state: FL

summary: PREA - Year 2 Cycle 4

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Marion Regional Juvenile Detention Center
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 01/04/2024
Auditor Certification
The contents of this report are accurate to the best of my knowledge.
No conflict of interest exists with respect to my ability to conduct an audit of the
agency under review.
I have not included in the final report any personally identifiable information (PII)
about any inmate/resident/detainee or staff member, except where the names of
administrative personnel are specifically requested in the report template.
Auditor Full Name as Signed: Robert Manville Date of
Signature:
01/04/
2024
AUDITOR INFORMATION
Auditor name: Manville, Robert
Email: robertmanville9@gmail.com
Start Date of On- 12/13/2023
Site Audit:
End Date of On-Site 12/14/2023
Audit:
FACILITY INFORMATION
Facility name: Marion Regional Juvenile Detention Center
Facility physical 3040 Northwest 10th Street , Ocala , Florida - 34475
address:
Facility mailing
address:
Primary Contact
Name: Kimbley Jacobs
Email Address: Kimbley.Jacobs@fldjj.gov
Telephone Number: (352)7321450
Superintendent/Director/Administrator
Name: Kimbley Jacobs
Email Address: Kimbley.Jacobs@fldjj.gov
Telephone Number: 352732-1450
Facility PREA Compliance Manager
Name: Kimbley Jacobs
Email Address: kimbley.jacobs@fldjj.gov
Telephone Number: O: 352-732-1450 ext 620
Facility Health Service Administrator On-Site
Name: Jennifer Wilson
Email Address: Jennifer.Wislon@fldjj.gov
Telephone Number: 352-732-1450
Facility Characteristics
Designed facility capacity: 60
Current population of facility: 66
Average daily population for the past 12 45
months:
Has the facility been over capacity at any Yes
point in the past 12 months?
Which population(s) does the facility hold? Both females and males
Age range of population: 9-20
Facility security levels/resident custody secure
levels:
Number of staff currently employed at the 56
facility who may have contact with
residents:
Number of individual contractors who have 11
contact with residents, currently
authorized to enter the facility:
Number of volunteers who have contact 17
with residents, currently authorized to
enter the facility:
AGENCY INFORMATION
Name of agency: Florida Department of Juvenile Justice
Governing authority
or parent agency (if
applicable):
Physical Address: 2737 Centerview Drive, Tallahassee, Florida - 32399
Mailing Address:
Telephone number: 8504881850
Agency Chief Executive Officer Information:
Name: Eric S. Hall
Email Address: Eric.Hall@fldjj.gov
Telephone Number: 8504881850
Agency-Wide PREA Coordinator Information
Name: Jeff Wenhold Email Address: jeff.wenhold@fldjj.gov
Facility AUDIT FINDINGS
Summary of Audit Findings
The OAS automatically populates the number and list of Standards exceeded, the number of
Standards met, and the number and list of Standards not met.
Auditor Note: In general, no standards should be found to be "Not Applicable" or "NA." A
compliance determination must be made for each standard. In rare instances where an auditor
determines that a standard is not applicable, the auditor should select "Meets Standard” and
include a comprehensive discussion as to why the standard is not applicable to the facility being
audited.
Number of standards exceeded:
7
• 115.313 - Supervision and monitoring
• 115.316 - Residents with disabilities
and residents who are limited English
proficient
• 115.318 - Upgrades to facilities and
technologies
• 115.321 - Evidence protocol and
forensic medical examinations
• 115.331 - Employee training
• 115.361 - Staff and agency reporting
duties
• 115.383 - Ongoing medical and mental
health care for sexual abuse victims
and abusers
Number of standards met:
36
Number of standards not met:
0
POST-AUDIT REPORTING INFORMATION
GENERAL AUDIT INFORMATION
On-site Audit Dates
1. Start date of the onsite portion of the 2023-12-13
audit:
2. End date of the onsite portion of the 2023-12-14
audit:
Outreach
10. Did you attempt to communicate Yes
with community-based organization(s)
or victim advocates who provide
No
services to this facility and/or who may
have insight into relevant conditions in
the facility?
a. Identify the community-based Marion County Child Advocacy (Kimberly
organization(s) or victim advocates with Cottage)
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 60
15. Average daily population for the past 45
12 months:
16. Number of inmate/resident/detainee 3
housing units:
17. Does the facility ever hold youthful Yes
inmates or youthful/juvenile detainees?
No
Not Applicable for the facility type audited
(i.e., Community Confinement Facility or
Juvenile Facility)
Audited Facility Population Characteristics on Day One of the Onsite
Portion of the Audit
Inmates/Residents/Detainees Population Characteristics on Day One of the Onsite Portion
of the Audit
36. Enter the total number of inmates/ 42
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
38. Enter the total number of inmates/ 0
residents/detainees with a physical
disability in the facility as of the first
day of the onsite portion of the audit:
39. Enter the total number of inmates/ 2
residents/detainees with a cognitive or
functional disability (including
intellectual disability, psychiatric
disability, or speech disability) in the
facility as of the first day of the onsite
portion of the audit:
40. Enter the total number of inmates/ 0
residents/detainees who are Blind or
have low vision (visually impaired) in the
facility as of the first day of the onsite
portion of the audit:
41. Enter the total number of inmates/ 0
residents/detainees who are Deaf or
hard-of-hearing in the facility as of the
first day of the onsite portion of the
audit:
42. Enter the total number of inmates/ 0
residents/detainees who are Limited
English Proficient (LEP) in the facility as
of the first day of the onsite portion of
the audit:
43. Enter the total number of inmates/ 0
residents/detainees who identify as
lesbian, gay, or bisexual in the facility as
of the first day of the onsite portion of
the audit:
44. Enter the total number of inmates/ 0
residents/detainees who identify as
transgender or intersex in the facility as
of the first day of the onsite portion of
the audit:
45. Enter the total number of inmates/ 0
residents/detainees who reported sexual
abuse in the facility as of the first day of
the onsite portion of the audit:
46. Enter the total number of inmates/ 0
residents/detainees who disclosed prior
sexual victimization during risk
screening in the facility as of the first
day of the onsite portion of the audit:
47. Enter the total number of inmates/ 0
residents/detainees who were ever
placed in segregated housing/isolation
for risk of sexual victimization in the
facility as of the first day of the onsite
portion of the audit:
48. Provide any additional comments Marion Regional Juvenile Detention Center is
regarding the population characteristics part of the Florida Department of Juvenile
of inmates/residents/detainees in the Justice Continuums of Care. Youth are
facility as of the first day of the onsite transported to the center from the Juvenile
portion of the audit (e.g., groups not Assessment Center awaiting trial or
tracked, issues with identifying certain placement in specialized programs. Due to
populations): the nature of the facility, the population
varies on any given day, based on juvenile
courts, community assessment, and
availability of specialized programs. Many
youth stay less than 24 hours, while some
stay several months awaiting placement in
specialized programs.
Staff, Volunteers, and Contractors Population Characteristics on Day One of the Onsite
Portion of the Audit
49. Enter the total number of STAFF, 56
including both full- and part-time staff,
employed by the facility as of the first
day of the onsite portion of the audit:
50. Enter the total number of 17
VOLUNTEERS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
51. Enter the total number of 11
CONTRACTORS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
52. Provide any additional comments Medical and Mental Health staff are
regarding the population characteristics contracted by Vital Pro. The Ocala County
of staff, volunteers, and contractors who School District provides teachers for the
were in the facility as of the first day of center.
the onsite portion of the audit:
INTERVIEWS
Inmate/Resident/Detainee Interviews
Random Inmate/Resident/Detainee Interviews
53. Enter the total number of RANDOM 15
INMATES/RESIDENTS/DETAINEES who
were interviewed:
54. Select which characteristics you Age
considered when you selected RANDOM
INMATE/RESIDENT/DETAINEE Race
interviewees: (select all that apply)
Ethnicity (e.g., Hispanic, Non-Hispanic)
Length of time in the facility
Housing assignment
Gender
Other
None
55. How did you ensure your sample of I interviewed resident from each of the
RANDOM INMATE/RESIDENT/DETAINEE housing units.
interviewees was geographically
diverse?
56. Were you able to conduct the Yes
minimum number of random inmate/
resident/detainee interviews?
No
57. Provide any additional comments No text provided.
regarding selecting or interviewing
random inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews,
barriers to ensuring representation):
Targeted Inmate/Resident/Detainee Interviews
58. Enter the total number of TARGETED 2
INMATES/RESIDENTS/DETAINEES who
were interviewed:
As stated in the PREA Auditor Handbook, the breakdown of targeted interviews is intended to
guide auditors in interviewing the appropriate cross-section of inmates/residents/detainees who
are the most vulnerable to sexual abuse and sexual harassment. When completing questions
regarding targeted inmate/resident/detainee interviews below, remember that an interview with
one inmate/resident/detainee may satisfy multiple targeted interview requirements. These
questions are asking about the number of interviews conducted using the targeted inmate/
resident/detainee protocols. For example, if an auditor interviews an inmate who has a physical
disability, is being held in segregated housing due to risk of sexual victimization, and disclosed
prior sexual victimization, that interview would be included in the totals for each of those
questions. Therefore, in most cases, the sum of all the following responses to the targeted
inmate/resident/detainee interview categories will exceed the total number of targeted inmates/
residents/detainees who were interviewed. If a particular targeted population is not applicable in
the audited facility, enter "0".
60. Enter the total number of interviews 0
conducted with inmates/residents/
detainees with a physical disability using
the "Disabled and Limited English
Proficient Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Prior to beginning the selection of residents to
to determine if this population exists in interview the clinical director, medical staff
the audited facility (e.g., based on and PREA compliance mangers review the
information obtained from the PAQ; VSAB and discussed each of the targeted
documentation reviewed onsite; and residents. The medical staff indicated they
discussions with staff and other inmates/ had no disabled residents at the time of the
residents/detainees). audit.
61. Enter the total number of interviews 2
conducted with inmates/residents/
detainees with a cognitive or functional
disability (including intellectual
disability, psychiatric disability, or
speech disability) using the "Disabled
and Limited English Proficient Inmates"
protocol:
62. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Blind or have low
vision (i.e., visually impaired) using the
"Disabled and Limited English Proficient
Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Prior to beginning the selection of residents to
to determine if this population exists in interview the clinical director, medical staff
the audited facility (e.g., based on and PREA compliance mangers review the
information obtained from the PAQ; VSAB and discussed each of the targeted
documentation reviewed onsite; and residents. The medical staff indicated there
discussions with staff and other inmates/ were no blind or low vision residents at this
residents/detainees). time.
63. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Deaf or hard-of-
hearing using the "Disabled and Limited
English Proficient Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Prior to beginning the selection of residents to
to determine if this population exists in interview the clinical director, medical staff
the audited facility (e.g., based on and PREA compliance mangers review the
information obtained from the PAQ; VSAB and discussed each of the targeted
documentation reviewed onsite; and residents. The medical staff indicated there
discussions with staff and other inmates/ were deaf of hard-of-hearing residents at this
residents/detainees). time.
64. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Limited English
Proficient (LEP) using the "Disabled and
Limited English Proficient Inmates"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Prior to beginning the selection of residents to
to determine if this population exists in interview the clinical director, medical staff
the audited facility (e.g., based on and PREA compliance mangers review the
information obtained from the PAQ; VSAB and discussed each of the targeted
documentation reviewed onsite; and residents. The staff indicated there were no
discussions with staff and other inmates/ LEP residents at this time
residents/detainees).
65. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as lesbian, gay,
or bisexual using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Prior to beginning the selection of residents to
to determine if this population exists in interview the clinical director, medical staff
the audited facility (e.g., based on and PREA compliance mangers review the
information obtained from the PAQ; VSAB and discussed each of the targeted
documentation reviewed onsite; and residents. The staff indicated there were no
discussions with staff and other inmates/ residents at this time that indicated they were
residents/detainees). gay, bisexual at this time.
66. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as transgender
or intersex using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Prior to beginning the selection of residents to
to determine if this population exists in interview the clinical director, medical staff
the audited facility (e.g., based on and PREA compliance mangers review the
information obtained from the PAQ; VSAB and discussed each of the targeted
documentation reviewed onsite; and residents. The staff indicated there were no
discussions with staff and other inmates/ transgender or intersex residents at this time.
residents/detainees).
67. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who reported sexual abuse in
this facility using the "Inmates who
Reported a Sexual Abuse" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Prior to beginning the selection of residents to
to determine if this population exists in interview the clinical director, medical staff
the audited facility (e.g., based on and PREA compliance mangers review the
information obtained from the PAQ; VSAB and discussed each of the targeted
documentation reviewed onsite; and residents. The staff indicated there were no
discussions with staff and other inmates/ residents the reported sexual abuse housed
residents/detainees). at the center at this time.
68. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who disclosed prior sexual
victimization during risk screening using
the "Inmates who Disclosed Sexual
Victimization during Risk Screening"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Prior to beginning the selection of residents to
to determine if this population exists in interview the clinical director, medical staff
the audited facility (e.g., based on and PREA compliance mangers review the
information obtained from the PAQ; VSAB and discussed each of the targeted
documentation reviewed onsite; and residents. The staff indicated there were no
discussions with staff and other inmates/ residents that claim prior victimization at this
residents/detainees). time.
69. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are or were ever placed
in segregated housing/isolation for risk
of sexual victimization using the
"Inmates Placed in Segregated Housing
(for Risk of Sexual Victimization/Who
Allege to have Suffered Sexual Abuse)"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies The center does not utilize Segregation for
to determine if this population exists in risk of victimization. There were no resident
the audited facility (e.g., based on that were noted in any segregated area
information obtained from the PAQ; during the tour and during the auditor
documentation reviewed onsite; and traveling through the living units though our
discussions with staff and other inmates/ the on-site audit.
residents/detainees).
70. Provide any additional comments No text provided.
regarding selecting or interviewing
targeted inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews):
Staff, Volunteer, and Contractor Interviews
Random Staff Interviews
71. Enter the total number of RANDOM 15
STAFF who were interviewed:
72. Select which characteristics you Length of tenure in the facility
considered when you selected RANDOM
STAFF interviewees: (select all that Shift assignment
apply)
Work assignment
Rank (or equivalent)
Other (e.g., gender, race, ethnicity,
languages spoken)
None
73. Were you able to conduct the Yes
minimum number of RANDOM STAFF
interviews?
No
74. Provide any additional comments No text provided.
regarding selecting or interviewing
random staff (e.g., any populations you
oversampled, barriers to completing
interviews, barriers to ensuring
representation):
Specialized Staff, Volunteers, and Contractor Interviews
Staff in some facilities may be responsible for more than one of the specialized staff duties.
Therefore, more than one interview protocol may apply to an interview with a single staff
member and that information would satisfy multiple specialized staff interview requirements.
75. Enter the total number of staff in a 11
SPECIALIZED STAFF role who were
interviewed (excluding volunteers and
contractors):
76. Were you able to interview the Yes
Agency Head?
No
77. Were you able to interview the Yes
Warden/Facility Director/Superintendent
or their designee?
No
78. Were you able to interview the PREA Yes
Coordinator?
No
79. Were you able to interview the PREA Yes
Compliance Manager?
No
NA (NA if the agency is a single facility
agency or is otherwise not required to have a
PREA Compliance Manager per the Standards)
80. Select which SPECIALIZED STAFF Agency contract administrator
roles were interviewed as part of this
audit from the list below: (select all that Intermediate or higher-level facility staff
apply) responsible for conducting and documenting
unannounced rounds to identify and deter
staff sexual abuse and sexual harassment
Line staff who supervise youthful inmates
(if applicable)
Education and program staff who work with
youthful inmates (if applicable)
Medical staff
Mental health staff
Non-medical staff involved in cross-gender
strip or visual searches
Administrative (human resources) staff
Sexual Assault Forensic Examiner (SAFE)
or Sexual Assault Nurse Examiner (SANE) staff
Investigative staff responsible for
conducting administrative investigations
Investigative staff responsible for
conducting criminal investigations
Staff who perform screening for risk of
victimization and abusiveness
Staff who supervise inmates in segregated
housing/residents in isolation
Staff on the sexual abuse incident review
team
Designated staff member charged with
monitoring retaliation
First responders, both security and non-
security staff
Intake staff
Other
81. Did you interview VOLUNTEERS who Yes
may have contact with inmates/
residents/detainees in this facility?
No
82. Did you interview CONTRACTORS Yes
who may have contact with inmates/
residents/detainees in this facility?
No
a. Enter the total number of 3
CONTRACTORS who were interviewed:
b. Select which specialized CONTRACTOR Security/detention
role(s) were interviewed as part of this
audit from the list below: (select all that Education/programming
apply)
Medical/dental
Food service
Maintenance/construction
Other
83. Provide any additional comments No text provided.
regarding selecting or interviewing
specialized staff.
SITE REVIEW AND DOCUMENTATION SAMPLING
Site Review
PREA Standard 115.401 (h) states, "The auditor shall have access to, and shall observe, all areas
of the audited facilities." In order to meet the requirements in this Standard, the site review
portion of the onsite audit must include a thorough examination of the entire facility. The site
review is not a casual tour of the facility. It is an active, inquiring process that includes talking
with staff and inmates to determine whether, and the extent to which, the audited facility's
practices demonstrate compliance with the Standards. Note: As you are conducting the site
review, you must document your tests of critical functions, important information gathered
through observations, and any issues identified with facility practices. The information you
collect through the site review is a crucial part of the evidence you will analyze as part of your
compliance determinations and will be needed to complete your audit report, including the Post-
Audit Reporting Information.
84. Did you have access to all areas of Yes
the facility?
No
Was the site review an active, inquiring process that included the following:
85. Observations of all facility practices Yes
in accordance with the site review
component of the audit instrument (e.g.,
No
signage, supervision practices, cross-
gender viewing and searches)?
86. Tests of all critical functions in the Yes
facility in accordance with the site
review component of the audit
No
instrument (e.g., risk screening process,
access to outside emotional support
services, interpretation services)?
87. Informal conversations with inmates/ Yes
residents/detainees during the site
review (encouraged, not required)?
No
88. Informal conversations with staff Yes
during the site review (encouraged, not
required)?
No
89. Provide any additional comments The Marion Regional Juvenile Detention
regarding the site review (e.g., access to Center (MRJDC), located in Ocala, Florida is
areas in the facility, observations, tests operated by the Florida Department of
of critical functions, or informal Juvenile Justice (FDJJ). It is a secure detention
conversations). facility that serves female and male juvenile
offenders between the ages of 9 and 20.
Residents are detained by the court’s pending
adjudication, disposition or placement in a
commitment facility. The average length of
stay is approximately 12 days. The facility’s
rated capacity is 60.
The comprehensive tour of the facility
included the housing areas, educational
areas, dining areas, and administrative areas.
The audit notice was posted using color and
large print that was easy to see and read. The
notices were strategically placed throughout
the facility, accessible to residents, staff,
visitors, and volunteers. The posted audit
notices contained the Auditor’s contact
information and included information
regarding confidentiality. No correspondence
was received during any phase of the audit.
The Audit notice was provided to the facility
by the FDJJ PREA Coordinator and had
previously been provided by the Auditor to
the FDJJ PREA Coordinator. The notice was
posted in English and Spanish at eye levels
easy for a person to see either standing or
sitting.
All residents in the facility during the time of
the interviews spoke and read English.,
posted signs were also observed regarding
Zero Policy for sexual abuse or sexual
harassment, ways of reporting sexual abuse
or sexual harassment, Marion County Child
Advocacy Center telephone number and
address, National Sexual Abuse Hotline,
Florida Sexual Abuse Hotline and Central
Communication Center (CCC) telephone
number. There was also a flyer that included
calling 911 in an emergency. Posting included
PREA brochure, End the Silence, and
additional PREA posters identified in the
standards. There was a total of 10 posters on
display throughout the facility. There is an
office that is utilized by the resident to make
these phone calls. The resident’s attorneys
and parent can utilize this same phone in
emergency or legal information. The auditor
called all the above numbers from a
telephone that is in the office area. All
telephone calls were answered. The call to the
Sexual Abuse Hotline was answered by staff
of the Florida child protection agency. The call
from the CCC received a text message to the
facility administrator. The Victim Advocacy
staff requested if the call was to report an
allegation or to talk to an on duty emotional
support staff.
Residents were observed interacting with staff
under staff’s direct supervision during dinner
time, leisure activities, and education
activities in the classrooms. Residents were
interviewed during the tour, and additionally
when the resident’s recreation time when the
auditor went on the yard and talked informally
with the residents. All residents indicated they
felt safe at the facility. Resident knew the
facility administrator and indicated that
administrative staff speaks with them daily
including most weekends. Staff were
engaging with the auditor. Several of the staff
have been at the facility since the first
implementation of PREA and provided a
historical perspective of how the facility had
implemented PREA into a cornerstone of
training and programming. The first PREA
audit of the facility was in 2015. A review of
logbooks and records revealed documentation
of safety and PREA rounds.
The Facility Administrator makes continuous
rounds throughout the center. Staff announce
their presence prior to entering a dormitory
housing resident of the other gender. When
the resident arrives staff bring the resident
folder which includes a suicide risk
assessment and Victimization Screening
Instrument in a sealed envelope. The
screening staff, medical and mental health
staff are notified prior to receiving the
residents and go to the intake area to begin
the intake process. The screening staff review
the screening instrument and complete
another screening during the process. The
staff show the PREA video that was also
shown at the sending Center. Staff then
discuss the film, PREA brochure and general
discussion about PREA. The mental health
staff will interview the resident about
victimization and predator behavior and offer
services to the residents at that time.
Medical Request Forms, PREA/grievance
forms, and the locked boxes for each are
posted in the common area, accessible to all
residents, staff, and visitors. All residents
have access to writing utensils needed for
completing the forms. The doors to closets
and storage rooms are kept locked. The
facility is maximum/high custody with
controlled entrance and egress for both staff
and contractors. A metal detector and wand
are used at the pedestrian entrance.
Visitors are received and required to sign-in/
out at the control room check point and are
searched in this area, assisted with the use of
a wand.
Through a Memorandum of Understanding
(MOU), victim advocacy services will be
provided by the Marion County Children’s
Advocacy Center also known as “Kimberly
Center”. The services to be provided were
confirmed by the Executive Director of the
advocacy agency and the parent agency’s
PREA Coordinator/Regional Director.
Information regarding the services has been
posted, accessible to residents and staff.
According to the MOU and interviews, the
advocacy agency services include but are not
limited to emotional support, counseling, and
referrals for services if a resident is
transferred to another facility or released.
Forensic medical services will be conducted
by Child Protective Team Pediatrics or
Advanced Registered Nurse Practitioners at
the Marion County Children’s Advocacy
Center.
The center has recently updated the camera
and monitoring system. The cameras are
strategically installed to supplement direct
staff supervision. A reasonable amount of
privacy is provided to residents when they
use the toilet, change clothes and shower.
The bathroom is equipped with doors to the
shower and toilet stalls. Residents are
provided privacy when they use the
bathroom.
Forms such as Grievance, Request to Speak,
and Sick Call were observed posted in the
living units along with locked boxes for
depositing the forms. All resident received a
PREA brochure when they arrive at the center.
The center has not had a PREA allegation of
sexual abuse or sexual harassment in the last
12 months. The residents and staff
interviewed were aware of their responsibility
to keep the center a sexually safe
environment. Two of the residents asked to
talk to the auditor during the tour. They were
interviewed and wanted to talk about how the
center provides them with a safe environment
and their role in making the facility a safe
place.
The overall impression of the center is that it
has fostered a sexually safe culture for staff
and residents.
Documentation Sampling
Where there is a collection of records to review-such as staff, contractor, and volunteer training
records; background check records; supervisory rounds logs; risk screening and intake
processing records; inmate education records; medical files; and investigative files-auditors must
self-select for review a representative sample of each type of record.
90. In addition to the proof Yes
documentation selected by the agency
or facility and provided to you, did you
No
also conduct an auditor-selected
sampling of documentation?
91. Provide any additional comments Resident Files Reviewed
regarding selecting additional Twelve resident records were reviewed. These
documentation (e.g., any documentation records included the. • Identification Number
you oversampled, barriers to selecting • Date of Birth • Date of Arrival • Date of
additional documentation, etc.). Screening • Date of PREA orientation/
education: •Mental Health Referrals; and
documentation from mental health provider of
date and time mental health initial meetings.
Employee Files Reviewed
Background Checks: Four (4) background
clearance files including new hired staff, five-
year tenure and promotions. All files
contained background checks by Florida
Department of Office of Inspector General
Background Unit Section
Background checks including National and
State Child Abuse Registry
All files contained the PREA questionnaire for
new hires, promotions and yearly staff
appraisal.
Staff training files were reviewed utilizing the
Skill Pro 1; 2;3;4; Florida Training Database
Administrative Files Reviewed
Six unannounced rounds were randomly
selected.
Grievance Log (No PREA noted)
Investigations (No investigations have been
completed)
SEXUAL ABUSE AND SEXUAL HARASSMENT ALLEGATIONS AND
INVESTIGATIONS IN THIS FACILITY
Sexual Abuse and Sexual Harassment Allegations and Investigations
Overview
Remember the number of allegations should be based on a review of all sources of allegations
(e.g., hotline, third-party, grievances) and should not be based solely on the number of
investigations conducted. Note: For question brevity, we use the term “inmate” in the following
questions. Auditors should provide information on inmate, resident, or detainee sexual abuse
allegations and investigations, as applicable to the facility type being audited.
92. Total number of SEXUAL ABUSE allegations and investigations overview during
the 12 months preceding the audit, by incident type:
# of allegations
# of
# of that had both
sexual # of criminal
administrative criminal and
abuse investigations
investigations administrative
allegations
investigations
Inmate- 0 0 0 0
on-
inmate
sexual
abuse
Staff- 0 0 0 0
on-
inmate
sexual
abuse
Total 0 0 0 0
93. Total number of SEXUAL HARASSMENT allegations and investigations overview
during the 12 months preceding the audit, by incident type:
# of allegations
# of sexual # of that had both
# of criminal
harassment administrative criminal and
investigations
allegations investigations administrative
investigations
Inmate-on- 0 0 0 0
inmate
sexual
harassment
Staff-on- 0 0 0 0
inmate
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Outcomes
Sexual Abuse Investigation Outcomes
Note: these counts should reflect where the investigation is currently (i.e., if a criminal
investigation was referred for prosecution and resulted in a conviction, that investigation
outcome should only appear in the count for “convicted.”) Do not double count. Additionally, for
question brevity, we use the term “inmate” in the following questions. Auditors should provide
information on inmate, resident, and detainee sexual abuse investigation files, as applicable to
the facility type being audited.
94. Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding
the audit:
Referred Indicted/
Convicted/
Ongoing for Court Case Acquitted
Adjudicated
Prosecution Filed
Inmate-on- 0 0 0 0 0
inmate sexual
abuse
Staff-on- 0 0 0 0 0
inmate sexual
abuse
Total 0 0 0 0 0
95. Administrative SEXUAL ABUSE investigation outcomes during the 12 months
preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 0 0
sexual abuse
Staff-on-inmate 0 0 0 0
sexual abuse
Total 0 0 0 0
Sexual Harassment Investigation Outcomes
Note: these counts should reflect where the investigation is currently. Do not double count.
Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors
should provide information on inmate, resident, and detainee sexual harassment investigation
files, as applicable to the facility type being audited.
96. Criminal SEXUAL HARASSMENT investigation outcomes during the 12 months
preceding the audit:
Indicted/
Referred
Court Convicted/
Ongoing for Acquitted
Case Adjudicated
Prosecution
Filed
Inmate-on- 0 0 0 0 0
inmate sexual
harassment
Staff-on- 0 0 0 0 0
inmate sexual
harassment
Total 0 0 0 0 0
97. Administrative SEXUAL HARASSMENT investigation outcomes during the 12
months preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 0 0
sexual
harassment
Staff-on-inmate 0 0 0 0
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Files Selected for
Review
Sexual Abuse Investigation Files Selected for Review
98. Enter the total number of SEXUAL 0
ABUSE investigation files reviewed/
sampled:
a. Explain why you were unable to The center has not had an allegation of sexual
review any sexual abuse investigation abuse in the last cycle.
files:
99. Did your selection of SEXUAL ABUSE Yes
investigation files include a cross-
section of criminal and/or administrative No
investigations by findings/outcomes?
NA (NA if you were unable to review any
sexual abuse investigation files)
Inmate-on-inmate sexual abuse investigation files
100. Enter the total number of INMATE- 0
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
101. Did your sample of INMATE-ON- Yes
INMATE SEXUAL ABUSE investigation
files include criminal investigations? No
NA (NA if you were unable to review any
inmate-on-inmate sexual abuse investigation
files)
102. Did your sample of INMATE-ON- Yes
INMATE SEXUAL ABUSE investigation
files include administrative No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual abuse investigation
files)
Staff-on-inmate sexual abuse investigation files
103. Enter the total number of STAFF- 0
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
104. Did your sample of STAFF-ON- Yes
INMATE SEXUAL ABUSE investigation
files include criminal investigations? No
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
105. Did your sample of STAFF-ON- Yes
INMATE SEXUAL ABUSE investigation
files include administrative No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
Sexual Harassment Investigation Files Selected for Review
106. Enter the total number of SEXUAL 0
HARASSMENT investigation files
reviewed/sampled:
a. Explain why you were unable to The center has not had an allegation of sexual
review any sexual harassment harassment in the last cycle.
investigation files:
107. Did your selection of SEXUAL Yes
HARASSMENT investigation files include
a cross-section of criminal and/or No
administrative investigations by
findings/outcomes?
NA (NA if you were unable to review any
sexual harassment investigation files)
Inmate-on-inmate sexual harassment investigation files
108. Enter the total number of INMATE- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
109. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT files
include criminal investigations? No
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
110. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
Staff-on-inmate sexual harassment investigation files
111. Enter the total number of STAFF- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
112. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include criminal No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
113. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
114. Provide any additional comments No text provided.
regarding selecting and reviewing
sexual abuse and sexual harassment
investigation files.
SUPPORT STAFF INFORMATION
DOJ-certified PREA Auditors Support Staff
115. Did you receive assistance from any Yes
DOJ-CERTIFIED PREA AUDITORS at any
point during this audit? REMEMBER: the
No
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
Non-certified Support Staff
116. Did you receive assistance from any Yes
NON-CERTIFIED SUPPORT STAFF at any
point during this audit? REMEMBER: the
No
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
AUDITING ARRANGEMENTS AND COMPENSATION
121. Who paid you to conduct this audit? The audited facility or its parent agency
My state/territory or county government
employer (if you audit as part of a consortium
or circular auditing arrangement, select this
option)
A third-party auditing entity (e.g.,
accreditation body, consulting firm)
Other
Identify the name of the third-party Correctional Management and
auditing entity Communication INC
Standards
Auditor Overall Determination Definitions
• Exceeds Standard
(Substantially exceeds requirement of standard)
• Meets Standard
(substantial compliance; complies in all material ways with the stand for the relevant
review period)
• Does Not Meet Standard
(requires corrective actions)
Auditor Discussion Instructions
Auditor discussion, including the evidence relied upon in making the compliance or non-
compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions.
This discussion must also include corrective action recommendations where the facility does not
meet standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Zero tolerance of sexual abuse and sexual harassment; PREA
115.311
coordinator
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Florida Department of Juvenile Justice Agency Org Chart
Facility Org Chart
Department of Juvenile Justice Policy 1919 PREA revised 4-16-19.
Zero tolerance poster specific for Marion Regional Juvenile Detention Center
5-01-2022-agency-overview-with-names
10 PREA Postings
115.311 (a): The Florida Department of Juvenile Justice is committed to a zero-
tolerance standard for incidents of sexual abuse and sexual harassment. The
agency has developed and implemented policies to comply with PREA standards for
Juvenile Facilities. Marion Regional Juvenile Detention Center (MRJDC) and other
stakeholders associated with MRJDC are committed to preventing, detecting, and
responding to sexual abuse and sexual harassment. Everyone has the right to be
free from sexual abuse, sexual harassment, neglect, and exploitation. This includes
not being subjected to sexually assaultive, abusive, and/or harassing behavior from
staff and other residents. Department of Juvenile Justice Policy 1919 PREA
establishes that all facilities, staff, residents, volunteers, contractors, or visitor are
committed to a zero-tolerance standard for incidents of sexual abuse and sexual
harassment. The policy serves as the agency policy for all programs. It includes
definitions, expectations, and consequences for not meeting the expectations. The
overall goal of the agency it to make every juvenile, staff, volunteer, interns, and
visitors safe from sexual abuse, harassment or extortion.
Residents with disabilities are afforded the same rights and will be provided access
to interpreters, presented material to effectively communicate with those residents
who have intellectual disabilities, limited reading skills, blind or have low vision.
Residents will have access to interpreters who can interpret effectively, accurately,
and impartially, both receptively and expressively, using any necessary specialized
vocabulary. Interpreters will be provided through local community resources.
Residents with disabilities have equal opportunity to participate in and benefit from
all aspects Marion Regional Juvenile Detention Center’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment. In interviews with clinical staff,
the center has not only embraced PREA mandates but has adapted PREA standards
and culture into the program model.
The agency has spent a large sum of money to upgrade the surveillance system at
the center to enhance the ability to protect residents. Interviews with residents were
refreshing echo of the hard work the agency and facility have dedicated to make
MRJDC a sexual safe environment for all residents and staff.
115.311 (b): Florida Department of Juvenile Justice employees a PREA Coordinator
that oversees the efforts to comply with the PREA standards in all Juvenile Facilities
under the umbrellas of Division of Juvenile Services. The PREA coordinator that
reports to the Division Director indicated he has sufficient time and authority to
develop, implement, and oversee agency efforts to comply with the PREA standards
in all of its facilities. The PREA Coordinator is extremely knowledgeable and is a
PREA auditor.
115.311 (c): The PREA coordinator ensures that all its facilities have a PREA
Compliance Manager with sufficient time and authority to coordinate the facilities
PREA efforts. The facility administrator is designated as the PREA compliance
manager at Marion Regional Juvenile Detention Center. The assistant facility
administrator works with the facility administrator to comply with the PREA
standards. The Florida Department of Juvenile Justice has regional analyst that
provide additional resources to the facility PREA compliance manager and works
with the State PREA coordinator to ensure corrective action plans are implemented
with required.
Exceed Compliance was determined by review of the organizational chart and
interviews with the PREA coordinator, PREA compliance manager, regional analyst,
and staff and residents at the facility.
115.312 Contracting with other entities for the confinement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
PREA Contract Language
PREA Contract and Monitoring Auditing
Florida Department of Juvenile Justice Contracts
Department of Juvenile Justice Policy 1919 PREA revised 4-16-19.
FDJJ contracts with facilities to operate residential facilities in Florida. Contracts
include specific information to the contractors of the requirements by the Florida
Department of Juvenile Justice to comply with the PREA Standards and participate in
PREA audits. The practice was also confirmed by completed PREA audit reports for
this facility and other contract sites. The State presently has privately managed
residential programs. All have undergone PREA audits within the last 3 years.
The Florida Department of Juvenile Justice PREA coordinator conducts an annual
PREA assessment of Private Juvenile Facilities and provides this information to the
facility on a yearly basis. Marion RYDC is a State operated facility.
115.313 Supervision and monitoring
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Staff to youth ratio docs
Unannounced Tours
Department of Juvenile Justice Policy FDJJ Policy 1919
Prison Rape Elimination Act (PREA) Facility Operating Procedures
Monthly Schedule Resident
Daily Rosters PREA
Pre-Audit Questionnaire
Staffing Plan - PREA 2023
Staffing Plan - PREA 2022 (2) Staffing Plan - PREA 2021
Facility Staffing Plan - PREA 2020
Management Events - Marion-PREA UAV (SharePoint Form)-12021
Marion PREA Facility Audit questionnaire (Agency) PREA Ratio Review
Staffing Deviation
115.313 (a): Each year the facility reviews staffing and the need for cameras,
staffing or rearranging the staffing plan to meet the required staff in order to
maintain a safe and secure operation. Their staffing plan’s annual reviews
conducted in June 2023 were found to be in compliance with this standard. The
staffing plan included: 1) Generally accepted detention and correctional/secure
residential practices. (2) Any judicial findings of inadequacy. (3) Any findings of
inadequacy from Federal investigative agencies. (4) Any findings of inadequacy
from internal or external oversight bodies. (5) All components of the facility’s
physical plant (including “blind spots” or areas where staff or residents may be
isolated). (6) The composition of the resident population. (7) The number and
placement of supervisory staff. (8) Institution programs occurring on a particular
shift. (9) Any applicable State or local laws, regulations, or standards. (10) The
prevalence of substantiated and unsubstantiated incidents of sexual abuse; and(11)
Any other relevant factors. The facility did not report any deviation from the staffing
plan during the past 12 months. According to the PAQ the staffing plan is based on
50 residents. Based on conversations with the PREA coordinator and facility
administrator it was obvious that the facility reviews all areas of the center for
additional staffing or cameras based on resident movement in order to meet the
requirement of this standard. The direct care staff were noted to be located
throughout the center during the tour or review of cameras monitoring. At least
once every year, the agency or facility, in collaboration with the PREA Coordinator,
reviews the staffing plan to see whether adjustments are needed to the staffing
plan; prevailing staffing patterns; the deployment of monitoring technology; or the
allocation of agency or facility resources to commit to the staffing plan, to ensure
compliance with the staffing plan.
115.313 (b): The facility administrator provided a daily roster that indicates the
staffing utilized during the prior 24 hours. During the pandemic the center had to
pay overtime and utilize some non-essential staff in order to provide staff that
ensured appropriate staff were available to meet the mandatory posts.
115.313 (c) Random interviewed direct care confirmed that they are assigned based
on activities at each unit which will impact the staffing plan. The random staff
stated that the center does not count control operators toward meeting this
requirement. The facility administrator provided a daily roster that indicates the
staffing utilized during the prior 24 hours. The facility's plan strives to maintain
staffing ratios of a minimum of 1 staff to 8 residents during resident waking hours
and 1 to 16 during resident sleeping hours. The facility has not had in deviation in
the ratios mandated by FDJJ Policy 1919. The facility has a hold over and overtime
pay program to provide coverage as required. Staff interviewed indicated they are
not allowed to abandon their post until properly relieved.
115.313 (d): FDJJ Policy 1919 - Juvenile Prison Rape Elimination Act mandates that
the staffing plan will be reviewed and approved by the PREA coordinator at least
yearly. The facility staffing plan for 2023 was submitted in June 2023. MRJDC
conducts an extensive review of all areas of facilities and assesses the need for
additional cameras, staff programing, and overall operation of the facility. During
the tour of the facility, the auditor found no blind spots or areas with residents
present without supervision.
115.313 (e): The Facility administrator and PREA compliance manager conduct and
document unannounced rounds on all shifts and all areas of the facility to monitor
and deter staff sexual abuse and harassment. Each shift supervisor makes rounds
several times during each shift. It is the policy of MRJDC that staff are not to inform
other staff when the shift supervisor, facility manager or regional administrators are
making rounds. During the tour the auditor reviewed the logbooks in all housing
units and noted that the shift supervisor, and facility administrator had signed to
logbook a minimum of one a day for the last three-week excluding weekends. Shift
supervisor had signed the logbooks on each day including weekends. FDJJ has
developed a PREA form that is utilized to conduct daily, weekly, and monthly
unannounced rounds by administrative staff that is then uploaded to the DJJ share
drive.
Throughout the audit the auditor made rounds throughout the facility. The ratio
during the daytime was one to six on each visit. One tour for the overnight shift, the
ratio was 1 to 6 with the exception of one living unit which as 1 to 7.
Compliance was determined by review of policies, documentation, and interview
with staff. During the audit the auditor visited all areas of the facility throughout the
audit. During the visit the auditor counted the number of residents and number of
staff in each area. The facility exceeded the requirement of this standard during
each visit.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 PREA - Searches Cross Gender viewing and searches.
PREA Statement of Preference
Female and Male Announcements
Training on Cross gender -gender
LBGTQ Cross-gender and transgender pat searches
Training Video on Guidance on Cross Gender and LBGTQ searches
MRJDC Cross Gender Frisk Searches Training Roster
115.315 (a): Based on interviews with staff and residents there have been no cross-
gender pat down searches in the last 12 months. An intake staff member indicated
that upon admission to MRJDC, the resident is then taken to a private area by two
staff of the same gender as the resident. The resident is asked to remove their outer
garments, but not to remove their undergarments. The staff member then confirms
that there is no contraband visually and identifies any tattoos, scars, bruises or
other marks.
115.315 (b): Search Procedures mandates the facility always refrain from
conducting any cross-gender pat down except in exigent circumstances. All staff
interviewed indicated they have never conducted a cross-gender search. All
residents interviewed stated they had never been searched by a staff of the other
gender.
115.315 (c): According to the PAQ there were no cross-gender searches during the
last 12 months.
115.315 (d): A tour of the center found that all areas that are utilized for housing
residents have necessary barriers to allow resident to shower without being viewed
by person of the opposite gender and privacy from other residents during the
showering process. MRJDC showering procedure requires that staff of the same
gender supervise all showers and will position themselves so they can’t see the
residents totally naked. All residents stated they are allowed to change clothes and
shower in private. A review of the cameras noted there were no cameras that
provided views of the shower or toilet areas in any of the units. All staff of the other
gender always announce their presence when entering a housing unit. There are
reminders poster placed at the entrance of each housing unit. Staff and residents
confirm that staff announce their presence and will knock on the door prior to
looking in during counts.
115.315 (e): Agency policy prohibits searching or physically examining a
transgender or intersex youth for the sole purpose of determining the youth’s
genital status. Policy mandates that if a resident’s genital status is unknown, the
facility determine genital status during conversations with the resident, by
reviewing medical records, or, if necessary, by learning that information as part of a
broader medical examination conducted in private by a medical practitioner.
115.315 (f): A review of the staff training plan includes intervention techniques and
standards required to be utilized prior to conducting any searches. Interview with
random staff confirmed they had received training on intervention techniques. This
training included conducting cross gender searches in a professional and respectful
manner.
Compliance was determined by review of policies, watching the cross-gender video,
and interview with resident and staff.
Residents with disabilities and residents who are limited English
115.316
proficient
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Zero Tolerance Poster English– Spanish English and Spanish Third-Party Posters
PREA Posters in English, Spanish, French and Creole
Bilingual Staff list
Department of Juvenile Justice Policy- 1919 PREA
Education Services
Global Language Telephone Contract Youth Request for Reasonable Accommodation
Recognizing Signs and Symptoms
Recognizing Developmental Disabilities
Public Schools Section 504
Partnering with an Interpreter
Quick Reference Card
115.316 (a)(c): Department of Juvenile Justice Policy- 1919 mandates that facilities
will ensure that residents with disabilities (e.g., those who are deaf, hard of hearing,
blind, have low vision, intellectual, psychiatric or speech disabilities) have an equal
opportunity to participate in or benefit from the facility’s efforts to prevent, detect,
and respond to Sexual Abuse and Sexual Harassment. Such steps will include, when
necessary to ensure effective communication with residents who are deaf or hard or
hearing, providing access to interpreters who can interpret effectively, accurately,
and impartially, both receptively and expressively, using any necessary specialized
vocabulary. MRJDC will ensure that all written materials to every resident is in
format or through methods that ensure effective communication with residents with
disabilities, including those who have intellectual disabilities, limited reading skills
or who are blind or have low vision. Facilities will not rely on resident, readers, or
other types of resident assistants except in limited circumstances where an
extended delay in obtaining an effective interpreter could compromise the
resident’s safety, the performance of first-response duties, or the investigation of
the resident’s allegations. Any use of these interpreters under these type
circumstances will be justified and fully documented in the written investigative
report. Residents receive information explaining the agency’s zero tolerance Policy
in an age-appropriate fashion including how to report incidents or suspicions of
sexual abuse or sexual harassment in the appropriate manner, taking into
consideration age, disabilities, sexual orientation, and language. The facility has a
cartoon style training book that is used to explain PREA to residents. The
comprehensive education is accessible to all residents, including those who are
limited English proficient, deaf, visually impaired, or otherwise disabled as well as to
the residents who have limited reading skills. If the youth report a deficiency or the
staff are aware of a deficiency in any of these areas, they will report to the
supervisor the need for an additional resource.
115.315 (b) FDJJ Policy mandates that information about services, consent forms,
rights, and program rules, etc. are communicated to youth with the use of
interpreters or other auxiliary aids. Also, these procedures will provide for an
effective exchange of information between staff/employees, youth and/or families
while services are being provided. All aid and/or assistance shall be provided by the
facility without cost to the person being serviced.
MRJDC will take such steps to provide reasonable accommodations as are necessary
to ensure that disabled persons, including those with impaired sensory, hearing or
speaking skills receive effective notice concerning benefits, services, or written
material concerning waivers of rights or consent to treatment. All aids needed to
provide this notice, e.g., sign-language interpreters, readers, or through other
auxiliary aids, shall be provided within the service limits and availability of qualified/
certified interpreters provided under contractual service without cost to the person
being served. The education department teachers are actively involved in providing
these services to residents. Residents that are special education receive an
Individualized Education Program meeting that includes parents, legal guardians or
child advocate. At the time of the audit, the center housed one artistic resident and
one resident that was cognitively challenged. Both were interviewed and indicated
that staff showed them the video and talked to them about PREA on an individual
basis.
Family members or friends of the youth may not be used as the sign language
interpreter, unless specifically requested by that individual. Other youth may not be
used to translate. The facility has a contract for language services including sign
language services. Staff would read all information required for an orientation into
the facility and the comprehensive PREA training for residents that can’t read. All of
the residents interviewed were able to articulate the training programs, recalled the
intake process and felt safe at the facility. At the time of the audit there were no
residents that required additional resources to receive training, reporting, or other
communication requirements. Whenever communication accommodations are
needed, the Program Director or Director of Clinical Services is responsible for
arranging for an interpreter or the use of another auxiliary aid to ensure reasonably
prompt and effective communication with the youth. In interviews with the mental
health staff, this is accomplished by assistance of the education staff.
The facility maintains an at-risk log that includes any medical or developmental
concerns that require assistance in providing services to the residents.
Exceed Compliance was determined by review of policy, language line contract, and
interviews with clinical supervisor director, education staff, facility administrator.
115.317 Hiring and promotion decisions
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Department of Juvenile Justice Policy 1919 – PREA
Department of Juvenile Justice Policy 1800 Background Screening
Five-year rescreening
DJJ Employee Handbook
BSU PREA Questionnaire
115.317 (a): MRJDC shall not hire or promote anyone who may have contact with
youth and shall not enlist the services of any contractor who may have contact with
youth, who. 1. Has engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C.
1997). 2. Has been convicted of engaging or attempting to engage in sexual activity
in the community facilitated by force, overt or implied threats of force, or coercion,
or if the victim did not consent or was unable to consent or refuse; or 3. Has been
civilly or administratively adjudicated to have engaged in or attempting to engage
in sexual activity in the community facilitated by force, overt or implied threats of
force, or coercion, or if the victim did not consent or was unable to consent or
refuse. 4. MRJDC shall consider any incidents of sexual harassment in determining
whether to hire or promote anyone, or to enlist the services of any contractor, who
may have contact with youth. MRJDC shall ensure that a criminal background
records check has been completed, and consult applicable child abuse registries,
before enlisting the services of any contractor who may have unsupervised contact
with youth. During initial interviews, prospective employees, interns, and volunteers
shall be informed of the background check procedure. MRJDC shall require the
following background checks on all DJJ staff, volunteers, interns, and contractors and
any applicant that is being considered for employment or promotion with DJJ: FDJJ
utilizes Live Scan Background checks on all staff. The program includes Florida
Crime Information Center, National Crime Information Center and Florida child
registry reviews.
115317 (b): The Agency Policy states any incidents of sexual harassment by a staff
member will be taken into consideration if the staff member is eligible for
promotion. Prior to a promotion the facility will conduct a promotion board. Prior to
meeting with the board, the applicant completes a questionnaire that includes all
areas of the standard. The interview questions for employment also address
previous misconduct. The evidence shows the facility considers any incident of
sexual harassment in determining whether to hire or promote anyone, or to enlist
the services of any contractor, who may have contact with residents. Policy states
any incidents of sexual harassment by a staff member will be taken into
consideration if the staff member is eligible for promotion. The interview questions
for employment also address previous misconduct. The evidence shows the facility
considers any incident of sexual harassment in determining whether to hire or
promote anyone, or to enlist the services of any contractor, who may have contact
with residents.
115.315 (c): During initial interviews, prospective employees, interns, and
volunteers shall be informed of the background check procedure. FDJJ shall require
the following background checks on all DJJ staff, volunteers, interns, and contractors
and any applicant that is being considered for employment or promotion with DJJ: 1.
Criminal background or records check. 2. Child abuse and neglect registry check.
The human resources staff indicated in interviewed and confirmed by reviewing
personnel files that she conducts a reference check on all prospective employees.
This check includes any past history of sexual abuse, sexual harassment including
sexual harassment toward other staff. During the last 12 months the facility has
conducted background checks on 87 people applying for a position at the facility.
There were 32 contractor background checks completed in the last 12 months.
115.317 (d): MRJDC shall ensure that a criminal background records check has been
completed, and consult applicable child abuse registries, before enlisting the
services of any contractor who may have unsupervised contact with youth.
115.317 (e): MRJDC shall conduct background checks or alternative background
checks on all staff, volunteers, interns, and contractors every five (5) years. FDJJ
utilized “Live Scan” for continuous background on staff, contracts or volunteers. This
includes a background check by the sheriff’s office. This was confirmed by reviewing
Live Scan background check for staff with 5 year or more tenure at the facility. At
the same time the agency conducts five-year background checks on all staff prior to
reaching their 5-year tenure.
115.317 (f): The agency asks applicants about previous misconduct described in
paragraph (a) of this section in written applications or during interviews for hiring or
promotions. The facility does a yearly staff appraisal and sexual abuse, or sexual
harassment is part of that appraisal This includes having staff review and sign the
BSU PREA Questionnaire
115.317 (g): FDJJ Policy 1800 – Background Screening and Hiring mandates that
employees and volunteers will report any arrest, which include any notice to appear
in court for a criminal charge, to their immediate supervisor within 24 hours of the
arrest or receipt of the notice to appear. Failure to report may result in disciplinary
action up to and including termination. Material omissions regarding such
misconduct, or the provision of materially false information, shall be grounds for
termination.
115.317 (h): Unless prohibited by law, the agency shall provide information on
substantiated allegations of sexual abuse or sexual harassment involving a former
employee upon receiving a request from an institutional employer for whom such
employee has applied to work. The interview with the Facility Administrator
confirmed the facility would provide this information if requested to do so. Policy
states the information would be provided when requested unless it is prohibited by
law to provide the information.
Based on the review of the documentation and the interview with the Facility
Administrator, and Human Resources staff the facility is complying of all provisions
of this standard. FJDC utilizes Live Scan which will provide any background
information while still completing a five-year background check on all staff with over
5-year tenure in the agency.
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Annual Facility Review June 2023
FDJJ Policy 1919 PREA
There have been no upgrades or expansion of the physical plant since the last PREA
cycle.
The center has been retrofitted with a new camera system that provides additional
camera coverages and utilizes the latest technology in the camera and monitoring
system.
The Facility Administrator showed the auditor several new cameras that have been
added in the last year. On a yearly basis the PREA coordinator and regional staff
conduct a review of the PREA and make recommendation for any upgrades or
additional cameras. The review for June 2023 did not recommend any additional
cameras.
Exceeds compliance was determined by review of the polices, camera video, tour of
the facility and interview with staff. Further exceed compliance was the modern
technology that was installed with the new system.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 PREA - Forensic Medical Exams
FDJJ Policy 1919 PREA - Investigative Protocols
Forensic medical Examinations
IG Compliance Form-directive 3-05
IG Directive 4-03
OIG request to Law Enforcement Officers to follow uniform evidence protocols.
Investigative protocol
MOU with Marion County Children’s Advocacy Center (Kimberly Cottage)
PREA Youth Posters
115.321 (a): Policy and directives provides for the uniform FDJJ Protocols to be
followed. The Protocol is outlined regarding appropriateness for youth and adults.
The FDJJ Protocol, developed by related professionals, addresses but is not limited to
interviewing; evidence collection; victim services; notifications; and prosecution of
sexual assault cases. The agency-based investigators (OIG) conduct administrative
investigations and the Marion County Sheriff’s Office investigate sexual abuse
allegations that are criminal in nature. The Sheriff’s Office agrees to follow the FDJJ
Protocol. Staff interviews confirmed an understanding of the facility’s protocol for
obtaining usable physical evidence if a resident alleges sexual abuse and
knowledge of the entities responsible for conducting investigations.
115.321 (b): and (F): The Department does not conduct criminal investigations into
youth related sexual abuse reports. Local Law enforcement and the Department of
Children and Families conduct such investigation involving youth in Florida. The
Department conducts administrative investigation and management reviews,
separate and apart for a criminal investigation. To the extent the agency is
responsible for investigating allegations of sexual abuse, the agency shall follow a
uniform evidence protocol that maximizes the potential for obtaining usable
physical evidence for administrative proceedings and criminal prosecutions. (b) The
protocol shall be developmentally appropriate for youth and as appropriate, shall be
adapted from or otherwise based on the most recent edition of the U.S. Department
of Justice’s Office on Violence Against Women publication, “A National Protocol for
Sexual Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly
comprehensive and authoritative protocols. Policy provides for the uniform Protocols
to be followed. The Protocol is outlined regarding appropriateness for youth and
adults. Staff interviews confirmed an understanding of the facility’s protocol for
obtaining usable physical evidence if a resident alleges sexual abuse and
knowledge of the entities responsible for conducting investigations.
115.321 (c): Policy and practice provides that forensic medical examinations will be
conducted by a qualified SAFE or SANE staff or if not, such staff is available by a
qualified physician. According to interviews with the Marion County Children’s
Advocacy Center, the center employs a qualified practitioner who would conduct the
evaluation at the Kimberly Cottage. The victim advocacy center and Florida DJJ
policy mandates that these services will be provided at no cost to the victim.
115.321 (d)(e): The facility does have a MOU with Marion County Children’s
Advocacy Center for victim advocacy services. This MOU includes advocacy services
and emotional support services. The center director was contacted and provided a
review of the program and services available to residents at they provide to
residents. The staff interviewed by telephone verified that the program had SANE
staff on duty and had a working relationship with Local Law Enforcement. A qualitied
victim advocate would accompany a resident for SANEs and during the
investigations. The advocate program would continue to offer emotional support,
crisis intervention and referrals. The center has full-time mental health staff that
would also provide crisis intervention as requested by the victim and as part of the
resident treatment plan. The center provided clinical staff documentation of
providing victim advocacy services if an advocate is not available at the time of a
sexual assault. The Kimberly Cottage have trained investigator to conduct the initial
investigation for victim of sexual abuse, incest, and trafficking. In interviews with
the staff at Kimberly Cottage, they indicated they use a holistic approach to children
that have suffered from victimization. This reduces the trauma and allows the child
to feel safe during the interview process.
115.321 (g) The facility has an MOU with Marion County Children’s Advocacy Center
(Kimberly Cottage).
Compliance was determined through the review of MOU with Victim Services Inc.
and interview with staff from Marion County Children’s Advocacy Center. The center
is a State-certified domestic violence center serving domestic violence victims of
Marion County and offers a variety of services to participants. Services provided are
confidential shelter, court advocacy, peer counseling, support groups, primary
prevention, transitional housing, economic empowerment workshops, 24-hour crisis
hotline and child therapy services. All services are free and confidential.
The center is in compliance with the standard based on review of policies and
contracts, interviews with Mental Health Provider, Medical Administrator, the Marion
County Children’s Advocacy Center staff and Chief of Investigations (OIG). The
program received an exceed due interviews with he mental health staff and
conversation with the Victim Advocate Center.
115.322 Policies to ensure referrals of allegations for investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 - Investigative Protocols
FDJJ MRJDC Facility Operating Procedures 3.01 Abuse-Free Environment
OIG Compliance Form-directive
OIG Directive request to Law Enforcement Officers to follow uniform evidence
protocols.
FDJJ Website Investigator Data Base
115.322 (a & b) MRJDC does not conduct criminal investigations for residents
related sexual abuse reports. Local Law enforcement and the Department of
Children and Families handle such investigation involving youth in Florida. The
Department conducts administrative investigation and management reviews,
separate and apart from a criminal investigation. The DJJ PREA Policy describes how
investigative responsibilities are handled for allegations of sexual abuse and
harassment can be found at the Florida DJJ's website. This information is available in
both English and Spanish. Further the agency has a Policy that requires allegations
of sexual abuse or sexual harassment be referred to an agency with the legal
authority to conduct criminal investigations unless the allegation does not involve
criminal behavior. Staff including the facility administrator and residents indicated
that any allegations that are received by residents, staff, volunteers, or contractors
would be “Hot Line” by the person with the most information when possible. This
information is sent to Central Control Center (CCC), Sexual Abuse Hotline and local
law enforcement within 2 hours of the first staff or volunteer is made aware of an
allegation. This information is documented on the Investigative database
maintained by the OIG office.
115.322 (c): FDJJ Policy 1919 and staff training mandates that that staff will secure
the scene, not let the victim or predator change clothing, brush teeth, use the
restroom or shower. The facility will assist the investigator in making available video
and other material as requested. There has been no allegation that was referred for
criminal investigation referral during the last 12 months.
Compliance was verified by reviewing policies, procedures, Florida DJJ website and
interviews with agency designee, facility administrator, investigators, staff, and
PREA Coordinator.
115.331 Employee training
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 PREA - Staff Training
PREA Acknowledgement form
Victimization and Sexual Aggressive
PREA Skill Pro training curriculum Part one and Part 2
PREA training 2023
PREA training 2021
PREA training 2022
PREA VSAB Training
115.331 (a): Marion Regional Juvenile Detention Center utilizes the Florida
Department of Juvenile Justice Training Program and augment the training for the
specialize residents’ programs components. All interviewed staff members were
familiar with the PREA information regarding primary components of preventing,
detecting and responding to sexual abuse or sexual harassment. PREA training is
provided to staff, as indicated by a review of policy and training documents. The
documents and staff interviews support refresher training are also conducted and is
documented. The direct care staff interviewed and the PREA Compliance Manager
reported the training is provided as required. All staff members interviewed, and
documentation reviewed verified the general topics below were included in the
training: 1. The center Zero Tolerance Policy for sexual abuse and sexual
harassment. 2. How to fulfill their responsibilities under the center sexual abuse and
sexual harassment prevention, detection, reporting, and response policies and
procedures. 3. Residents’ right to be free from sexual abuse and sexual harassment.
4. The right of residents and employees to be free from retaliation for reporting
sexual abuse and sexual harassment. 5. The dynamics of sexual abuse and sexual
harassment juvenile facilities. 6. The common reactions of juvenile victims of sexual
abuse and sexual harassment. 7. How to detect and respond to signs of threatened
and actual sexual abuse and how to distinguish between consensual sexual contact
and sexual abuse between residents. 8. How to avoid inappropriate relationships
with residents. 9. How to communicate effectively and professionally with residents,
including lesbian, gay, bisexual, transgender, intersex, or gender nonconforming
residents. 10. How to comply with relevant laws related to mandatory reporting of
sexual abuse to outside authorities; and 11. Relevant laws regarding the applicable
age of consent. The training is extremely thorough in each standard and application
of the standards.
115.331 (b): Such training shall be tailored to the unique needs and attributes of
residents of juvenile facilities and to the gender of the residents at the employee’s
facility. All employees receive training that includes managing and communicating
with male and female residents. The facility houses male and female residents. The
training considers the needs of the population as determined by a review of training
curricula and interviews with random staff. The agency training for all staff also
includes working with LGBTI youth in DJJ facilities. Additionally, the agency has
developed training for First Responder duties and responsibilities.
115.331 (c): The agency provides each employee with refresher each year to ensure
that all employees know the agency’s current sexual abuse and sexual harassment
policies and procedures. In recent years the yearly in services added a video on
conducting cross gender or persons frisk searches (pat down). All staff are required
to complete this training. Training roster and training records were reviewed and
documented this training for staff working at MRJDC. Additional training is provided
at the facility for the onsite training staff. A review of the topic included an
additional refresher to most topics found in the Skill Pro Curriculum. The agency
Policy addresses PREA-related training for staff.
All interviewed staff members were familiar with the PREA information regarding
primary components of preventing, detecting and responding to sexual abuse or
sexual harassment. Interviews with non-direct care staff and contracting staff and
files of non-direct care and contracting staff confirmed that all staff working at
MRJDC receive the same training.
Staff attend the FDJJ training academy ant receive the initial training at the
academy. In interviews with staff, each indicated that PREA was discussed on a daily
basis and a formal training is a four hour training by instructors and completed the
skill pro which includes a questionnaire.
Policy and procedure mandate that staff are training a minimum of once each year.
All staff indicated they had to complete preservice prior to working with any
residents. Several stated they had to shadow staff for at least two weeks after
receiving their preservice training.
115.331 (d): The agency document training, through employee signature or
electronic verification that employees understand the training they have received.
The policy provides all training to be documented. Staff members sign training
rosters and training acknowledgement statements. A checklist is utilized for
orientation training for all new employees and contains the elements of PREA
training. The facility provided the Auditor with several examples for verification of
the training occurring and the training was verified through staff interviews. PREA
training is provided to staff, as indicated by a review of policy and training
documents. The documents and staff interviews support refresher training is also
conducted and is documented. The direct care staff interviewed and the PREA
Compliance Manager reported the training is provided as required. All direct care
staff members interviewed, and document reviewed verified the general topics
below were included in the training: At the facility, it was evident through
documentation, interviews, and observation of the day-to-day operations the staff is
trained continually about the PREA standards during shift briefings, monthly staff
meetings, and the completion of various on-line and instructor led trainings.
MRJDC requires staff to go through PREA training on a quarterly bases and each
month when an all-staff meeting. Staff interviewed indicated that one of the
administrators meets with the staff during staff briefings at least once a month to
discuss PREA related topics. There are over 10 Posters about Sexual safety located
throughout the facility. Many of the staff interviewed were able to articulate each of
the training topics and explain how the facility manages these topics. Several staff
articulates that the Facility Administrator would ask them about PREA on his daily
rounds at the facility. The staff credited their training in preventing any sexual abuse
or sexual harassment at the facility.
Exceed Compliance was determined by reviewing preservice and in service training
curriculum and a review of the training records of staff. An interview with random
staff also confirmed that they received the training and refresher training as
mandated by policy. Interviewed included questions about the specialized training
programs. Staff were able to articulate an understanding of working with LGBTI
youth.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Volunteers and Contractors Training
Educator Training
Medical Staff Training
FDJJ Policy 1919 - Volunteer and contractor Training
FOP 1.01 Background and Training for Volunteer and Contractors Training Sign in
Sheets
FDJJ Policy 8.17 Volunteer/Contractor Information Sheet (PREA)
115.332 (a): Prior to having contact with the residents all volunteers and
contractors receive training on their responsibilities under the agency’s sexual
abuse and sexual harassment prevention, detention, and response policies and
procedures. The level and type of training provided shall be based on the services
they provide and the level of contact they have with residents, but all volunteers
and contractors who have contact with residents shall be notified of the agency’s
zero tolerance Policy regarding sexual abuse and sexual harassment and be
informed how to report such incidents.
115.332 (b): All volunteers and contractors who have contact with residents shall be
notified of the agency’s zero-tolerance Policy regarding sexual abuse and sexual
harassment and informed how to report such incidents.
115.332 (c): The agency shall maintain documentation confirming that volunteers
and contractors understand the training they have received. The PREA Notification
document contains the information reviewed with the contractor and volunteer. The
document also serves as the training acknowledgement statement containing the
signature of the participant and the date, confirming their understanding of the
PREA information. During the last year 11 contractors received contractor training.
During the audit the Auditor interviewed the Lead Teacher to discuss contracting
teacher training. The medical director also discussed the training medical staff
attend as contractors.
A review of the training curriculum, staff acknowledge forms and interviews with
contractor, personnel staff and PREA compliance manager confirm compliance with
this standard.
115.333 Resident education
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 - Youth Training and education
PREA acknowledgement form
Ten Different PREA Brochures (French Creole, Spanish, and English)
Special accommodations for disability
Youth education sign in Youth training Education material
Advocacy Posters including National Child Abuse
PREA Education Rosters
Resident acknowledgement forms
PREA Education Video
15 Resident Files
115.333 (a): The agency shall provide resident education in formats accessible to
all residents, including those who are limited English proficient, deaf, visually
impaired, or otherwise disabled, as well as to residents who have limited reading
skills. The agency maintains documentation of participation in the education
program. In addition to providing such education, the agency shall ensure that key
information is continuously and readily available or visible to residents through
posters, resident handbooks, or other written formats. The center conducts initial
training on all new residents when received at the facility usually within 72 hours
that provide all aspects of the training requirements. At the present time the facility
is providing comprehensive training when resident complete the intake process. The
resident and parent get a copy of the resident handbook that contains information
about PREA. One resident that was artistic and one resident that was cognitive
challenged were interviewed. Each indicated they saw the video and staff meet with
them after the video and discussed PREA and how to report. Each indicated that the
mental health staff told them to contact her anytime they felt unsafe.
115.333 (b): Residents receive information explaining the agency’s zero tolerance
Policy in an age-appropriate fashion including how to report incidents or suspicions
of sexual abuse or sexual harassment in the following manner. The comprehensive
education is in a format accessible to all residents, including those who are limited
English proficient, deaf, visually impaired, or otherwise disabled as well as to the
residents who have limited reading skills. The facility has the capability of providing
the PREA education in formats accessible to all residents including those who may
be limited English proficient; deaf; visually impaired, or otherwise disabled, and to
residents who have limited reading skills. According to documentation and interview
with Facility Director and the Assistant Facility Administrator, the local school
system will assist with the provision of services for disabled and limited English
proficient residents. If the youth report a deficiency or the staff are aware of a
deficiency in any of these areas, they report to the supervisor the need for an
additional resource. The supervisor notifies the facility administrator who will
contact the appropriate community resource services including the local board of
education. Arrangements will be made for an interpreter who can interpret
effectively, accurately, and impartially, both receptively and expressively, using any
necessary specialized vocabulary, when necessary. In all circumstances this center
will not rely on resident interpreters. Special needs youth are provided training that
is age and maturity-based training per FOP Special Needs. Compliance was
confirmed by review of the. The staff conducting the comprehensive training
reviews the resident brochure and read the training that is found in a “comic strip”
type training book.
115.333 (c): FDJJ Policy 1919 - Youth Training and education requires that residents
receive such education upon arrival or transfer at the facility and shall receive
education upon transfer to a different FDJJ center to the extent that the policies and
procedures of the resident’s new facility differ from those of the previous center.
115.333 (d): The agency shall provide resident education in formats accessible to all
residents, including those who are limited English proficient, deaf, visually impaired,
or otherwise disabled, as well as to residents who have limited reading skills. The
facility has the capability to provide the PREA education in formats accessible to all
residents including those who may be hearing impaired; Deaf; have intellectual,
psychiatric and speech disabilities; low vision; blind; limited reading, limited English
proficient, and based on the individual need of the resident. Documentation was
reviewed of a contracting service for language lines. Posted PREA information is in
English and Spanish accessible to residents, staff, contractors, volunteers, and
visitors. Staff interviews confirmed residents are not used as translators or readers
for other residents. The facility staff indicated that the facility director, education
supervisor and medical staff would work with the community resources to provide
education to residents regardless of their limitations or disabilities. The education
department assists in providing information one-on-one in large print, visual aid and
magnifiers, translation, and other services through the residents individual
Education Plan.
115.333 (e): The agency shall maintain documentation of resident participation in
these education sessions. A sample of signed acknowledgement statements were
reviewed which supported the residents’ involvement in PREA education sessions.
The residents were aware of PREA information, including their rights regarding
PREA, how to report allegations and that they would not be punished for reporting
allegations of sexual abuse or sexual harassment. The Intake staff were interviewed
regarding PREA education for residents. Staff ensures residents’ receipt of the
information, including the resident signing the acknowledgement form. A review of
fifteen (15) resident files confirmed they acknowledged they received a PREA
orientation. during intake and a comprehensive training within 10 days of arrival at
the facility. In the last 12 months 849 residents received comprehensive training as
indicated in the PAQ.
115.333 (f): In addition to providing such education, the agency shall ensure that
key information is continuously and readily available or visible to residents through
posters, resident handbooks, or other written formats. The PREA education
materials provide residents information on how to report allegations of sexual
harassment and sexual abuse. A safety guide is provided to each resident to
eliminate incidents of sexual abuse and sexual harassment. The guide provides
educational information regarding sexual abuse and victims in a cartoon format. The
residents revealed they can report allegations of sexual abuse or sexual harassment
by telling a staff member or telling a family. There was PREA educational
documentation noted throughout the facility including the lobby, visitation and
living units.
All residents interviewed formally and informally during tour and subsequent visits
to the recreation area confirmed that their therapist of administrative staff talks to
them on a daily basis about PREA. They indicated that the staff that conduct round
will ask them questions about PREA. They also indicated that during their initial
treatment team meetings the therapist will talk about PREA with their parents.
Exceed Compliance was determined by review of the agency policies, training
curriculum, posters, and resident files and interviews with staff and residents.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Prison Rape Elimination Act - OIG investigator training PREA Management
PREA Compliance Form 2022
PREA Current Inspector Training Roster
115.334 (a): MRJDC does not conduct any form of administrative or criminal sexual
abuse investigation. All OIG investigators undergo extensive training prior to
conducting administrative investigations which includes the “Basic Investigation
Training” requirement.
115.334 (b): In addition to the general training provided to all employees pursuant
to §115.331, the agency shall ensure that, to the extent the agency itself conducts
sexual abuse investigations, its investigators have received training in conducting
such investigations in confinement settings. Provision (b): Specialized training shall
include techniques for interviewing juvenile sexual abuse victims, proper use of
Miranda and Garrity warnings, sexual abuse evidence collection in confinement
settings, and the criteria and evidence required to substantiate a case for
administrative action or prosecution referral. A copy of the training curriculums was
accessible to the auditor and was reviewed for compliance with this standard.
115.334 (c): The agency provided certifications from all staff that have received the
specialized training. There are 12 trained OIG inspectors at the time of the onsite
audit.
Compliance was determined by review of the training curriculum, interviews with
chiefs of investigations, PREA coordinator and the facility administrator.
115.335 Specialized training: Medical and mental health care
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 -
Specialized Training Medical-MH Medical training
Mental health training
PREA-Mental Health and Medical Professionals Specialized training for medical and
mental health
PREA-Mental Health and Medical Professionals Skill Pro Medical/Mental Health
Modules
115.335 (a): FDJJ Policy 1919 PREA - Specialized Training Medical-MH Medical
training provides medical and mental health staff members receive the regular
PREA training and the specialized training is provided as part of FDJJ Sill Pro training
modules. In addition to the Zero Tolerance policy, all full- and part-time medical and
mental health care practitioners will be trained in the following: 1. How to detect
and assess signs of sexual abuse and sexual harassment. 2. How to preserve
physical evidence of sexual abuse. 3. How to respond effectively and professionally
to juvenile victims of sexual abuse and sexual harassment. 4. How and to whom to
report allegations or suspicions of sexual abuse and sexual harassment. 5. Medical
and mental health practitioners are required by mandatory reporting laws to report
sexual abuse. 6. Medical and mental health practitioners shall inform residents at
the initiation of services of their duty to report and the limitations of confidentiality
regarding sexual abuse.
115.335 (b): Forensic medical examinations are not conducted by the facility
medical staff or mental health staff.
115.335 (c): The facility acknowledges training indicating that medical and mental
health staff had attended medical specialized training. Based on PAQ 100% of the
medical and mental health employed at the center have received specialized
training.
115.335 (d): The mental health and medical staff completed the general and
refresher training provided for all staff members. Since this a diverse population of
residents the clinical staff provide additional training on de-escalation, suicide
prevention, recognizing the needs of transgender residents, and sexual orientation,
gender identify expression.
A review of the training curriculum, acknowledgement documentation and interview
with medical and mental health staff confirmed that the staff have received
specialized training and generalized training as required by standards and have
additional training that exceeds the expectations of the standards.
115.341 Obtaining information from residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Screening procedures Vulnerability for Victimization and Sexual Aggressive Behavior
(VSAB)
FDJJ Policy 1919 - Screening (VSAB) Sample VSAB female/ Male
Suicide Risk Screening Instrument
FDJJ Facility Operating Procedure 3.03 Behavioral Confinement Staff VSAB Training
115.341 (a) and (b) FDJJ Policy 1919 PREA - Screening mandates that all residents
will be interviewed using an objective screening instrument for risk of victimization
potential vulnerabilities or sexual abusiveness tendencies to act out with sexually
aggressive predatory behavior within seventy-two (72) hours. All residents are
screened within twenty-four hours upon arrival at the facility to determine
placement and their special needs. The medical and mental health screenings,
conversations, classification assessments as well as reviewed court records and
case files. The Florida Department of Juvenile Justice has developed a seamless
system to provide youth in the State a Florida the best possible program to succeed.
Prior to arriving at the facility, the Juvenile Assessment Center will meet with the
resident, review PREA and conduct the VSAB screening. This information is
transported in a sealed envelope to the facility intake staff. When the resident
leaves the Regional Juvenile Detention Center, the VSAB accompanies the resident.
Medical and mental health review the VSAB prior to admission of the resident. The
intake staff will administer a new VSAB when the resident arrives at the facility. FDJJ
Policy 1919 - Screening (VSAB) mandates that staff conduct a screening. All
residents that make an allegation or sexual abuse or are named in the sexual abuse
allegation will be rescreened. Medical, mental health, and supervisory staff may
conduct an additional rescreening based on reasonable concerns of the resident
safety. There were 531 residents that remained at the center for more than 72
hours. However, all residents receive the VSAB screening prior to be transported to
the Detention center.
All staff that utilize the VSAB must complete the Skill Pro Training on conducting
Screenings. The facility uses the information gathered to make room and
programming assignments for the residents with the goal of keeping him safe and
free from sexual abuse. The program is prohibited from using isolating. The staff
members conducting the intake process will complete the screening using the PREA
screening tool and will immediately report any heightened risks to the supervisor on
duty before making housing decisions. Residents will be reassessed as needed. A
review of the resident files determined that most residents have been rescreened on
several occasions. Resident that was involved in an allegation of sexual abuse or
sexual harassment were rescreened during the investigative process.
115.341 (c): Risk of Victimization and Sexually Aggressive Behavior screening
include mental, physical, or developmental disabilities, age, physical build, prior
incarcerations, criminal history (violent and non-violent), prior convictions for sex
offenses against an adult or child, prior acts of sexual abuse, prior convictions for
violent offenses, history of prior institutional violence or sexual abuse, prior sexual
victimization, perception of vulnerability, and if the resident is or is perceived to be
(LGBTQI) or gender nonconforming.
115.341 (d): FDJJ Policy mandates that all residents will be interviewed using an
objective screening instrument for risk of victimization potential vulnerabilities or
sexual abusiveness tendencies to act out with sexually aggressive predatory
behavior within seventy-two (72) hours. Screening staff interviewed indicated staff
review the residents court records, suicide screening reports, family information and
any other documents that are provided to them at the time of intake. The screening
staff utilizes the screening instrument during the initial intake process that includes
conversation with the resident in a private setting. The screening staff indicated
they introduce the screening instrument to the resident by explaining the purpose
of the questions and acknowledges to the residents that that the know they just had
the same questions, but it is important in order to make sure they are safe and get
the most out of the stay at the center. After the initial screening or prior to the
screening the medical staff interviews the residents and conducts a medical
screening. The nurse indicated she talks about sexual transmitted diseases and
residents’ perception of vulnerability. The clinical staff then interview the resident,
review the resident’s file, the VSAB and suicide screening and have a general
conversation with the resident to determine the clinician opinion on best placement
for the residents.
The auditor reviewed an intake and noted that medical saw the resident and then
the resident was interviewed in a private office by a case manager where they were
reviewing the previous VSAB with the resident and asking him questions from a new
VSAB he was completing on the resident.
Based on the review of the agency Policy and procedures, observations and
information obtained through staff and resident interviews, and review of 15
resident files, the facility has demonstrated compliance with this standard.
115.342 Placement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives and documentation were reviewed in formulating
compliance with this standard:
FDJJ Policy 1919 - Placement of Youth
MHSA Intake and Screening
Alert Screening Wizard
Staff VSAB Training
Screening information
VSAB skill Pro training
Suicide Risk Screening Instrument sample
Statement of Fact
115.342 (a): FDJJ Policy 1919 - Placement of Youth establishes protocol to house
residents in a safe environment, taking into consideration his VSAB, programming
plan, and sexual orientation. There were no transgender residents at the center
during the onsite audit. The clinical director indicated the center would take into
consideration the residents housing assignment in determination of their
assignment. The resident’s perception and own views with respect to her safety
would be given serious consideration when making the housing placement decision.
Procedures state screening information shall be used to determine housing, bed,
work, education, and programming assignments within the facility in order to keep
potential victims away from potential abusers. The computerized management
system will initiate a code for identified predator, potential predator, high
aggression risk, moderate aggression risk, identified prey, potential prey, high
victimization risk, moderate victimization risk. The screening alert system (Alert
Screening Wizard utilizes the intake VASB and related documentation to identify
residents that are at risk of being victimized or being a predator. The instrument
provides the clinical staff with information that is utilized for single room housing,
placement options, and mental health follow-up requirements.
115.342 (b): Individualized determinations are made about how to ensure the
safety of each resident. Residents who score at risk of victimization or abusiveness
are referred for further evaluation with the Mental Health provider. Residents have
an option of refusing these services. The center has not segregated or removed
residents from the program for a PREA incident in the last 12 months. The agency
PREA compliance manager, and facility administrator interviewed indicated that the
center would comply with requirements of the standard if transgender were housed
at the facility. The Facility Administrator indicated that the initial screening and any
updated screening information is considered for placement of residents on a
continuous basis.
115.342 (c): Policy and practice mandates that making housing and programming
assignments for transgender or intersex residents, the facility will consider on a
case by-case basis whether the placement would present management or security
problems.
115.342 (d) – (f) A transgender or intersex resident’s housing and program
assignments will be reassessed every six months to review any threats to safety
experienced by the resident. Transgender and intersex residents’ placement and
programming are reviewed as needed, but at least every six months. A transgender
or intersex residents’ own views of their safety is taken into consideration.
115.342 (g-I) Transgender and intersex residents are offered the opportunity to
shower separately from other residents as indicated in their Statement of Search/
Shower/Pronoun Preference Form. The facility did have a transgender or intersex
resident during the audit period. The facility does not use isolation to separate
residents. The facility has one-man rooms and multiple housing unit to house
residents. The center has not segregated or removed residents from the program for
a PREA incident in the last 12 months.
The agency PREA coordinator, and facility administrator interviewed indicated that
the center would comply with requirements of the standard if transgender were
housed at the facility. The Facility Administrator indicated that the initial screening
and any updated screening information is considered for placement of residents on
a continuous basis.
The staff place predator resident close to the officers’ station and/or mandates
single room assignments.
Compliance of this standard were determined by review of the screening
instrument, interviews with medical and mental health director, and facility
administrator.
115.351 Resident reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
CCC Florida Administrative code 63F FDJJ Policy 1919 PREA –
Youth reporting General Counsel - PREA immigration status. Youth/Parent Handbook
PREA Brochures
Memo from DJJ General Counsel – Civil Immigration.
Employee Handbook
Mail and phone procedures
Youth reporting Posters
MRJDC Facility Operating Procedures 3.01 Abuse-Free Environment
2020 Florida Statues Title V Chapter 39 Proceedings related to Children.
115.351 (a) The above policies and External reporting mechanism identifies the
multiple internal ways for residents to report sexual abuse and harassment
incidents, retaliation, staff neglect or violation of responsibilities that may have
contributed to such incidents. Included are reporting to the Department of Children
and Family hotline, or to Central Communication Center Hotline. Both of these
hotlines may be confidential. Reports to these entities will be received and will be
forwarded to the Office of Inspector General or local Child and Family program.
Policies also identified the resident’s accessibility to filing a grievance,
communication (telephone, visitation, and correspondence) with their attorney and/
or parent/guardian, staff providing access to the hotline without asking the resident
the purpose of the call, the staff requirement of mandatory reporting and
completing an incident report. The department has provided a method for staff to
privately report sexual abuse and sexual harassment of residents. Florida Law
explicitly mandates reporting of sexual abuse sexual harassment. It also established
a State Child Abuse Hotline which is under the supervision of the Department of
Children and Family Services. The reporting of child abuse, abandonment, or neglect
is codified in 2020 Florida Statues Title V Chapter 39-“39.201” Mandatory reports of
child abuse, abandonment, or neglect; mandatory reports of death; central abuse
hotline.— (1)(a) Any person who knows, or has reasonable cause to suspect, that a
child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or
other persons responsible for the child’s welfare, as defined in this chapter, or that a
child is in need of supervision and care and has no parent, legal custodian, or
responsible adult relative immediately known and available to provide supervision
and care shall report such knowledge or suspicion to the department in the manner
prescribed in subsection (2). (b) Any person who knows, or who has reasonable
cause to suspect, that a child is abused by an adult other than a parent, legal
custodian, caregiver, or other person responsible for the child’s welfare, as defined
in this chapter, shall report such knowledge or suspicion to the department in the
manner prescribed in subsection
(2). (c) Any person who knows, or has reasonable cause to suspect, that a child is
the victim of childhood sexual abuse or the victim of a known or suspected juvenile
sexual offender, as defined in this chapter, shall report such knowledge or suspicion
to the department in the manner prescribed in subsection (2). (d) Reporters in the
following occupation categories are required to provide their names to the hotline
staff: 1. Physician, osteopathic physician, medical examiner, chiropractic physician,
nurse, or hospital personnel engaged in the admission, examination, care, or
treatment of persons; 2. Health or mental health professional other than one listed
in subparagraph 1.; 3. Practitioner who relies solely on spiritual means for healing;
4. School teacher or other school official or personnel; 5. Social worker, day care
center worker, or other professional childcare, foster care, residential, or
institutional worker; 6. Law enforcement officer; or 7. Judge.” Talk to, call or send a
letter or note to any of the following: A staff member you trust. Program
Administrator Your attorney or advocate Your parents or guardians Child Abuse
Hotline, Central Communication Center Hotline. Residents have the right to privately
report sexual assault, abuse, harassment or retaliation by other residents or staff for
reporting sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents to Direct Care Staff,
Volunteer, Intern, Supervisor, PREA Compliance Manager, and Facility Administrator
Resident can request facility staff call CCC, Sexual abuse registry (DCF), victim
advocate center to make an allegation of sexual abuse or sexual harassment. These
programs were called using the telephone available for residents and was able test
the telephone. In each case the auditor was able to make a report to the program.
CCC responded to the report by text to the facility administrator. There are
telephones located in the common group room area of the facility. The center has
posters for the Ocala Sexual Abuse hotline that was called and was disconnected. A
search of the center found that the program was no longer available. The auditor
recommended that the center pull this poster. The center also has a poster for the
Kimberly Cottage which is Part of the Marion County Victim Advocacy program and
is utilized to provide SANE and emotional support. This number was answered by
staff at the Kimberly Cottage.
115.351 (b): The agency shall also provide at least one way for residents to report
abuse or harassment to a public or private entity or office that is not part of the
agency and that is able to receive and immediately forward resident reports of
sexual abuse and sexual harassment to agency officials, allowing the resident to
remain anonymous upon request. Residents may call the Child sexual abuse hotline
or Central Control Center. Residents may request to use a telephone with some
degree of privacy to call the hotline without having to obtain staff permission and
that mandates staff not to question residents about the reason for the call. A
resident can request writing materials to write and send a letter to one of these
sources. Random residents interviewed were aware of the abuse hotline and were
able to articulate how they could gain access.
115.351 (c): Staff shall accept reports made verbally, in writing, anonymously, and
from third parties and shall promptly document any verbal reports. The staff
interviews confirmed the methods available to residents for reporting allegations of
sexual abuse and sexual harassment. Staff members are required to accept third
party reports and to document verbal reports. All residents interviewed revealed
they are familiar with the provisions of the standard. The resident interviews
demonstrated their familiarity with the various ways they may report either in
person, in writing, by phone, completing a PREA/grievance or Medical Request Form,
or through a third-party. The residents were aware third-party reports could be made
and that reports can be made anonymously. Staff members interviewed were aware
of their duty to receive and document third-party reports.
115.351 (d): The facility provides residents with access to tools necessary to make
a written report. Writing materials are readily available for residents to complete the
accessible forms. Prior to the site visit pictures were sent to the auditor showing the
reporting forms such as PREA/Grievance forms and Medical Request Forms and the
accessibility of writing utensils. During the site visit and while on the site review, the
auditor observed the accessibility of writing utensils to the residents. Staff must
report sexual abuse and sexual harassment immediately to the Facility
Administrator and must immediately notify the State Sexual Abuse Registry Hotline.
Staff and Facility Administrator confirmed that staff may report directly to the facility
administrator, and he will coordinate with the staff to call CCC, sexual abuse
registry, local law enforcement and legal guardian.
115.351 (e): Staff may make anonymous reports of sexual abuse and sexual
harassment of residents to their local law enforcement, state reporting agency
(CCC), Department of Family and Children Hotline, PREA Coordinator, facility
administrator or the PREA compliance manager.
Compliance was determined by review of posters, policy, and interview with staff,
calls to CCC, child abuse registry hotline, and PREA Coordinator.
115.352 Exhaustion of administrative remedies
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 Youth Grievance
Youth/Parent Handbook
Youth Grievances Forms
Florida Administrative Code Rule 63f-11 Central Communications Center (CCC)
15.252 (a): Resident may file a grievance regarding sexual abuse or sexual
harassment. However, the director will forward the grievance to the CCC within 2
hours of receiving the grievance. The facility will not undertake investigations of the
grievance, however if it is an emergency grievance and the resident claims or
appears to be imminent danger or if the grievance claims staff member sexual
abuse, the facility director will take immediate steps to protect the resident, to
preserve the crime scene and to remove the staff from the areas where the resident
is housed or placed staff member on administrative leave pending investigation.
Instructions on how to file grievances are provided to residents on PREA Education
Manual for Residents and PREA posters. While the agency utilizes the Grievance
system only for residents to make allegations of sexual abuse or sexual harassment,
the grievance system does meet the standards for reporting non PREA related
allegations.
Florida Administrative Code Rule 63f-11 Central Communications Center (CCC)
requires that any allegation of sexual misconduct or youth-on-youth sexual activity
be reported to the CCC. The person making the report shall provide basic
information such as the date and time of the incident, where the incident occurred,
the supervising staff, and who may be involved. The CCC will make appropriate
notification to senior DJJ management who will in turn make subsequent notification
to management overseeing the facility where the alleged abuse occurred. Other
than making appropriate notification through Department channels, staff should
take no further actions other than those directed by law enforcement or first
responders. There is no time limit on when a youth may report an allegation of
sexual misconduct. Youth shall be provided multiple internal ways to privately report
sexual misconduct, retaliation by other youth or staff for reporting sexual
misconduct, and staff neglect or violation of responsibilities that may have
contributed to such incidents.
Compliance was determined by review of the policies, interview PREA compliance
managers, residents, and presence of grievance provides a procedure for residents
to submit grievances regarding sexual abuse and the agency has procedures for
dealing with these grievances.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
DJJ Policy 1919 - Outside Support
MOU - Rape Crisis Agreement Marion County Children’s Advocacy Center
MOU/ Interview
Child Help National Child Abuse Hotline
Brochures English US Citizenship and Immigration Services – Spanish
Memo for Chief DJJ attorney N/A
Victim Advocate Brochures
115.353 (a): DJJ Policy 1919 mandates the facility shall provide residents with
access to outside victim advocates for emotional support services related to sexual
abuse, by providing, posting, or otherwise making accessible mailing addresses and
telephone numbers, including toll free hotline numbers where available, of local,
State, or national victim advocacy or rape crisis organizations, and, for persons
detained solely for civil immigration purposes, immigrant services agencies. The
facility shall enable reasonable communication between residents and these
organizations and agencies, in as confidential a manner as possible. MRJDC ensures
residents are provided access to outside confidential support services. The facility
has established an MOU with Marion County Children’s Advocacy Center which
provides emotional support, counselling, follow-up support, and referral for
treatment after release or transfer to another facility. The staff indicated that
besides providing victim advocacy, they provide a telephone number that will allow
the resident to talk to a trained counselor for emotional support. They would also
make arrangements to visit with the victim or have the victim brought to them or
another location if allowed by the facility.
The MRJDC does not house residents for solely civil immigration purposes. There
are posters located throughout the facility regarding US Citizenship and Immigration
Services and corresponding address and telephone number.
115.353 (b): The facility shall inform residents, prior to giving them access, of the
extent to which such communications will be monitored and the extent to which
reports of abuse will be forwarded to authorities in accordance with mandatory
reporting laws. The policy addresses confidentiality of the advocacy support
services. The resident receives information regarding the limitations of
confidentiality during the intake process. An acknowledgement statement specific to
the review of the reporting and advocacy services contains information regarding
the advocacy services to be provided by Marion County Children’s Advocacy Center.
When contacted by phone the center’s staff explained they always tell the caller
that the telephone calls or confidential however, they have a responsibility to report
allegations of child abuse or child neglect.
115.353 (c): The agency shall maintain or attempt to enter into memoranda of
understanding or other agreements with community service providers that are able
to provide residents with confidential emotional support services related to sexual
abuse. The agency shall maintain copies of agreements or documentation showing
attempts to enter into such agreements. The FOP states the resident may use the
phone, located on each living unit, and push the appropriate number to gain access
and speak with a victim advocate. The agency is identified on the signage along
with directions for reporting allegations or requesting advocacy services. The Facility
Administrator confirmed the availability and accessibility of outside confidential
support services to residents.
115.353 (d): The facility shall also provide residents with reasonable and
confidential access to their attorneys or other legal representation and reasonable
access to parents or legal guardians. The interview’s confirmed residents have
access to attorneys and court workers and reasonable access to their parents/legal
guardians. The site tour revealed areas where residents could meet privately with a
legal representative and the visitation area for visits with family members. All
residents interviewed stated families could visit and they provided the days and
times of visitation and for phone calls. Residents interviewed confirmed the facility
would allow them to see or talk with their lawyer, another lawyer, or a court
representative privately. Residents interviewed confirmed the facility would allow
them to see and talk with their parents or someone else, such as a legal guardian.
Visitors to the facility are informed of PREA.
The Facility Administrator confirmed the facility provides residents with reasonable
and confidential access to their attorneys or court representatives and reasonable
access to parents or legal.
Residents interviewed formally and informally while tour the facility indicated they
are allowed to visit their families and are allowed to talk privately with their parent
of legal counsel.
Compliance was determined by review of center visitation rules, policies, and
memorandums, poster located throughout the facility and interview with Staff of
Kimberly Cottage, facility administrator and random staff and residents.
115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
PREA Brochure
Posted Information National Child Abuse Hotline
FDJJ Website
FDJJ Policy 1919 PREA- Third Party Reporting
FDJJ Policy 1.12 Incident Reporting
PREA Posters
MRJDC shall provide youth with reasonable and confidential access to their
attorneys or other legal representation and reasonable access to parent(s) or legal
guardian(s) in accordance with DJJ Policy. Third Party Reporting process, instructs
staff to accept third party reports from any source, provides information for anyone
who sees or suspects sexual abuse, sexual harassment, or victimization of any kind
to report it promptly through FDJJ websites provides the public with information
regarding third party reporting of sexual abuse or sexual harassment on behalf of a
resident.
Additionally, the staff provides the parent/guardian with a packet containing varied
forms, victim advocate services and third-party reporting information.
Reporting Posters were posted in the visitation room during the audit and the main
lobby of the facility. The youth/family handbook contains phone number and the
various ways for families to make notification of sexual abuse or sexual harassment
to FDJJ or to MRJDC.
Compliance was determined by interviews with random staff and residents as well
as review of policies and posters.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 PREA; - Reporting Allegations
FDJJ Staff PREA Education and Training
Florida Code 39 Section 201-2020
FDJJ Policy 1.12 Incident- CCC reporting Staff Training
FOP 3.09 Staff and Agency Reporting
115.361 (a) (b): During the intake process, residents are informed of the facility’s
duty to report and the limitations of confidentiality. Medical and Mental Health Staff
meet with the resident upon arrival at the facility. Medical conducts a nurse’s
appraisal and mental health does a suicide screening. During the intake process
residents are informed on their duties to report and sign an acknowledgement form.
1. Employees, Contractors, and Volunteers are required to immediately report any of
the following:
a. Knowledge, suspicion, or information regarding an incident of sexual abuse,
sexual harassment, or exploitation that occurred in the facility.
b. Retaliation against residents or employees who reported such an incident.
c. Any employee, contractor, or volunteer neglect or violation of responsibilities
that may have contributed to an incident or retaliation.
3. Any employee, contractor, or volunteer suspecting abuse, neglect, or exploitation
must immediately report the incident to DJJ CCC and child abuse registry hotline. 4.
Following a report, the employee, volunteer, or contractor suspecting sexual abuse
or sexual harassment will immediately notify the PREA Compliance Manager or
Administrator On-Duty.
5. If an alleged crime occurs against a child or adolescent, the PREA Compliance
Manager, Administrator On-Duty, or designee shall immediately notify law
enforcement authorities.
6.The alleged victim’s parents/legal guardians will also be notified, unless the
facility has official documentation showing the parents or legal guardians should not
be notified.
7.If a juvenile court has jurisdiction over the alleged victim, and contact information
is able to be obtained, the Administrator On-Duty or designee will also report the
allegation to the alleged victim’s attorney, juvenile probation officer, or other legal
representative of record within 14 days of receiving the allegation.
All attempts to contact the child’s attorney or receive contact information for the
child’s attorney will be documented. FDJJ Policy 1919 - Reporting Allegations and
FDJJ Staff training mandates that all employees, volunteers, interns, and contractors
shall immediately report to their supervisor any knowledge, suspicion, or
information regarding an incident of sexual abuse or sexual harassment that
occurred in the facility, retaliation against residents or staff who reported such an
incident, and any staff neglect or violation of responsibilities that may have
contributed to an incident or retaliation. Upon receiving any allegation of sexual
abuse, facility administrator promptly reports allegations to the Agency’s Central
Control Center (CCC). Florida Administrative Code Rule 63f-11 Central
Communications Center (CCC) requires that any allegation of sexual misconduct or
youth-on-youth sexual activity be reported to the CCC. The person making the
report shall provide basic information such as the date and time of the incident,
where the incident occurred, the supervising staff, and who may be involved. The
CCC will make appropriate notification to senior DJJ management who will in turn
make subsequent notification to management overseeing the facility where the
alleged abuse occurred. Other than making appropriate notification through
Department channels, staff should take no further actions other than those directed
by law enforcement or first responders.
115.361 (c): Only designated employees specified by policy should be informed of
the incident in order to respect the victim’s privacy, security, and identity. All
allegations of sexual abuse shall be handled in a confidential manner throughout
the investigation. All conversations and contact with the alleged victim should be
sensitive, supportive and non-judgmental.
115.361 (d): Medical and Mental Health staff interviewed confirmed their
responsibility to inform residents under 18 years old of their duty to report and
limitations of confidentiality during the intake process.
115.361 (e): PREA Compliance Manager, Administrator On-Duty, or designee shall
immediately notify law enforcement authorities. The alleged victim’s parents/legal
guardians will also be notified, unless the facility has official documentation showing
the parents or legal guardians should not be notified. If a juvenile court has
jurisdiction over the alleged victim, and contact information is able to be obtained,
the Administrator On-Duty or designee will also report the allegation to the alleged
victim’s attorney, juvenile probation officer, or other legal representative of record
within 14 days of receiving the allegation. All attempts to contact the child’s
attorney or receive contact information for the child’s attorney will be documented.
115.361 (f): Staff training and policy mandates that all employees, volunteers,
interns, and contractors shall immediately report any knowledge, suspicion, or
information regarding an incident of sexual abuse or sexual harassment that
occurred in the facility, retaliation against residents or staff who reported such an
incident, and any staff neglect or violation of responsibilities that may have
contributed to an incident or retaliation to the shift supervisor, PCM
or Administrator. The Administrator or highest-ranking staff on duty will notify CCC
and child abuse registry hotline within 2 hours of be informed of an allegation of
sexual abuse or sexual harassment. CCC will make notification to OIG. The facility
staff on duty will immediately notify Local Law Enforcement of any allegation that is
criminal in nature. Policy and training also require reporting any third-party reports
of sexual abuse, sexual harassment, staff neglect and retaliation.
Exceeds compliance was determined by review of policies, training, and interviews
with direct care staff and first responders that are not direct care staff, the facility
administrator, and the agency head designee and the PREA coordinator. The
center's response plan provides all of the notification and specific timeline to meet
the mandatory reporting notifications.
115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 - Agency Protection Duties
FDJJ Policy 1.12 Reporting Incidents to CCC
FOP Agency Protective Duties
PAQ
115.362 (a) Policy 1919 require staff to protect the residents through immediately
implementing protective measures. Interviews with the residents revealed their
concerns about their own safety and are discussed during the intake process and
during the administration of Screening assessments. Policies require that if the
resident alleges, they are at substantial risk of imminent sexual abuse, staff will
take immediate steps to ensure the safety of the resident. The direct care staff will
take steps to separate the alleged victim from the alleged perpetrator and notify the
staff with highest authority at the facility and the assistant facility administrator, or
facility director. These staff will then determine the best options to protect the
victim. The staff will then follow the mandatory reporting steps. There have been no
instances where residents were at imminent danger of sexual abuse.
Compliance was determined by review of policies and interviews with direct care
staff, non-direct care staff, and the facility administrator.
115.363 Reporting to other confinement facilities
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1.12 Incident- CCC reporting
FDJJ Policy 1919 - Reporting to other facilities Statement of Fact
115.363(a-d) In the event that a resident alleges that Sexual Abuse occurred while
confined at another Facility, the Facility will document the allegations, notify the
send facility administrator, CCC, DFC and local law enforcement of the allegations. If
the allegation was criminal in nature the facility administrator would also notify local
law enforcement and OIG. The report will be reported to the sending center as soon
as possible, but no later than 72 hours after receiving the notification. The facility
will notify CCC within 2 hours of being advised of the reported allegations. During
the past 12 months, there were no allegations received that a resident was abused
while confined to another facility nor were there allegations of sexual abuse
received by MRJDC from other facilities.
Based on the review of the agency Policy and procedures, observations and
information obtained through staff interviews and review of documentation, the
facility has demonstrated compliance with this standard.
115.364 Staff first responder duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
MRJDC First Responder Plan
FOP 3.09 First Responder Duties
FDJJ Policy 1919 - Responding to Allegations
FDJJ Policy 1.12 Incident/CCC reporting PREA –
Volunteer and Contractor Training
Investigation procedures from OIG
OIG Investigator Training Roster Statement of Fact
115.364 (a): Upon receipt of a report that a resident was sexually abused, or if an
employee sees abuse, the first staff member to respond will: a. Separate the alleged
victim and abuser. b. Call for emergency medical care for the victim, if necessary. c.
Immediately notify the Administrator On-Duty and remain on the scene until
relieved by responding personnel. d. Preserve and protect the scene of the alleged
abuse until appropriate steps can be taken to collect any evidence. When
appropriate, the staff member will remove all residents from the room or area. e.
Assign the alleged victim and abuser to separate areas and ensure supervision by a
same sex employee. f. If the alleged abuser is an employee, student intern or
program volunteer, a supervisor must stay with the employee until further
instruction is provided by an Administrator (e.g., safety plan, administrative leave).
If the alleged abuse occurred within the past 96 hours, the employee(s) should
request that the alleged victim not take any actions that could destroy physical
evidence (e.g., washing, brushing teeth, changing clothes, urinating, defecating,
drinking, or eating). h. Ensure that the alleged abuser not take any actions that
could destroy physical evidence (e.g., washing, brushing teeth, changing clothes,
urinating, defecating, drinking, or eating). i. Apart from reporting to designated
supervisors, employees shall not reveal any information related to the incident to
anyone other than to individuals involved with investigating the alleged incident. j.
Document detailed description of 1) Victim and abuser locations and affect (e.g.,
emotions, appearance) 2) Wounds and their location 3) Anything the victim or
abuser reported to the employee.
115.364 (b): If the first staff responder is not a security staff member, the responder
shall be required to request that the alleged victim not take any actions that could
destroy physical evidence. Staff interviewed confirmed they knew their obligations
when a resident makes an allegation, or they suspect an incident of sexual abuse
has occurred.
During the last 12 months there were no allegations of sexual abuse.
Interview with the education staff determined several were aware of their first duty
responsibilities.
Compliance was determined by a review of center training plan, first responder flow
chart and interviews with all staff including administrative support staff that do not
deal directly with resident, however, do go to the area where resident are located.
115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Coordinated Response Plan
FDJJ Policy 1919 PREA - Coordinated Response PREA Response checklist
MRJDC Coordinated Response Plan
MRJDC Coordinated Response includes a written plan to coordinate actions of
employee first responders, medical and mental health practitioners, investigators,
and facility leadership in response to an incident of sexual abuse. FDJJ has a system
in place providing the staff with clear actions to be taken by staff including
contacting administrative staff, medical and mental health staff, OIG and law
enforcement, victim advocate services, & parent/guardian and several other
individuals. Staff members are directed to follow the steps outlined and to utilize the
checklist in addressing the situation.
MRJDC Coordinated Response Plan
1. Upon discovery of an incident defined as sexual abuse, the first responding staff
members are responsible for taking immediate actions to ensure the safety of the
victim. These actions include, but are not limited to:
a. Identifying victim(s)
b. Identifying suspects
c. Making every attempt to preserve evidence
d. Notify the Shift Supervisor
e. Notify law enforcement
2. Upon notification of a PREA related incident the Shift Supervisor will:
a. Immediately report the incident to the CCC, providing as much facts and detail as
possible about the incident(s) and victim(s), suspect(s) or witnesses. The CCC will
make appropriate notification to senior DJJ management who will in turn notify
management overseeing the facility where the alleged abuse occurred.
b. Ensure that law enforcement has been called.
c. Notify Superintendent and/or Assistant Superintendent.
d. Make referral to mental health personnel.
e. Make referral to medical personnel.
f. Assist the staff in gathering as much information as possible so that the
details can be reported to the arriving Law Enforcement and Child Protection
Investigator.
3. It is essential that all the clothing worn by the people involved be protected to
ensure that evidence is not further contaminated. The scene(s) where the alleged
act(s) occurred must also be secured. This means simply securing any evidence
until the arrival of law enforcement.
4. Staff should not:
a. Move, touch, or inspect the evidence in any way.
b. Discuss any facts of the incidents with anyone except for those directly involved
in response or investigation of the incident.
5. If a sexual abuse incident is reported by the victim, first responder staff should:
a. Ensure the victim is safe.
b. Immediately notify law enforcement (911) and ask them to come to the facility.
c. Immediately prohibit the subject (staff or youth) from contact with any other
youth.
d. Identify perpetrator and notify security staff.
e. Immediately contact the Florida Central Abuse Hotline.
f. Notify the CCC and management within two (2) hours of the incident or learning of
the incident.
g. Take no further immediate action, except at the direction of law enforcement.
h. Secure the area where the incident allegedly occurred.
6. If a sexual abuse incident is reported by someone else and the victim is in your
care or custody, staff should:
a. Locate the victim.
b. Ensure the victim is safe.
c. Immediately notify law enforcement (911) and ask them to come to the facility.
d. Immediately prohibit the subject (staff or youth) from contact with any other
youth.
e. Do not allow access to the area by anyone, including staff, until the arrival of, and
at the direction of, law enforcement.
f. Do not question the victim, other than to identify basic information about where
the incident occurred and who may be involved.
g. Provide as much detail as possible to the police and responding emergency
services.
h. If the subject (the person who allegedly committed the offence) is in your care,
control, or custody do not notify them of the victim’s report, but take adequate
steps to ensure the safety of other youth and report subject information to law
enforcement when they arrive.
i. Ensure that any clothing, bedding, or related materials are not disposed of or
cleaned up by staff. Keep those materials secure or free from contamination by
anyone else until instructed to do differently by law enforcement.
j. Do not discuss any facts of the incidents with anyone except those directly
involved in response or investigation of the incident.
k. Cooperate fully with law enforcement.
7. The Superintendent or Assistant Superintendent shall notify the alleged victim’s
parents or guardians, unless there is official documentation showing the parents or
legal guardians should not be contacted.
a. If the youth is in the custody of DCF, the caseworker shall be notified. If
applicable, they youth’s attorney or other legal representative of record shall be
notified of the allegation within 14 days of receiving the allegation.
8. Medical personnel are to be immediately notified by the Shift Supervisor. They
will also ensure that physical evidence is preserved. In the event they are not
available the Shift Supervisor will make a referral within 24 hours.
b. Medical staff will conduct a follow up with youth as a precautionary measure to
ensure any prescribed medical treatment is completed.
c. Evaluate youth to determine if any other follow up medical referrals are necessary
and make appropriate referrals.
9. Mental health personnel are to be immediately notified by the Shift Supervisor.
The facility staff will seek their assistance in ensuring the youth is evaluated and
treated. In the event they are not available the Shift Supervisor will ensure that a
referral is made to the facility mental health personnel within 24 hours.
b. Mental health staff will assess the youth and determine if further evaluation and
treatment is needed, and make the appropriate referrals.
10. Full cooperation will be rendered to responding law enforcement agencies and
responding medical emergency teams. More than likely, the victim will have to be
transported out with a supervising staff to the hospital after the investigation is
launched to be evaluated and treated, to include the use of a rape kit. As this is a
very traumatic experience for the victim follow-up treatment to Kimberly Cottage
will be offered as well as access to victim advocates. Once the law enforcement take
their leave of the facility and the youth has been transported out for medical
services regular programming will resume at the facility.
11. The Superintendent shall:
a. Ensure all follow-ups are conducted within the specified timeframes, that every
effort is made not to re-traumatize the victim and that the subjects are removed
from victim contact.
b. If it is a staff person who has been reported as the subject, they will be removed
from all youth contact during the investigation.
c. If allegations occurred at another facility the Superintendent will immediately
notify the Superintendent of that facility to report allegations
Compliance was determined by review of the Coordinated Response and interviews
with random staff. The facility administrator, medical staff, mental health staff, shift
supervisors, random staff and education staff were asked of their roles in the
coordinated response and each new their essential roles
Preservation of ability to protect residents from contact with
115.366
abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Sexually Abusive Behavior Prevention and Intervention Program (PREA)
AFSCE Master Contract
Employee Handbook
115.366 (a): In every case where the alleged abuser is an employee, contractor or
volunteer there will be no contact between the alleged abuser and the alleged
victim pending the outcome of an investigation. Separation orders (e.g., safety
plans) requiring “no contact” will be documented by facility management. A
memorandum will be printed and maintained as part of the related investigation
file. FDJJ will not enter or renew any collective bargaining agreement or other
agreement that limits a facility’s ability to remove alleged Employee sexual abusers
from contact with any resident pending the outcome of an investigation or of a
determination of whether and to what extent discipline is warranted.
Compliance was determined by with agency head, PREA coordinator and facility
administrator.
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 - Protection against Retaliation
FOP 3.09 Agency Protection Against Retaliation
MRJDC Retaliation Form
PAQ
115.367 (a): Facility PREA Response Plan establishes for protection or resident
against retaliation and staff for reports of sexual abuse or harassment or
cooperation with investigations. Allegations of retaliation shall be immediately
reported to the site supervisor or designee. In instances where the supervisor is
believed to be involved in the retaliation, the employee shall notify the supervisor or
designee at the next appropriate supervisory level. For 90 calendar days, or longer
based on continuing need, following a report of sexual abuse, the PREA retaliation
monitor (assistant administrator) shall monitor the conduct or treatment of any
individual, youth or employee, who were involved in a reported incident, and shall
act promptly to remedy any such retaliation. Monitoring steps include reviewing
group, or facility assignments, reviewing youth progress reports, periodic status
checks with the youth, and performance reviews or reassignments of employees
involved in the initial report or investigation. During the last 12 months there were
no retaliation for reporting allegations of sexual abuse or sexual harassment. There
have been no allegation of sexual abuse or sexual harassment alleged at the center
during the last 12 months.
FDJJ has developed an agency wide form for all facilities managed by the
cooperation to document retaliation monitoring. During the last 12 months there
were no allegations of sexual abuse that required retaliation monitoring.
115.367 (b): The agency shall employ multiple protection measures, such as
housing changes or transfers for resident victims or abusers, removal of alleged
staff or resident abusers from contact with victims, and emotional support services
for residents or staff who fear retaliation for reporting sexual abuse or sexual
harassment or for cooperating with investigations. The policy identifies measures to
protect staff and residents including the following: a. Initiating housing changes or
transfers for resident victims or abusers; b. Removing alleged staff or resident
abusers from contact with victims; and c. Providing emotional support services. The
interview confirmed the facility would protect residents and staff from retaliation for
sexual abuse and sexual harassment allegations. Protective measures would include
housing changes, transfers, removing alleged abusers, and emotional support
services. The Retaliation Monitor identified protective measures that are aligned
with the standard, including separating the alleged abuser from the alleged victim.
115.367 (c): For at least 90 days following a report of sexual abuse, the agency shall
monitor the conduct or treatment of residents or staff who reported the sexual
abuse and of residents who were reported to have suffered sexual abuse to see if
there are changes that may suggest possible retaliation by residents or staff and
shall act promptly to remedy any such retaliation. Items the agency should monitor
include any resident disciplinary reports, housing, or program changes, or negative
performance reviews or reassignments of staff. The agency shall continue such
monitoring beyond 90 days if the initial monitoring indicates a continuing need. FDJJ
Policy 1919 requires the monitoring of items identified in this provision of the
standard. The Retaliation Monitor explained during the interview how he would
discharge those duties, including monitoring the items identified in the standard and
whether a resident filed a grievance alleging sexual abuse or sexual harassment.
Retaliation monitoring would occur for 90 days to see if there are any changes that
may suggest possible retaliation by residents or staff, and shall act promptly to
remedy any such retaliation, according to Policy. The monitoring will continue
beyond ninety (90) days if the initial monitoring indicates a continuing need. There
have been no incidents of retaliation during the 12 months preceding the audit.
115.367 (d): In the case of residents, such monitoring shall also include periodic
status checks. The Retaliation Monitor indicated status checks would be initiated
with staff and residents. The FOP states periodic status will occur. The Retaliation
Status Checklist would be used to document the status checks as well as the
Retaliation Monitoring Checklist to document the ongoing motoring and use of the
Retaliation Status Checklist.
115.367 (e): If any other individual who cooperates with an
investigation expresses a fear of retaliation, the facility shall take appropriate
measures to protect that individual against retaliation. Policy states if any other
individual who cooperates with an investigation expresses the occurrence of
retaliation from another resident or staff member, MRJDC shall take appropriate
measures to protect that individual against retaliation. The assistant facility
administrator indicated he would visit the resident whenever an allegation is lodged
by residents or third party immediately and discuss her role to monitor for
retaliation. The facility administrator indicated he would monitor staff that report
and cooperated with any investigations. The retaliation monitor interviewed
indicated he would meet with the resident on a weekly basis to assure there are no
retaliation for reporting sexual abuse or sexual harassment.
Compliance was determined by review of policies, the monitoring check list and
interviews with the retaliation monitor, facility administrator and PREA coordinator.
115.368 Post-allegation protective custody
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Facility PREA Response Plan
FDJJ Policy 1919 PREA
Statement of Fact
115.368 (a): Residents may be isolated from others only as a last resort when less
restrictive measures are inadequate to keep them and other residents safe, and
then only until an alternative means of keeping all residents safe can be arranged.
The facility shall clearly document the basis for the facility’s concerns for the
resident’s safety and the reason no alternative means of separation can be
arranged.
Youth in an isolated area shall not be denied large muscle exercise and educational
programming. Residents shall receive daily visits from the medical and mental
health practitioners.
Medical and mental health staff interviews indicated that anytime a resident is
placed in an isolated area they will visit the resident a minimum of once during each
shift.
There have been no residents placed in an isolated area for a PREA incident. There
have been no resident that requested separation for fear of being sexually abused.
According to interviews with the facility administrator and mental health staff the
only time a resident is separated from other residents are when they are physically
aggressive and then they may be placed in a control observation room.
Compliance was determined by review of policy, interviews with facility
administrator, medical and mental health staff.
115.371 Criminal and administrative agency investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 PREA – Investigations
FDJJ Policy 1.12 Incident/CCC reporting
FDJJ Policy 1316 Data Storage
Investigation procedures from OIG Investigative
Notifications
Investigative Files Review
115.371 (a): FDJJ Policy 1919 establishes the agency Policy that all allegations of
sexual abuse or sexual harassment will be investigated. Florida Department of
Juvenile Justice does not conduct their own investigations of sexual abuse and
harassment. The Office of the Inspector General conduct administrative
investigations and criminal investigations are conducted by local law enforcement.
The Department of Family and Children conducts a separate investigation involving
residents under the age of eighteen.
115.371 (b): The Office of Inspector General follows protocols in conducting
administrative investigations in FDJJ settings and the investigators receive training
on the related agency policies Florida Department of Juvenile Justice has requested
the agencies that conduct allegation of sexual abuse or sexual harassment follow
the PREA standards.
15.371 (c): Investigators shall gather and preserve direct and circumstantial
evidence, including any available physical and DNA evidence and any available
electronic monitoring data; shall interview alleged victims, suspected perpetrators,
and witnesses; and shall review prior complaints and reports of sexual abuse
involving the suspected perpetrator.
115.371 (d): The agency shall not terminate an investigation solely because the
source of the allegation recants the allegation.
115.371 (e): Any criminal investigations are conducted by local law enforcement
and would be referred to appropriate jurisdiction for prosecution. Completed reports
shall be retained in the Office of the inspector general in accordance with the state
retention schedule.
Interviews with Facility Administrator and investigator confirmed that the present
retention period is the agency retain all written reports referenced in 115.371 for as
long as the alleged abuser is incarcerated or employed by the agency, plus five
years.
115.371 (f): The credibility of an alleged victim, suspect, or witness shall be
assessed on an individual basis and shall not be determined by the person’s status
as resident or staff. No agency shall require a resident who alleges sexual abuse to
submit to a polygraph examination or other truth-telling device as a condition for
proceeding with the investigation of such an allegation.
115.371 (g): Administrative investigations shall include an effort to determine
whether staff actions or failures to act contributed to the abuse; and shall be
documented in written reports that include a description of the physical and
testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings.
115.371 (h): Criminal investigations shall be documented in a written report that
contains a thorough description of physical, testimonial, and documentary evidence
and attaches copies of all documentary evidence where feasible.
115.371 (i): Substantiated allegations of conduct that appear to be criminal shall be
referred for prosecution.
115.371 (j): The agency shall retain all written reports referenced in paragraphs (g)
and (h) of this section for as long as the alleged abuser is incarcerated or employed
by the agency, plus five years, unless the abuse was committed by a juvenile
resident and applicable law requires a shorter period of retention.
115.371 (k): The departure of the alleged abuser or victim from the employment or
control of the facility or agency shall not provide a basis for terminating an
investigation.
115.371 (l): Any State entity or Department of Justice component that conducts
such investigations shall do so pursuant to the above requirements.
115.371 (m): When outside agencies investigate sexual abuse, the facility shall
cooperate with outside investigators and shall endeavor to remain informed about
the progress of the investigation. As part of the responsive planning staff are trained
in protecting the crimes scene and cooperating with investigative units. There have
been no allegations of sexual abuse made during the last 12 months.
Compliance was determined by interviews with the facility investigator, PREA
coordinator, Agency Head, Agency website and facility administrator.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 – Investigations
FDJJ Policy 1.12 Incident/CCC
FDJJ Office of the Inspector General conducts administrative investigations. The
investigator may make a finding of Substantiated, Not Substantiated, Unfounded, or
Pending Further Investigation. The finding will be made using the standard of proof
of the preponderance of the evidence (51 % of the evidence). The Investigator must
objectively review all the evidence which is in favor of or contrary to the finding. The
investigator must objectively consider and balance the evidence in favor of or
contrary to the finding; and to support a finding of child abuse or neglect by a
Preponderance of Evidence. Investigator must be convinced that the evidence in
favor of the finding outweighs the evidence against the finding, or is convinced that
the evidence, when taken as a whole, shows that it is more probable than not that
the alleged incident took place in this case.
Compliance of the standard was determined by reviewing the Policy, and interview
with the agency PREA coordinator and chief investigator.
115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 – Reporting to Youth Office of Inspector General
FOP 3.09 Notification to Youth
FOP 3.09 Attachment
Notifications to Residents Blank form
115.373 (a): At the conclusion of an investigation, OIG or PREA Compliance
Manager, or staff member designated by the facility administrator will inform the
victim of the allegation in writing, whether the allegation has been substantiated,
unsubstantiated, unfounded.
115.373 (b): FDJJ Policy 1919 Investigating PREA Allegations requires that if the
facility did not conduct the investigation, it will request the relevant information
from the investigating agency in order to inform the individual.
115.373 (c): Following a resident’s allegation that a staff member has committed
sexual abuse against the resident, the agency shall subsequently inform the
resident (unless the agency has determined that the allegation is unfounded)
whenever: (1) The staff member is no longer posted within the resident’s unit; (2)
The staff member is no longer employed at the facility; (3) The agency learns that
the staff member has been indicted on a charge related to sexual abuse within the
facility; or (4) The agency learns that the staff member has been convicted on a
charge related to sexual abuse within the facility.
115.373 (d): Following a resident’s allegation that he or she has been sexually
abused by another resident, the agency shall subsequently inform the alleged
victim whenever: (1) The agency learns that the alleged abuser has been indicted
on a charge related to sexual abuse within the facility; or (2) The agency learns that
the alleged abuser has been convicted on a charge related to sexual abuse within
the facility.
115.373 (e): Policy requires all such notifications or attempted notifications shall be
documented. The PREA Coordinator has developed a form that for notification to
residents of the outcome of investigations that includes a signature from the
resident. During the last 12 months there no residents that was notified of the
outcome of an investigation that was completed by the facility. There was no
allegation of sexual abuse or harassment in the last audit cycle.
Based on review of policy and interviews with PREA compliance manager and PREA
coordinator it was determined that the agency is in compliance with this standard
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 – Disciplinary sanctions for Staff
DJJ Employee Handbook
Statement of Fact
115.376 (a): Staff is subjected to disciplinary sanctions up to and including
termination for violating agency sexual abuse or sexual harassment policies.
115.376 (b): All allegations of sexual abuse shall be immediately investigated.
Upon the conclusion of the investigation, if staff is determined that they were
involved in sexual abuse of a resident, that staff will be terminated immediately,
and the investigation will be forwarded to law enforcement for further review and
charges. 115.376 (c): Disciplinary sanctions for violations of agency policies relating
to sexual abuse and harassment other than engaging in sexual abuse will be
commensurate with the nature and circumstances of the acts committed. However,
most likely any degree of sexual abuse and harassment will be met with termination
of the staff member.
115.376 (d): All staff members who are terminated or resign in lieu of termination
due to violations of the sexual abuse and sexual harassment policy shall be reported
to law enforcement. Staff who resign because they would have been terminated, are
reported to the local law enforcement unless the activities were not clearly criminal.
There has been no adverse action taken against staff for violation of agency policy
1919 PREA or related policies.
Compliance was determined by review of the agency policy, interview with PREA
coordinator and facility administrator.
115.377 Corrective action for contractors and volunteers
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 – Disciplinary sanctions for Contractors or Volunteers Contractor
Training
Contractor Acknowledgement for Training
Statement of Fact
115.377 (a) Investigating PREA Allegations provide any contractor or volunteer who
engages in sexual abuse is prohibited from contact with residents. The policies also
provide for contractors and volunteers who engage in sexual abuse to be reported
to law enforcement and to relevant licensing bodies.
115.377 (b) The documentation and interviews with the PREA coordinator, assistant
facility administrator revealed the provision of information to volunteers and
contractors that sexual misconduct with a resident is strictly prohibited. In the case
of any other violation of agency sexual abuse or sexual harassment policies by a
contractor or volunteer, the facility will take appropriate remedial measures, and
consider whether to prohibit further contact with residents, however, would most
likely prohibit them from further contact with residents. Volunteer and contracting
staff indicated that all PREA related training includes facility's policy involving any
violation of PREA standards. Each indicated they were aware that the facility would
take appropriate action including reporting to law enforcement and licensing board.
There have been no allegations of sexual abuse or sexual harassment involving
contracting and volunteers during the last 12 months.
115.378 Interventions and disciplinary sanctions for residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 – Disciplinary sanctions and interventions for Youth
Florida Statue section 985.701
FDJJ Intervention and Discipline
FOP 3.09 Placement of Residents
FOP 3. 09 Intervention and Discipline of Residents
FOP 3.09 PREA Ongoing Medical Care
Statement of Fact
PAQ
115.378 (a): Florida Statue section 985.701 and FDJJ Policy 1919 provide guidance
and procedures for disciplinary action to be used for residents. Section 985.701,
Florida Statutes, makes certain acts of sexual misconduct between a youth and staff
person a felony. A youth's consent to sexual acts with a staff member is not a
defense under this subsection of the law.
Youth must be allowed unimpeded access to report any allegation of misconduct or
neglect to the Florida Abuse Hotline operated by the Department of Children and
Families. Youth 18 years of age or older would call the CCC or local law enforcement
to report an allegation of abuse or neglect.
Youth shall be advised that any person who knowingly and willfully makes a false
report to the Florida Abuse Hotline or counsels another to make a false report is
guilty of a third-degree felony in accordance with Chapter 39.205, Florida Statutes.
Anyone reporting in a good faith shall be immune from any civil or criminal liability.
A report of sexual misconduct made in good faith based upon a reasonable belief
that the alleged conduct occurred shall not constitute falsely reporting an incident,
even if an investigation does not establish evidence sufficient to substantiate the
allegation.
Individuals in MRJDC who are found guilty of engaging in sexual abuse involving
other individuals in the facility (either through administrative or criminal
investigations) will be subject to formal disciplinary sanctions. Sanctions will be
commensurate with the nature and circumstances of the abuse committed, the
individual’s disciplinary history, and the sanctions imposed for comparable offenses
by other individuals with similar histories.
The disciplinary process will consider whether an individual’s mental disabilities or
mental illness contributed to his or her behavior when determining what type of
sanction, if any should be imposed. d. If the facility offers counseling or other
treatment interventions designed to address the reasons or motivations for the
abuse, the facility will consider requiring the offending individual to participate.
Disciplining an individual in a FDJJ facility for sexual contact with an employee is
prohibited unless it is found that the employee did not consent to the contact. A
report of sexual abuse made in good faith by an individual in a FDJJ facility, based
upon a reasonable belief that the alleged conduct occurred, will not constitute false
reporting or lying. g. Facilities may not deem that sexual activity between
individuals in a FDJJ facility is sexual abuse unless it is determined that the activity
was coerced.
The PREA Compliance Manager will receive copies of all disciplinary reports
regarding sexual activity, sexual harassment and sexual abuse for monitoring
purposes. The incident will be reported to law enforcement unless the activity was
clearly not criminal.
115.378 (b): Any disciplinary sanctions shall be commensurate with the nature and
circumstances of the abuse committed, the resident’s disciplinary history, and the
sanctions imposed for comparable offenses by other residents with similar histories.
Isolation will not be utilized for a disciplinary sanction.
115.378 (c): The disciplinary process shall consider whether a resident’s mental
disabilities or mental illness contributed to his or her behavior when determining
what type of sanction, if any, should be imposed. MRJDC provides that the
disciplinary process considers whether a resident’s mental disabilities or mental
illness contributed to his or her behavior when determining what type of sanction, if
any, should be imposed. This was confirmed by the interview with the Clinical
Director.
115.378 (d): The facility is a detention center and doesn’t offer therapy, counseling,
or other interventions designed to address and correct underlying reasons or
motivations for the abuse However, the detention center is part of the FDJJ
continuum of care and would provide the information to community partners such
as Juvenile Probation Officers for consideration whether to offer the offending
resident participation in one of the State’s Sexual Offender programs. The agency
may require participation in such interventions as a condition of access to any
rewards-based behavior management system or other behavior-based incentives,
but not as a condition to access to general programming or education.
115.378 (e): The agency may discipline a resident for sexual contact with staff only
upon a finding that the staff member did not consent to such contact.
115.378 (f): For the purpose of disciplinary action, a report of sexual abuse made in
good faith based upon a reasonable belief that the alleged conduct occurred shall
not constitute falsely reporting an incident or lying, even if an investigation does not
establish evidence sufficient to substantiate the allegation. Investigating PREA
Allegations states a report of sexual abuse made in good faith based upon a
reasonable belief that the alleged conduct occurred shall not constitute falsely
reporting an incident or lying, even if an investigation does not establish evidence
sufficient to substantiate the allegation.
115.378 (g): MRJDC prohibits all sexual activity between residents and may
discipline residents for such activity. An agency may not, however, deem such
activity to constitute sexual abuse if it determines that the activity is not coerced.
Residents interviewed indicated they were advised that they would be discipline for
any sexual abuse, sexual harassment or sexual misconduct. Most indicated that
they are reminded of their duties to hold each other responsible to maintain a safe
environment for all residents. The statement of fact indicated during this audit
period this facility has not had any incidents that require intervention for residents
having sexual conduct.
Based on the review of the agency policy, observations and information obtained
through the staff interview and review of documentation, the facility has
demonstrated exceed compliance with this standard.
115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 – MH and Medical Screening
Crisis Assessment
Screening Referrals to Mental Health Staff
FDJJ Health Education Records
Health Services .002 Authority for evaluation and treatment (AET)
Health Services. 029 Sexually Transmitted Infection Screening VSAB Form
MRJDC FOP 2.03 Alerts
Copy of Alert Wizard Computerized Program
115.381 (a) If any of the intake screening forms indicates a resident has
experienced prior sexual victimization, whether it occurred in an institutional setting
or in the community, the facility administrator or other intake officer shall document
the information on the Follow up Notification Form. If the resident makes the
notification during the Juvenile Assessment Center, the center will send a referral
along with the VSAB to the intake staff when the resident is transported to the
center. According to the Clinical Director all residents that arrive at MRJDC are seen
by the clinical director within 72 hours of arrival and the same question about
victimization is discussed during their initial Mental Health intake. However, the
screening staff document and forward a follow up notification form. As noted in
standard 115.341 the center conducts several screenings for residents that arrive at
the center. These screenings are utilized for housing, placement, and programming
of resident.
115.381 (b) If any of the intake screening forms indicates a resident has previously
perpetrated sexual abuse, whether it occurred in an institutional setting or in the
community, staff ensure that the resident is offered a follow-up meeting with a
mental health practitioner within 14 days of the intake screening. This same
information is discussed with the clinical staff within 72 hours of intake. However,
the screening staff document and forward a follow up notification form. DJJ Policy
1919 investigation requires that when an allegation of sexual abuse or sexual
harassment occurs the facility will complete a rescreening on the victim and
accused perpetrator. The facility refers all residents that have history of
victimization or have concerns about victimization to Kimberly Cottage for
emotional support. Staff at the center verified that the detention reaches out to
allow residents to speak with their therapist.
Whenever the VSAB or related documentation such as charging offenses, past
history or reviewed during the intake process a Wizard Alert Program will be utilized
to make referrals to mental health or other services based on this alert system.
115.381 (c): Any information related to sexual victimization or abuse that occurred
in an institutional setting shall be strictly limited to medical and mental health
practitioners and other staff, as necessary, to develop treatment plans and security
and management decisions, including housing, bedding, education, and bedding,
education, and program assignments, or as otherwise required by Federal, State, or
Local law.
115.381 (d): Medical and mental health staff is required to notify residents at the
initiation of services their duty to report, limitations of confidentiality, and must
obtain informed consent from youth who are 18 years old or older before reporting
information about the resident’s prior sexual victimization that did not occur in an
institutional setting. Residents who report prior sexual victimization or disclose prior
incidents of perpetrating sexual abuse, either in an institution or in the community,
are required to be offered a follow-up with a medical or mental health practitioner
within 14 days of admission/screening.
Compliance was determined by review of the agency policy and interviews with
medical and mental health staff.
115.382 Access to emergency medical and mental health services
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Resident medical treatment forms
FDJJ Policy 1919 PREA – Access to Emergency Medical and Mental Health Services
PREA Advocacy Interview
Florida Department of Juvenile Justice Authority for Evaluation and Treatment (AET)
Health Education Records
FOP 3.09 PREA- Access to Emergency Medical Care
115.382 (a): PREA Response Plan Following Resident Report mandate youth victims
of sexual abuse receive timely and unimpeded access to onsite and offsite
emergency medical treatment and crisis intervention services, the nature and scope
as determined by the judgement of medical and mental health professionals.
Medical and mental health staff interviews confirmed emergency medical care and
crisis intervention services will be provided by medical and mental health staff as
required. Observations revealed medical and mental health staff members maintain
secondary materials that document services to residents and these staff 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 staff treatment
services will be provided at no cost to the victim, whether or not the victim
cooperates with the investigation. Residents are provided access to an outside
victim advocacy agency for services through a MOU with Marion County Child
Advocacy Center which includes but is not limited to emotional support and
accompaniment through the forensic examination and investigative interviews.
Marion County Child Advocacy Center has a SANE staff on duty or on call and would
conduct the examination at the Child Advocacy Center or the Avant Medical Center.
There have been no allegations of sexual abuse during this audit period that include
a SANE or SAFE. The facility houses male and female residents. The facility PREA
response plan and operational procedure requires evaluation and treatment shall
include, as appropriate, follow-up services, treatment plans, and when necessary,
referrals for continued care following their transfer to, or placement in, other
facilities, or their release from custody. Medical and mental health services shall be
provided to the victims consistent with the community level of care. Resident
victims of sexual abuse shall be offered tests for sexually transmitted infections as
medically appropriate. Treatment services shall be provided to the victim without
financial cost and regardless of the victim’s names the abuser or cooperates with
any investigation of the incident.
115.382 (b): If no qualified medical or mental health practitioners are on duty at the
time a report of recent abuse is made, staff first responders shall take preliminary
steps to protect the victim pursuant to § 115.362 and shall immediately notify the
appropriate medical and mental health practitioners. The interviews with clinical
staff revealed residents have unimpeded access to emergency services. The
coordinated response plan flow chart provides guidance to staff in protecting
residents and for contacting the appropriate staff regarding allegations or incidents
of sexual abuse, including contacting medical and mental health staff. The on-call
medical list has the names of medical staff and their emergency contact numbers. A
medical staff member is on-call 24/7 as determined by the interview. Interviews with
Marion County Child Advocacy Center indicated there is an on call SAFE staff
available 24/7 for forensic examinations. There is also a Victim Advocate on call
24/7 to support a resident that has been sexually assaulted.
115.382 (c): Resident victims of sexual abuse while incarcerated shall be offered
timely information about and timely access to emergency contraception and
sexually transmitted infections prophylaxis, in accordance with professionally
accepted standards of care, where medically appropriate. All residents are provided
access to infection prophylaxis when they arrive at the facility. The PAQ and
interviews confirmed processes and services are in place for a victim to receive
timely access to sexually transmitted infection prophylaxis, where medically
appropriate. Additionally, follow-up services as needed will be provided by the
facility’s medical and mental health staff, according to the interviews with clinical
staff.
115.382 (d): PREA Response Plan Following Resident Report mandates that
treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any
investigation arising out of the incident. This was also confirmed through staff
interviews. The policy revealed emergency services will be provided by medical and
mental health staff.
The medical and mental health staff interviews revealed they are knowledgeable of
actions to take regarding an incident of sexual abuse. It is documented through
policy and understood by the medical and mental health staff that treatment
services will be provided at no cost to the victim.
Based upon the review of policies, interviews with the medical, mental health staff,
and interviews with staff from the Marion County Child Advocacy Center is
compliant with this standard.
Ongoing medical and mental health care for sexual abuse victims
115.383
and abusers
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
Statement of Fact
FDJJ Policy 1919 PREA – Ongoing Medical and Mental Health Services
AET Standard of Care
Facility Operating Procedures 3.09 PREA Ongoing Medical Care
Off Site Medical Record
115.383 (a): The facility shall offer medical and mental health evaluation and, as
appropriate, treatment to all residents who have been victimized by sexual abuse in
any prison, jail, lockup, or juvenile facility. The medical and mental health staff
indicated in interview that the facility would provide treatment as indicated as prior
victimization can be part of the treatment needed for recovering youth. The facility
makes a referral to mental health for anyone that provides information on prior
victimization or past predator behavior in order to comply with the standard.
However, the clinical director indicated that all residents that go through intake at
the facility are seen by mental health within 72 hours. Marion County Child
Advocacy Center provides ongoing mental health counseling services for residents
assigned from their geographic location and makes referrals to Florida Coalition
against sexual victimization.
According to interviews with the mental health and medical staff, when a resident
goes out for medical care, the center receives a discharge summary from the
provider. Medical notifies the medical clinical director to continue the services or the
physician will come to the center and review the discharge summary, exam the
resident and create an additional care plan. The mental health staff will notify the
psychologist or psychiatrist if the resident is prescribed medication and develop a
treatment plan in consultation with these providers. The mental health staff
indicated they would also contact the Kimberly Cottage if the services were
provided for a Sane at the center.
115.383 (b): Facility PREA Response Plan Following Resident Report includes a
provision that the evaluation and treatment of such victims shall include, as
appropriate, follow-up services, treatment plans, and, when necessary, referrals for
continued care following their transfer to, or placement in, other facilities, or their
release from custody. Interviews with the clinical staff and observations confirmed
on-going medical and mental health care will be provided as appropriate and will
include but not limited to additional testing and medical services; medication
management, if prescribed; individual counseling; trauma group; and referrals as
needed. The Marion County Child Advocacy Center would provide resident with
support programs when released from the center or provide information and
arrange for a transfer for emotional support to a certified victim advocacy program
within the Florida Coalition of Victim Services in other areas of Florida. Marion
County Child Advocacy Center provides in house and walk in programs for victims of
sexual abuse for and Marion and other outlying counties base on MOU and
interviews with Marion County Child Advocacy Center staff.
115.383 (c): Based on interviews with the medical and mental health staff the
facility shall provide victims with medical and mental health services consistent with
the community level of care.
115.383 (d-e): As indicated by the nurse, resident victims of sexually abusive
vaginal penetration while incarcerated will be offered pregnancy test and if
pregnancy results from the conduct described in paragraph § 115.383(d), victims
receive timely and comprehensive information about and timely access to all lawful
pregnancy-related medical services.
115.383 (f) The policy and interviews ensure that victims of sexual abuse will be
provided tests for sexually transmitted infections as medically appropriate. Testing
would be done at the local hospital and follow-up services may be done at the
facility, as needed.
115.383 (g) All treatment services will be provided at no cost to the victim,
according to policy and staff interviews.
115.383 (h) Policy provides for attempts to be made for a mental health
practitioner to conduct a mental health evaluation within 60 days on all known
resident-on resident abusers and offer appropriate treatment by mental health staff.
Services will include but not be limited to individual, group and family counseling.
Additionally, an evaluation or reassessment will be administered utilizing the
Vulnerability Assessment.
Any resident that makes an allegation of past victimization are allowed to call the
Marion County Child Advocacy Center program and staff from the program will go to
the facility and meet with the resident and offer their services when released from
the center.
Based on a review of the PREA policies, and interviews with the Gulf Coast Sexual
Abuse Program, mental health director, medical staff, PREA coordinator and Facility
Administrator the facility is in compliance with this standard.
115.386 Sexual abuse incident reviews
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 – Incident Reviews Incident
Statement of Fact
Review Meeting reports (form)
115.386 (a): Facility PREA Response Plan Following Resident Report require an
incident review team meeting within 30 days of the conclusion of each investigation
unless the finding is unfounded. The policy mandates review team participation to
include the agency wide PREA Coordinator, the facility’s PREA Compliance Manager,
facility administrator, medical and mental health staff. There was one allegations of
sexual abuse during the last 12 months. The investigation and finding were
completed after the onsite audit and was determined to be unfounded. The
interview with the PREA Compliance Manager and a review of the form used to
document the incident review team’s findings indicate the team: consider whether
the allegation or investigation indicates a need to change policy or practice to
better prevent, detect, or respond to sexual abuse considers whether the incident or
allegation was motivated by race; ethnicity; gender identity; lesbian, gay, bisexual,
transgender, or intersex identification, status, or perceived status; gang affiliation;
or other group dynamics at the facility; examine the area in the facility where the
incident allegedly occurred to assess whether physical barriers in the area may
enable abuse; assess the adequacy of staffing levels in that area during different
shifts; assess whether monitoring technology should be deployed or augmented to
supplement supervision by staff.
115.386 (b): The Agency policy requires that the reviews occur within 30 days of the
conclusion of the investigation. There has been no allegation of sexual abuse that
required an IRT meeting.
115.386 (c): The policy mandates review team participation to include the agency
wide PREA Coordinator, the facility’s PREA Compliance Manager, facility
administrator, medical and mental health staff.
115.386 (d): The committee reviewed the following: 1) Consider whether the
allegation or investigation indicates a need to change policy or practice to better
prevent, detect, or respond to sexual abuse. (2) Consider whether the incident or
allegation was motivated by race; ethnicity; gender identity; lesbian, gay, bisexual,
transgender, or intersex identification, status, or perceived status; or, gang
affiliation; or was motivated or otherwise caused by other group dynamics at the
facility; (3) Examine the area in the facility where the incident allegedly occurred to
assess whether physical barriers in the area may enable abuse; (4) Assess the
adequacy of staffing levels in that area during different shifts; (5) Assess whether
monitoring technology should be deployed or augmented to supplement supervision
by staff; and (6) Prepare a report of its findings, including but not necessarily limited
to determinations made pursuant to paragraphs (d)(1)-(d)(5) of this section, and
any recommendations for improvement and submit such report to the facility head
and PREA Compliance Manager.
115.386 (e): The policy outlines the requirements of the standard for the areas to be
assessed by the incident review team. The interview with the Facility Administrator,
review documentation confirmed the incident review team meeting are
documented, including recommendations and the document provided to the Facility
Administrator.
The interview with the Incident Review Team Member confirmed the facility would
prepare a report of its findings and any recommendations for improvement when
conducting a sexual abuse incident review. He confirmed the team would consider
all factors required by the standard.
115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 – Data Collection
FOP 3.09 PREA – Data Collection
FDJJ 1919 - Incident Operations Center
PREA FY 2017-18 Annual Report
Final PREA FY 2018-19 Annual Report
PREA FY 2019-20 Annual Report
PREA FY 2021-22 Annual Report
PREA FY 2022-2023 Annual Report
115.387 (a): A review of reports confirms 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 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). FDJJ 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. FDJJ aggregates the sexual
abuse data which culminates into an annual report. The agency provides DOJ with
data as requested.
115.387 (b): The facility collects and maintains data in accordance with directives
by FDJJ. A standardized instrument and specific guidelines and definitions are used
to assist in identifying the data.
115.387 (c): The format used for FDJJ facilities capture the information required to
complete the most recent version of the Survey of Sexual Violence conducted by
U.S. Department of Justice (DOJ)
115.387 (d): The facility maintains and collects various types of identified data and
related documents regarding PREA. The facility collects and maintains data in
accordance with Policy directives.
115.387 (e): 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). Private facilities are
required to follow the same PREA policies and procedures and report the information
on the same basics as State operated facilities. MRJDC is a State operated facility.
115.387 (f): FDJJ policy mandates that upon request, FDJJ shall provide all such data
from the previous calendar year to the Department of Justice no later than June 30.
A request was not made for the previous calendar year.
A review of the 2022-2023 data determined there were no allegations of sexual
abuse or sexual harassment at Marion Regional Juvenile Detention Center.
Compliance was determined by reviewing data collections for preceding two years,
review of FDJJ Policies and interview with the PREA coordinator, facility administrator
and FDJJ agency head.
115.388 Data review for corrective action
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ 2021 Annual PREA Report
FDJJ Policy 2020 – Data Collection
FOP 3.09 PREA – Data Collection
PREA FY 2022-2023 Annual Report
PREA FY 2021-22 Annual Report
PREA FY 2022-23 Annual Report
115.388 (a): FDJJ Policy 1919 – Data Collection recognizes the purpose of conducting
annual reports and annual PREA assessments are to review data collected and
aggregated pursuant to § 115.387 in order to assess and improve the effectiveness
of its sexual abuse prevention, detection, and response policies, practices, and
training, including by: Identifying problem areas to assess and improve the
effectiveness of its sexual abuse prevention, detection, and response policies,
practices, and training, including by taking corrective action on an ongoing basis.
Further to assess and improve the effectiveness of its sexual abuse prevention,
detection, and response policies, practices, and training, including by preparing an
annual report of its findings and corrective actions for each facility, as well as the
agency as a whole.
115.388 (b): A review of the annual reports for the last 3 years included a
comparison of the current year’s data and corrective actions with those from prior
years and provide an assessment of the agency’s progress in addressing sexual
abuse.
115.388 (c): The annual report is reviewed by PREA coordinator, his supervisor and
agency administrative staff and signed by the Agency Head. Compliance was
determined by the PREA policy and website review.
115.388 (d): FDJJ Policy 1919 indicates that all information that is placed on the
website will not include personal identities. The annual report has been reviewed
and the report is accessible to the public through the facility’s website. There are no
personal identifiers on the annual report. In the last three years the data
documented on the FDJJ website revealed there had been no allegations of sexual
abuse and no allegation sexual harassment at Marion Regional Juvenile Detention
Center during the fiscal year 2022-2023.
Compliance was determined by reviewing data collections for preceding three years
and review of FDJJ website.
115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ1316 Policy - Data storage
Florida Department of Juvenile Justice Procedure Records and Information
Management Procedures
Florida Department of Juvenile Justice Procedure- Records and Information
Management Procedures requires that data be collected and securely
retained for 10 years. The aggregated sexual abuse data was reviewed, and all
personal identifiers are removed. The website included State and privately operated
facilities. During the tour of the facility the auditor requested access to review
resident files. The files were maintained in a limited access file room under lock and
key. The electronic copy is maintained on a database program that is password
protected and also limited in the persons that have access to this data. In interviews
with the DJJ PREA Coordinator, the OIG staff, agency head and have access to this
database.
Compliance was determined by review of the website and interview with the agency
Head and PREA coordinator.
115.401 Frequency and scope of audits
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memorandum and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 PREA
PREA Audit 2015
PREA Audit 2018
PREA Audit 2021
115.401 (a): FDJJ Policy 1919 requires all DJJ facilities be audited every three years
for compliance with the Prison Rape Elimination Act The initial PREA audit of Marion
Regional Juvenile Detention Center was conducted 2015 by a DOJ certified PREA
auditor. The second audit was conducted in 2018 by a DOJ Certified auditor. The
third audit of this facility was conducted in 2021 by a certified PREA auditor. This is
the fourth audit of the facility. The on-site audit occurred in 2023.
115.401 (b): According to PREA Coordinator and the annual PREA report, during the
three-year period beginning on August 20, 2013, FDJJ ensured that each of its
facilities were audited at least once and continues to ensure that its facilities are
audited every three years. During the last cycle many audits were scheduled,
rescheduled, and postponed due to the pandemic. However, each facility was
audited during the last 3-year cycle. This is the second year of this cycle.
115.401 (h): During the audit, I was allowed access to all areas of Facility. I was
allowed to visit areas throughout the facility during the official tour and additional
visits to different areas of the facility while interviewing and observing camera
locations.
115.401 (i): I requested personnel files, resident files, training records, investigation
files, logbooks, and pertinent forms utilized to carry out the requirement of the audit
process. Each document was provided in a timely basis.
115.401 (m): I interviewed random staff on duty for the for the first 24 hours of the
audit and random sample of residents during the onsite audit. Interviews were
conducted in a private area of the facility.
115.401 (n): Posting were displayed throughout the facility with the name and
address of the PREA auditor. The auditor did not receive any correspondences from
residents. The information was posted on October 11, 2023. The auditor interviewed
the PREA Compliance Manager and asked if residents were allowed to send mail to
auditor in the same manner as legal mail system. He indicated they were and
provided how you stamps legal mail that it has not been opened or censured and
mailed same date as it is removed from the mailboxes located throughout the
facility. The PREA Compliance manager indicated that he or the Facility
Administrator check the mailbox, PREA Box and Grievance Box a minimum of two
times a day during the week and at least once a day on weekends.
Compliance was determined by review of three past audits, email providing dates
of audit postings and interviews with Facility Administrator, PREA Coordinator and
Agency Head designee.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
FDJJ Policy 1919 requires all DJJ facilities be audited every three years for
compliance with the Prison Rape Elimination Act The initial PREA audit of Marion
Regional Juvenile Detention Center was conducted in 2015 by a DOJ certified PREA
auditor. The second audit was conducted in 2018 by a DOJ Certified auditor. The
third audit of this facility conducted in 2021 by a certified PREA auditor. This is the
fourth PREA audit for this facility. All reports were reviewed on the Florida
Department of Juvenile Justice Website. The website was found to be user friendly
and was accessed by doing a google search of Florida Department of Juvenile Justice
PREA audits.
Appendix: Provision Findings
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(a) coordinator
Does the agency have a written policy mandating zero tolerance yes
toward all forms of sexual abuse and sexual harassment?
Does the written policy outline the agency’s approach to yes
preventing, detecting, and responding to sexual abuse and sexual
harassment?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(b) coordinator
Has the agency employed or designated an agency-wide PREA yes
Coordinator?
Is the PREA Coordinator position in the upper-level of the agency yes
hierarchy?
Does the PREA Coordinator have sufficient time and authority to yes
develop, implement, and oversee agency efforts to comply with
the PREA standards in all of its facilities?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(c) coordinator
If this agency operates more than one facility, has each facility yes
designated a PREA compliance manager? (N/A if agency operates
only one facility.)
Does the PREA compliance manager have sufficient time and yes
authority to coordinate the facility’s efforts to comply with the
PREA standards? (N/A if agency operates only one facility.)
115.312
Contracting with other entities for the confinement of residents
(a)
If this agency is public and it contracts for the confinement of its yes
residents with private agencies or other entities including other
government agencies, has the agency included the entity’s
obligation to adopt and comply with the PREA standards in any
new contract or contract renewal signed on or after August 20,
2012? (N/A if the agency does not contract with private agencies
or other entities for the confinement of residents.)
115.312
Contracting with other entities for the confinement of residents
(b)
Does any new contract or contract renewal signed on or after yes
August 20, 2012 provide for agency contract monitoring to ensure
that the contractor is complying with the PREA standards? (N/A if
the agency does not contract with private agencies or other
entities for the confinement of residents OR the response to
115.312(a)-1 is "NO".)
115.313
Supervision and monitoring
(a)
Does the agency ensure that each facility has developed a staffing yes
plan that provides for adequate levels of staffing and, where
applicable, video monitoring, to protect residents against sexual
abuse?
Does the agency ensure that each facility has implemented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility has documented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
prevalence of substantiated and unsubstantiated incidents of
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Generally accepted juvenile detention and correctional/secure
residential practices?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
judicial findings of inadequacy?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from Federal investigative agencies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from internal or external oversight bodies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: All
components of the facility’s physical plant (including “blind-spots”
or areas where staff or residents may be isolated)?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
composition of the resident population?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
number and placement of supervisory staff?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Institution programs occurring on a particular shift?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
applicable State or local laws, regulations, or standards?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
other relevant factors?
115.313
Supervision and monitoring
(b)
Does the agency comply with the staffing plan except during yes
limited and discrete exigent circumstances?
In circumstances where the staffing plan is not complied with, na
does the facility fully document all deviations from the plan? (N/A
if no deviations from staffing plan.)
115.313
Supervision and monitoring
(c)
Does the facility maintain staff ratios of a minimum of 1:8 during yes
resident waking hours, except during limited and discrete exigent
circumstances? (N/A only until October 1, 2017.)
Does the facility maintain staff ratios of a minimum of 1:16 during yes
resident sleeping hours, except during limited and discrete
exigent circumstances? (N/A only until October 1, 2017.)
Does the facility fully document any limited and discrete exigent yes
circumstances during which the facility did not maintain staff
ratios? (N/A only until October 1, 2017.)
Does the facility ensure only security staff are included when yes
calculating these ratios? (N/A only until October 1, 2017.)
Is the facility obligated by law, regulation, or judicial consent yes
decree to maintain the staffing ratios set forth in this paragraph?
115.313
Supervision and monitoring
(d)
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The staffing plan established
pursuant to paragraph (a) of this section?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: Prevailing staffing patterns?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The facility’s deployment of
video monitoring systems and other monitoring technologies?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The resources the facility has
available to commit to ensure adherence to the staffing plan?
115.313
Supervision and monitoring
(e)
Has the facility implemented a policy and practice of having yes
intermediate-level or higher-level supervisors conduct and
document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? (N/A for non-secure facilities )
Is this policy and practice implemented for night shifts as well as yes
day shifts? (N/A for non-secure facilities )
Does the facility have a policy prohibiting staff from alerting other yes
staff members that these supervisory rounds are occurring, unless
such announcement is related to the legitimate operational
functions of the facility? (N/A for non-secure facilities )
115.315
Limits to cross-gender viewing and searches
(a)
Does the facility always refrain from conducting any cross-gender yes
strip or cross-gender visual body cavity searches, except in
exigent circumstances or by medical practitioners?
115.315
Limits to cross-gender viewing and searches
(b)
Does the facility always refrain from conducting cross-gender pat- yes
down searches in non-exigent circumstances?
115.315
Limits to cross-gender viewing and searches
(c)
Does the facility document and justify all cross-gender strip yes
searches and cross-gender visual body cavity searches?
Does the facility document all cross-gender pat-down searches? yes
115.315
Limits to cross-gender viewing and searches
(d)
Does the facility implement policies and procedures that enable yes
residents to shower, perform bodily functions, and change clothing
without nonmedical staff of the opposite gender viewing their
breasts, buttocks, or genitalia, except in exigent circumstances or
when such viewing is incidental to routine cell checks?
Does the facility require staff of the opposite gender to announce yes
their presence when entering a resident housing unit?
In facilities (such as group homes) that do not contain discrete yes
housing units, does the facility require staff of the opposite gender
to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions,
or changing clothing? (N/A for facilities with discrete housing
units)
115.315
Limits to cross-gender viewing and searches
(e)
Does the facility always refrain from searching or physically yes
examining transgender or intersex residents for the sole purpose
of determining the resident’s genital status?
If a resident’s genital status is unknown, does the facility yes
determine genital status during conversations with the resident,
by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted
in private by a medical practitioner?
115.315
Limits to cross-gender viewing and searches
(f)
Does the facility/agency train security staff in how to conduct yes
cross-gender pat down searches in a professional and respectful
manner, and in the least intrusive manner possible, consistent
with security needs?
Does the facility/agency train security staff in how to conduct yes
searches of transgender and intersex residents in a professional
and respectful manner, and in the least intrusive manner possible,
consistent with security needs?
115.316 Residents with disabilities and residents who are limited
(a) English proficient
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are deaf or hard of hearing?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are blind or have low vision?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have intellectual disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have psychiatric disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have speech disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Other? (if "other," please explain in overall determination notes.)
Do such steps include, when necessary, ensuring effective yes
communication with residents who are deaf or hard of hearing?
Do such steps include, when necessary, providing access to yes
interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any
necessary specialized vocabulary?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
intellectual disabilities?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
limited reading skills?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Who are
blind or have low vision?
115.316 Residents with disabilities and residents who are limited
(b) English proficient
Does the agency take reasonable steps to ensure meaningful yes
access to all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment to residents
who are limited English proficient?
Do these steps include providing interpreters who can interpret yes
effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary?
115.316 Residents with disabilities and residents who are limited
(c) English proficient
Does the agency always refrain from relying on resident yes
interpreters, resident readers, or other types of resident assistants
except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s
safety, the performance of first-response duties under §115.364,
or the investigation of the resident’s allegations?
115.317
Hiring and promotion decisions
(a)
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has engaged in sexual
abuse in a prison, jail, lockup, community confinement facility,
juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been convicted of
engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or
coercion, or if the victim did not consent or was unable to consent
or refuse?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been civilly or
administratively adjudicated to have engaged in the activity
described in the bullet immediately above?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has
engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as
defined in 42 U.S.C. 1997)?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
convicted of engaging or attempting to engage in sexual activity
in the community facilitated by force, overt or implied threats of
force, or coercion, or if the victim did not consent or was unable to
consent or refuse?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
civilly or administratively adjudicated to have engaged in the
activity described in the two bullets immediately above?
115.317
Hiring and promotion decisions
(b)
Does the agency consider any incidents of sexual harassment in yes
determining whether to hire or promote anyone, or to enlist the
services of any contractor, who may have contact with residents?
115.317 Hiring and promotion decisions
(c)
Before hiring new employees who may have contact with yes
residents, does the agency: Perform a criminal background records
check?
Before hiring new employees who may have contact with yes
residents, does the agency: Consult any child abuse registry
maintained by the State or locality in which the employee would
work?
Before hiring new employees who may have contact with yes
residents, does the agency: Consistent with Federal, State, and
local law, make its best efforts to contact all prior institutional
employers for information on substantiated allegations of sexual
abuse or any resignation during a pending investigation of an
allegation of sexual abuse?
115.317
Hiring and promotion decisions
(d)
Does the agency perform a criminal background records check yes
before enlisting the services of any contractor who may have
contact with residents?
Does the agency consult applicable child abuse registries before yes
enlisting the services of any contractor who may have contact
with residents?
115.317
Hiring and promotion decisions
(e)
Does the agency either conduct criminal background records yes
checks at least every five years of current employees and
contractors who may have contact with residents or have in place
a system for otherwise capturing such information for current
employees?
115.317
Hiring and promotion decisions
(f)
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in written applications or
interviews for hiring or promotions?
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in any interviews or
written self-evaluations conducted as part of reviews of current
employees?
Does the agency impose upon employees a continuing affirmative yes
duty to disclose any such misconduct?
115.317
Hiring and promotion decisions
(g)
Does the agency consider material omissions regarding such yes
misconduct, or the provision of materially false information,
grounds for termination?
115.317
Hiring and promotion decisions
(h)
Unless prohibited by law, does the agency provide information on yes
substantiated allegations of sexual abuse or sexual harassment
involving a former employee upon receiving a request from an
institutional employer for whom such employee has applied to
work? (N/A if providing information on substantiated allegations of
sexual abuse or sexual harassment involving a former employee is
prohibited by law.)
115.318
Upgrades to facilities and technologies
(a)
If the agency designed or acquired any new facility or planned any yes
substantial expansion or modification of existing facilities, did the
agency consider the effect of the design, acquisition, expansion,
or modification upon the agency’s ability to protect residents from
sexual abuse? (N/A if agency/facility has not acquired a new
facility or made a substantial expansion to existing facilities since
August 20, 2012, or since the last PREA audit, whichever is later.)
115.318
Upgrades to facilities and technologies
(b)
If the agency installed or updated a video monitoring system, yes
electronic surveillance system, or other monitoring technology,
did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if
agency/facility has not installed or updated a video monitoring
system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit,
whichever is later.)
115.321
Evidence protocol and forensic medical examinations
(a)
If the agency is responsible for investigating allegations of sexual yes
abuse, does the agency follow a uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for
administrative proceedings and criminal prosecutions? (N/A if the
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
115.321
Evidence protocol and forensic medical examinations
(b)
Is this protocol developmentally appropriate for youth? (N/A if the yes
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
Is this protocol, as appropriate, adapted from or otherwise based yes
on the most recent edition of the U.S. Department of Justice’s
Office on Violence Against Women publication, “A National Protocol
for Sexual Assault Medical Forensic Examinations, Adults/
Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative
sexual abuse investigations. )
115.321
Evidence protocol and forensic medical examinations
(c)
Does the agency offer all residents who experience sexual abuse yes
access to forensic medical examinations, whether on-site or at an
outside facility, without financial cost, where evidentiarily or
medically appropriate?
Are such examinations performed by Sexual Assault Forensic yes
Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs)
where possible?
If SAFEs or SANEs cannot be made available, is the examination yes
performed by other qualified medical practitioners (they must
have been specifically trained to conduct sexual assault forensic
exams)?
Has the agency documented its efforts to provide SAFEs or yes
SANEs?
115.321
Evidence protocol and forensic medical examinations
(d)
Does the agency attempt to make available to the victim a victim yes
advocate from a rape crisis center?
If a rape crisis center is not available to provide victim advocate yes
services, does the agency make available to provide these
services a qualified staff member from a community-based
organization, or a qualified agency staff member?
Has the agency documented its efforts to secure services from yes
rape crisis centers?
115.321
Evidence protocol and forensic medical examinations
(e)
As requested by the victim, does the victim advocate, qualified yes
agency staff member, or qualified community-based organization
staff member accompany and support the victim through the
forensic medical examination process and investigatory
interviews?
As requested by the victim, does this person provide emotional yes
support, crisis intervention, information, and referrals?
115.321
Evidence protocol and forensic medical examinations
(f)
If the agency itself is not responsible for investigating allegations yes
of sexual abuse, has the agency requested that the investigating
entity follow the requirements of paragraphs (a) through (e) of this
section? (N/A if the agency is responsible for investigating
allegations of sexual abuse.)
115.321
Evidence protocol and forensic medical examinations
(h)
If the agency uses a qualified agency staff member or a qualified na
community-based staff member for the purposes of this section,
has the individual been screened for appropriateness to serve in
this role and received education concerning sexual assault and
forensic examination issues in general? (Check N/A if agency
attempts to make a victim advocate from a rape crisis center
available to victims per 115.321(d) above.)
115.322
Policies to ensure referrals of allegations for investigations
(a)
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual abuse?
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual
harassment?
115.322
Policies to ensure referrals of allegations for investigations
(b)
Does the agency have a policy in place to ensure that allegations yes
of sexual abuse or sexual harassment are referred for
investigation to an agency with the legal authority to conduct
criminal investigations, unless the allegation does not involve
potentially criminal behavior?
Has the agency published such policy on its website or, if it does yes
not have one, made the policy available through other means?
Does the agency document all such referrals? yes
115.322
Policies to ensure referrals of allegations for investigations
(c)
If a separate entity is responsible for conducting criminal yes
investigations, does such publication describe the responsibilities
of both the agency and the investigating entity? (N/A if the
agency/facility is responsible for criminal investigations. See
115.321(a))
115.331
Employee training
(a)
Does the agency train all employees who may have contact with yes
residents on: Its zero-tolerance policy for sexual abuse and sexual
harassment?
Does the agency train all employees who may have contact with yes
residents on: How to fulfill their responsibilities under agency
sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures?
Does the agency train all employees who may have contact with yes
residents on: Residents’ right to be free from sexual abuse and
sexual harassment
Does the agency train all employees who may have contact with yes
residents on: The right of residents and employees to be free from
retaliation for reporting sexual abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: The dynamics of sexual abuse and sexual
harassment in juvenile facilities?
Does the agency train all employees who may have contact with yes
residents on: The common reactions of juvenile victims of sexual
abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: How to detect and respond to signs of threatened
and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents?
Does the agency train all employees who may have contact with yes
residents on: How to avoid inappropriate relationships with
residents?
Does the agency train all employees who may have contact with yes
residents on: How to communicate effectively and professionally
with residents, including lesbian, gay, bisexual, transgender,
intersex, or gender nonconforming residents?
Does the agency train all employees who may have contact with yes
residents on: How to comply with relevant laws related to
mandatory reporting of sexual abuse to outside authorities?
Does the agency train all employees who may have contact with yes
residents on: Relevant laws regarding the applicable age of
consent?
115.331
Employee training
(b)
Is such training tailored to the unique needs and attributes of yes
residents of juvenile facilities?
Is such training tailored to the gender of the residents at the yes
employee’s facility?
Have employees received additional training if reassigned from a yes
facility that houses only male residents to a facility that houses
only female residents, or vice versa?
115.331
Employee training
(c)
Have all current employees who may have contact with residents yes
received such training?
Does the agency provide each employee with refresher training yes
every two years to ensure that all employees know the agency’s
current sexual abuse and sexual harassment policies and
procedures?
In years in which an employee does not receive refresher training, yes
does the agency provide refresher information on current sexual
abuse and sexual harassment policies?
115.331
Employee training
(d)
Does the agency document, through employee signature or yes
electronic verification, that employees understand the training
they have received?
115.332
Volunteer and contractor training
(a)
Has the agency ensured that all volunteers and contractors who yes
have contact with residents have been trained on their
responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and
procedures?
115.332
Volunteer and contractor training
(b)
Have all volunteers and contractors who have contact with yes
residents been notified of the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment and informed how
to report such incidents (the level and type of training provided to
volunteers and contractors shall be based on the services they
provide and level of contact they have with residents)?
115.332
Volunteer and contractor training
(c)
Does the agency maintain documentation confirming that yes
volunteers and contractors understand the training they have
received?
115.333
Resident education
(a)
During intake, do residents receive information explaining the yes
agency’s zero-tolerance policy regarding sexual abuse and sexual
harassment?
During intake, do residents receive information explaining how to yes
report incidents or suspicions of sexual abuse or sexual
harassment?
Is this information presented in an age-appropriate fashion? yes
115.333
Resident education
(b)
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from sexual abuse and
sexual harassment?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from retaliation for
reporting such incidents?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Agency policies and procedures for responding to
such incidents?
115.333
Resident education
(c)
Have all residents received such education? yes
Do residents receive education upon transfer to a different facility yes
to the extent that the policies and procedures of the resident’s
new facility differ from those of the previous facility?
115.333
Resident education
(d)
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are limited English proficient?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are deaf?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are visually impaired?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are otherwise disabled?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Have limited reading skills?
115.333
Resident education
(e)
Does the agency maintain documentation of resident participation yes
in these education sessions?
115.333
Resident education
(f)
In addition to providing such education, does the agency ensure yes
that key information is continuously and readily available or visible
to residents through posters, resident handbooks, or other written
formats?
115.334
Specialized training: Investigations
(a)
In addition to the general training provided to all employees na
pursuant to §115.331, does the agency ensure that, to the extent
the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such
investigations in confinement settings? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.334
Specialized training: Investigations
(b)
Does this specialized training include: Techniques for interviewing na
juvenile sexual abuse victims? (N/A if the agency does not conduct
any form of administrative or criminal sexual abuse investigations.
See 115.321(a).)
Does this specialized training include: Proper use of Miranda and na
Garrity warnings? (N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See
115.321(a).)
Does this specialized training include: Sexual abuse evidence na
collection in confinement settings? (N/A if the agency does not
conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
Does this specialized training include: The criteria and evidence na
required to substantiate a case for administrative action or
prosecution referral? (N/A if the agency does not conduct any form
of administrative or criminal sexual abuse investigations. See
115.321(a).)
115.334
Specialized training: Investigations
(c)
Does the agency maintain documentation that agency na
investigators have completed the required specialized training in
conducting sexual abuse investigations? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.335
Specialized training: Medical and mental health care
(a)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to detect and assess signs of sexual
abuse and sexual harassment? (N/A if the agency does not have
any full- or part-time medical or mental health care practitioners
who work regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to preserve physical evidence of sexual
abuse? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual
harassment? (N/A if the agency does not have any full- or part-
time medical or mental health care practitioners who work
regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How and to whom to report allegations or
suspicions of sexual abuse and sexual harassment? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(b)
If medical staff employed by the agency conduct forensic na
examinations, do such medical staff receive appropriate training
to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams or the agency does not
employ medical staff.)
115.335
Specialized training: Medical and mental health care
(c)
Does the agency maintain documentation that medical and yes
mental health practitioners have received the training referenced
in this standard either from the agency or elsewhere? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(d)
Do medical and mental health care practitioners employed by the yes
agency also receive training mandated for employees by
§115.331? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Do medical and mental health care practitioners contracted by yes
and volunteering for the agency also receive training mandated
for contractors and volunteers by §115.332? (N/A if the agency
does not have any full- or part-time medical or mental health care
practitioners contracted by or volunteering for the agency.)
115.341
Obtaining information from residents
(a)
Within 72 hours of the resident’s arrival at the facility, does the yes
agency obtain and use information about each resident’s personal
history and behavior to reduce risk of sexual abuse by or upon a
resident?
Does the agency also obtain this information periodically yes
throughout a resident’s confinement?
115.341
Obtaining information from residents
(b)
Are all PREA screening assessments conducted using an objective yes
screening instrument?
115.341
Obtaining information from residents
(c)
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Prior sexual
victimization or abusiveness?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any gender
nonconforming appearance or manner or identification as lesbian,
gay, bisexual, transgender, or intersex, and whether the resident
may therefore be vulnerable to sexual abuse?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Current
charges and offense history?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Age?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Level of
emotional and cognitive development?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical size
and stature?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Mental illness
or mental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Intellectual or
developmental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical
disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: The resident’s
own perception of vulnerability?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any other
specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or
separation from certain other residents?
115.341
Obtaining information from residents
(d)
Is this information ascertained: Through conversations with the yes
resident during the intake process and medical mental health
screenings?
Is this information ascertained: During classification assessments? yes
Is this information ascertained: By reviewing court records, case yes
files, facility behavioral records, and other relevant documentation
from the resident’s files?
115.341
Obtaining information from residents
(e)
Has the agency implemented appropriate controls on the yes
dissemination within the facility of responses to questions asked
pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or
other residents?
115.342
Placement of residents
(a)
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Housing Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Bed assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Work Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Education
Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Program Assignments?
115.342
Placement of residents
(b)
Are residents isolated from others only as a last resort when less yes
restrictive measures are inadequate to keep them and other
residents safe, and then only until an alternative means of
keeping all residents safe can be arranged?
During any period of isolation, does the agency always refrain yes
from denying residents daily large-muscle exercise?
During any period of isolation, does the agency always refrain yes
from denying residents any legally required educational
programming or special education services?
Do residents in isolation receive daily visits from a medical or yes
mental health care clinician?
Do residents also have access to other programs and work yes
opportunities to the extent possible?
115.342
Placement of residents
(c)
Does the agency always refrain from placing: Lesbian, gay, and yes
bisexual residents in particular housing, bed, or other assignments
solely on the basis of such identification or status?
Does the agency always refrain from placing: Transgender yes
residents in particular housing, bed, or other assignments solely
on the basis of such identification or status?
Does the agency always refrain from placing: Intersex residents in yes
particular housing, bed, or other assignments solely on the basis
of such identification or status?
Does the agency always refrain from considering lesbian, gay, yes
bisexual, transgender, or intersex identification or status as an
indicator or likelihood of being sexually abusive?
115.342
Placement of residents
(d)
When deciding whether to assign a transgender or intersex yes
resident to a facility for male or female residents, does the agency
consider on a case-by-case basis whether a placement would
ensure the resident’s health and safety, and whether a placement
would present management or security problems (NOTE: if an
agency by policy or practice assigns residents to a male or female
facility on the basis of anatomy alone, that agency is not in
compliance with this standard)?
When making housing or other program assignments for yes
transgender or intersex residents, does the agency consider on a
case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would
present management or security problems?
115.342
Placement of residents
(e)
Are placement and programming assignments for each yes
transgender or intersex resident reassessed at least twice each
year to review any threats to safety experienced by the resident?
115.342
Placement of residents
(f)
Are each transgender or intersex resident’s own views with yes
respect to his or her own safety given serious consideration when
making facility and housing placement decisions and
programming assignments?
115.342
Placement of residents
(g)
Are transgender and intersex residents given the opportunity to yes
shower separately from other residents?
115.342
Placement of residents
(h)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The basis for the facility’s
concern for the resident’s safety? (N/A for h and i if facility doesn’t
use isolation?)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The reason why no alternative
means of separation can be arranged? (N/A for h and i if facility
doesn’t use isolation?)
115.342
Placement of residents
(i)
In the case of each resident who is isolated as a last resort when yes
less restrictive measures are inadequate to keep them and other
residents safe, does the facility afford a review to determine
whether there is a continuing need for separation from the general
population EVERY 30 DAYS?
115.351
Resident reporting
(a)
Does the agency provide multiple internal ways for residents to yes
privately report: Sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: 2. Retaliation by other residents or staff for
reporting sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: Staff neglect or violation of responsibilities that
may have contributed to such incidents?
115.351
Resident reporting
(b)
Does the agency also provide at least one way for residents to yes
report sexual abuse or sexual harassment to a public or private
entity or office that is not part of the agency?
Is that private entity or office able to receive and immediately yes
forward resident reports of sexual abuse and sexual harassment to
agency officials?
Does that private entity or office allow the resident to remain yes
anonymous upon request?
Are residents detained solely for civil immigration purposes yes
provided information on how to contact relevant consular officials
and relevant officials at the Department of Homeland Security to
report sexual abuse or harassment?
115.351
Resident reporting
(c)
Do staff members accept reports of sexual abuse and sexual yes
harassment made verbally, in writing, anonymously, and from
third parties?
Do staff members promptly document any verbal reports of sexual yes
abuse and sexual harassment?
115.351
Resident reporting
(d)
Does the facility provide residents with access to tools necessary yes
to make a written report?
115.351
Resident reporting
(e)
Does the agency provide a method for staff to privately report yes
sexual abuse and sexual harassment of residents?
115.352
Exhaustion of administrative remedies
(a)
Is the agency exempt from this standard? yes
NOTE: The agency is exempt ONLY if it does not have
administrative procedures to address resident grievances
regarding sexual abuse. This does not mean the agency is exempt
simply because a resident does not have to or is not ordinarily
expected to submit a grievance to report sexual abuse. This
means that as a matter of explicit policy, the agency does not
have an administrative remedies process to address sexual abuse.
115.352
Exhaustion of administrative remedies
(b)
Does the agency permit residents to submit a grievance regarding na
an allegation of sexual abuse without any type of time limits? (The
agency may apply otherwise-applicable time limits to any portion
of a grievance that does not allege an incident of sexual abuse.)
(N/A if agency is exempt from this standard.)
Does the agency always refrain from requiring an resident to use na
any informal grievance process, or to otherwise attempt to resolve
with staff, an alleged incident of sexual abuse? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(c)
Does the agency ensure that: A resident who alleges sexual abuse na
may submit a grievance without submitting it to a staff member
who is the subject of the complaint? (N/A if agency is exempt from
this standard.)
Does the agency ensure that: Such grievance is not referred to a na
staff member who is the subject of the complaint? (N/A if agency
is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(d)
Does the agency issue a final agency decision on the merits of any na
portion of a grievance alleging sexual abuse within 90 days of the
initial filing of the grievance? (Computation of the 90-day time
period does not include time consumed by residents in preparing
any administrative appeal.) (N/A if agency is exempt from this
standard.)
If the agency determines that the 90 day timeframe is insufficient na
to make an appropriate decision and claims an extension of time
(the maximum allowable extension of time to respond is 70 days
per 115.352(d)(3)) , does the agency notify the resident in writing
of any such extension and provide a date by which a decision will
be made? (N/A if agency is exempt from this standard.)
At any level of the administrative process, including the final level, na
if the resident does not receive a response within the time allotted
for reply, including any properly noticed extension, may a resident
consider the absence of a response to be a denial at that level?
(N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(e)
Are third parties, including fellow residents, staff members, family na
members, attorneys, and outside advocates, permitted to assist
residents in filing requests for administrative remedies relating to
allegations of sexual abuse? (N/A if agency is exempt from this
standard.)
Are those third parties also permitted to file such requests on na
behalf of residents? (If a third party, other than a parent or legal
guardian, files such a request on behalf of a resident, the facility
may require as a condition of processing the request that the
alleged victim agree to have the request filed on his or her behalf,
and may also require the alleged victim to personally pursue any
subsequent steps in the administrative remedy process.) (N/A if
agency is exempt from this standard.)
If the resident declines to have the request processed on his or na
her behalf, does the agency document the resident’s decision?
(N/A if agency is exempt from this standard.)
Is a parent or legal guardian of a juvenile allowed to file a na
grievance regarding allegations of sexual abuse, including
appeals, on behalf of such juvenile? (N/A if agency is exempt from
this standard.)
If a parent or legal guardian of a juvenile files a grievance (or an na
appeal) on behalf of a juvenile regarding allegations of sexual
abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her
behalf? (N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(f)
Has the agency established procedures for the filing of an na
emergency grievance alleging that a resident is subject to a
substantial risk of imminent sexual abuse? (N/A if agency is
exempt from this standard.)
After receiving an emergency grievance alleging a resident is na
subject to a substantial risk of imminent sexual abuse, does the
agency immediately forward the grievance (or any portion thereof
that alleges the substantial risk of imminent sexual abuse) to a
level of review at which immediate corrective action may be
taken? (N/A if agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency provide an initial response within 48 hours? (N/A if
agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency issue a final agency decision within 5 calendar days?
(N/A if agency is exempt from this standard.)
Does the initial response and final agency decision document the na
agency’s determination whether the resident is in substantial risk
of imminent sexual abuse? (N/A if agency is exempt from this
standard.)
Does the initial response document the agency’s action(s) taken in na
response to the emergency grievance? (N/A if agency is exempt
from this standard.)
Does the agency’s final decision document the agency’s action(s) na
taken in response to the emergency grievance? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(g)
If the agency disciplines a resident for filing a grievance related to na
alleged sexual abuse, does it do so ONLY where the agency
demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.)
115.353 Resident access to outside confidential support services and
(a) legal representation
Does the facility provide residents with access to outside victim yes
advocates for emotional support services related to sexual abuse
by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll-free hotline
numbers where available, of local, State, or national victim
advocacy or rape crisis organizations?
Does the facility provide persons detained solely for civil yes
immigration purposes mailing addresses and telephone numbers,
including toll-free hotline numbers where available of local, State,
or national immigrant services agencies?
Does the facility enable reasonable communication between yes
residents and these organizations and agencies, in as confidential
a manner as possible?
115.353 Resident access to outside confidential support services and
(b) legal representation
Does the facility inform residents, prior to giving them access, of yes
the extent to which such communications will be monitored and
the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws?
115.353 Resident access to outside confidential support services and
(c) legal representation
Does the agency maintain or attempt to enter into memoranda of yes
understanding or other agreements with community service
providers that are able to provide residents with confidential
emotional support services related to sexual abuse?
Does the agency maintain copies of agreements or documentation yes
showing attempts to enter into such agreements?
115.353 Resident access to outside confidential support services and
(d) legal representation
Does the facility provide residents with reasonable and yes
confidential access to their attorneys or other legal
representation?
Does the facility provide residents with reasonable access to yes
parents or legal guardians?
115.354
Third-party reporting
(a)
Has the agency established a method to receive third-party yes
reports of sexual abuse and sexual harassment?
Has the agency distributed publicly information on how to report yes
sexual abuse and sexual harassment on behalf of a resident?
115.361
Staff and agency reporting duties
(a)
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding an incident of sexual abuse or
sexual harassment that occurred in a facility, whether or not it is
part of the agency?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding retaliation against residents or
staff who reported an incident of sexual abuse or sexual
harassment?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding any staff neglect or violation of
responsibilities that may have contributed to an incident of sexual
abuse or sexual harassment or retaliation?
115.361
Staff and agency reporting duties
(b)
Does the agency require all staff to comply with any applicable yes
mandatory child abuse reporting laws?
115.361
Staff and agency reporting duties
(c)
Apart from reporting to designated supervisors or officials and yes
designated State or local services agencies, are staff prohibited
from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency
policy, to make treatment, investigation, and other security and
management decisions?
115.361
Staff and agency reporting duties
(d)
Are medical and mental health practitioners required to report yes
sexual abuse to designated supervisors and officials pursuant to
paragraph (a) of this section as well as to the designated State or
local services agency where required by mandatory reporting
laws?
Are medical and mental health practitioners required to inform yes
residents of their duty to report, and the limitations of
confidentiality, at the initiation of services?
115.361
Staff and agency reporting duties
(e)
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
appropriate office?
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
alleged victim’s parents or legal guardians unless the facility has
official documentation showing the parents or legal guardians
should not be notified?
If the alleged victim is under the guardianship of the child welfare yes
system, does the facility head or his or her designee promptly
report the allegation to the alleged victim’s caseworker instead of
the parents or legal guardians? (N/A if the alleged victim is not
under the guardianship of the child welfare system.)
If a juvenile court retains jurisdiction over the alleged victim, does yes
the facility head or designee also report the allegation to the
juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation?
115.361
Staff and agency reporting duties
(f)
Does the facility report all allegations of sexual abuse and sexual yes
harassment, including third-party and anonymous reports, to the
facility’s designated investigators?
115.362
Agency protection duties
(a)
When the agency learns that a resident is subject to a substantial yes
risk of imminent sexual abuse, does it take immediate action to
protect the resident?
115.363
Reporting to other confinement facilities
(a)
Upon receiving an allegation that a resident was sexually abused yes
while confined at another facility, does the head of the facility that
received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse
occurred?
Does the head of the facility that received the allegation also yes
notify the appropriate investigative agency?
115.363
Reporting to other confinement facilities
(b)
Is such notification provided as soon as possible, but no later than yes
72 hours after receiving the allegation?
115.363
Reporting to other confinement facilities
(c)
Does the agency document that it has provided such notification? yes
115.363
Reporting to other confinement facilities
(d)
Does the facility head or agency office that receives such yes
notification ensure that the allegation is investigated in
accordance with these standards?
115.364
Staff first responder duties
(a)
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Separate the alleged victim and abuser?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Request that the alleged victim not take any actions
that could destroy physical evidence, including, as appropriate,
washing, brushing teeth, changing clothes, urinating, defecating,
smoking, drinking, or eating, if the abuse occurred within a time
period that still allows for the collection of physical evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating,
defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical
evidence?
115.364
Staff first responder duties
(b)
If the first staff responder is not a security staff member, is the yes
responder required to request that the alleged victim not take any
actions that could destroy physical evidence, and then notify
security staff?
115.365
Coordinated response
(a)
Has the facility developed a written institutional plan to coordinate yes
actions among staff first responders, medical and mental health
practitioners, investigators, and facility leadership taken in
response to an incident of sexual abuse?
115.366 Preservation of ability to protect residents from contact with
(a) abusers
Are both the agency and any other governmental entities yes
responsible for collective bargaining on the agency’s behalf
prohibited from entering into or renewing any collective
bargaining agreement or other agreement that limits the agency’s
ability to remove alleged staff sexual abusers from contact with
any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is
warranted?
115.367
Agency protection against retaliation
(a)
Has the agency established a policy to protect all residents and yes
staff who report sexual abuse or sexual harassment or cooperate
with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff?
Has the agency designated which staff members or departments yes
are charged with monitoring retaliation?
115.367
Agency protection against retaliation
(b)
Does the agency employ multiple protection measures for yes
residents or staff who fear retaliation for reporting sexual abuse or
sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers,
removal of alleged staff or resident abusers from contact with
victims, and emotional support services?
115.367
Agency protection against retaliation
(c)
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents or staff who reported the sexual abuse to
see if there are changes that may suggest possible retaliation by
residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents who were reported to have suffered sexual
abuse to see if there are changes that may suggest possible
retaliation by residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Act promptly to remedy any
such retaliation?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident housing
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident program
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Negative performance
reviews of staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Reassignments of
staff?
Does the agency continue such monitoring beyond 90 days if the yes
initial monitoring indicates a continuing need?
115.367
Agency protection against retaliation
(d)
In the case of residents, does such monitoring also include yes
periodic status checks?
115.367
Agency protection against retaliation
(e)
If any other individual who cooperates with an investigation yes
expresses a fear of retaliation, does the agency take appropriate
measures to protect that individual against retaliation?
115.368
Post-allegation protective custody
(a)
Is any and all use of segregated housing to protect a resident who yes
is alleged to have suffered sexual abuse subject to the
requirements of § 115.342?
115.371
Criminal and administrative agency investigations
(a)
When the agency conducts its own investigations into allegations na
of sexual abuse and sexual harassment, does it do so promptly,
thoroughly, and objectively? (N/A if the agency does not conduct
any form of administrative or criminal investigations of sexual
abuse or harassment. See 115.321(a).)
Does the agency conduct such investigations for all allegations, na
including third party and anonymous reports? (N/A if the agency
does not conduct any form of administrative or criminal
investigations of sexual abuse or harassment. See 115.321(a).)
115.371
Criminal and administrative agency investigations
(b)
Where sexual abuse is alleged, does the agency use investigators yes
who have received specialized training in sexual abuse
investigations involving juvenile victims as required by 115.334?
115.371
Criminal and administrative agency investigations
(c)
Do investigators gather and preserve direct and circumstantial yes
evidence, including any available physical and DNA evidence and
any available electronic monitoring data?
Do investigators interview alleged victims, suspected yes
perpetrators, and witnesses?
Do investigators review prior reports and complaints of sexual yes
abuse involving the suspected perpetrator?
115.371
Criminal and administrative agency investigations
(d)
Does the agency always refrain from terminating an investigation yes
solely because the source of the allegation recants the allegation?
115.371
Criminal and administrative agency investigations
(e)
When the quality of evidence appears to support criminal yes
prosecution, does the agency conduct compelled interviews only
after consulting with prosecutors as to whether compelled
interviews may be an obstacle for subsequent criminal
prosecution?
115.371 Criminal and administrative agency investigations
(f)
Do agency investigators assess the credibility of an alleged victim, yes
suspect, or witness on an individual basis and not on the basis of
that individual’s status as resident or staff?
Does the agency investigate allegations of sexual abuse without yes
requiring a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition
for proceeding?
115.371
Criminal and administrative agency investigations
(g)
Do administrative investigations include an effort to determine yes
whether staff actions or failures to act contributed to the abuse?
Are administrative investigations documented in written reports yes
that include a description of the physical evidence and testimonial
evidence, the reasoning behind credibility assessments, and
investigative facts and findings?
115.371
Criminal and administrative agency investigations
(h)
Are criminal investigations documented in a written report that yes
contains a thorough description of the physical, testimonial, and
documentary evidence and attaches copies of all documentary
evidence where feasible?
115.371
Criminal and administrative agency investigations
(i)
Are all substantiated allegations of conduct that appears to be yes
criminal referred for prosecution?
115.371
Criminal and administrative agency investigations
(j)
Does the agency retain all written reports referenced in yes
115.371(g) and (h) for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years unless
the abuse was committed by a juvenile resident and applicable
law requires a shorter period of retention?
115.371
Criminal and administrative agency investigations
(k)
Does the agency ensure that the departure of an alleged abuser yes
or victim from the employment or control of the facility or agency
does not provide a basis for terminating an investigation?
115.371
Criminal and administrative agency investigations
(m)
When an outside entity investigates sexual abuse, does the facility yes
cooperate with outside investigators and endeavor to remain
informed about the progress of the investigation? (N/A if an
outside agency does not conduct administrative or criminal sexual
abuse investigations. See 115.321(a).)
115.372
Evidentiary standard for administrative investigations
(a)
Is it true that the agency does not impose a standard higher than yes
a preponderance of the evidence in determining whether
allegations of sexual abuse or sexual harassment are
substantiated?
115.373
Reporting to residents
(a)
Following an investigation into a resident’s allegation of sexual yes
abuse suffered in the facility, does the agency inform the resident
as to whether the allegation has been determined to be
substantiated, unsubstantiated, or unfounded?
115.373
Reporting to residents
(b)
If the agency did not conduct the investigation into a resident’s yes
allegation of sexual abuse in an agency facility, does the agency
request the relevant information from the investigative agency in
order to inform the resident? (N/A if the agency/facility is
responsible for conducting administrative and criminal
investigations.)
115.373
Reporting to residents
(c)
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer posted within the resident’s unit?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer employed at the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been indicted on a charge related to
sexual abuse in the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been convicted on a charge related to
sexual abuse within the facility?
115.373
Reporting to residents
(d)
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been indicted on a charge related to sexual abuse
within the facility?
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been convicted on a charge related to sexual abuse
within the facility?
115.373
Reporting to residents
(e)
Does the agency document all such notifications or attempted yes
notifications?
115.376
Disciplinary sanctions for staff
(a)
Are staff subject to disciplinary sanctions up to and including yes
termination for violating agency sexual abuse or sexual
harassment policies?
115.376
Disciplinary sanctions for staff
(b)
Is termination the presumptive disciplinary sanction for staff who yes
have engaged in sexual abuse?
115.376
Disciplinary sanctions for staff
(c)
Are disciplinary sanctions for violations of agency policies relating yes
to sexual abuse or sexual harassment (other than actually
engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s
disciplinary history, and the sanctions imposed for comparable
offenses by other staff with similar histories?
115.376
Disciplinary sanctions for staff
(d)
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to: Law
enforcement agencies, unless the activity was clearly not
criminal?
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to:
Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(a)
Is any contractor or volunteer who engages in sexual abuse yes
prohibited from contact with residents?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Law enforcement agencies (unless the activity was
clearly not criminal)?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(b)
In the case of any other violation of agency sexual abuse or sexual yes
harassment policies by a contractor or volunteer, does the facility
take appropriate remedial measures, and consider whether to
prohibit further contact with residents?
115.378
Interventions and disciplinary sanctions for residents
(a)
Following an administrative finding that a resident engaged in yes
resident-on-resident sexual abuse, or following a criminal finding
of guilt for resident-on-resident sexual abuse, may residents be
subject to disciplinary sanctions only pursuant to a formal
disciplinary process?
115.378
Interventions and disciplinary sanctions for residents
(b)
Are disciplinary sanctions commensurate with the nature and yes
circumstances of the abuse committed, the resident’s disciplinary
history, and the sanctions imposed for comparable offenses by
other residents with similar histories?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied daily
large-muscle exercise?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied access
to any legally required educational programming or special
education services?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident receives daily visits
from a medical or mental health care clinician?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the resident also have access to other programs
and work opportunities to the extent possible?
115.378
Interventions and disciplinary sanctions for residents
(c)
When determining what types of sanction, if any, should be yes
imposed, does the disciplinary process consider whether a
resident’s mental disabilities or mental illness contributed to his or
her behavior?
115.378
Interventions and disciplinary sanctions for residents
(d)
If the facility offers therapy, counseling, or other interventions yes
designed to address and correct underlying reasons or motivations
for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions?
If the agency requires participation in such interventions as a yes
condition of access to any rewards-based behavior management
system or other behavior-based incentives, does it always refrain
from requiring such participation as a condition to accessing
general programming or education?
115.378
Interventions and disciplinary sanctions for residents
(e)
Does the agency discipline a resident for sexual contact with staff yes
only upon a finding that the staff member did not consent to such
contact?
115.378
Interventions and disciplinary sanctions for residents
(f)
For the purpose of disciplinary action, does a report of sexual yes
abuse made in good faith based upon a reasonable belief that the
alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish
evidence sufficient to substantiate the allegation?
115.378
Interventions and disciplinary sanctions for residents
(g)
Does the agency always refrain from considering non-coercive yes
sexual activity between residents to be sexual abuse? (N/A if the
agency does not prohibit all sexual activity between residents.)
115.381
Medical and mental health screenings; history of sexual abuse
(a)
If the screening pursuant to § 115.341 indicates that a resident yes
has experienced prior sexual victimization, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a medical or
mental health practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(b)
If the screening pursuant to § 115.341 indicates that a resident yes
has previously perpetrated sexual abuse, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a mental health
practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(c)
Is any information related to sexual victimization or abusiveness yes
that occurred in an institutional setting strictly limited to medical
and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions,
including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local
law?
115.381
Medical and mental health screenings; history of sexual abuse
(d)
Do medical and mental health practitioners obtain informed yes
consent from residents before reporting information about prior
sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18?
115.382
Access to emergency medical and mental health services
(a)
Do resident victims of sexual abuse receive timely, unimpeded yes
access to emergency medical treatment and crisis intervention
services, the nature and scope of which are determined by
medical and mental health practitioners according to their
professional judgment?
115.382
Access to emergency medical and mental health services
(b)
If no qualified medical or mental health practitioners are on duty yes
at the time a report of recent sexual abuse is made, do staff first
responders take preliminary steps to protect the victim pursuant
to § 115.362?
Do staff first responders immediately notify the appropriate yes
medical and mental health practitioners?
115.382
Access to emergency medical and mental health services
(c)
Are resident victims of sexual abuse offered timely information yes
about and timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically
appropriate?
115.382
Access to emergency medical and mental health services
(d)
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(a) victims and abusers
Does the facility offer medical and mental health evaluation and, yes
as appropriate, treatment to all residents who have been
victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility?
115.383 Ongoing medical and mental health care for sexual abuse
(b) victims and abusers
Does the evaluation and treatment of such victims include, as yes
appropriate, follow-up services, treatment plans, and, when
necessary, referrals for continued care following their transfer to,
or placement in, other facilities, or their release from custody?
115.383 Ongoing medical and mental health care for sexual abuse
(c) victims and abusers
Does the facility provide such victims with medical and mental yes
health services consistent with the community level of care?
115.383 Ongoing medical and mental health care for sexual abuse
(d) victims and abusers
Are resident victims of sexually abusive vaginal penetration while yes
incarcerated offered pregnancy tests? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(e) victims and abusers
If pregnancy results from the conduct described in paragraph § yes
115.383(d), do such victims receive timely and comprehensive
information about and timely access to all lawful pregnancy-
related medical services? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(f) victims and abusers
Are resident victims of sexual abuse while incarcerated offered yes
tests for sexually transmitted infections as medically appropriate?
115.383 Ongoing medical and mental health care for sexual abuse
(g) victims and abusers
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(h) victims and abusers
Does the facility attempt to conduct a mental health evaluation of yes
all known resident-on-resident abusers within 60 days of learning
of such abuse history and offer treatment when deemed
appropriate by mental health practitioners?
115.386
Sexual abuse incident reviews
(a)
Does the facility conduct a sexual abuse incident review at the yes
conclusion of every sexual abuse investigation, including where
the allegation has not been substantiated, unless the allegation
has been determined to be unfounded?
115.386
Sexual abuse incident reviews
(b)
Does such review ordinarily occur within 30 days of the conclusion yes
of the investigation?
115.386
Sexual abuse incident reviews
(c)
Does the review team include upper-level management officials, yes
with input from line supervisors, investigators, and medical or
mental health practitioners?
115.386
Sexual abuse incident reviews
(d)
Does the review team: Consider whether the allegation or yes
investigation indicates a need to change policy or practice to
better prevent, detect, or respond to sexual abuse?
Does the review team: Consider whether the incident or allegation yes
was motivated by race; ethnicity; gender identity; lesbian, gay,
bisexual, transgender, or intersex identification, status, or
perceived status; gang affiliation; or other group dynamics at the
facility?
Does the review team: Examine the area in the facility where the yes
incident allegedly occurred to assess whether physical barriers in
the area may enable abuse?
Does the review team: Assess the adequacy of staffing levels in yes
that area during different shifts?
Does the review team: Assess whether monitoring technology yes
should be deployed or augmented to supplement supervision by
staff?
Does the review team: Prepare a report of its findings, including yes
but not necessarily limited to determinations made pursuant to §§
115.386(d)(1)-(d)(5), and any recommendations for improvement
and submit such report to the facility head and PREA compliance
manager?
115.386
Sexual abuse incident reviews
(e)
Does the facility implement the recommendations for yes
improvement, or document its reasons for not doing so?
115.387
Data collection
(a)
Does the agency collect accurate, uniform data for every yes
allegation of sexual abuse at facilities under its direct control
using a standardized instrument and set of definitions?
115.387
Data collection
(b)
Does the agency aggregate the incident-based sexual abuse data yes
at least annually?
115.387
Data collection
(c)
Does the incident-based data include, at a minimum, the data yes
necessary to answer all questions from the most recent version of
the Survey of Sexual Violence conducted by the Department of
Justice?
115.387
Data collection
(d)
Does the agency maintain, review, and collect data as needed yes
from all available incident-based documents, including reports,
investigation files, and sexual abuse incident reviews?
115.387
Data collection
(e)
Does the agency also obtain incident-based and aggregated data yes
from every private facility with which it contracts for the
confinement of its residents? (N/A if agency does not contract for
the confinement of its residents.)
115.387
Data collection
(f)
Does the agency, upon request, provide all such data from the yes
previous calendar year to the Department of Justice no later than
June 30? (N/A if DOJ has not requested agency data.)
115.388
Data review for corrective action
(a)
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Identifying problem areas?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Taking corrective action on an
ongoing basis?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Preparing an annual report of
its findings and corrective actions for each facility, as well as the
agency as a whole?
115.388
Data review for corrective action
(b)
Does the agency’s annual report include a comparison of the yes
current year’s data and corrective actions with those from prior
years and provide an assessment of the agency’s progress in
addressing sexual abuse?
115.388
Data review for corrective action
(c)
Is the agency’s annual report approved by the agency head and yes
made readily available to the public through its website or, if it
does not have one, through other means?
115.388
Data review for corrective action
(d)
Does the agency indicate the nature of the material redacted yes
where it redacts specific material from the reports when
publication would present a clear and specific threat to the safety
and security of a facility?
115.389
Data storage, publication, and destruction
(a)
Does the agency ensure that data collected pursuant to § 115.387 yes
are securely retained?
115.389
Data storage, publication, and destruction
(b)
Does the agency make all aggregated sexual abuse data, from yes
facilities under its direct control and private facilities with which it
contracts, readily available to the public at least annually through
its website or, if it does not have one, through other means?
115.389
Data storage, publication, and destruction
(c)
Does the agency remove all personal identifiers before making yes
aggregated sexual abuse data publicly available?
115.389
Data storage, publication, and destruction
(d)
Does the agency maintain sexual abuse data collected pursuant to yes
§ 115.387 for at least 10 years after the date of the initial
collection, unless Federal, State, or local law requires otherwise?
115.401
Frequency and scope of audits
(a)
During the prior three-year audit period, did the agency ensure yes
that each facility operated by the agency, or by a private
organization on behalf of the agency, was audited at least once?
(Note: The response here is purely informational. A "no" response
does not impact overall compliance with this standard.)
115.401
Frequency and scope of audits
(b)
Is this the first year of the current audit cycle? (Note: a “no” no
response does not impact overall compliance with this standard.)
If this is the second year of the current audit cycle, did the agency yes
ensure that at least one-third of each facility type operated by the
agency, or by a private organization on behalf of the agency, was
audited during the first year of the current audit cycle? (N/A if this
is not the second year of the current audit cycle.)
If this is the third year of the current audit cycle, did the agency na
ensure that at least two-thirds of each facility type operated by
the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle?
(N/A if this is not the third year of the current audit cycle.)
115.401
Frequency and scope of audits
(h)
Did the auditor have access to, and the ability to observe, all yes
areas of the audited facility?
115.401
Frequency and scope of audits
(i)
Was the auditor permitted to request and receive copies of any yes
relevant documents (including electronically stored information)?
115.401
Frequency and scope of audits
(m)
Was the auditor permitted to conduct private interviews with yes
inmates, residents, and detainees?
115.401
Frequency and scope of audits
(n)
Were inmates, residents, and detainees permitted to send yes
confidential information or correspondence to the auditor in the
same manner as if they were communicating with legal counsel?
115.403
Audit contents and findings
(f)
The agency has published on its agency website, if it has one, or yes
has otherwise made publicly available, all Final Audit Reports. The
review period is for prior audits completed during the past three
years PRECEDING THIS AUDIT. The pendency of any agency
appeal pursuant to 28 C.F.R. § 115.405 does not excuse
noncompliance with this provision. (N/A if there have been no Final
Audit Reports issued in the past three years, or, in the case of
single facility agencies, there has never been a Final Audit Report
issued.)

source: DJJ

report_type: PREA

pdf_url: https://www.djj.state.fl.us/content/download/1127681/file/Florida_Marion Regional Juvenile Detention Center_Year2Cycle4.pdf?version=1

cycle: Year 2 Cycle 4