state: FL

facility_name: martin's girls academy

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: Martin Girls Academy
Physical Address: 800 SE Monterey Road, Stuart, FL 34994
Date report submitted: March 31, 2016
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: March 7, 2016
Facility Information
Facility Mailing Address: 2336 SE Ocean Blvd., Ste. 362, Stuart, FL 34996
Telephone Number: 772-233-4406
The Facility is: Military County Federal
X Private for profit Municipal State
Private not for profit
Facility Type: Detention Corrections X Other: Residential
Name of PREA Compliance Manager: Anne W. Posey Title: Facility Administrator
Email Address: anne.posey@us.g4s.com Telephone Number:
772-233-4406
ext.101
Agency Information
Name of Agency: G4S Youth Services
Governing Authority or
Parent Agency:
Physical Address: 6302 Benjamin Road, Suite 400, Tampa, FL 33634
Mailing Address: Same as Physical Address
Telephone Number: 813-514-6275
Agency Chief Executive Officer
Name: James C. Hill, Jr. Title: President
Email Address: jim.hill@us.g4s.com Telephone Number: 8 1 3 - 5 1 4 - 6 2 7 5
Agency Wide PREA Coordinator
Name: Bobbi Pohlman-Rodgers Title: Senior Director of JJDPA/PREA Compliance
954-818-5131
Email Address: bobbi.pohlman@us.g4s.com Telephone Number:
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AUDIT FINDINGS
NARRATIVE:
Martin Girls Academy is a 30-bed intensive mental health residential program for female juvenile
offenders who have been committed to the Florida Department of Juvenile Justice (FDJJ) and are
classified as high or maximum risk. The facility is located in Stuart, Florida and is operated by G4S
Youth Services through a contract with FDJJ. Mental health and substance abuse treatment services
are available to all residents who are determined to meet clinical criteria to receive such services. All
youth referred to the program are pre-screened by FDJJ based on their individualized history and
identified needs. The facility serves residents ranging from 13 to 21 years of age. The length of stay
is from 9-12 months for high risk residents and 18-36 months for maximum risk residents. The
facility is accredited by the Commission on Accreditation of Rehabilitative Facilities (CARF).
Medical and mental health screenings are conducted during the intake process and on-going services
are provided throughout the resident’s stay in the facility. Medical services are provided by the
Health Services Administrator, two other Registered Nurses, and there is also the service of a
Registered Nurse who works in the medical clinic on an as-needed basis. A pediatrician visits the
facility weekly. Mental health services are provided by the Clinical Director; Assistant Clinical
Director; two Therapists; Certified Behavior Analyst; Certified Addiction Professional; and
Recreation Therapist. A psychiatrist and a psychologist are on-site weekly. Academic and career
education services are provided through a contract with the Martin County School District. The
academic courses offered are English; Mathematics; Science; Social Studies; and Reading. Career
and technical services include business education courses. Residents are also provided case
management, social and transition services.
The Martin Girls Academy program addresses youth trauma utilizing an evidenced-based model
which also teaches practical skills to enable youth to gain control of Post-Traumatic Stress Disorder
(PTSD) symptoms. The goal of the program is to provide a nurturing culture that validates the unique
quality of each female. Residents receive individual, group and family therapy; testing; and
psychiatric evaluation services. A behavior management system exist where a resident may earn
advancing levels through earning points for demonstrating positive behavior.
DESCRIPTION OF FACILITY CHARACTERISTICS:
There are two primary buildings that house the program. The entrance of the main building contains a
reception area and includes the Facility Administrator’s office. Beyond the entrance is the locked
area where the dining room is located and which also contains an area reserved for group meetings.
Located in this area of the building are offices; group room 1; group room 2; master control; and the
medical clinic. Beyond this section of the building is the hall that contains the residents’ rooms,
shower area and two controlled observation rooms. The canteen, referred to as the Boutique, is also
contained in this area and is stocked with items that can be purchased by residents with their earned
positive behavior points. The education building contains three classrooms and offices. Cameras are
installed in the facility and can be monitored from master control and the offices of the Facility
Administrator and the Assistant Facility Administrator.
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The facility procedures and practices provide residents with a reasonable amount of privacy during
showers, while using the toilet, and when changing clothes. PREA related information is posted in
various areas of the facility and the telephone for abuse reporting is mounted on the wall in the
hallway of the living area. The outside grounds contain a recreation yard where residents may play
basketball, kickball, volleyball, soccer and engage in other recreation activities. A pavilion is
adjacent to the outside recreation area. The Martin County School District provides breakfast and
lunch and other meals are prepared and delivered by a caterer.
The designed facility capacity is 30 and there were 26 residents in the facility during the on-site visit.
The number of residents admitted to the facility during the past 12 months is 24. The number of staff
employed at the facility during the past 12 months is 58 and there were 32 staff members hired
during the last 12 months who may have contact with residents.
SUMMARY OF AUDIT FINDINGS:
An introductory telephone conference call was held prior to the site visit and the audit process was
discussed with facility staff and the FDJJ statewide PREA Coordinator. The notifications of the on-
site audit were posted in the facility prior to the site visit and pictures of the postings were
forwarded to this Auditor and the locations of the postings were identified. The Pre-Audit
Questionnaire was uploaded to a flash drive with policies and supporting documentation and was
received prior to the site visit. There was follow-up communication with the Facility Administrator
who also serves as the PREA Compliance Manager; additional documentation was requested and
provided and information was clarified.
The on-site audit was conducted March 7, 2016. Introductions were conducted and a comprehensive
tour of the facility was provided by one of the residents and the Facility Administrator. The resident
was articulate and knowledgeable about the program services, rules and activities. During the tour,
staff members were observed to be providing direct and engaged supervision to the residents.
Randomly selected residents and randomly selected staff members from all shifts were interviewed.
Specialized interviews were conducted which included a telephone interview with a volunteer.
During the on-site visit, additional documentation was provided as requested. A close-out meeting
was held at the conclusion of the site visit. The G4S Senior Regional Director was present at the
facility during the site visit.
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’s Policy and Procedure 10-25, Prison Rape Elimination Act (PREA) and Policy
1919 of the Florida Department of Juvenile Justice (FDJJ 1919) are aligned and jointly serve
as the guide for PREA compliance. The facility’s PREA Policy provides that the facility is
contractually obligated to adopt and comply with the PREA standards outlined in FDJJ 1919.
The policies include the strategies for implementing the zero-tolerance of all forms of sexual
abuse and sexual harassment. The Policies contain definitions of prohibited behaviors and
sanctions for those found to have participated in the prohibited behaviors.
Policy 10-25 states that the Facility Administrator or a person designated by the G4S Regional
Director serves as the PREA Compliance Manager. The interview with the Facility
Administrator and a review of the organizational chart confirmed that the Facility
Administrator (FA) manages the facility and serves as the PREA Compliance Manager. The
FA stated that there is sufficient time and she has the authority to implement and coordinate
the activities related to PREA compliance. The FA in the capacity of the PREA Compliance
Manager reports to the G4S Senior Regional Director regarding the implementation 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)
Auditor Comments:
This standard is not applicable. The facility does not contract with other facilities for the
confinement of its 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)
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Auditor Comments:
Policies 10-25 and 10-8; the staffing plan; and the practice of periodic internal management
reviews of the staffing schedule, ensure adequate levels of staffing for all shifts. According to
documents reviewed, staff interviews, and observations, the staffing ratio is at least 1:5
during the awake hours and 1:6 during the sleeping hours. The agency has a hold-over
process that ensures compliance with the staffing plan and reports no deviations from the
staffing plan. The staffing plan document requires that deviations from the plan are to be
documented on the shift reports and in the logbook. The facility reports that the average daily
number of residents in which the staffing plan was predicated is 30.
A Staffing Plan Assessment was reviewed which was completed by the FDJJ statewide
PREA Coordinator and includes a review of the items listed in the standard and other related
areas of facility operations. The Staffing Plan Assessment contains a review of the staffing
plan; staffing patterns; deployment of cameras; unannounced rounds; operating procedures;
and other factors that contribute to maintaining compliance with the staffing plan and the
PREA standard.
Policy 10-25 provides that the Administrative Duty Officer conducts unannounced rounds at
least once a month and that the visits are documented. The Administrative Duty Officer
(ADO) completes the Youth Services Administrator on Duty Report which instructs the ADO
to, among other duties, “conduct a PREA walk through of all youth areas and interact with
the youth and staff.” The form provides for the notation of related concerns, deficiencies, and
any observations that would be classified as a risk. A review of documentation and an
interview with the Assistant Facility Administrator (AFA) confirmed that unannounced
rounds occur and that she participates in them. The PREA Policies prohibit staff from alerting
other staff of the occurrence of the unannounced visits and the practices of the AFA support
the Policies.
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 10-3 addresses this standard and is supported by staff and resident interviews and
observations. Staff members and residents shared that cross-gender pat-down searches and
cross-gender strip searches are not conducted at this facility. Policy 10-3 addresses staff
conducting searches of residents and provides the details of each type search and requires
documentation of the searches. Although the practice of the facility is that cross-gender
searches are not conducted, Policy 10-3 does provides for when a male staff may assist a
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female staff by acting as a second person in the search area, observing the staff, while not
viewing the resident. The Policy requires that in these circumstances, the reason for the
opposite gender assisting in the search must be authorized by the Facility Administrator and
the reason for the search documented.
Staff interviews revealed that training and discussions regarding the searches of all residents
include that they are done in a professional and respectful manner as also directed in policy.
Direct care staff interviews indicated that they are aware of the requirement of Policy 8-14,
where transgender or intersex residents are not to be searched or physically examined for the
sole purpose of determining their genital status. They further revealed that no such searches
occurred during this audit period.
Policy 10-25, resident and staff interviews, and observations of the demonstrated shower
procedures provide that residents are able to shower, use the toilet, and change clothes without
being viewed by male staff and that male staff members do not supervise those activities. The
residents are provided with a cloth that serves as a shade that they may place in the window to
their room door when a little more privacy is temporarily needed. This practice was also
demonstrated to this auditor by the resident tour guide. All residents and staff interviewed
confirmed that male staff follow the prompting of the observed posted signs and announce
their presence when entering the 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:
According to Policy 10-25 disabled residents are provided equal opportunity to participate in
or benefit from resident education to protect them from sexual abuse and sexual harassment.
Policies 10-25 and FDJJ 1919 require that residents are not to be used as interpreters or
readers, unless in limited circumstances where an extended delay in obtaining an interpreter
could compromise the resident’s safety, the performance of the first responder duties, or the
investigation of the resident’s allegation. The facility may use the Registry of Certified Court
Interpreters as a resource, as well as other G4S staff members who may serve as interpreters.
The facility provides an extensive list of internal interpreters which identifies the G4S facility
the staff member works in and other contact information as well as the language for which
they may provide interpreter services.
The list for the external interpreters, Registry of Certified Court Interpreters, is composed of
several pages that contain the contact information as well as the language specialty. Contact
information for American Sign Language interpreters is also included in the lists of external
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interpreters. The lists of interpreters are available to shift supervisors. The staff interview
responses were that other staff would be used as interpreters or outside resources would be
contacted and that residents are not used as interpreters for other 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:
Hiring and promoting practices are addressed in Policies 3-16, FDJJ 1800 and FDJJ 1919
regarding hiring or promoting anyone who has engaged in sexual abuse in a jail, lockup or
similar facility; has been convicted of engaging or attempting to engage in coerced or forced
sexual activity; or has been adjudicated for any of the aforementioned activities. The Policies
prohibit hiring, promoting or contracting with anyone who has been convicted of engaging in
any activity prohibited by the standard and it provides directions regarding background
checks and screenings. Any incident of sexual harassment is considered regarding the hiring
or promotion of anyone.
Compliance was determined through the review of policies, a random sample of personnel
files and an interview with the Regional Human Services Manager. The review of the sample
of personnel files revealed that they include background checks; signed acknowledgement
forms regarding PREA related issues and information received. The staff interview also
revealed that hiring and promotion decisions are based on background information obtained
and according to the considerations required by the standards. The policies provide that the
omission of information regarding misconduct is grounds for termination of employment.
The Regional Human Services Manager confirmed the hiring and background checks
processes; knowledge of the PREA requirements in the area of personnel; and that it is the
employee’s continuous duty to disclose any related misconduct within 24 hours.
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
In addition to direct supervision, a camera system is used to support the monitoring of
residents that can be monitored from main control. The video monitoring system was
upgraded during the past year. The Facility Administrator and the Assistant Facility
Administrator have the capability to monitor the cameras from their offices. Observations and
interviews confirmed that monitoring technology is used in support of direct and engaged
supervision.
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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:
Policies 10-25 and FDJJ 1919 and staff interviews provide that the facility is not responsible
for conducting administrative or criminal investigations. According to FDJJ 1919 and 10-25,
the FDJJ Office of the Inspector General is responsible for conducting administrative
investigations; the Florida Department of Children and Families is responsible for conducting
allegations of child abuse; and local law enforcement is responsible for conducting criminal
investigations. The Facility Administrator has obtained and is familiar with the FDJJ written
document that contains information regarding PREA related investigations and
comprehensive uniform evidence protocols that is to be shared with law enforcement
personnel prior to an investigation.
The facility has provided for victim services, at no cost to the victim, through entering a
Memorandum of Understanding (MOU) with the Sexual Assault Assistance Program of the
Treasure Coast. Services agreed to be provided are aligned with the PREA standards and
include but are not limited to forensic examinations conducted by a Sexual Assault Nurse
Examiner; access to a 24/7 hotline; confidential emotional support services; referral
information; follow-up directives for follow-up care at the facility’s medical clinic. The
MOA provides that a victim advocate will accompany the victim through the forensic
medical examination, conducted at the Martin Memorial North emergency room.
A telephone interview with the Victim Services Director for the State Attorney’s Office and
the Sexual Assault Program Assistance Program of the Treasure Coast confirmed the content
of the MOU and that advocacy services and access to a Sexual Assault Nurse Examiner will
be provided to a victim when requested. There have been no forensic examinations
conducted during this audit period. The Sexual Assault Assistance Program of the Treasure
Coast provides the facility with posters and literature. Prior to entering the agreement with
the advocacy agency, the facility identified a qualified staff member, the Assistant Clinical
Director, to provide supportive services to alleged victims of sexual abuse.
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)
8
Auditor Comments:
Policies 10-25; FDJJ 1919; FDJJ 2020; document review; and staff interviews support that an
administrative or criminal investigation is completed for all allegations of sexual abuse and
sexual harassment. The Policies identify the entity responsible for conducting the criminal
and administrative investigations and instructs staff to cooperate with investigations. During
this audit period there was one investigation conducted by the Martin County Sheriff’s Office
and the allegations were determined to be unfounded. Two other allegations that were alleged
prior to this audit period are included on the July 2014-June 2015 PREA Incident Reports
document. One of these was investigated by the FDJJ Office of the Inspector General (OIG)
and was determined to be unfounded. The other one was investigated by the Martin County
Sheriff’s Office and the OIG; the youth was subsequently charged with sexual assault and
was removed from the facility. One resident disclosed to her Therapist regarding an incident
that occurred while she was in the community; the Department of Children and Families was
contacted and followed up regarding the allegations.
The Florida Department of Juvenile Justice website contains the policy regarding reporting
allegations of sexual abuse and sexual harassment. The OIG follows unit specific policy in
conducting administrative investigations. Additionally, the facility provides parents/guardians
and visitors with information regarding how they, as well as the residents, may report
allegations of sexual abuse and sexual harassment allegations. Staff interviews support policy
and the practice that all referrals of allegations for investigations are documented.
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:
Employee training is addressed in Policies 5-1 and 5-2. Staff interviews and a review of the
Staff Development & Training-SkillPro System Comprehensive Report and other training
documents confirmed the training as required by the standard and include the zero-tolerance
policies. Documents and staff interviews also support that PREA refresher training is
provided at least annually as reported. The training is tailored to the needs of the population
served and staff members have received training as required by the standard. There is
documentation of the receipt of PREA training and the PREA training materials. Florida DJJ
provides on-line training and the facility’s agency training and updates are also provided
regarding specific areas of the standards.
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)
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Auditor Comments:
FDJJ 1919, a review of the training document, and other training documentation support the
PREA education for volunteers and contractors. The volunteers and contractors receive
training on their responsibilities regarding the zero-tolerance of sexual assault and sexual
harassment and how to report any allegations or incidents. Interviews with the Facility
Administrator and a volunteer, by telephone, confirmed that the training occurs. The
volunteer that was interviewed provided an overview of the content of the training.
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:
According to Policy 10-25, resident and staff interviews, and a review of documentation
acknowledging resident participation in PREA education sessions, all residents are provided
age-appropriate PREA information during the intake process. All residents receive PREA
education regardless if they are transferring from another facility or are a new admission and
the facility policy addresses retaliation if a resident should report an allegation from a former
facility or the current one.
Staff members may assist with the PREA education for residents that are limited English
proficient, visually impaired, otherwise disabled, or have limited reading skills. Additional
support services may be obtained from the Registry of Certified Court Interpreters, Florida
Registry of Interpreters for the Deaf, and staff members that work at other G4S facilities. The
PREA information is posted within the facility and program handbooks remain available to
all residents.
Interviews revealed that residents were lacking in their awareness of the specific services that
may be provided if needed and the confidentiality practices of the victim advocacy agency. A
corrective action plan was implemented, after the on-site visit, and a PREA education session
was scheduled where the specific services and confidentiality practice of The Sexual Assault
Assistance Program were reviewed with the residents. The Facility Administrator forwarded
the education roster containing each resident’s signature, date and title of the training. The
Facility Administrator also provided information regarding additional related training that is
planned for 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)
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Auditor Comments:
The facility staff members do not conduct administrative or criminal investigations. Staff
interviews confirmed that they are aware of the investigative agencies responsible for
investigating PREA related allegations. Florida DJJ Policy addresses the training of the Office
of the Inspector General Investigators, including the related policies and procedures regarding
the handling of sexual misconduct incidents and reports. Appropriate training is provided to
investigative staff regarding conducting investigations in FDJJ settings. The Facility
Administrator has the information sheet, disseminated by FDJJ, regarding appropriate
protocols for PREA investigations that is to be shared with local law enforcement
investigators.
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:
FDJJ 1919 and facility Policies 5-1 and 5-2 address staff training. The medical and mental
health staff members have received the training developed for those areas, as well as the
initial PREA training. The specialized training is developed by FDJJ and is accessible to
medical and mental health staffs online and is documented through the Staff Development &
Training SkillPro System. The medical and mental health staff members interviewed
indicated completion of the specialized PREA modules. The 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:
Policies 9-1, 9-3, 10-25, 8-14, and FDJJ 1919 provide that all youth admitted to the facility
are properly screened. Staff and resident interviews and a review of documentation confirmed
that residents are also screened for risk of victimization and abusiveness. This vulnerability
screening occurs within 24 hours of intake, whether the youth is transferred from another
facility or is a new admission. The screening is conducted using the FDJJ objective
instrument, Screening for Vulnerability to Victimization and Sexuality Aggressive Behavior
(VSAB). The VSAB is used to obtain the information required by the standard, including but
not limited to prior sexual victimization or abusiveness; the youth’s self-identification;
current charges and offense history; intellectual or developmental disabilities. The residents
and the staff responsible for administering the screening stated that it occurs the same day of
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admission; a review of VSABS support that this is the practice.
The facility reports that all residents admitted to the facility within the past 12 months
received the VSAB screening which, according to staff, is administered through asking
questions; probing where needed; talking to parents or guardians; and reviewing related
paperwork. Additional screening and assessment tools are used to obtain information to aid
staff in meeting the individual needs of the residents. Interviews revealed that reassessment
screenings are conducted as needed on a formal basis and on an informal basis through
resident meetings with treatment staff. The information from the risk screening is accessible
to the clinical staff and the files were observed to be maintained in a confidential manner.
The residents interviewed were able to identify specific areas that are inquired about in the
administration of the VSAB and similar questions related to safety.
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:
Policies 8-14, 9-3 and FDJJ 1919 address this standard and provide guidance to staff
regarding the information from the VSAB and other risk screening instruments and outline
how the information is to be used. The information gleaned from the screening instruments
assists in determining bed, education and other program assignments with the goal of keeping
all residents safe and meeting individual needs.
There has not been a resident placed in isolation or controlled observation during this audit
period due to concern for their safety from sexual assault. The Facility Administrator shared
that the controlled observation rooms would not be used for protective custody regarding the
risk of sexual abuse but are used for brief periods for a resident to calm down and re-gain
control of acting-out behavior. According to Policy 10-14, control observation may be used in
response to a dangerous crisis situation when staff cannot control highly aggressive and
violent behavior with less restrictive measures, or when less restrictive measures are
inappropriate.
During the on-site visit, a resident was observed in one of the controlled observation rooms
and sight and sound supervision was provided with staff posted at the door and recording
safety checks at least every 15 minutes in accordance with Policy 10-14. The resident was in
the room for a short duration and staff interviews revealed that time in the controlled
observation room does not interfere with the residents being afforded their rights and are
visited by clinical staff.
Policy 8-14 prohibits placing lesbian, bisexual, transgender, or intersex residents in specific
housing or making other assignments solely based on how the residents identify or their
status. The Policy also prohibits staff from considering the identification as an indicator that
these residents may be sexually abusive. Facility policies and staff interviews support that
housing and program assignments for transgender or intersex residents are made on a case-
by-case basis. The staff members are aware of the policies and practices that would be
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implemented when there are transgender or intersex residents within the resident population.
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:
Policies 8-3, 10-25 and FDJJ 1919 and practice address this standard and provide multiple
internal ways a resident may report, including how she can privately report: sexual abuse and
sexual harassment; retaliation for reporting; and staff neglect or violations of responsibilities
that may lead to the aforementioned incidents. Residents may report allegations of sexual
abuse or sexual harassment by telephone, using the FDJJ abuse hotline phone located on the
living unit and other phones utilizing the 800 numbers for the abuse hotline and the victim
advocacy agency. Staff may also use the abuse hotline to privately report sexual abuse and
sexual harassment of residents.
There are additional internal ways a resident may report, such as completing a grievance
form; talk to any staff member; complete a “Chatty Cathy” Form requesting to speak to a
specific staff member; complete a Sick Call Request; and third parties may report allegations.
Access to writing tools is provided for residents so that they are able to complete the forms.
Resident and staff interviews revealed their awareness of the methods a resident may report
allegations.
Staff and residents are aware of policy and practice regarding accepting reports of allegations
of sexual abuse and sexual harassment that are made verbally, in writing, anonymous, and by
third-parties. All residents interviewed stated that they have contact with someone who does
not work at the facility and could report abuse to that person if needed. Policies and staff
interviews support that staff members are required to document verbal reports and to report
the information immediately to their supervisor and it is relayed to the Central
Communications Center. Staff receives this information on how to report through policies
and procedures, training, and posted information.
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)
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Auditor Comments:
FDJJ 1919 and facility practice provide that grievances regarding sexual abuse or sexual
harassment may be completed and submitted at any time and may be placed in the locked
grievance box. The resident is not required to handle an emergency grievance informally by
attempting to resolve the situation with staff. During the past 12 months, there has not been a
grievance submitted alleging sexual abuse.
When a grievance is received regarding sexual abuse or sexual harassment, it is immediately
provided to the Facility Administrator. The policies and procedures for reporting allegations
of sexual abuse or sexual harassment are initiated and a report is made as required by policy.
The grievance system does not include a process for facility staff to investigate or resolve
allegations of sexual abuse or sexual harassment. The content of the grievance is reported
and an investigation may be conducted by the FDJJ Office of Inspector General, Florida
Department of Children and Families or local law enforcement. The purpose of the
submission of a PREA related grievance provides residents and staff another avenue for
ensuring the reporting of allegations and provides management staff with the opportunity to
protect the resident.
Policy 10-25 provides staff with the required information for reporting sexual abuse and
sexual harassment of residents. The facility and agency policies provide that a resident may
be disciplined when it has been determined that a report alleging sexual abuse has been made
in bad faith. Residents understand that they will not be punished if a report is made in good
faith. The residents and staff interviewed identified the grievance system as one of the
methods that may be used to report allegations of abuse and the residents are aware of how
grievances are handled regarding sexual abuse or sexual harassment.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 10-25 addresses this standard and requires that the Facility Administrator ensures
accessibility of residents to an outside victim advocacy agency for emotional support services.
The details of the MOU for the provision of victim support services were recently completed
and a written document was signed. The details of the support services had not yet been
thoroughly reviewed with the residents prior to the site visit. A corrective action was planned
during the on-site visit and was implemented afterwards for a PREA education session to be
conducted with all residents regarding a review of the specific services and the confidentiality
practice of the Sexual Assault Assistance Program of the Treasure Coast, based on the
materials received from the agency and the MOU. A roster has been submitted indicating
completion of the PREA education refresher session. The training roster contained signatures
of the residents, date, and title of the specific PREA education session. Additionally, the
Facility Administrator informed this Auditor that she has made arrangements for another
14
community agency, who serves victims of sexual violence, to speak to the residents regarding
the services they offer and a Sexual Assault Forensic Examiner has agreed to speak to the
residents about how a forensic examination takes place.
Interviews with staff and residents revealed that residents are afforded reasonable privacy
regarding reporting allegations of sexual abuse. This practice will continue during any
instance where a resident may contact the Sexual Assault Assistance Program. The reporting
information was observed on postings in the facility which included how to contact the
advocacy agency for services. The MOU includes how services will be provided to victims in
a confidential manner. Services to be provided that are contained in the MOU were confirmed
through a telephone interview with a representative of the advocacy agency. In addition to
other support services, the agency will provide residents with an advocate to be present during
the forensic examination and provide a Sexual Assault Nurse Examiner to conduct the
examination. According to policy and residents’ interviews, the facility provides residents
with reasonable and confidential access to court workers and their Probation Officers. A
review of Policy and other documentation and according to resident interviews, reasonable
access to parents or legal guardians is provided. All residents interviewed were aware of the
visitation days, weekly phone calls, and the Family Day. Family Day is held at the facility
once a quarter.
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:
Policies 8-3 and 10-25 address third-party reporting and interviews revealed that residents are
aware that third-party reporting of sexual abuse and sexual harassment can be done. All
residents interviewed stated that they knew someone who did not work at the facility that they
could report to regarding allegations of sexual abuse. Staff interviews revealed their
knowledge of third-party reporting and that they can receive allegations from third parties.
Information regarding reporting is provided through observed postings that are located in areas
of the facility that are accessible to visitors, residents and staff members. The FDJJ website
contains information regarding third-party reporting.
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)
15
Auditor Comments:
Policies 8-3, 10-25 and FDJJ 1919 provide that all staff immediately report any knowledge,
suspicion, or information regarding an incident of sexual abuse, sexual harassment or incidents
of retaliation according to Department policy and mandatory reporting laws. Reporting
according to the mandatory laws was evident through document review regarding a resident
and an alleged incident that occurred while the youth was still in the community. A report was
made and the visit by the Department of Children and Family (DCF) Worker is documented,
as well as follow-up mental health services.
Staff members are instructed to immediately report all allegations to their immediate
supervisor and the supervisors are to ensure the direct report to the Central Communications
Center (CCC). Policy 10-25 prohibits staff from revealing any related information to anyone
other than to the extent necessary to make treatment, investigation and other security and
management decisions. The CCC will make appropriate notification to senior DJJ
management who will make notification to management overseeing the facility where the
alleged abuse occurred. Policy 10-25 requires the Facility Administrator to notify the alleged
victim’s parents or legal guardians. If the resident is under DCF Custody, the Case Worker
will be notified and if applicable, the attorney of record will be notified of the allegation
within 14 days of receipt of the allegation, according to the Policy.
Interviews with direct care, mental health and medical staffs revealed that they are aware of
the requirements regarding their reporting duties and understand that they are mandated
reporters. According to interviews with the Clinical Director and Health Services
Administrator and the document review, the residents are informed at the initiation of services
of the limitations of confidentiality and duty to report by the clinical staff.
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:
Policies 10-25 and FDJJ 1919 instruct staff to take immediate action to keep residents safe
when they learn that there is substantial risk of imminent threat of sexual abuse. Interviews
with staff confirmed their knowledge of this policy and they were able to verbalize measures
they would take to protect residents who are at substantial risk of imminent sexual abuse. The
steps include immediately alerting supervisor and other staff; provide for the resident at risk to
sleep in one of the group rooms; and one-on-one staff supervision. The residents are provided
written safety tips for self-protection while in the facility. The facility reports that during the
past year, no resident was at substantial risk of sexual abuse. Residents indicated that during
the intake process, their feelings about their safety are part of the inquiries by staff and are
explored by staff during treatment meetings.
16
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 FDJJ 1919, the Facility Administrator, upon receiving an allegation that a
resident was sexually abused while confined at another facility, must notify the head of that
facility where the alleged abuse occurred. Notification must be made as soon as possible but
no later than 72 hours after receipt of the allegation. The Facility Administrator must also
notify the Central Communications Center to report the incident for an investigation. The
facility reports that during this audit period, there has not been a report about an incident of
abuse occurring while the resident was confined in another facility. The Facility Administrator
is aware of the policy regarding reporting to other confinement facilities and the requirement
that allegations received from other facilities must be investigated.
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 10-25 outlines the first responder duties which are generally to separate the victim
from the abuser; preserve and protect the scene; and request that the alleged victim does not
take any action that would destroy physical evidence. Initial training and a refresher training
as needed is conducted with staff through a combination of online statewide training and in-
house refresher training and updates. Staff interviews revealed that they are aware of the steps
to take if they are the first responder to an alleged incident. FDJJ 1919 directs that if the
employee first responder is not direct care staff, they should request that physical evidence is
preserved and direct care staff should be notified. During the past 12 months there was one
allegation of sexual abuse occurring in the facility; it was not an incident that required first
responder actions by direct care or non-direct care staff.
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)
17
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has a written institutional plan, Sexual Abuse Incident Coordinated Response
Plan, which outlines the coordinated actions of the various identified staff such as the first
responder, supervisors, medical, mental health, and management staffs. This coordinated
response to an incident of sexual abuse is also aligned with FDJJ 1919. Staff members
interviewed were familiar with their role regarding the response to an alleged incident of
sexual assault.
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)
Auditor Comments:
This standard is not applicable. The facility does not maintain 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:
Policies 10-25 and FDJJ 1919 provide protection to residents and staff from retaliation. The
retaliation monitor has been identified as the Facility Administrator. An interview revealed
that she understands the responsibility of observing for whether or not retaliation occurs after a
resident or staff reports allegations of sexual abuse or cooperates with an investigation. The
interview further revealed some of the things that would be considered in detecting retaliation,
as outlined in Policy. Some areas to be monitored according to Policy 10-25 and the interview
include resident disciplinary reports; housing or program changes; negative performance
review or reassignment of staff; and status checks. The Facility Administrator reports that
there has not been an incident of retaliation during the past 12 months.
Standard 115.368 Post Allegation Protective Custody
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)
18
Auditor Comments:
This standard is not applicable. Segregated housing is not used at this facility for residents who
allege or would have suffered sexual abuse.
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:
Policies 10-25 and FDJJ 1919, staff interviews, and a review of documentation provide that
administrative investigations are conducted by the FDJJ Office of the Inspector General and
criminal investigations are conducted the Martin County Sheriff’s Office. The Florida
Department of Children and Families are also called when there is an allegation of sexual
abuse. There was one alleged incident that was investigated by the Martin County Sheriff’s
Office which was concluded as unfounded. The Policies direct facility staff to cooperate with
investigations and FDJJ 1919 further provides that an investigation is not terminated because
the source recants the allegation.
The Office of Inspector General follows protocols in conducting administrative investigations
in FDJJ settings and the investigators receive training on the related Department policies. The
Facility Administrator maintains the information sheet developed by FDJJ that is to be given
to the law enforcement investigator. The information provides law enforcement investigators
with the expected protocols related to PREA investigations that are criminal in nature and the
practice is that substantiated allegations are referred for prosecution. A review of
documentation support staffs’ cooperation in investigations and that reports include
descriptions and investigative facts and findings as prescribed by the standard.
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 policy and practice of the Office of Inspector General, responsible for administrative
investigations, impose a standard of a preponderance of the evidence for determining whether
allegations are substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
19
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to FDJJ 1919, the victim is to be informed when the investigation is completed
and Policy 10-25 provides that the Facility Administrator notifies the victim or victim’s
parents or legal guardians. Documents show that the information is provided to the resident.
During the past 12 months there was one allegation of sexual abuse made by a resident
against a staff member which was investigated and was determined unfounded. Documented
notification was made to the resident regarding the completion of the investigation and it
included who the complaint was against; identified the investigative entity; stated the
findings; and the work status of the staff returning to regular duty. The letter also contained
the signatures of the Facility Administrator and the resident. Another investigation of an
allegation of resident-on-resident assault occurring at the end of 2014 was completed in the
last 12 months and the resident was subsequently arrested and removed from the facility. The
documented incident review states that the Director of Clinical Services provided the victim
with a treatment plan, including mental health services in response to this incident.
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 3-3 provides for disciplinary sanctions, up to and including termination for those staff
that violate the facility’s sexual abuse and sexual harassment zero-tolerance policy. The
facility reports that during this audit period, no staff member violated facility or agency policy
regarding sexual abuse or sexual harassment. Disciplinary sanctions for violations of
facility/agency policies relating to sexual abuse, other than actually engaging in the act, and
sexual harassment are appropriate to the circumstances of the incident, staff’s disciplinary
history, and the sanctions for similar cases of other staff.
During this audit period, no staff member has been disciplined for violation of sexual abuse or
sexual harassment policies or reported to law enforcement by the facility for violating such
policies. Policies provide that terminations or resignations by staff that would have been
terminated if not for their resignation are reported to law enforcement if the situation appears
to be criminal in nature and to relevant licensing bodies. The interviews with the Regional
Personnel Manager and the Facility Administrator revealed knowledge of the related policies
and practices.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
20
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 addresses this standard, including requiring that any contractor or volunteer who
engages in sexual abuse be prohibited from contact with residents. It also provides for
contractors and volunteers who engage in sexual abuse to be reported to law enforcement and
to relevant licensing bodies. Policy 10-25 prohibits sexual activity between residents and
volunteers and contracted personnel. According to documentation and interviews, the facility
takes measures to provide volunteers and contractors a clear understanding that a sexual
relationship with a resident is strictly prohibited and is a serious breach of conduct. An
interview with a volunteer and review of training documentation supported the occurrence of
related training occurs. During this audit period, there have been no allegations of sexual
assault or sexual harassment regarding a contractor or volunteer.
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:
Policies 8-1 and FDJJ 1919 addresses an administrative process for dealing with violations,
including resident-on-resident sexual abuse. Policy 8-1 and staff interviews support that the
formal process is therapeutic and promotes positive social change while holding the residents
accountable for their actions. A resident may also be referred to law enforcement for charges
and possible removal from the facility regarding resident-on-resident abuse. Sexual activity
between residents is prohibited and court or administrative processes and sanctions occur
when it has been determined that the sexual activity was coerced. Isolation is not used as a
disciplinary sanction in this facility. Residents would be disciplined for sexual contact with
staff only when it has been determined that the staff member did not consent to the sexual
contact.
Policy 10-25 states that anyone reporting in good faith shall be immune from any civil or
criminal liability. During the past 12 months there have been no administrative findings or
criminal findings of guilt regarding resident-on-resident sexual abuse. Policies 10-25 and
FDJJ 1919 and interviews with mental health and medical staffs support that counseling or
other interventions will be offered to address and correct the underlying reasons or motivations
for abuse when the resident remains in or returns to the facility after an incident. Any type
interventions or treatment services provided would not be dependent on the resident’s
participation in the behavior management system, education or other programs.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
21
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 7-30, 10-25, and FDJJ 1919 address this standard, including providing for a follow-up
meeting with a medical or mental health practitioner within 14 days when the resident
discloses any prior incidents of sexual abuse whether victim or perpetrator. Interviews with
medical and mental health staff and a review of documentation involving disclosure of a prior
alleged incident occurring in the community confirmed the practice of residents being
generally seen by treatment staff as soon as possible. The practice is that all residents are seen
by medical and mental health staffs on the same day of admission as part of the intake process.
Documentation shows that after the disclosure by an alleged victim of an incident occurring in
the community, supportive counseling was provided during that time as well as during follow-
up sessions and contact was made with the resident’s mother. The incident was reported and
there was follow-up by the Department of Children and Families.
Policy supports that information related to sexual victimization or abusiveness that occurred in
an institutional setting is limited to medical and mental health practitioners and those staff,
based on their need to know. A review of files show that medical and mental health staff
members maintain documentation of the services they provide to the residents. Medical and
mental health staffs discussed their knowledge of informed consent, in accordance with policy.
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 7-30, 10.25 and FDJJ 1919; staff interviews; and a review of documented practices
revealed that emergency medical care and crisis intervention services will be provided by
medical and mental health staffs as required. Processes and services are in place for a victim to
receive timely access to emergency contraception and sexually transmitted infections
prophylaxis, where medically appropriate.
Observations of files show that medical and mental health staff members maintain secondary
materials that document services to residents and these staffs are knowledgeable of what must
occur in an incident of sexual abuse. It is documented through policies and understood by the
medical and mental health staffs that treatment services will be provided at no cost to the
victim, whether or not the victim names the abuser, or whether or not the victim cooperates
with the investigation. The interviews with the Health Services Administrator and the Director
of Clinical Services revealed that residents have access to unimpeded emergency services and
that medical and mental health services are determined according to their professional
judgment.
22
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:
Policies 10-25 and 7-30 and interviews with medical and mental health staff members
confirmed that on-going medical and mental health care will be provided for sexual abuse
victims and abusers, as appropriate. If pregnancy should result from sexual abuse in the
facility, pregnancy tests will be offered and where needed the victim will be provided timely
and comprehensive information about all lawful pregnancy related medical services, according
to the staff interview. Staff interviews supported that on-going services would include follow-
up medical and mental health services and referrals as needed. The MOU with the victim
advocacy agency also provides for referral services as needed when a resident is released from
the facility.
Policy 10-25; staff interviews; document review; and observations revealed that medical and
mental health services are consistent with the community level of care. Policies, interviews
and document review support that medical and mental health evaluations and treatment will be
offered to all residents who have been victimized by sexual abuse in any prison, jail, lockup,
or a juvenile facility. The Policy also provides for a mental health practitioner to conduct a
mental health evaluation within 60 days on a resident who discloses youth-on-youth abuse.
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:
Policies 10-25 and FDJJ 1919 provide for an incident review to be conducted within 30 days
of the completion of an investigation in accordance with the standard. The Policies outline the
requirements of the standard for the areas to be assessed by the incident review team. The
Policies also identify the positions that comprise the team. The current Facility Administrator
and the current Assistant Facility Administrator are knowledgeable of the purpose of the
incident review process.
During this audit period, there was one investigation completed that met the requirement of an
incident review being completed. The investigation was completed by the Martin County
Sheriff’s Office and the allegations substantiated. A form/format has been developed for the
incident review process and allows for the inclusion of recommendations. The report is
provided to the Facility Administrator, who also serves as the PREA Compliance Manager.
There is documentation of an incident review occurring during this audit period. The incident
23
review was conducted within 30 days of the completion of the investigation and identified the
participants. The document identified the implementation of corrective actions that the current
Facility Administrator had already implemented and it was noted that the camera system had
been updated since the incident.
Standard 115.387 Data Collection
Exceeds Standard (substantially exceeds requirement of standard)
XMeets 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 a review of reports confirm that FDJJ collects incident-based, uniform data
regarding allegations of sexual abuse at facilities under its direct control, including
contractors, using a standardized instrument and specific guidelines. The format used for
FDJJ facilities and contractors capture the information required to complete the most recent
version of the Survey of Sexual Violence conducted by the U. S. Department of Justice
(DOJ).
Florida DJJ maintains and collects various types of identified data and related documents
regarding sexual abuse incidents. The facility collects and maintains data in accordance with
directives by FDJJ and Policy 1-5. Florida DJJ aggregates the sexual abuse data which
culminates into an annual report. The agency provides DOJ with data as requested.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 provides guidance regarding this standard. The collected and aggregated data is
reviewed to assess and improve the effectiveness of the PREA related efforts and initiatives
by identifying problem areas; developing and implementing corrective actions as needed; and
preparing an annual report based on the collected data. The Policy also states that an annual
report will be prepared that will provide an assessment of the agency’s progress in addressing
sexual misconduct. The annual report is approved as required. It is obvious from staff
interviews, observations, and document review that the agency has compared the results of
annual reports and used them to continuously improve policies; procedures; practices; and
training on a statewide basis. The annual reports have been reviewed and the report is
accessible to the public through the agency’s website. There are no personal identifiers on the
annual reports.
24
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:
FDJJ 1919 provides that all data collected will be securely stored and maintained for at least
10 years after the initial collection date, unless statutes require otherwise. According to the
Policy, the aggregated sexual abuse data from all facilities will be readily available to the
public through the agency’s website; the practice is that the report is posted on the agency’s
website. A review of the annual report verified that there are no personal identifiers, as
required.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and
no conflict of interest exists with respect to his or her ability to conduct an audit of the agency under
review.
March 31, 2016
Auditor Signature Date
25

source: DJJ

report_type: PREA

program_name_raw: martin's girls academy