff Supervision of Youth
Transition/Exit Conferences
Treatment Team Meetings
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Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report
Basic Score: 30 Points
1. Primary Service and Supplemental Service Types POS: 30 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Seven Challenges. The program was awarded 25 points
because the Primary Service is identified as a Group 4 Service. The specific Sub-Component
Service Type identified is Group Counseling. The Primary Service was identified as this type of
service as it focuses on psychological or interpersonal problems or issues faced by an individual
and involves a group of youths interacting with each other.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated by the Bureau of Monitoring and Quality Improvement while
on-site during the annual compliance review.
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Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report
Basic Score: 20 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 100%
The Quality of Service Delivery Score is the sum of the scores for the seven treatment quality
indicators. The Program Optimization Percentage Rating determines the Overall Quality of
Service Level:
Indicator Sum Score 0-3 = Low; Sum Score 4-7 = Medium; Sum Score 8-10 = High.
Sum of all Indicator Scores (a – g below): 10 Points
Overall Quality of Service Delivery Level:
Low (Raw Score = 5)
Medium (Raw Score = 10)
High (Raw Score = 20 Points)
Basic Score: 1 Point(s)
a. Facilitator Training
Maximum Possible Score: 1 Point
All facilitator(s) of the Primary Service must have received formal training specific to the
intervention or model/protocol.
The two facilitators of Seven Challenges both received formal training in the intervention. Both
facilitators were trained by qualified trainers.
Basic Score: 2 Point(s)
b. Treatment Manual/Protocol
Maximum Possible Score: 2 Points
There is a specific written manual/protocol detailing delivery of the Primary Service.
The facilitators use the Seven Challenges manual. The manual consists of worksheets and
detailed lesson plans. Each group session has an introduction, guided group activity, worksheets,
and a conclusion/wrap-up.
Basic Score: 1 Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
A group session was observed. The facilitator was observed following the manual throughout the
delivery of the session.
Basic Score: 2 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
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Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report
The program has not had any turnover in the facilitators of Seven Challenges or gaps in the
service delivery for the Standardized Program Evaluation Protocol (SPEP) period evaluated.
Basic Score: 2 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
The lead mental health therapist conducts the fidelity monitoring and received the required
training for Seven Challenges. Fidelity monitoring occurs every month.
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
There was no corrective action required, however the facility has a process in place to address
corrections needed if identified.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
The annual evaluation of the facilitators was specific to Seven Challenges and did not note any
issues regarding performance.
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Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report
3. Amount of Service - Duration
Basic Score: 0 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 0%
Research indicates the target duration of 24 weeks for this type of service. Of the 32 youth in the
sample, 3% (1 of 32) reached at least the indicated target duration. Further explanation is detailed
in the Summary and Recommendations below.
Note: Dosage information (duration) is calculated from the Juvenile Justice Information System
(JJIS) Evidence-Based Services module. Duration is included for the youth in the SPEP sample.
4. Amount of Service – Contact Hours
Basic Score: 6 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 60%
Research indicates a target of 40 contact hours for this type of service. Of the 32 youth in the
sample, 66% (21 of 32) reached the indicated target contact hours. Further explanation is detailed
in the Summary and Recommendations below.
Note: Dosage information (contact hours) is calculated from the Juvenile Justice Information
System (JJIS) Evidence-Based Services module. Contact hours are included for the youth in the
SPEP sample.
5. Risk Level of Youth Served:
Basic Score: 23 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 92%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 94%
Moderate to High Score: 10 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 83%
Table 1
Moderate = 6 youth
Moderate-High = 12 youth
High = 12 youth
Total Youth in Sample = 32 youth
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Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report
Percentage of Youth with High-Risk Level to Reoffend: 38%
High Score: 13 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 100%
Table 2
High = 12 youth
Total Youth in Sample = 32 youth
The risk level score is compiled by calculating the total percent of the SPEP sample that score
Moderate to High-Risk to reoffend and also the total percent of the SPEP sample that score High-
Risk to reoffend.
Of the SPEP sample, 94% (30 of 32) youth scored Moderate to High-Risk to reoffend, for a score
of 10 points.
Of the SPEP sample, 38% (12 of 32) youth scored High-Risk to reoffend, for a score of 13 points.
Note: The latest Community Positive Achievement Change Tool (C-PACT) prior to the placement
date was used in the derivation of the risk level score. This C-PACT provides the best indication
of the risk to re-offend level of the youth when the youth was first placed in the program.
Summary and Recommendations
Program Program
Category Basic Score Optimization Optimization
Score Percentage
Primary and Supplemental Service Type 30 30 100%
Quality of Service Delivery 20 20 100%
Amount of Service: Duration 0 10 0%
Amount of Service: Contact Hours 6 10 60%
Risk Level of Youth Served 23 25 92%
Totals 79 95 83%
This SPEP report evaluates Seven Challenges, an intervention delivered at Okaloosa Youth
Academy.
The program scored High for Quality of Service Delivery.
The program earned 0 points for Amount of Service: Duration. The targeted number of weeks for
this type of intervention is 24 weeks. Of the 32 total youth sampled, only 2 had dosage recorded
in EBS with end dates. Of 2 youth with dosage, 1 received at least the recommended weeks of
service. The 2 youth completed 20 and 32 weeks of service, respectively.
The program earned 6 points for Amount of Service: Contact Hours. The targeted number of
hours for this type of intervention is 40 hours. Of the 32 total youth sampled, only 31 had dosage
recorded in EBS. Of 31 youth with dosage, 21 received at least the recommended hours of
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Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report
service. Youth in the sample completed between 26 and 100 hours of service, with an average of
52 hours.
The program was awarded 23 available points for Risk Level of Youth Served. This is calculated
using data from the Community - Positive Achievement Change Tool (C-PACT) assessment. This
score reflects youths' most recent C-PACT score prior to placement at the program. The program
itself has no control over youths' C-PACT risk level because the scored assessment was
administered prior to the youths' admission.
RECOMMENDATION(S):
Okaloosa Youth Academy can maintain their SPEP Quality of Service Delivery score by
continuing the processes in place at the time of this review. The program should have a plan in
place to address turnover should that become an issue.
Okaloosa Youth Academy can optimize their SPEP Amount of Service score by ensuring that
dosage for all youth is recorded accurately in EBS and by ensuring that youth receive the full
targeted dosage of service.
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Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report

report_type: SPEP

program_status_note: Open

service_type: Seven Challenges