state: FL

facility_name: charles britt academy

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY REPORT
JUVENILE FACILITIES
Name of Facility: Charles Britt Academy
Physical Address: 3001 26th Street; St. Petersburg, Florida 33712
Date report submitted January 12, 2015
Auditor information : Lois Jenkins
Address 2820 Weybourne Way; Columbia, SC 29223
Email: lljenk2@bellsouth.net
Telephone number: 803-463-9554
Date of facility visit : June 25-26, 2014
Facility Mailing Address: Same as Above
(if different from above)
Telephone Number: 727-954-5402
County
Municipal
Correction
Name of PREA Compliance Manager: Johnnie Downing, Jr. Title: Program Director
Email Address: Johnnie.Downing@ysii.com Telephone Number: 727-954-5402
Name of Agency: Youth Services International, Inc.
Governing Authority or
Parent Agency: (if
applicable)
Physical Address: 6000 Cattleridge Drive, Suite 200; Sarasota, Florida 34232
Mailing Address: (if
different from above) Same as Above
Telephone Number: 941-953-9199
Name: James Slattery Title: President
Email Address: jim.slattery@ysii.com Telephone 941-953-9199, ext. 217
Number:
Name: Jesse Williams Title: PREA Coordinator
Telephone
Email Address: jwilliams@ysii.com 941-704-8796
Number:
PREA AUDIT: AUDITOR’S SUMMARY REPORT 1
AUDIT FINDINGS
NARRATIVE:
Charles Britt Academy (CBA) is a Youth Services International, Inc. (YSI) operated program located in St.
Petersburg, Florida. Under contract with the Florida Department of Juvenile Justice (FDJJ) the academy opened July
1, 2013 and operates as a substance-abuse treatment program. All CBA residents are placed in the program by the
FDJJ. Charles Britt Academy (CBA) is a 28-bed residential program for moderate-risk boys, ages 14 to 18, who are
in need of substance abuse treatment services. Substance abuse treatment services are provided for youth with a
diagnosed substance related disorder and functional impairment associated with substance abuse or substance
dependence. The reported goals of the program are: to create a trauma-focused restraint-free environment; provide
comprehensive substance abuse, medical and mental health treatment services; and implement evidenced- based and
promising practices. The expected average length of stay is 6 to 9 months.
CBA employs a staff of 30 to support program needs. Daily operational oversight is provided by a full-time facility
administrator and assistant facility administrator while a team of youth Counselors, group leaders, case managers,
and therapist focus on resident and staff safety, security, order, and the provision of substance abuse treatment.
Medical needs are attended to by two full-time registered nurses with the support and services of a contracted part-
time medical doctor who serves as the designated health authority. The program also employs one human resource
and payroll technician, a plant manager, a food services manager, and food service workers.
The Pinellas County Public School System supplies teachers who provide general academic instruction and
vocational programming for the residents at Charles Britt Academy.
DESCRIPTION OF FACILITY CHARACTERISTICS:
Charles Britt Academy is a one-building facility marked by two distinct corridors. The South end of the North/South
corridor intersects with the center of the East/West corridor. Access into the facility via the front entrance brings you
into a small waiting area adjacent to the administration suite which houses the multi-purpose reception office, offices
of the facility administrator and assistant facility administrator and a conference room. Access to the North/South
corridor can be gained from the front waiting area. From the North/South corridor staff and residents can enter the
classrooms, the multi-purpose house meeting room, human resources office, and the cafeteria.
The East end of the East/West corridor provides access to the resident’s bedrooms and open community-style shower
and bathroom areas. Residents share bedrooms and there are no private bedrooms or private showers. Charles Britt
Academy does not have isolation rooms or segregation units.
The West end of the East/West corridor provides access to additional resident bedrooms, the laundry room, medical
staff office and exam room, and clinical staff offices. At the back of the facility there is a patio and fenced outdoor
area where recreation can occur when the weather permits. The multi-purpose house meeting room is also used as a
recreation area. There are a total of 16 surveillance cameras located inside and outside the building, but none are
located in the resident’s bedroom and shower/toileting areas.
SUMMARY OF AUDIT FINDINGS:
The notification of the on-site audit was posted on May 14, 2014, six weeks prior to the first date of the on-site audit.
The posting of the notice was verified by photographs received electronically from the Facility Administrator/PREA
Compliance Manager. The photographs indicated notices were posted in various locations throughout the facility
including the housing unit and administrative areas.
On June 12, 2014 a USB flash drive containing the completed Pre-Audit Questionnaire, policies, and other
supporting documentation was received from the PREA Compliance Manager. The information received was well
organized. Upon review of the Pre-Audit Questionnaire and supporting documentation, it became clear that some
required information was not included in the packet. Moreover, it became clear that completion of the Pre-Audit
Questionnaire form was done as if The Florida Department of Juvenile Justice is the agency when in fact Charles
Britt Academy is operated by Youth Services International, Inc. Between phone calls and e-mails, this issue was
addressed and the discrepancies were corrected. A follow-up call was placed on June 16, 2014 to discuss the Pre-
PREA AUDIT: AUDITOR’S SUMMARY REPORT 2
Audit Questionnaire, documentation checklist, and explain the on-site audit process. No resident communication was
received from the audit notification posting.
The on-site audit was conducted June 25-26, 2014, and began with a brief meeting with the Facility
Administrator/PREA Compliance Manager, and the Assistant Facility Administrator. After meeting we took a tour
of the facility and I was able to observe all of the physical plant and grounds. Notification of the PREA audit was
posted in various places in the facility, as well as posters informing residents of the Zero-tolerance policy against
sexual abuse and harassment and how to report. For resident reporting purposes, there is a pre-programmed phone
with a direct line to the Florida Department of Children and Families Abuse Registry located on the wall of the
North/South corridor.
The most recent Staffing Plan Assessment for CBA showed 16 security surveillance cameras and they were verified
during the tour. Observation of the master control surveillance system in the Facility Administrator’s office showed
there are blind spots, as well as one camera malfunctioning so that the surveillance area showed blacked out on the
master surveillance screen. These concerns were noted. There are no cameras in the resident’s rooms or
shower/toileting area so residents are not seen on the surveillance system while showering or toileting, but can be
viewed by same-sex staff as they supervise the community shower area.
There were a total of 29 residents in the program during the audit. While touring I observed that the residents were in
school and under supervision of teachers and security staff. I also observed that residents were under supervision of
staff while engaging in other activities throughout the day and evening hours. I interviewed 10 random residents
while conducting the audit. The residents were informed of their right to be free from sexual abuse and harassment,
and how to report sexual abuse and harassment, but generally did not know services provided by community-based
victims’ advocates or how to contact them. The facility has begun initial talks to enter into an agreement or MOU
with Suncoast Center, a Rape Crisis center of Pinellas County, to provide victim advocacy services for any sexual
assault victim.
While touring I encountered and spoke with security, clinical, intake, and cafeteria staff. I interviewed a total of 17
staff during the on-site audit that included specialized staff and 10 random staff from all three shifts. For the most
part, staff interviews revealed they have been trained on PREA standards and understand their responsibilities and
duties to prevent, detect, and respond to sexual abuse and harassment.
Charles Britt Academy reports they have not had any allegations of incidents of sexual abuse or harassment since
they opened in July, 2013.
Through the pre-audit and on-site audit processes, it was determined that 17 standards were not met. A corrective
action plan for compliance was developed and implemented to bring Charles Britt Academy into full compliance
with PREA standards. Details of corrective actions are written under each applicable standard within this report.
Number of standards exceeded: 0
Number of standards met: 36
Number of standards not met: 0
Number of standards Not Applicable: 5
PREA AUDIT: AUDITOR’S SUMMARY REPORT 3
Standard 115.311 – Zero To tolerance of sexual abuse and sexual harassment.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
YSI Charles Britt Academy (CBA) PREA Policy dated November 5, 2013 and Florida Department of Juvenile
Justice, Policy 1919 revised April 10, 2014 have clearly written language mandating a zero tolerance for all forms of
sexual abuse and sexual harassment. Within the 41 page CBA policy, the agency’s approach to preventing detecting
and responding to acts of sexual abuse and harassment is outlined.
The agency, YSI, has a PREA Coordinator who oversees PREA compliance efforts for the agency. The CBA Facility
Administrator is designated as the PREA Compliance Manager. When interviewed, both the PREA Coordinator and
PREA Compliance Manager said they had authority and sufficient time to manage PREA compliance related
responsibilities.
Standard 115.312 - Contract with other entities for the confinement of residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable (CBA is a YSI Youth Services, INC. program that operates under contract with the Florida
Department of Juvenile Justice (FDJJ) and does not contract with other entities for the confinement of residents.)
Standard 115.313 - Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA began operations July, 2013 under contractual agreement with the FDJJ to provide twenty-four hour supervision
every day of the year at a minimum level of 1:10 staff to resident ratio during resident awake hours and 1:10 during
resident sleep hours. The CBA PREA policy requires that at least once a year, the PREA Coordinator in consultation
with program staff will assess, determine, and document whether adjustments are needed to the staffing plan. The
policy further requires that the staffing plan assessment is to consider elements 1 through 11 outlined in section (a) of
this standard. Documentation shows that the most recent Staffing Plan Assessment was completed May 16, 2014. The
staffing ratio remains 1:10 during resident awake hours and 1:10 during resident sleep hours.
There are no findings of inadequacies from judicial, federal investigative agencies, nor internal or external oversight
bodies; and there were no documented deviations from the staffing plan. The Facility Administrator/PREA
Compliance manager stated that deviations to the staffing plan would not occur because the facility has a “hold over”
contingency plan to preempt any potential deviations.
Review of the Staffing Plan Assessment and interviews with staff served to validate that in establishing and
maintaining the agreed upon ratios, consideration was given to needs of the residents to be served, physical location
and layout of the facility, as well as the location of available video surveillance cameras. The Staffing Plan
Assessment documents a total of 16 cameras and notes where they are located. During the facility tour said cameras
PREA AUDIT: AUDITOR’S SUMMARY REPORT 4
were observed but it was determined that there are portions of the facility that cannot be seen on the master control
surveillance monitor and are considered to be “blind spots” as well as one camera malfunctioning so that the
surveillance area showed blacked out on the master surveillance screen. Specifically, blind spots exist in the computer
lab located between the two classrooms, the back side of the stove in the kitchen, the pantry and office area of the
kitchen, and a portion of the patio.
CBA Policy mandates that facility supervisors shall conduct unannounced rounds during day and night shift hours; and
that the rounds must be documented. No documentation of unannounced rounds was provided to the auditor. The
policy does not have the specific wording, intermediate-level or higher level supervisors conduct and document
unannounced rounds….”
Corrective Action: CBA PREA policy (effective date September 3, 2014) was revised with wording consistent with
the standard. Documentation that unannounced rounds are occurring consistent with requirements of the standard was
provided to the auditor. As well as documentation of a plan for supervision of all areas of the facility including those
any blind spots on all shifts.
Standard 115.315 - Limits to cross gender viewing and searches
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy outlines all mandates compliant with sections (a) through (d) of this standard. The policy requires
that staff shall not conduct cross-gender strip searches, cross-gender visual body cavity searches (meaning a search
of the anal or genital opening), or cross gender pat-down searches except in exigent circumstances; all cross-
gender strip searches, cross-gender visual body cavity searches, and cross-gender pat down searches shall be
documented; the facility must be set up to enable youth to shower, perform bodily functions, and change clothing
without non-medical 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; and staff of the opposite sex shall
announce their presence when entering a youth housing facility or an area where youth are likely to be showering,
performing bodily functions, or changing clothing. During the facility tour the auditor observed that CBA has open
community-style showers that do not provide privacy for residents to shower. During the course of the 2-day audit
female staff was observed announcing their presence when entering the housing unit.
Policy also prohibits staff from searching or physically examining a transgender or intersex youth for the sole
purpose of determining the youth's genital status. During interviews, staff reports there has not been any
transgender or intersex resident at CBA
During the past 12 months, there were no cross-gender strip and body cavity searches and no cross-gender pat-down
searches. Staff and resident interviews verified that the mandates of section (a) through (d) of this standard and CBA
policy are adhered to by staff.
There was no documentation provided that verified security staff received training in how to conduct searches as
outlined in section (f).
Corrective Action: Documentation of security staff acknowledging they received training on how to conduct
searches compliant with section (f) was provided.
FDJJ has provided documentation of a work order and contract with a construction Company to proceed with
installation of shower partitions at CBA to provide privacy for residents to shower.
Standard 115.316 - Residents with disabilities and residents who are limited English proficient
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 5
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
It is written into the CBA PREA policy that CBA will ensure that all youth with disabilities (including, for
example, youth who are deaf or hard of hearing, those who are blind or have low vision, or those who have
intellectual, developmental, psychiatric, or speech disabilities), have an equal opportunity to participate in or
benefit from all aspects of CBA's efforts to prevent, detect, and respond to sexual misconduct. CBA will also
ensure meaningful access to its efforts to prevent, detect, and respond to sexual misconduct to youth who are
limited English proficient, including steps to provide interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any necessary specialized vocabulary. The facility may not
use youth or staff as interpreters, readers, or other assistants to perform such functions except in limited
circumstances where an extended delay in obtaining an effective interpreter/reader/assistant could compromise
the youths' safety, the performance of the first responder duties, or the investigation of the youth's allegations.
The facility does not use resident assistants and there were no instances of resident interpreter or readers being used in
the past 12 months. Resident interviews validated compliance.
The PREA Compliance Manager indicated that CBA has begun discussions to enter into an agreement with Pinellas
County School Board to provide the services required by this standard but documentation of contracts or agreements
for interpreters or other professionals hired to ensure services for disabled and/or limited English proficient residents
was not provided.
Corrective Action: Documentation of a signed Memorandum of Understanding between CBA and Pinellas County
School Board to provide the services outlined in this standard was provided.
Standard 115.317 - Hiring and promotion decisions
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
Elements required by this standard are outlined in CBA PREA Policy. Persons desiring employment with CBA
completes the application packet; a portion of which is sent from CBA to the FDJJ Office of the Inspector General for
background screening. Details of the screening are described on the FDJJ’s website and include conducting two
background screenings; the Level II pre-employment screening and a 5-year re-screening. Background
screenings consist of a state and national fingerprint check through the Florida Department of Law Enforcement and
the Federal Bureau of Investigations, and a demographic search of the Florida Clerk of the Courts. As a criminal
justice agency, the Department has access to juvenile, sealed, and expunged criminal history information. Upon
request, background screening is conducted on state and contract provider directors, owners, applicants, employees,
volunteers, mentors, and interns. The term contract provider includes grant recipient employees, volunteers, mentors,
and interns.
Interview with Human Resources (HR) staff affirmed that the policy is in practice for staff and contractors. The
auditor’s review of 17 staff HR files validated at 100% that criminal background records checks were completed, and
applicants seeking employment are asked about previous misconduct outlined in section (a) of this standard.
Consistent with the PREA requirement and Florida Statutes 768.096 and 435.10, CBA has in place a process for
contacting prior employers for information before hiring and sharing information with employers.
Of 30 employees, none had CBA hire dates that met the 5 year threshold for background checks.
The policy states that staff being considered for promotion shall disclose any sexual misconduct and material
PREA AUDIT: AUDITOR’S SUMMARY REPORT 6
omission regarding such misconduct, or the provision of materially false information shall be grounds for termination.
Standard 115.318 - Upgrades to facilities and technology
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable -- (CBA has not acquired any new facilities, or done any expansion or modification since opening
July, 2013.)
Standard 115.321- Evidence protocol and forensic medical examinations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA policy states that CBA does not conduct criminal investigations for youth-related sexual misconduct
reports. By policy CBA staff is directed upon notice that any sexual abuse has occurred to immediately notify law
enforcement (911) and summon their presence; immediately notify the Florida Department of Children and Families
Abuse Registry; notify Florida Department of Juvenile Justice (FDJJ) Office of the Inspector General – Central
Communications Center (CCC) hotline within 2 hours; and notify management. Criminal investigations would be
conducted by the St. Petersburg Police Department. Administrative investigations would be conducted by the FDJJ
Office of the Inspector General.
There were no allegations of sexual abuse during the past 12 months and no forensic medical examinations conducted
in the past 12 months.
YSI is in the process of negotiating for an agreement with Suncoast Center but no documentation was provided of a
formalized contract or agreement to provide the services required by sections (c) through (e) and (h) of this standard
and at no financial cost to the victim. Documentation was not provided that the agency has requested the responsible
investigative agencies follow requirements in paragraph 115.321 (a) through (e) of the standards.
Corrective Action: A Memorandum of Understanding between CBA and Suncoast Center, Inc., and the St.
Petersburg Police Department to provide the services required to be compliant with the standard was provided.
Standard 115. 322 - Policies to ensure referrals of allegations for investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
In Florida, local law enforcement agencies and the Department of Children and Families handle criminal
investigations. CBA policy requires that any staff receiving a report of sexual misconduct must ensure that it is
reported to facility administration, the Florida Department of Children and Families abuse registry, local law
enforcement (the St. Petersburg Police Department) if criminal in nature, and the Central Communication Center
PREA AUDIT: AUDITOR’S SUMMARY REPORT 7
(CCC) of the FDJJ, Office of the Inspector General.
The FDJJ conducts administrative investigations. CBA Policy requires that in cooperation with the FDJJ, CBA will
ensure that all administrative investigation and reviews are completed for all allegations of sexual misconduct. FDJJ
Policy 1919 describes the agency’s investigative responsibilities and duties for its facilities and is published on the
FDJJ website.
During the past 12 months CBA did not have any allegations of sexual abuse or sexual harassment; therefore none
that resulted in an administrative investigation or referral for criminal investigation. Interviews with staff validated
CBA did not have sexual abuse or harassment allegations during the past 12 months.
Standard 115.331 - Employee training
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy dated November 5, 2013 requires all current employees not trained on the agency’s zero-tolerance
of sexual misconduct must be trained within 6 months of the effective date of the policy. The policy also requires each
employee to take a refresher training every two years and document through employee signature or electronic
verification that employees understand the training they received. Policy directs staff to the FDJJ PREA webpage for
information on current sexual misconduct policies. FDJJ Policy 1919 outlines training requirements for staff that is
consistent with this standard. The FDJJ webpage information is that all employees and contracted employees have an
obligation to adopt and comply with PREA standards and must take the PREA course that is available in SkillPro, a
link to the training course. Upon completion of the PREA course with a passing score, staff must complete the
Training and Acknowledgement Form and provide a copy for the training file. All training forms must be readily
available for the PREA auditor upon request.
Reviews of 14 staff training printouts from an on-line training system validated employees have received PREA
training with documented Pre and Post Test scores. Staff interviews also served to further validate that training
occurred for both newly hired employees and those employed with CBA from the time it became operational in July,
2013.
Standard 115. 332 - Volunteer and contractor training
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy requires that all volunteers and contracted providers must be trained on their responsibilities under
the sexual misconduct prevention, detection and response policy and procedures; and that at a minimum volunteers and
contractor staff who have contact with residents must be notified of the department’s zero-tolerance policy regarding
sexual misconduct and be informed how to report such incidents. Additional training provided to volunteers and
contractors is based on the service they provide and the level of contact they have with residents.
CBA volunteers take the FDJJ PREA training, “A Course for Volunteers” and upon completion, sign the form
acknowledging that they have completed the course and understand FDJJ PREA Policy 1919 and the procedures. This
was verified through a May 27, 2014 memorandum from a church proving volunteer services and confirming a list of
PREA trained volunteers; and 11 signed training acknowledgement forms with various dates between April and June,
2014.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 8
Documentation for contracted employees was not provided.
Corrective Action: Documentation of contract employees acknowledging that they received training consistent with
the requirements of the standard was provided.
Standard 115.333 - Resident education
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy requires that during intake all residents will be provided with information on zero-tolerance
regarding sexual misconduct including how to report sexual abuse and suspicion of any sexual misconduct.
As a part of intake, residents are given a youth handbook that provides some information on preventing detecting and
responding to sexual assault and harassment; and includes the telephone numbers for reporting to the Florida Abuse
Registry and the FDJJ Office of the Inspector General. At the end of the intake session residents acknowledge
through signature that they understand their right to be safe from sexual misconduct, abuse and harassment. The
intake staff acknowledged during the interview that the practice of providing resident with PREA required education
in individual sessions with staff the day they arrive at the facility began within the last month prior to the audit.
During interviews of 10 random residents they stated the PREA information was given to them the day they arrived.
However, signed Acknowledgement and Notification of the Prison Rape Elimination Act forms were provided for 28
of the 29 current residents with dates ranging between February 25, 2014 and June 23, 2014. The date of the
acknowledgement form did not necessarily correspond to the resident’s admission date.
Policy also requires that within 10 days of intake, all residents will be provided with comprehensive education
regarding their right to be free from sexual misconduct; their right to be free from retaliation for reporting; and the
agency’s sexual misconduct response policies and procedures. Documentation was provided that confirmed the
training was provided. During interviews with staff, it was confirmed that an in-service type PREA training was
conducted for all current residents which ended with them signing the acknowledgement form.
During the tour of the facility, posters in multiple languages outlining the sexual abuse zero tolerance policy, duty to
report, and instructions for reporting, were posted in various locations including the living units. The posters are letter
size and not visible from a short distance. Larger size posters would likely provide for clearer visibility.
Documentation for 115.333 (d)-1 was not made available to the auditor.
Corrective Action: Documentation of a signed Memorandum of Understanding between CBA and Pinellas County
School Board to provide the services outlined in section (d) of this standard was provided. Also provided was
documentation that newly admitted residents to CBA are receiving the required education at intake, and documentation
of displaying larger sized posters outlining zero-tolerance policies for sexual abuse and harassment in the facility.
Standard 115.334 - Specialized training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable (CBA does not employ facility investigators. Investigations are referred to outside agencies.)
Standard 115.335 - Specialized training: Medical and mental health care
PREA AUDIT: AUDITOR’S SUMMARY REPORT 9
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy and FDJJ Policy 1919 mandates training for medical and mental health care workers consistent
with numbers 1 through 4 of section (a) of this standard. As verified through interviews, medical and mental health
staff employed by CBA does not conduct forensic examinations. The medical and mental health staff interviewed
indicated they have had the PREA training course offered by the agency but no specialized training and there was no
documentation provided that the CBA medical and mental health staff received the required training referenced in
section (a) of this standard.
Corrective Action: Documentation was provided that Medical and Mental Health staff received the required training
referenced in section (a) of the standard.
Standard 115.341 - Screening for risk of victimization and abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy describes the process staff is to use for screening for Vulnerability to Victimization and Sexual
Aggressive Behavior (VSAB) but does not say it must occur within 72 hours of their arrival at the facility and
periodically throughout a resident’s confinement.
CBA utilizes the FDJJ VSAB form dated (Revised December 2006) as the instrument for screening. A review of 10
resident files with admission dates ranging from July 2013 to June 23, 2014 validated at 100% compliance for
completion of the VSAB screening instrument. The screening instrument met 10 of 11 minimum required elements
outlined in section (c) of the standard. The instrument does not include the question, “Do you identify as lesbian, gay,
bisexual, transgender, or intersex?”
The screening instrument and interview with the staff performing screenings verified compliance with all elements of
section (d).
Interviews with the PREA Compliance Manager and the staff responsible for risk screening confirmed that
information from the VSAB is disseminated on a “Need to Know” basis.
Corrective Action: CBA PREA policy (effective date September 3, 2014) was revised with wording consistent with
the standard; and the VSAB form was revised to meet the requirements of the standard.
Standard 115. 342 - Use of screening information
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 10
CBA PREA Policy requires that the information gathered from screening for vulnerability to sexual victimization and
abusiveness shall be to guide treatment plans and security and management decisions, including housing bed, work,
education and program assignments. Interviews with staff validated that this practice is in place at CBA.
At CBA residents share bedrooms and there are no isolation rooms.
There were no identified LGBTI residents in the population at the time of the audit. CBA PREA Policy directs staff
in the treatment of LGBTI residents consistent with those outlined in sections (c) through (f) of this standard. The
CBA PREA policy does not require that LGBTI residents be given the opportunity to shower separately from other
residents.
Corrective Action: CBA PREA policy (effective date September 3, 2014) was revised to be compliant with the
standard requiring LGBTI residents be given the opportunity to shower separately from other residents.
Standard 115. 351 - Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy requires the provision of multiple internal ways for residents to privately report sexual misconduct
and harassment by other residents and staff for reporting sexual misconduct and staff neglect or violation of
responsibilities that may have contributed to such incidents. During interviews staff and residents identified the
multiple ways residents can report including telling a staff member, writing a grievance, asking to speak with the
Facility Administrator, and calling the Florida Department of Children and Families abuse hotline.
CBA has provided a pre-programmed phone with a direct line to the Florida Department of Children and Families
Abuse Registry on the wall of the North/South corridor so that residents are afforded unimpeded access to report
sexual abuse and harassment.
CBA does not detain residents solely for civil immigration purposes.
It is written in the CBA PREA policy that reports of sexual misconduct can be received verbally, in writing,
anonymously, and from third parties. During interviews staff said they would accept and document all reports of sexual
abuse or harassment including those made verbally or through third parties.
Staff and residents validated that residents have access to the tools necessary to make a report.
Staff may privately report sexual abuse or harassment of residents by calling the FDJJ Central Communications Center.
Standard 115.352 - Exhaustion of administrative remedies
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable
During the past 12 months no sexual abuse grievance was filed. Policy outlining the agency’s administrative
PREA AUDIT: AUDITOR’S SUMMARY REPORT 11
procedures for resident grievances regarding sexual abuse or sexual harassment was not provided.
Corrective Action: CBA does not have administrative procedures to address resident grievances regarding sexual
abuse. Policy dictates that all PREA related incidents will be handled directly by the Program Director or Assistant
Program Director in accordance with FDJJ 1919 which stipulates that such allegation must be reported to and
investigated by Law Enforcement and the State Department of Children and Families
Standard 115.353 - Resident access to outside confidential support services and legal representation
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy requires that residents shall have access to outside victim advocates, the facility shall post and make
accessible mailing addresses and telephone numbers, including hotline numbers of victim advocacy or rape crisis
organizations, and residents shall have reasonable and confidential access to attorneys, parents or legal guardians.
CBA reports entering into discussions with Suncoast Center staff to provide the services required in this standard.
Documentation was not made available to the auditor.
CBA does not detain residents solely for immigration purposes.
Interviews with residents suggest CBA did not provide mailing addresses and telephone numbers of local, state, or
national victim advocacy or rape crisis organizations.
Corrective Action: CBA entered into a Memorandum of Understanding (MOU) with Suncoast Center, Inc.to provide
the services required to be compliant with the standard. The MOU and documentation of signed and dated Youth
Acknowledgement forms that they were provided information required for compliance with the standard was provided
by the PREA Compliance Manager.
Standard 115.354 - Third-party reporting
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for the
relevant review period)
Does Not Meet Standard (requires corrective action)
CBA is a FDJJ contracted facility and CBA through the FDJJ website informs the public with information regarding
third-party reporting of sexual abuse and harassment on behalf of facility residents. The FDJJ website also has a
section dedicated to parents and among other information includes this statement, “Abuse and neglect are serious
issues that need to be handled with care. In the event of an emergency abuse situation, ALWAYS call 911 FIRST and
call the Florida Abuse Hotline second at 1-800-962-2873. In a non-emergency situation, contact the Florida Abuse
Hotline via phone, fax, or web to receive assistance.”
CBA can receive third-party reports of sexual abuse and harassment through the Florida Department of Children and
Families Abuse hotline and the FDJJ Office of the Inspector General - Central Communications Center hotline.
Interviews with residents revealed they are aware sexual abuse or harassment may be reported through a third party.
Standard 115.361- Staff and agency reporting duties
PREA AUDIT: AUDITOR’S SUMMARY REPORT 12
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
The employees at CBA are mandatory reporters and CBA directs staff to immediately report any abuse, knowledge,
suspicion or information they receive regarding an incident of abuse or harassment. Policy also directs staff to report
any retaliation against residents or other staff who reported an incident; and any staff neglect or violation of
responsibilities that may have contributed to an incident of abuse or retaliation. CBA policies further direct staff in
complying with the elements outlined in sections (b) through (f) of this standard. Interviews with the Facility
Administrator/PREA Compliance Manager, and random selected staff served to validate that the staff are aware of the
policies and their duty to report.
Standard 115.362 - Agency protection duties
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy requires that when staff learns that a resident is subject to a substantial risk of imminent sexual
abuse it shall take immediate action to protect the resident from harm or further threat. During the past 12 months no
resident was identified to be of such risk. Interviews with the Agency Head Designee, Facility Administrator/PREA
Compliance Monitor and random sample of staff validated that staff is aware of their mandate to immediately take
steps necessary to keep the resident safe, but the policy does not outline what specific steps staff should take.
Corrective Action: CBA PREA policy (effective date September 3, 2014) was revised to include the specific steps that
staff are expected to take when learning that a resident is subject to a substantial risk of imminent sexual abuse.
Standard 115.363 - Reporting to other confinement facilities
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
During the past 12 months CBA staff did not receive any reported allegations that a CBA resident was abused while
confined at another facility. Likewise, during the past 12 months CBA did not receive any reports of allegations of
sexual abuse from other facilities that residents previously confined at CBA were sexually abused while there.
CBA and FDJJ policies require that facility leadership ensure that all allegations are immediately reported to the FDJJ
Office of the Inspector General (OIG) - Central Communications Center within a 2 hour window of learning of the
allegation. Notification to the facility management overseeing the facility where the alleged abuse occurred will be
provided by the OIG’s office.
Standard 115.364 - Staff first responder duties
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 13
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy mandates in responding to sexual abuse that staff take specific steps consistent with those outlined
in sections (a) and (b) of this standard, except for, “requesting the alleged victim not take any action that could destroy
physical evidence; and ensuring the alleged abuser does not take any action to destroy physical evidence.”
CBA does not have investigators so beyond the actions identified in sections (a) and (b), staff are directed to make the
report to local law enforcement, The Florida Department of Children and Families and the FDJJ Office of the
Inspector General – Central Communications Center; and cooperate with the investigators when they arrive. Staff was
able to articulate these duties and responsibilities during interviews.
During the past 12 months CBA had no allegations that a resident was sexually abused or harassed and in no instance
was a non-security staff member the first responder. Policy does not delineate duties and responsibilities for first staff
responder who is not a security staff member.
Corrective Action: CBA PREA policy (effective date September 3, 2014) was revised to include the specific wording
required for compliance with the standard, as well as outlining steps for duties for first staff responder who is not a
security staff.
Standard 115.365 - Coordinated response
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
There is no documentation of a plan specific to CBA for a coordinated response to sexual assault among staff first
responders, medical and mental health practitioners, investigators and facility leadership. Interview with the Facility
Administrator/PREA Compliance Manager verified that CBA does not yet have a plan.
Corrective Action: A coordinated response plan specific to CBA was developed and submitted to the auditor along
with documentation of staff training.
Standard 115.366 - Preservation of ability to protect residents from contact with abusers.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable (Charles Britt Academy does not participate in collective bargaining.)
Standard 115.367 - Agency protection against retaliation
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 14
CBA PREA Policy establishes that residents and staff are to be protected from retaliation for reporting sexual
misconduct. Further, the policy requires that staff comply with sections (b), (d) and (f) of this Standard. Section (c), of
this PREA standard is worded, “For at least 90 days following a report….” The CBA policy is worded, “At each 90
day period following a report ….” This is a significant difference in meaning and is not in compliance with the
Standard. Section (e) of this standard is not included in policy.
There were no incidents of retaliation that occurred in the past 12 months.
Corrective Action: CBA PREA policy (effective date September 3, 2014) was revised with wording consistent with
this standard. Section (e) of the standard was written into policy.
Standard 115.368 - Post allegation protective custody
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA is a substance abuse treatment program and reports isolation is not utilized; and there are no isolation rooms or
segregated housing. Residents at CBA share bedrooms.
Standard 115.371 - Criminal and administrative agency investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA does not employ facility investigators. All allegations of abuse are reported to the Florida Department of
Children and Families, the St. Petersburg Police Department, and the FDJJ Office of the Inspector General – Central
Communications Center. CBA does not report any sustained allegations of conduct appearing to be criminal that
were referred for prosecution since August 20, 2012.
There were no reports of sexual abuse or harassment to generate investigative reports.
.
Standard 115.372 - Evidentiary standards for administrative investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA Policy requires that all allegations of abuse are reported to FDJJ Office of the Inspector General – Central
Communications Center. Staff from the Inspector General’s office conducts the administrative investigation and
provides a report back to CBA.
Standard 115.373 - Reporting to residents
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 15
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy reads, “At the conclusion of any law enforcement investigation where a sexual abuse incident has
been reported, the victim or victim’s parents or legal guardians should be notified that the investigation is concluded,
either by the investigating law enforcement agency or through a victim service agency officer or representative. At
the conclusion of any administrative investigation conducted by the OIG, the victim’s parents or legal guardians will
be notified by receipt of a final administrative investigative report.”
There were no reported allegations and no investigations. During the interview the Facility Administrator /PREA
Compliance Manager was knowledgeable of the reporting requirement and verified that notification would be
provided.
Standard 115.376 - Disciplinary sanctions for staff
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
It is written in the CBA PREA Policy that staff shall be subject to disciplinary action up to and including dismissal for
failure to comply with the facility’s policy prohibiting sexual abuse and harassment. As written in policy, termination
will be the presumptive disciplinary sanction for staff who has engaged in sexual abuse. The policy also mandates that
violations be reported to law enforcement unless it was clearly not criminal but stops short of mandating reports to
relevant licensing bodies as specified in this standard. (The specific wording of the standard, “All terminations for
violations of the agency sexual abuse and harassment policies, or resignations by staff who would have been
terminated if not for their resignations, shall be reported to law enforcement agencies, unless the activity was clearly
not criminal, and to any relevant licensing bodies”)
During the past 12 months no staff from CBA has been terminated or resigned for violating agency sexual abuse or
harassment policies, nor reported to law enforcement or licensing boards for violating agency sexual abuse and sexual
harassment policies.
Corrective Action: CBA PREA policy (effective date September 3, 2014) was revised to include wording required for
compliance with the standard.
Standard 115.377 - Corrective Action for contractors and volunteers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy requires that like staff, volunteers and contracted personnel in violation of the facility’s policies and
procedures regarding sexual abuse and harassment of residents will be reported to local law enforcement. The specific
wording that they be “prohibited from contact with residents and shall be reported to law enforcement agencies,
unless the activity was clearly not criminal, and to relevant licensing bodies” is not written in the policy.
CBA reports not having any incident of allegation of sexual abuse or harassment by contractors or volunteers therefore
PREA AUDIT: AUDITOR’S SUMMARY REPORT 16
no reports to law enforcement or licensing bodies and no remedial measures were taken. Interviews with the Facility
Administrator/PREA Compliance Manager revealed knowledge of the remedial measures that would be taken.
Corrective Action: CBA PREA policy (effective date September 3, 2014) was revised to include wording required for
compliance with the standard.
Standard 115.378 - Disciplinary sanctions for residents
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA is designated as a treatment facility. During the past 12 months there has been no administrative finding of
resident-on-resident sexual abuse; and no criminal finding of guilt for resident-on-resident sexual abuse at CBA. No
residents were placed in isolation. Interviews with medical and mental health staff verified that in the event of such a
finding, the treatment team would make decisions for appropriate treatment modifications if necessary.
Standard 115.381 - Medical and mental health screenings; history of sexual abuse
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA Policy requires that if during intake screening, health/mental health screening, or health history, a resident
discloses prior sexual victimization or perpetrated sexual abuse, whether it occurred in a facility setting or in the
community, staff shall ensure the resident is referred for medical and mental health services within 14 day of the
screening. Policy also mandates that information gathered from screenings related to sexual victimization or
abusiveness shall be limited to medical and mental health practitioners and other staff as needed to guide treatment
plans and security management decisions, including housing, bed, and work, education, and program assignments.
Policy also requires medical and mental health practitioners to obtain informed consents for youth 18 and older.
Interviews with the medical and mental health staff and documentation review verified compliance with this standard.
Standard 115.382 - Access to emergency medical and mental health services
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy requires that residents who are victims of sexual assault shall be provided timely unimpeded
access to emergency medical treatment immediately; according to the medical personnel’s professional judgment; and
the victim would be offered timely information about access to emergency contraception and sexually transmitted
infection prophylaxis. There were no sexual assault victims during the past 12 months; however, the facility
administrator verified that services would be provided at no cost to the victim.
Standard 115.383 - Ongoing medical and mental health care for sexual abuse victims and abusers
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 17
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy mandates ongoing medical and mental health care for sexual abuse victims and abusers consistent
with those outlined in this standard to include mental health evaluations and services as appropriate and medical health
care services consistent with the community level of care. There has not been any sexual abuse victim during the last
12 months. Interviews with medical and mental health staff verified that there are procedures in place for on-going
medical and mental health care should an incident of sexual abuse occur.
Standard 115.386 - Sexual abuse incident reviews
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA PREA Policy mandates that the facility shall create a Review Team with specific staff consistent with those
outlined in section (c) of the standard. The policy further mandates that the Review Team shall ordinarily conduct the
incident review within 30 days of the conclusion of every sexual misconduct investigation or administrative review.
The policy outlines the specifics of the Review Team’s duties the same as those in section (d) of the standard; and
directs that Review Team recommendation must be implemented or justification provided for not implementing the
recommendations. There were no incidents to be reviewed during the past 12 months. Interview with Facility
Administrator/PREA Compliance Manager verified that the facility would comply with policy and this standard.
Standard 115.387 - Data collection
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for the
relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ Policy 1919 requires the Department to collect uniform data in the Office of the Inspector General’s – Central
Communications Center for every allegation of sexual misconduct at its facilities, both state-operated and those under
contracted providers. Upon request, the PREA Coordinator will provide all sexual misconduct data collected in the
Central Communications Center to the Department of Justice no later than June 30 of each year
Interview with the YSI Agency Head Designee verified that CBA collects and feeds data to FDJJ and FDJJ publishes
the Annual Report.
Standard 115.388 Data review for corrective action
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for the
relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ Policy 1919 requires the PREA Coordinator to review data collected and aggregated in order to assess and
PREA AUDIT: AUDITOR’S SUMMARY REPORT 18
improve the effectiveness of the Department’s sexual misconduct prevention, detection and response policies, practices,
and training. Policy also requires that FDJJ will prepare an annual report of sexual misconduct incidents, findings, and
corrective actions for all facilities, state and contracted, and the Department as a whole; the report will include a
comparison of the current years’ data and corrective actions with those from prior years and will provide an assessment
of progress in addressing sexual misconduct; the report will be reviewed and approved by the agency head and made
available to the public through the FDJJ website; and information that may present a clear and specific threat to the
safety and security of the facility may be redacted, but will indicate the nature of the information redacted.
Standard 115.389 Data storage, publication and destruction
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard for
the relevant review period)
Does Not Meet Standard (requires corrective action)
CBA is a contracted facility and feeds data to FDJJ Office of the Inspector General’s – Central Communications
Center and FDJJ publishes the Annual Report. FDJJ Policy 1919 established that aggregated sexual abuse data be
reviewed annually and placed on the facility’s website after all personal identifiers are removed. All data collected
will be maintained for at least 10 years after the date of the initial collection.
AUDITORTOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and no conflict of interest
exists with respect to his or her ability to conduct an audit of the agency under review.
January 12, 2015
Auditor Signature Date
PREA AUDIT: AUDITOR’S SUMMARY REPORT 19

source: DJJ

program_name_raw: charles britt academy