state: FL

summary: PREA - Year 3 Cycle 4

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Broward Youth Treatment Center
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 11/22/2024
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: Shirley Turner Date of Signature: 11/22/2024
AUDITOR INFORMATION
Auditor name: Turner, Shirley
Email: shirleyturner3199@comcast.net
Start Date of On- 10/07/2024
Site Audit:
End Date of On-Site 11/11/2024
Audit:
FACILITY INFORMATION
Facility name: Broward Youth Treatment Center
Facility physical 8301 South Palm Drive Building 2, Pembroke Pines, Florida - 33025
address:
Facility mailing 8301 South Palm Drive, madison bldg 2, Miramar, FL,
address:
Primary Contact
Name: Carmita Rosenberg
Email Address: carmita.rosenberg@youthopportunity.com
Telephone Number: 3057882029
Superintendent/Director/Administrator
Name: Carmita Rosenberg
Email Address: carmita.rosenberg@youthopportunity.com
Telephone Number: 9549621088
Facility PREA Compliance Manager
Name: Carmita Rosenberg
Email Address: carmita.rosenberg@youthopportunity.com
Telephone Number: 954-962-1088
Name: Tricia Lockhart
Email Address: tricia.lockhart@youthopportunity.com
Telephone Number: 954-962-1088
Facility Health Service Administrator On-Site
Name: Sharmen Hill-Smith
Email Address: sharmen.hill-smith@youthopportunity.com
Telephone Number: 9549621088
Facility Characteristics
Designed facility capacity: 40
Current population of facility: 37
Average daily population for the past 12 32
months:
Has the facility been over capacity at any No
point in the past 12 months?
What is the facility’s population Mens/boys
designation?
Which population(s) does the facility hold?
Select all that apply (Nonbinary describes a
person who does not identify exclusively as
a boy/man or a girl/woman. Some people
also use this term to describe their gender
expression. For definitions of “intersex”
and “transgender,” please see
https://www.prearesourcecenter.org/
standard/115-5)
Age range of population: 13-18
Facility security levels/resident custody None Secure
levels:
Number of staff currently employed at the 50
facility who may have contact with
residents:
Number of individual contractors who have 3
contact with residents, currently
authorized to enter the facility:
Number of volunteers who have contact 6
with residents, currently authorized to
enter the facility:
AGENCY INFORMATION
Name of agency: Youth Opportunity Investments, LLC.
Governing authority
or parent agency (if
applicable):
Physical Address: 701 94th Avenue North , Suite 100, St. Petersburg , Florida - 33702
Mailing Address:
Telephone number:
Agency Chief Executive Officer Information:
Name:
Email Address:
Telephone Number:
Agency-Wide PREA Coordinator Information
Name: Joseph Nixon Email Address: joseph.nixon@youthopportunity.com
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:
0
Number of standards met:
43
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 2024-10-07
audit:
2. End date of the onsite portion of the 2024-11-11
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 Nancy J. Cotterman Center - Oakland Park, FL
organization(s) or victim advocates with
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 40
15. Average daily population for the past 32
12 months:
16. Number of inmate/resident/detainee 2
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
18. Enter the total number of inmates/ 39
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
19. Enter the total number of inmates/ 1
residents/detainees with a physical
disability in the facility as of the first
day of the onsite portion of the audit:
20. Enter the total number of inmates/ 11
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:
21. Enter the total number of inmates/ 1
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:
22. 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:
23. Enter the total number of inmates/ 2
residents/detainees who are Limited
English Proficient (LEP) in the facility as
of the first day of the onsite portion of
the audit:
24. Enter the total number of inmates/ 1
residents/detainees who identify as
lesbian, gay, or bisexual in the facility as
of the first day of the onsite portion of
the audit:
25. 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:
26. 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:
27. 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:
28. 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:
29. Provide any additional comments No text provided.
regarding the population characteristics
of inmates/residents/detainees in the
facility as of the first day of the onsite
portion of the audit (e.g., groups not
tracked, issues with identifying certain
populations):
Staff, Volunteers, and Contractors Population Characteristics on Day One of the Onsite
Portion of the Audit
30. Enter the total number of STAFF, 50
including both full- and part-time staff,
employed by the facility as of the first
day of the onsite portion of the audit:
31. Enter the total number of 6
VOLUNTEERS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
32. Enter the total number of 3
CONTRACTORS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
33. Provide any additional comments No text provided.
regarding the population characteristics
of staff, volunteers, and contractors who
were in the facility as of the first day of
the onsite portion of the audit:
INTERVIEWS
Inmate/Resident/Detainee Interviews
Random Inmate/Resident/Detainee Interviews
34. Enter the total number of RANDOM 12
INMATES/RESIDENTS/DETAINEES who
were interviewed:
35. 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
36. How did you ensure your sample of Reviewed the population sheet and housing
RANDOM INMATE/RESIDENT/DETAINEE assignments; observed population; conferred
interviewees was geographically with staff.
diverse?
37. Were you able to conduct the Yes
minimum number of random inmate/
resident/detainee interviews?
No
38. 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
39. Enter the total number of TARGETED 7
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".
40. Enter the total number of interviews 1
conducted with inmates/residents/
detainees with a physical disability using
the "Disabled and Limited English
Proficient Inmates" protocol:
41. Enter the total number of interviews 3
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:
42. Enter the total number of interviews 1
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:
43. 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:
43. 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.
43. Discuss your corroboration Reviewed risk screenings; observed
strategies to determine if this population; conferred with staff.
population exists in the audited facility
(e.g., based on information obtained
from the PAQ; documentation reviewed
onsite; and discussions with staff and
other inmates/residents/detainees).
44. Enter the total number of interviews 1
conducted with inmates/residents/
detainees who are Limited English
Proficient (LEP) using the "Disabled and
Limited English Proficient Inmates"
protocol:
45. 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:
45. 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.
45. Discuss your corroboration Reviewed risk screenings; conferred with
strategies to determine if this staff.
population exists in the audited facility
(e.g., based on information obtained
from the PAQ; documentation reviewed
onsite; and discussions with staff and
other inmates/residents/detainees).
46. Enter the total number of interviews 1
conducted with inmates/residents/
detainees who identify as transgender
or intersex using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
47. 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:
47. 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.
47. Discuss your corroboration Reviewed investigation reports; reviewed
strategies to determine if this population sheet; conferred with staff.
population exists in the audited facility
(e.g., based on information obtained
from the PAQ; documentation reviewed
onsite; and discussions with staff and
other inmates/residents/detainees).
48. 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:
48. 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.
48. Discuss your corroboration Reviewed risk screenings and conferred with
strategies to determine if this staff.
population exists in the audited facility
(e.g., based on information obtained
from the PAQ; documentation reviewed
onsite; and discussions with staff and
other inmates/residents/detainees).
49. 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:
49. 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.
49. Discuss your corroboration Observations and conferred with staff. The
strategies to determine if this facility does not use and is not structured for
population exists in the audited facility segregated housing.
(e.g., based on information obtained
from the PAQ; documentation reviewed
onsite; and discussions with staff and
other inmates/residents/detainees).
50. 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
51. Enter the total number of RANDOM 12
STAFF who were interviewed:
52. 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
53. Were you able to conduct the Yes
minimum number of RANDOM STAFF
interviews?
No
54. 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.
55. Enter the total number of staff in a 6
SPECIALIZED STAFF role who were
interviewed (excluding volunteers and
contractors):
56. Were you able to interview the Yes
Agency Head?
No
57. Were you able to interview the Yes
Warden/Facility Director/Superintendent
or their designee?
No
58. Were you able to interview the PREA Yes
Coordinator?
No
59. 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)
60. 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
61. Did you interview VOLUNTEERS who Yes
may have contact with inmates/
residents/detainees in this facility?
No
61. Enter the total number of 2
VOLUNTEERS who were interviewed:
61. Select which specialized VOLUNTEER Education/programming
role(s) were interviewed as part of this
audit from the list below: (select all that Medical/dental
apply)
Mental health/counseling
Religious
Other
62. Did you interview CONTRACTORS Yes
who may have contact with inmates/
residents/detainees in this facility?
No
62. Enter the total number of 2
CONTRACTORS who were interviewed:
62. Select which specialized Security/detention
CONTRACTOR role(s) were interviewed
as part of this audit from the list below: Education/programming
(select all that apply)
Medical/dental
Food service
Maintenance/construction
Other
63. Provide any additional comments The PREA Coordinator was interviewed as the
regarding selecting or interviewing agency head designee.
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.
64. Did you have access to all areas of Yes
the facility?
No
Was the site review an active, inquiring process that included the following:
65. 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)?
66. 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)?
67. Informal conversations with inmates/ Yes
residents/detainees during the site
review (encouraged, not required)?
No
68. Informal conversations with staff Yes
during the site review (encouraged, not
required)?
No
69. Provide any additional comments No text provided.
regarding the site review (e.g., access to
areas in the facility, observations, tests
of critical functions, or informal
conversations).
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.
70. 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?
71. Provide any additional comments No text provided.
regarding selecting additional
documentation (e.g., any documentation
you oversampled, barriers to selecting
additional documentation, etc.).
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.
72. 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- 1 0 1 0
on-
inmate
sexual
abuse
Staff- 1 1 1 1
on-
inmate
sexual
abuse
Total 2 1 2 1
73. 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.
74. 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
75. Administrative SEXUAL ABUSE investigation outcomes during the 12 months
preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 1 0
sexual abuse
Staff-on-inmate 0 0 1 0
sexual abuse
Total 0 0 2 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.
76. 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
77. 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
78. Enter the total number of SEXUAL 2
ABUSE investigation files reviewed/
sampled:
79. 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
80. Enter the total number of INMATE- 1
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
81. 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)
82. 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
83. Enter the total number of STAFF-ON- 1
INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
84. Did your sample of STAFF-ON-INMATE Yes
SEXUAL ABUSE investigation files
include criminal investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
85. Did your sample of STAFF-ON-INMATE Yes
SEXUAL ABUSE investigation files
include administrative investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
Sexual Harassment Investigation Files Selected for Review
86. Enter the total number of SEXUAL 0
HARASSMENT investigation files
reviewed/sampled:
86. Explain why you were unable to There were no allegations of sexual
review any sexual harassment harassment during this audit period.
investigation files:
87. 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
88. Enter the total number of INMATE- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
89. 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)
90. 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
91. Enter the total number of STAFF-ON- 0
INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
92. Did your sample of STAFF-ON-INMATE Yes
SEXUAL HARASSMENT investigation files
include criminal investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
93. Did your sample of STAFF-ON-INMATE Yes
SEXUAL HARASSMENT investigation files
include administrative investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
94. Provide any additional comments There were no allegations of sexual
regarding selecting and reviewing harassment during this audit period.
sexual abuse and sexual harassment
investigation files.
SUPPORT STAFF INFORMATION
DOJ-certified PREA Auditors Support Staff
95. 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
96. 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.
96. Enter the TOTAL NUMBER OF NON- 1
CERTIFIED SUPPORT who provided
assistance at any point during this audit:
AUDITING ARRANGEMENTS AND COMPENSATION
97. 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 Communications Group, LLC
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
Documents:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Organization Charts
Interviews:
Superintendent
PREA Compliance Manager
PREA Coordinators
Provision (a):
An agency shall have a written policy mandating zero tolerance toward all forms of
sexual abuse and sexual harassment and outlining the agency’s approach to
preventing, detecting, and responding to such conduct.
The facility is operated by Youth Opportunity Investments, LLC through a contract
with the Florida Department of Juvenile Justice (DJJ). The policies of the agency and
facility mandate a zero-tolerance toward sexual abuse and sexual harassment of
residents. The policies also provide guidance to staff regarding the facility’s
approach to preventing, detecting, and responding to allegations of sexual abuse
and sexual harassment. Both policies provide and address conduct that violates the
zero-tolerance approach regarding all forms of sexual abuse and sexual harassment.
Definitions of prohibited behaviors of sexual abuse and sexual harassment are
contained in policy and include sanctions for those found to have participated in the
prohibited behaviors. The DJJ Policy FDJJ 1919, serves as the overarching PREA Policy
for state-run and contract facilities.
Information about programs, services and activities conducted at the facility are
summarized on the Youth Opportunity Investment and DJJ websites. Both websites
contain PREA related information and collectively include how to report allegations,
facility reports, annual reports, general PREA information and PREA related policies.
The websites also provide a specific overview of the facility.
Accessibility to PREA information by staff and residents; risk screening; and
monitoring assist in detecting sexual abuse and sexual harassment. The identified
and supporting policies include but are not limited to responding to sexual abuse
and sexual harassment through prevention; responsive planning; training and
education; reporting; investigations; medical and mental care; assessments;
disciplinary sanctions for residents and staff; and data collection and review. The
interviews confirmed knowledge of the zero-tolerance and other related policies
regarding sexual abuse and sexual harassment.
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA Coordinator
with sufficient time and authority to develop, implement, and oversee agency
efforts to comply with the PREA standards in all of its facilities.
Policy provides for the designation of a PREA Coordinator. The DJJ PREA Coordinator
manages the PREA implementation efforts statewide. The contract agency has
identified a PREA Coordinator. Both have knowledge of the standards,
implementation, and audit processes. Collaboration exists with the PREA
Coordinators and Superintendent as needed. The interview with the PREA
Coordinators revealed their authority to oversee the PREA initiatives and efforts at
the facility. The DJJ statewide PREA Coordinator lends support and direction to all of
the contract facilities as determined from interviews, observations, review of
documentation, previous interview and continual communication between the
Auditor and the DJJ statewide PREA Coordinator.
Provision (c):
Where an agency operates more than one facility, each facility shall designate a
PREA Compliance Manager with sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards.
The position of Superintendent has been designated as the PREA Compliance
Manager and reports directly to the contract agency PREA Coordinator. The
interview indicated the time to fulfill the PREA duties and it was determined there is
the authority required to fulfill those duties. Interviews conducted with staff
revealed their awareness of the role of the PREA Compliance Manager. Observations
confirmed the Superintendent has the support of the facility staff and the PREA
Coordinators.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, it was determined there is compliance with this standard.
115.312 Contracting with other entities for the confinement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Provider Contract
Previous PREA Audit Report
Interview:
Superintendent
Agency Contract Administrator
Provisions (a) and (b):
(a): A public agency that contracts for the confinement of its residents with private
agencies or other entities, including other government agencies, shall include in any
new contract or contract renewal the entity’s obligation to adopt and comply with
the PREA standards. (b): Any new contract or contract renewal shall provide for
agency contract monitoring to ensure that the contractor is complying with the
PREA standards.
The Florida Department of Juvenile Justice (DJJ), contracts for the confinement of
some of its residents with Youth Opportunity Investments, LLC. Contracts exist that
inform all providers of the requirements by the Florida Department of Juvenile
Justice to comply with the PREA Standards and be subject to PREA audits by third-
party certified PREA Auditors. The practice was also confirmed by the interview with
the Superintendent; interview with the DJJ statewide PREA Coordinator; and the
facility’s last completed PREA audit report. The facility is not involved in a contract
with other facilities for the confinement if its assigned youth.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined compliance with this standard.
115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919
Staffing Plan
Annual Staffing Assessments
Master Schedule
Logbook Entries
Administrator Duty Officer Expectations and Fidelity Checks
Interviews:
Superintendent
Assistant Superintendent
PREA Coordinator
Provision (a):
The agency shall ensure that each facility it operates shall develop, implement, and
document a staffing plan that provides for adequate levels of staffing, and, where
applicable, video monitoring, to protect residents against sexual abuse. In
calculating adequate staffing levels and determining the need for video monitoring,
facilities shall take into consideration:
(1) Generally accepted juvenile 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 staffing plan and supporting policy provide details for maintaining the staffing
ratios and the staffing plan outlines the staffing requirements. The facility’s staffing
plan, internal controls and management ensures that the PREA staffing ratios are
maintained during the waking hours and during the sleeping hours. Direct
supervision is provided to residents during the daily activities and program services.
The number of staff increases as needed due to program activities, one-on-one
supervision indicated, or other relevant factors. Observations during the site review
and interviews indicated the PREA staffing ratios are maintained. The facility
maintains a mandatory hold-over system to ensure adherence to the staffing ratio
and staffing plan. The average daily number of residents is 32; the staffing plan is
predicated on 40.
The camera monitors are located in the Superintendent's and Assistant
Superintendent's offices and are periodically monitored. Provisions of the standard
are taken into consideration regarding adequate staffing levels as confirmed
through the interviews, policy and staffing plan which outline staffing requirements.
The work schedules are based on the facility’s staffing plan and population. There is
collaboration and review of the work schedules on a regular basis by the
Superintendent and Assistant Superintendent. In addition to program activities and
special needs of residents, the shift schedules are made regarding the
considerations that ensure adequate shift coverage including standard security
practices; composition of the resident population; inclement weather; and
emergencies. Supervisors are assigned to each shift. The staffing ration required by
the contract are 1:8 during the awake hours and 1:10 during the sleeping hours.
Provision (b):
The agency shall comply with the staffing plan except during limited and discrete
exigent circumstances, and shall fully document deviations from the plan during
such circumstances.
There are no reported deviations from the staffing ratios in the past 12 months. A
coordinated effort was described in maintaining the staffing ratios through
communication, holdovers, in accordance with the staffing plan, consideration of the
population, and the agency requirements in the written contract. The facility is
prepared to document any deviations from the staffing requirements. The
Superintendent and Assistant Superintendent monitor the effectiveness of the work
schedules based on the staffing plan requirements. The staffing plan shows the
required staffing ratios. The staffing plan provides for the PREA staffing ratios to be
met and practice provides for additional staff for days and times if increased staffing
is required. The holdover system and required training of all facility employees
ensure the internal staffing ratios are met.
Provision (c):
Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8 during
resident waking hours and 1:16 during resident sleeping hours, except during
limited and discrete exigent circumstances, which shall be fully documented. Only
security staff shall be included in these ratios. Any facility that, as of the date of
publication of this final rule, is not already obligated by law, regulation, or judicial
consent decree to maintain the staffing ratios set forth in this paragraph shall have
until October 1, 2017, to achieve compliance.
Staffing ratios for the facility are routinely provided by the direct care staff and staff
with the same required training to act in the stead due to staff shortage. The
security practices and policies ensure the PREA ratios of 1:8 during the waking
hours and 1:10 during the sleeping hours. The facility’s contract requires less
residents to a staff member during the sleeping hours (1:10) which ensures the
PREA ratios will be met. The ratios were discussed and observed for and met during
the site review. Direct care staff members provide direct observation of residents.
Since the last PREA audit the average daily number of residents is 32. Since the last
PREA audit, the average daily number of residents on which the staffing plan was
predicated is 40. The facility is not involved in any lawsuits or consent decrees.
Provision (d):
Whenever necessary, but no less frequently than once each year, for each facility
the agency operates, in consultation with the PREA Compliance Manager required
by §115.311, the agency shall assess, determine, and document whether
adjustments are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this section;
(2) Prevailing staffing patterns;
(3) The facility’s deployment of video monitoring systems and other monitoring
technologies; and
(4) The resources the facility has available to commit to ensure adherence to the
staffing plan.
There was evidence of staffing plan assessments conducted in 2022, 2023 and 2024
by the Department of Juvenile Justice's statewide PREA Coordinator in collaboration
with the PREA Compliance Manager. The staffing plan assessments review but are
not limited to the following areas: prevailing staffing patterns and review of staffing
plan; electronic monitoring system; and review of other areas related to adequate
supervision. The review considers any adjustments that need to be made by the
construction and implementation of a corrective action plan that would be indicated
through findings or recommendations. Each annual assessment documents the
summarization of the review including the staffing, physical plant and the electronic
monitoring system. The Staffing Plan Assessments did not contain any
recommendations for corrective actions or any type adjustments to the staffing
plan.
Provision (e):
Each secure facility shall implement a policy and practice of having intermediate-
level or higher-level supervisors conduct and document unannounced rounds to
identify and deter staff sexual abuse and sexual harassment. Such policy and
practice shall be implemented for night shifts as well as day shifts. Each secure
facility shall have a policy to prohibit staff from alerting other staff members that
these supervisory rounds are occurring, unless such announcement is related to the
legitimate operational functions of the facility.
Unannounced rounds are conducted by management and supervisory staff
members and the rounds are documented through the use of logbooks and the
Administrator Duty Officer Expectations and Fidelity Checks form. The rounds are
made at various times and shifts by the intermediate-level and higher-level staff.
The interview with the Assistant Superintendent and review of documentation and
policy confirmed the unannounced rounds occur. The staff conducting the
unannounced rounds are the Superintendent, Assistant Superintendent, Director of
Case Management, Kitchen Manager, Human Resources Manager, Operations
Manager, and Nurse Manager.
The staff is not informed when the rounds will occur; administrative, management
and leadership staff randomly conduct unannounced rounds. The unannounced
rounds are conducted throughout the facility to identify and deter sexual abuse and
sexual harassment. Staff members are prohibited from alerting other staff when the
rounds are occurring which is in accordance with policy. Camera footage was
reviewed by the Auditor which showed the Assistant Superintendent making an
unannounced round which was previously documented.
Conclusion:
Based upon the review and analysis of the available evidence and the staff
interview, the Auditor determined the facility is adhering to this standard.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 519, PREA
Agency Policy FDJJ 1919
Training Curricula
Statement of Preference Form
Interviews:
Random Staff
Residents
Provision (a):
The facility shall not conduct cross-gender strip searches or cross-gender visual
body cavity searches (meaning a search of the anal or genital opening) except in
exigent circumstances or when performed by medical practitioners.
Cross-gender strip, visual body cavity and pat-down searches are prohibited and
searches must be documented. Policy and training provide guidance to staff on how
the searches are to be conducted. There is no evidence of cross-gender searches of
any type occurring at the facility in the last 12 months. Based on the review of the
Pre-audit Questionnaire and according to the interviews, no type of cross-gender
search has been conducted at the facility during the past 12 months.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent
circumstances.
Policy does not support staff conducting cross-gender pat-down searches. All
searches must be documented. Responses from staff included that only male staff
conduct searches. Staff receives training on how to conduct searches, including
cross gender searches and searches of transgender and intersex youth. Staff
interviews confirmed awareness of how to conduct searches. No residents or staff
interviewed reported the occurrence of any cross-gender searches. The evidence
shows cross-gender pat-down searches have not occurred at the facility during the
last 12 months.
Provision (c):
The facility shall document and justify all cross-gender strip searches, cross-gender
visual body cavity searches, and cross-gender pat-down searches.
Cross-gender strip and cross-gender visual body cavity searches are prohibited.
Policy provides for documenting the occurrence of searches. All interviews
confirmed that no cross-gender searches have occurred at the facility during this
audit period. Staff members are aware of the requirement to document all searches.
There was no evidence documenting any type cross-gender searches.
Provision (d):
The facility shall implement policies and procedures that enable 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. Such
policies and procedures shall require staff of the opposite gender to announce their
presence when entering a resident housing unit. In facilities (such as group homes)
that do not contain discrete housing units, staff of the opposite gender shall be
required to announce their presence when entering an area where residents are
likely to be showering, performing bodily functions, or changing clothing.
Bathroom/Shower Protocols exist and are posted at those areas. Residents are able
to shower, perform bodily functions, and change clothes without staff of the
opposite gender viewing them, supported by policy and interviews. No residents
interviewed reported ever having been naked in full view of the opposite gender
staff while showering, changing clothes, and performing bodily functions. During the
site review, the Superintendent explained how hygiene practices are conducted and
the bathroom procedures. It was observed that residents have a reasonable amount
of privacy during use of the bathroom. Residents use the bathroom one at a time
and shower curtains are utilized and the toilets are encased.
Staff members of the opposite gender announce their presence when entering the
residents’ housing or bathroom area as demonstrated during the site review. The
residents and staff stated female staff announce their presence upon entering the
living units. The evidence shows residents shower, perform bodily functions, and
change clothing without non-medical staff of the opposite gender viewing their
buttocks or genitalia. The staff interviews and observations support that viewing of
the camera monitors does not show residents when they are showering, using the
toilet or changing clothes. The bathroom area does not allow staff to get a view of
the resident while performing bodily functions. Hygiene practices are performed
with the expectations of reasonable privacy for each resident.
Provision (e):
The facility shall not search or physically examine a transgender or intersex resident
for the sole purpose of determining the resident’s genital status. If the resident’s
genital status is unknown, it may be determined 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.
Policy and staff training prohibit the search of transgender or intersex residents
solely for the purpose of determining the residents’ genital status. Staff interviews
verified no such searches have occurred or would occur at the facility. The facility
reports that staff received the training on conducting searches and searches of
transgender and intersex youth. Staff interviews confirmed they are aware that
policy prohibits staff from conducting a physical examination of transgender or
intersex youth solely for the purpose of determining the resident’s genital status.
When the genital status of a resident is unknown, learning this information would be
part of a broader medical examination conducted by a medical practitioner in
private. The facility will utilize the Statement of Preference Form when indicated by
a resident regarding the gender of the staff preferred to conduct the search as
directed by FDJJ Policy 1919.
Provision (f):
The agency shall train security staff in how to conduct cross-gender pat-down
searches, and searches of transgender and intersex residents, in a professional and
respectful manner, and in the least intrusive manner possible, consistent with
security needs.
The training curricula for staff provides information on conducting cross-gender pat-
down searches and searches of transgender and intersex youth. Training materials
indicate the provision of search techniques consistent with the security needs. A
dedicated form, Statement of Preference, is to be used for a youth to identify the
sexual preference of the staff to conduct the searches. No such searches have been
conducted during the past 12 months.
Conclusion:
Based on the reviewed documentation and interviews, the Auditor determined
compliance with this standard.
Residents with disabilities and residents who are limited English
115.316
proficient
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19, PREA
Facility Policy 1-22, Americans With Disabilities Act
Agency Policy FDJJ 1919
Video Remote Interpreting Agreement
Posted List of Bilingual Staff for Assistance
Posted PREA Information
Interviews:
Superintendent
Random Staff
Agency Head Designee
VRI-Video Remote Interpreting Representative
Provision (a):
The agency shall take appropriate steps to ensure that residents with disabilities
(including, for example, residents who are deaf or hard of hearing, those who are
blind or have low vision, or those who have intellectual, psychiatric, or speech
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. Such steps shall include, when necessary to ensure effective
communication with residents who are deaf or hard of hearing, providing access to
interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary. In
addition, the agency shall ensure that written materials are provided in formats or
through methods that ensure effective communication with residents with
disabilities, including residents who have intellectual disabilities, limited reading
skills, or who are blind or have low vision. An agency is not required to take actions
that it can demonstrate would result in a fundamental alteration in the nature of a
service, program, or activity, or in undue financial and administrative burdens, as
those terms are used in regulations promulgated under title II of the Americans With
Disabilities Act, 28 CFR 35.164.
Policy and procedures address the provision of support services for disabled
residents by providing these residents the equal opportunity to participate in or
benefit from all aspects of the facility’s efforts to prevent, detect, and respond to
sexual abuse and sexual harassment. Policy prohibits the use of resident
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, performance of first responder duties, or the
investigation of the allegations. The facility has a written VRI-Video Remote
Interpreting Agreement for services to be used for juveniles, parents or guardians
that are unable to speak and understand English or are Deaf. Accommodations may
be provided by the education unit for disabled residents and residents that are
limited English proficient. Mental Health professionals are also trained to provide
appropriate responses regarding PREA education to residents, when needed. PREA
information is accessible to residents in English, Spanish and over 300 other
languages are obtainable as requested.
Provision (b):
The agency shall take reasonable steps to ensure meaningful 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, including steps to
provide interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary.
The evidence shows residents with disabilities and who may be limited English
proficient are provided 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. All staff interviewed confirmed residents are not used as interpreters
and understand prior arrangements have been made regarding language
interpreters. There are staff who speak Spanish or Creole and have been identified
to assist when needed. The list of approved staff is posted and the list provide the
notice to staff that residents must not be used as interpreters or to provide any
assistance regarding a youth that is limited English proficient.
The evidence and interviews demonstrate 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, including taking steps to provide
interpreters who can interpret effectively, accurately, and impartially, using any
necessary specialized vocabulary. There was no targeted interviewee in the facility
during the onsite audit phase.
Provision (c):
The agency shall not rely on resident 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.
The facility prohibits the use of resident interpreters, resident readers or any kind of
resident assistants except when a delay in obtaining interpreter services could
jeopardize a resident’s safety, performance of the first responder duties, or the
investigation of the allegation. Staff interviews confirmed residents have not been
used to relate PREA information to or from other residents in the past 12 months.
There were no residents in need of an interpreter during the site visit. However, the
intake staff explained how a professional interpreter will be contacted. The Auditor
confirmed the professional interpreting services through a customer service
representative at the VRI, staff interviews, and a review of the master contract. The
facility provides an easy reference guide for staff in the control room for staff to
access an interpreter as needed.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the
facility is compliant with this standard.
115.317 Hiring and promotion decisions
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 1-04, Initial Background Screening and Rescreening
Facility Policy 10-25, PREA
Agency Policy FDJJ 1800, Background Screening and Hiring Practice
Agency Policy FDJJ 1919, PREA
Criminal History Acknowledgement and PREA Compliance Form
Personnel Records
Employee Handbook
Interview:
Human Resources Staff
Provisions (a) & (f):
(a): The agency shall not hire or promote anyone who may have contact with
residents, and shall not enlist the services of any contractor who may have contact
with residents, 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 the activity
described in paragraph (a)(2) of this section.
(f): The agency shall also ask all applicants and employees who may have contact
with residents directly about previous misconduct described in paragraph (a) of this
section in written applications or interviews for hiring or promotions and in any
interviews or written self-evaluations conducted as part of reviews of current
employees. The agency shall also impose upon employees a continuing affirmative
duty to disclose any such misconduct.
The collective documents address hiring and other personnel matters, including but
not limited to promotion processes and decisions; position descriptions; and
background checks, including child abuse registries. The background checks occur
initially and every five years thereafter, aligned with policy and the Standard. The
personnel files include the completed background checks and hiring documents.
Background checks are obtained through the Florida Department of Juvenile Justice,
Background Screening Unit. Policy FDJJ 1919 prohibits hiring or promoting anyone
who may have contact with residents with residents when they have been involved
in sexual abuse and sexual harassment behavior.
Through the employment application process, prior to hire and promotion,
applicants are asked to verify, in writing, the following information which is a part of
the background screening information packet:
Have 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);
Have 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,
Have been civilly or administratively adjudicated to have engaged in the activity
described above.
The aforementioned is also gleaned from current employees during evaluations.
Staff are informed of their continuing duty to report any related misconduct. The
interview and a review of policies provided details about the hiring process,
completion of background checks, and grounds for termination. The forms
completed and included in the personnel files are responsive to the provisions of
this standard. All applicants are asked about any prior misconduct involving any
sexual activity. The documentation and interview support the facility does not hire
anyone who has engaged in sexual abuse or anyone who has used or attempted to
use force in the community to engage in sexual abuse. This documentation is a part
of the background information packet, required for conducting the criminal
background checks. A sample of background checks were reviewed which confirmed
that they are conducted in accordance with policy and the interview.
Provision (b):
The agency 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 residents.
Policies support that the facility does not hire or promote anyone who has been
civilly or administratively adjudicated or have been convicted of engaging in or
attempted to engage in sexual activity by any means. The interview was aligned
with the standard and the documentation shows the inquiries made during the
application process regarding previous misconduct.
Policy and the interview indicate the facility considers any incidents of sexual
harassment in determining whether to hire or promote anyone, or to enlist the
services of any contractor or volunteer, who may have contact with residents. No
applicant will be considered for employment if a background check reveals any
history of inappropriate sexual behavior or arrest for inappropriate sexual behavior.
A sample of background checks were reviewed onsite confirming the background
checks occur.
Provisions (c) & (d):
(c): Before hiring new employees who may have contact with residents, the agency
shall:
(1) Perform a criminal background records check;
(2) Consult any child abuse registry maintained by the State or locality in which the
employee would work; and
(3) 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.
(d): The agency shall also perform a criminal background records check, and
consult applicable child abuse registries, before enlisting the services of any
contractor who may have contact with residents.
The background check process includes consulting a child abuse registry as
confirmed during the interview. The prospective employee or contractor also has to
be cleared through the Florida Department of Children and Families. Best efforts are
made to identify information of incidents or allegations of sexual abuse by a
prospective employee. The facility conducts background checks on contractors and
volunteers.
Provision (e):
The agency shall either conduct criminal background records 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.
Initial background checks are conducted and are conducted every five years
thereafter, in accordance with policy. The interview, review of documentation and a
review of the policies provide details about the hiring process, completion of
background checks, and the grounds for termination in accordance with the PREA
standard. A sample of Re-Screens (five-year background checks) were reviewed by
the Auditor.
Provision (g):
Material omissions regarding such misconduct, or the provision of materially false
information, shall be grounds for termination.
The omission of sexual misconduct information or providing false information is
grounds for termination in accordance with policy. According to the interview, this
information is also covered in the new employee orientation. Staff members have a
continuing duty to report related misconduct as indicated in the Employee
Handbook. Employees are informed during new employee orientation that they
have a continuing affirmative duty to disclose any such misconduct. Additionally,
the facility receives an alert if an employee is arrested.
Provision (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 revealed that when a former employee applies for work at another
institution, upon the request from that institution, the employment and hire date
may be verified. Other requests will be forwarded to regional administrative
personnel staff.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has
determined the facility meets the provisions of the standard.
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
PREA Pre-audit Questionnaire (PAQ)
Annual Staffing Plan Assessment
Interviews:
Superintendent
Agency Head Designee
Provision (a):
If the agency designed or acquired any new facility or planned any 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?
The PAQ revealed no substantial modification to the facility; however, the interview
with the Superintendent revealed remodeled bathrooms and the construction of a
control room in the front of the building which is felt to enhance the program
operations. The new and relocated control room provides for additional space in the
administrative area and the inclusion of a conference room in that area.
Provision (b):
If the agency installed or updated a video monitoring system, electronic surveillance
system, or other monitoring technology, the agency considered how such
technology may enhance the agency’s ability to protect residents from sexual
abuse.
The camera system supplements direct supervision provided to residents by staff.
The system was replaced during this audit period. The new system has more
functions including zoom capability; monitors in the Superintendent and Assistant
Superintendent offices; and the storage of footage for up to 45 days. The facility has
a total of 70 cameras with some placed in identified blind spots.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Communication Re: Memorandum of Understanding (MOU)
PREA Compliance Form
Resident & Parent Program Handbook
PREA Comprehensive Education for Youth Sign-in Sheets
PREA Education Acknowledgement Statements
Staff Licensure
Interviews:
Random Staff
PREA Compliance Manager
PREA Coordinator
Advocacy Agency Representative
Provisions (a) & (b):
(a): 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
developed after 2011.
Administrative investigations are conducted by the Florida Department of Juvenile
Justice (DJJ), Office of Inspector General (OIG), agency investigators. Allegations of
sexual abuse that are criminal in nature are also reported to the Florida Department
of Children and Families and law enforcement. According to staff interviews, policy,
and the investigation report was followed regarding investigations of sexual abuse
in accordance with the standard. The investigative staff’s interview from a previous
audit, investigation report, and the12 random staff members’ interviews confirmed
awareness of protocol for obtaining usable physical evidence and knowledge of the
entities responsible for conducting investigations. The protocols for investigations
are appropriate for youth and provided by DJJ/OIG to law enforcement through each
facility by the PREA Compliance Form. The PREA Compliance Form is shared with
local law enforcement investigators which outlines the PREA standards that must be
adhered to regarding an investigation of an allegation of sexual abuse. The DJJ
investigators are also aware of the PREA Compliance Form and investigation
protocols as provided in the interview conducted previously with DJJ investigative
staff.
Provision (c):
The agency shall offer all residents who experience sexual abuse access to forensic
medical examinations whether on-site or at an outside facility, without financial
cost, where evidentiarily or medically appropriate. Such examinations shall be
performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse
Examiners (SANEs) where possible. If SAFEs or SANEs cannot be made available, the
examination can be performed by other qualified medical practitioners. The agency
shall document its efforts to provide SAFEs or SANEs.
The alleged victim will get services within the facility as well as timely services in
the community. An alleged victim will be transported to the Nancy J. Cotterman
Center (NJCC) for a forensic medical examination that will be conducted by a Sexual
Assault Nurse Examiner (SANE). The examination and any follow-up treatment will
be performed at no cost to the victim, and in accordance with policy. Medical and
mental health staff members maintain secondary materials and documentation of
encounters with residents confirming the provision of general and emergency
services.
Continuity of care will be provided at the facility to include medical and mental
health follow-up services. No forensic medical examinations were conducted during
this audit period. Information regarding advocacy services is posted in the facility
which is accessible to residents, staff and visitors. Correspondence between the
Superintendent and the advocacy agency representative confirmed cooperation in
finalizing a written MOU regarding the provision and availability of services to
residents by the NJCC. The interview with the NJCC representative revealed that
services will not be withheld due to the lack of a MOU. The MOU is under review by
staff at NJCC.
Provisions (d) & (e):
(d): The agency shall attempt to make available to the victim a victim advocate
from a rape crisis center. If a rape crisis center is not available to provide victim
advocate services, the agency shall make available to provide these services a
qualified staff member from a community-based organization or a qualified agency
staff member. Agencies shall document efforts to secure services from rape crisis
centers. For the purpose of this standard, a rape crisis center refers to an entity that
provides intervention and related assistance, such as the services specified in 42
U.S.C. 14043g(b)(2)(C), to victims of sexual assault of all ages. The agency may
utilize a rape crisis center that is part of a governmental unit as long as the center is
not part of the criminal justice system (such as a law enforcement agency) and
offers a comparable level of confidentiality as a nongovernmental entity that
provides similar victim services. (e): As requested by the victim, the victim
advocate, qualified agency staff member, or qualified community-based
organization staff member shall accompany and support the victim through the
forensic medical examination process and investigatory interviews and shall provide
emotional support, crisis intervention, information, and referrals.
Victim advocacy services have been confirmed and are aligned with the standard.
This victim advocacy agency provides a range of programs and services including
forensic examinations, accompaniment, advocacy and resource assistance for
survivors, and emotional support. The advocacy agency follows all applicable laws
and regulations with respect to confidentiality as well as other required mandates
through compliance with applicable standards as a Certified Rape Crisis Center. The
advocacy agency may be notified by the resident, facility staff, or law enforcement.
The victim advocacy agency offers the following services:
· 24-hour hotline services;
· Information;
· Referrals;
· Access to counseling services;
· Accompaniment services;
· Follow-up support services; and
· Staff Education, upon request.
Information regarding victim advocacy services is provided to the residents during
the intake process, according to intake staff, and is provided through the
accessibility of posted information. Victim advocacy services are provided at no cost
to the victim in accordance with agency policy. Auxiliary aids, interpreter/language
services and accommodations due to a disability will be provided as needed and
also at no cost to the victim. The advocacy agency representative confirmed the
available services for the residents. The NJCC adheres to standards and these
standards include maintaining privileged communication with clients.
Provisions (f) & (g):
(f): To the extent the agency itself is not responsible for investigating allegations of
sexual abuse, the agency shall request that the investigating agency follow the
requirements of paragraphs (a) through (f) of this section. (g): The requirements of
paragraphs (a) through (f) of this section shall also apply to:
(1) Any State entity outside of the agency that is responsible for investigating
allegations of sexual abuse in juvenile facilities; and
(2) Any Department of Justice component that is responsible for investigating
allegations of sexual abuse in juvenile facilities.
The Department of Juvenile Justice/Office of Inspector General investigators from its
central office conduct administrative investigations in accordance with agency
policy, and the protocols as outlined on the PREA Compliance Form, aligned with the
Standards. Investigations of allegations of sexual abuse or sexual harassment that
are criminal in nature are investigated by law enforcement and the Florida
Department of Families and Children.
Provision (h):
For the purposes of this standard, a qualified agency staff member or a qualified
community-based staff member shall be an individual who has been screened for
appropriateness to serve in this role and has received education concerning sexual
assault and forensic examination issues in general.
The facility has made arrangements for victim advocacy services with the NJCC
confirmed through the interviews and draft agreement. The NJCC met the
requirements of the Superintendent when initially seeking advocacy services and is
a Certified Rape Crisis Center. The background and training of a facility treatment
staff person provides them with familiarity of general sexual assault and forensic
examination issues and they may be of service to a resident as an advocate if
needed.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the provisions of this standard.
115.322 Policies to ensure referrals of allegations for investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Investigation Reports
PREA Compliance Form
Websites
Interviews:
Investigative Staff
Agency Head Designee
Provision (a):
The agency shall ensure that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment.
The Florida Department of Juvenile Justice (DJJ) ensures an administrative or
criminal investigation is completed for all allegations of sexual abuse and sexual
harassment in State-run and contract facilities such as this facility. Policy provides
that staff report all allegations of sexual abuse and sexual harassment and to
document reports; staff members are aware of the requirements. The facility reports
two allegations of sexual abuse; one resident-on-resident and one staff-on-resident.
Sexual abuse and sexual harassment allegations are referred to the DJJ/Office of
Inspector General (OIG), Florida Department of Children and Families, and law
enforcement if criminal in nature. Both allegations were investigated by a DJJ/OIG
investigators. The results of the administrative investigations determined the
allegation involving staff was closed as unsubstantiated and the resident-on-
resident allegation was closed as information only. Law enforcement was also called
regarding the allegation of staff-on-resident sexual abuse. Law enforcement
responded to an the facility for an allegation of sexual battery. According to the
report, "it was determined that no crimes were committed, and the allegation was
unfounded due to the video footage proving the incident to be false." Policy and
interviews provide for investigations of all allegations of sexual abuse and sexual
harassment.
Provisions (b) & (c):
(b): The agency shall have in place a policy to ensure that allegations 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. The agency shall publish such policy on its
website or, if it does not have one, make the policy available through other means.
The agency shall document all such referrals. (c): If a separate entity is responsible
for conducting criminal investigations, such publication shall describe the
responsibilities of both the agency and the investigating entity.
DJJ has an overarching PREA policy that requires allegations of sexual abuse or
sexual harassment be referred for investigation to an agency with the legal
authority to conduct criminal investigations which include the Florida Department of
Children and Families and law enforcement. The DJJ does not conduct criminal
investigations; only administrative investigations. Policy, indicating which
investigative entities investigate what, and reporting information are located on the
DJJ and facility’s parent agency websites and posted within the facility, accessible to
the public. Policies, investigation reports, and interviews confirmed allegations of
sexual abuse and sexual harassment are investigated. Administrative investigations
are conducted by DJJ/OIG trained investigators. Allegations that are criminal in
nature are referred to law enforcement.
Provision (d):
Any State entity responsible for conducting administrative or criminal investigations
of sexual abuse or sexual harassment in juvenile facilities shall have in place a
policy governing the conduct of such investigations.
The DJJ/OIG has policy/directive governing investigations. The agency utilizes
trained investigators. A previous documented interview with an investigative staff,
investigation reports, and agency previous reports confirm that administrative
investigations are conducted by a trained investigator and allegations that are
criminal in nature are referred to law enforcement.
Provision (e):
Any Department of Justice component responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in juvenile facilities
shall have in place a policy governing the conduct of such investigations.
The Department of Justice is not responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in this facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.331 Employee training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Training Curricula
Training Schedules
Course Participant Reports
Interviews:
Random Staff
Provisions (a) & (c):
(a): The agency shall train all employees who may have contact with residents on:
(1) Its zero-tolerance policy for sexual abuse and sexual harassment;
(2) How to fulfill their responsibilities under agency 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 in 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;
and
(10) How to comply with relevant laws related to mandatory reporting of sexual
abuse to outside authorities;
(11) Relevant laws regarding the applicable age of consent.
(c): All current employees who have not received such training shall be trained
within one year of the effective date of the PREA standards, and the agency shall
provide each employee with refresher training 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,
the agency shall provide refresher information on current sexual abuse and sexual
harassment policies.
The agency and facility provide and/or conduct the required training, according to
the standard, for all employees who may have conduct with residents. Policies
address PREA related training for staff which is formally provided initially and
annually; refresher sessions are provided throughout employment. Refresher
sessions may be conducted in staff meetings and shift briefings which include any
changes in policy, procedures, and practice; and general PREA related practices that
do not occur at all or very little in order to keep staff alert. Interviewed staff
members were generally familiar with the PREA information. PREA training is
provided to staff, as indicated by a review of facility and agency policies, training
documents, and interviews. All staff have contact with residents and have received
PREA training.
Provision (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. The
employee shall receive additional training if the employee is reassigned from a
facility that houses only male residents to a facility that houses only female
residents, or vice versa.
The facility houses males and staff training considers the needs of the population
served as indicated by the interviews. Policies and interviews support training being
tailored to the needs and attributes of the population served. All staff within the
facility are provided PREA training.
Provision (d):
The agency shall document, through employee signature or electronic verification
that employees understand the training they have received.
The PREA training reviewed was documented electronically. maintained in the
agency's database and verified through staff interviews.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with the standard.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJ 1919
Training Curricula
Acknowledgement Statements
Interviews:
Volunteers
Contractors
Superintendent
Provision (a):
The agency shall ensure that all volunteers and contractors who 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.
Volunteers and contractors who have contact with residents must be trained on
PREA and their responsibilities regarding sexual assault prevention, detection, and
response to allegations of sexual abuse and sexual harassment. A review of
documents, training curriculum, interviews and observation confirmed the training
occurs. The training curriculum includes but is not limited to information in the
following areas: reporting allegations of sexual abuse and sexual harassment;
related definitions; detecting sexual abuse and sexual harassment; and maintaining
professional relationships with residents. The contents of the training was verified
by the volunteers and contractors.
Provision (b):
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, 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
informed how to report such incidents.
The interviews and review of documentation revealed the PREA training informs the
participants of their role in reporting allegations of sexual abuse and sexual
harassment. The participants are informed of their responsibilities regarding sexual
abuse prevention, detection, and response to an allegation of sexual abuse or
sexual harassment. The training is based on the services provided by the
contractors and volunteers. Training participants sign an acknowledgement
statement for receipt of the information.
The interviews revealed familiarity with the zero-tolerance policy regarding sexual
abuse and sexual harassment of residents, including how to report which is
reviewed during the training with the participants. The interviews confirmed the
review of the zero-tolerance policy is included in the PREA training. The volunteers
interviewed provide life skills education services to the residents. PREA education is
available within the facility by staff and through a Department of Juvenile Justice
online course or the downloaded training curriculum.
Provision (c):
The agency shall maintain documentation confirming that volunteers and
contractors understand the training they have received.
The training documentation and interviews confirmed the receipt and awareness of
PREA training by contractors and volunteers. The interviews and acknowledgement
statements indicated understanding of the training received. The PREA training is
made available to volunteers and contractors prior to the provision of services
within the facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with the provisions of this standard.
115.333 Resident education
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Youth & Parent Program Handbook
Youth Orientation Checklist
PREA Comprehensive Education for Youth forms
PREA Brochure
Multilingual Posters
Education Video
Posted List of Bilingual Staff
VRI-Video Remote Interpreting Agreement
Youth Acknowledgement and Notification of PREA
Interviews:
Residents
Targeted Interviewees
Intake Staff
Provisions (a) & (b):
(a): During the intake process, residents shall receive information explaining, in an
age- appropriate fashion, the agency’s zero tolerance policy regarding sexual abuse
and sexual harassment and how to report incidents or suspicions of sexual abuse or
sexual harassment. (b): Within 10 days of intake, the agency shall provide
comprehensive age-appropriate education to residents either in person or through
video regarding their rights to be free from sexual abuse and sexual harassment
and to be free from retaliation for reporting such incidents, and regarding agency
policies and procedures for responding to such incidents.
Youth receive information at the time of intake about PREA including the zero-
tolerance policy of the facility and how to report allegations of sexual abuse and
sexual harassment. Policies provide that all residents admitted receive PREA
education. Residents receive directions on how to report allegations of sexual abuse
and sexual harassment; and the right to be free from retaliation for reporting,
according to the documentation and interview with the intake staff. The residents
have a clear understanding of the aforementioned and the various ways of how to
report allegations of sexual abuse and sexual harassment.
A review of the education materials indicated the information provided to the
residents is age-appropriate. It was revealed that PREA refresher education sessions
are conducted during group sessions as a rotating topic among treatment topics
covered in group activities. The intake staff is available to also address questions
that a resident may have regarding PREA. A review of the education materials show
the information is age-appropriate. The residents initially sign acknowledgement
statements which represent receipt of the PREA information provided. All 12
residents interviewed had a clear understanding of how to report allegations of
sexual abuse and sexual harassment. Three of the 12 residents did not have a clear
understanding of the information provided regarding advocacy services. The three
residents indicated knowledge of PREA information posted on the walls.
Provision (c):
Current residents who have not received such education shall be educated within
one year of the effective date of the PREA standards, and shall receive education
upon transfer to a different facility to the extent that the policies and procedures of
the resident’s new facility differ from those of the previous facility.
Based on the evidence shown documenting the PREA education sessions in
Provisions (a) and (b), all residents received PREA education. The facility reports 47
youth were admitted to the facility during the past 12 months and that all
participated in PREA education sessions. Formal interviews and informal
conversations with residents and interview with intake staff and review of
documentation support that all youth admitted to the facility receive PREA
education during the intake process. Acknowledgement statements and the
interviews indicate that general PREA education is provided by providing
customized information regarding outside advocacy services which is incorporated
and emphasized in the PREA education sessions. Policy provides that all youth
admitted to the facility receive PREA education.
Provision (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, per policy. The
education unit is also a resource for accessibility, supportive services, and
translation services and other accommodations. Assistance may also be provided by
the mental health staff to ensure all residents’ understanding of the PREA
information. The facility has bilingual staff and the list is posted.
Policy provides for interpreter and translation services. There is documentation and
policy that provide information and accessibility for the accommodations for
residents with special needs in this area. The education staff provides services
through certified teachers with the educational background to modify/adapt
information for all residents to understand. Posted and other printed PREA
information is in English and Spanish. The facility’s parent agency has a contract
with VRI-Video Remote Interpreting for translation and interpreting services that
may be used as needed. A VRI representative confirmed the available translating
services, including services for the Deaf and access to over 300 languages.
The random staff interviews revealed a practice of residents not used as translators
or readers for other residents. There is a collective awareness of the availability of
bilingual staff and professional translating and interpreting services. The facility has
knowledge of the youth’s arrival to the facility prior to the admission date. This time
period provides for the identified staff to make plans to accommodate the special
needs of residents. The special arrangements are coordinated by treatment team
staff in collaboration with the Superintendent. PREA posters, information sheets,
and other printed materials are available in English and Spanish. There is access to
other languages as needed.
Provision (e):
The agency shall maintain documentation of resident participation in these
education sessions.
Signed acknowledgement statements were reviewed which supported the residents’
involvement in PREA education sessions. The residents’ interviews revealed the
exposure to PREA through the PREA education sessions. The residents were aware
of how to report allegations of sexual abuse and sexual harassment and that they
would not be punished for reporting such.
Provision (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. PREA information is posted and
provided to residents to assist in eliminating incidents of sexual abuse and sexual
harassment. The printed materials provide information on sexual abuse and sexual
harassment; steps victims may take; and reporting information. Each resident is
provided a handbook and an orientation packet which also contains PREA
information. PREA-related information was observed posted or displayed throughout
the facility.
PREA signage is placed at varying eye levels and are colorful and/or graphic with
consistent messages. The interviews with the residents revealed they know where
to find information on the wall if they need it. The interviews confirmed the PREA
audit notices had been up for awhile and that the PREA information is always on the
walls. PREA information is located in the housing area; common areas for staff,
residents, contractors, volunteers, and visitors; lobby; and offices.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, it was determined the facility is compliant with the standard.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Agency Policy FDJJ 1800
Training Curriculum
PREA Compliance Form
Interviews:
Investigative Staff
Superintendent
Provisions (a) & (b):
(a): 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. (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.
Administrative investigations are conducted by the contract agency, Florida
Department of Juvenile Justice (DJJ), Office of Inspector General (OIG). PREA training
is required in addition to the specialized training regarding conducting
administrative investigations. Allegations of sexual abuse are referred for
investigation to be conducted by law enforcement. The interview with the
investigative staff and review of agency documents confirmed administrative
investigations are conducted by trained investigators within the DJJ/OIG. The
specialized training includes but is not limited to interviewing techniques; proper
use of Garrity and Miranda warnings; preserving evidence; and criteria for
supporting a finding of substantiated, unsubstantiated or unfounded.
Provision (c):
The agency shall maintain documentation that agency investigators have
completed the required specialized training in conducting sexual abuse
investigations.
Training records of the administrative investigators are maintained by DJJ.
Allegations of sexual abuse are referred to law enforcement and the Florida
Department of Children and Families, in accordance with policy. All allegations of
sexual abuse and sexual harassment are reported to DJJ, Office of Inspector General.
Provision (d):
Any State entity or Department of Justice component that investigates sexual abuse
in juvenile confinement settings shall provide such training to its agents and
investigators who conduct such investigations.
The DJJ provides training to its investigators who will conduct administrative
investigations at the contract facilities which was confirmed by interviews. Local law
enforcement is responsible for training their investigators who conduct sexual abuse
investigations and allegations that are criminal in nature.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.335 Specialized training: Medical and mental health care
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Training Curricula
Training Records
Interviews:
Mental Health Staff
Medical Staff
Provision (a):
The agency shall ensure that all full- and part-time medical and mental health care
practitioners who work regularly in its facilities have been trained in:
(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; and
(4) How and to whom to report allegations or suspicions of sexual abuse and sexual
harassment.
The Florida Department of Juvenile Justice (DJJ) requires medical and mental health
staff members to receive the regular PREA training as well as the specialized
training provided through the DJJ. Electronic training records and interviews
document PREA training and the specialized training for medical and mental health
staff members and the interviews confirmed the training.
Provision (b):
If medical staff employed by the agency conduct forensic examinations, such
medical staff shall receive the appropriate training to conduct such examinations.
Forensic examinations are not conducted by facility staff.
Provision (c):
The agency shall maintain documentation that medical and mental health
practitioners have received the training referenced in this standard either from the
agency or elsewhere.
Electronic training records and interviews with medical and mental health staffs
confirmed receipt of the regular and specialized training. The regular and
specialized PREA training is provided online by the DJJ. The specialized training is
provided through different modules. Regular and refresher PREA trainings are also
provided online and at the facility through sessions incorporated in staff meetings
and training sessions when appropriate.
Provision (d):
Medical and mental health care practitioners shall also receive the training
mandated for employees under Standard 115.331 or for contractors and volunteers
under Standard 115.332, depending upon the practitioner’s status at the agency.
Medical and mental health staff completed the general training that is provided for
all employees as indicated by training documentation and the interviews. The
standard PREA training is provided to all employees and the specialized training is
provided online by DJJ and the records are maintained electronically.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.341 Obtaining information from residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
PREA Compliance Manager
Statewide PREA Coordinator
Residents
Provision (a):
The Policy provides that upon arrival or within 72 hours of the resident’s arrival at
the facility and periodically throughout a resident’s confinement, the agency shall
obtain and use information about each resident’s personal history and behavior to
reduce the risk of sexual abuse by or upon a resident.
Policies provide for each resident admitted to the facility to be screened for risk of
victimization or abusiveness, prior to room assignment in order to reduce the risk of
sexual abuse by or upon a resident. The interviews and practice indicate the risk
assessment is completed on the day of admission. According to the risk screener,
the youth is asked questions and an explanation or breakdown of a question is
provided as needed; probing may be required depending on the youth. Information
is obtained from the youth and other documents about personal history and
behavior. The process described indicated a rapport is established with the youth
prior to asking any questions. Information may also be obtained from the parent/
guardian and through review of the court packet.
The intake screening instrument, VSAB, is used to document such information and is
administered in a private office. The interviews revealed the practice of the risk
screening being conducted in accordance with the policies. Screening instruments
and interview with the risk screener confirmed the information obtained includes
but is not limited to:
Prior sexual victimization or abusiveness;
Resident’s own perception of vulnerability;
Current charges and offense history;
Self-identification of resident;
Intellectual or developmental disabilities;
Physical disabilities;
Mental illness or mental disabilities
Information regarding relationships with other youth
Confirmation of size and stature
Confirmation of Age
Policy addresses the occurrence and criteria regarding formal reassessments of
residents. It is reported that the number of youths admitted to the facility within the
past 12 months who were screened during the admission process for risk of sexual
victimization and the risk of sexually abusing other residents is 47. The risk
assessments are accessible to the clinical and case management staff; information
is discussed in classification meetings. The resident files were observed to be
maintained in a confidential manner in a locked file cabinets in lockable offices
which are a part of the key control system. Electronic information is password
protected with access only to identified staff. The state agency also has a virtual
private network that support private and confidential information of residents.
Provision (b):
Such assessments shall be conducted using an objective screening instrument.
An objective screening instrument is used to obtain the information required by the
standard, including but not limited to prior sexual victimization or abusiveness; self-
identification; current charges and offense history; disabilities; and a resident’s
concern regarding his/her own safety. The instrument, VSAB, is tabulated based on
the information received where identified responses can identify any special needs
and safety concerns. Assessments are conducted through the use of the VSAB
containing verifiable items that collectively provide a presumptive determination of
risk for victimization or abusiveness. The VSAB is administered by case
management staff, the same trained group, which also assists in minimizing
subjective interpretation and bias.
Provision (c):
At a minimum, the agency shall attempt to ascertain information about:
(1) Prior sexual victimization or abusiveness;
(2) 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;
(3) Current charges and offense history;
(4) Age;
(5) Level of emotional and cognitive development;
(6) Physical size and stature;
(7) Mental illness or mental disabilities;
(8) Intellectual or developmental disabilities;
(9) Physical disabilities;
(10) The residents’ own perception of vulnerability; and
(11) Any other specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or separation from
certain other residents.
The Auditor reviewed the screening instrument and determined the items required
by this provision of the standard are included within the instrument. The interview
with the risk screener confirmed awareness of the elements of the risk screening
instrument. The resident interviews also confirmed the administration of the
screening instrument and the general inquiries made. The interviews revealed the
practice is that the instrument is administered the first day of the youth’s admission
to the facility.
Provision (d):
This information shall be ascertained through conversations with the resident during
the intake process and medical and mental health screenings; during classification
assessments; and by reviewing court records, case files, facility behavioral records,
and other relevant documentation from the resident’s files.
The information to complete the risk screening instrument is gleaned from various
sources. Information in determining the risk for victimization or abusiveness is
obtained through interviewing the youth. Additional information to complete the
screening instrument includes review of the court packet and interviews with a
parent/guardian. The facility is aware of the youth’s pending arrival to the facility
and treatment staff has the opportunity to review the residents electronic record in
an effort to preliminarily prepare for the needs prior to their arrival. Additional
assessments are completed after the youth is admitted to the facility to obtain
supportive information for treatment planning and keeping the youth safe.
Provision (e):
The agency shall implement appropriate controls on the 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.
Appropriate controls are taken to ensure that sensitive information is protected and
not exploited by maintaining the files securely in a locked file cabinets in locked
offices when unoccupied. The key to the offices are in the key control system.
Electronic information is password protected with limited and identified staff access.
The risk screener addressed the management of sensitive information and the
expectation of confidentiality by staff. Confidentiality is a component of staff
training and addressed by policy. The case management staff have access to the
risk screening instruments and the information is discussed in classification
meetings with other treatment and program staff.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.342 Placement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 2-1, Admission and Orientation
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
Admission Classification Form
Re-Classification Form
Mental Health Services Referral Form
Interviews:
Staff Responsible for Risk Screening
PREA Compliance Manager
Medical Staff
Mental Health Staff
Residents
Provision (a):
The agency shall use all information obtained pursuant to §115.341 and
subsequently to make housing, bed, program, education, and work assignments for
residents with the goal of keeping all residents safe and free from sexual abuse.
The facility uses information from the risk screening required to inform housing,
bed, work, education, and program assignments. Policies collectively provide
guidance to staff regarding the use of the information obtained from the screening
instrument. The interviews indicate the screening information is used to inform
staff, based on the need to know, about housing and program assignments, and
assist in identifying treatment and any special services. Housing and other
assignments are not made by the Case Manager until the VSAB is completed.
Provision (b):
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. During any
period of isolation, agencies shall not deny residents daily large-muscle exercise and
any legally required educational programming or special education services.
Residents in isolation shall receive daily visits from a medical or mental health care
clinician. Residents shall also have access to other programs and work opportunities
to the extent possible.
The practice is the facility does not use isolation as identified through the interviews
and observations. The staff interviews indicated that protective measures will be
taken immediately when needed and include separating residents, closer
supervision, and notifying supervisors and administrators. There were not any
residents identified as at-risk of sexual victimization during this audit period. Policy
does exists if the situation should ever occur.
Provision (c):
Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in
particular housing, bed, or other assignments solely on the basis of such
identification or status, nor shall agencies consider lesbian, gay, bisexual,
transgender, or intersex identification or status as an indicator of likelihood of being
sexually abusive.
Gay, bisexual, transgender, or intersex residents are not placed in specific housing
solely based on how the residents identify or their status. Staff members are
prohibited from considering the identification as an indicator that these residents
may be more likely to be sexually abusive. During the site review, there were no
rooms or units observed or identified to be reserved for LGBTI youth. Housing
assignments are made on a case-by-case basis as supported by policy, interviews,
and practice demonstrated by the forms used.
Provision (d):
In deciding whether to assign a transgender or intersex resident to a facility for
male or female residents, and in making other housing and programming
assignments, the agency shall consider on a case-by-case basis whether a
placement would ensure residents’ health and safety, and whether the placement
would present management or security problems.
Policy and practice support that housing and program assignments for transgender
or intersex residents are made on a case-by-case basis which was evident from staff
interviews and observations. The interview with the risk screener confirmed that
staff considers on a case-by-case basis whether a placement ensures a resident’s
health and safety, and whether the placement will present management or security
problems. The interviews indicate staffs’ awareness and efforts in keeping residents
safe. There were no residents in the facility in this category in the facility for the
past year.
Provision (e):
Placement and programming assignments for each transgender or intersex resident
shall be reassessed at least twice each year to review any threats to safety
experienced by the resident.
Policy provides placement and programming assignments for each transgender or
intersex resident be reassessed twice per year to determine any threats to safety
experienced by the resident. The interview with the risk screener confirmed
awareness of policy. The practice of reassessments occurring with all residents
provides that the reassessment of transgender and intersex youth will occur at least
twice per year.
Provision (f):
A transgender or intersex resident’s own views with respect to his or her own safety
shall be given serious consideration.
The resident’s concern for her own safety is taken into account through the
administration of the risk vulnerability screening instrument, treatment team
meetings and individual sessions and interactions with mental health staff and Case
Managers. The interviews with staff and review of documentation were aligned with
the policy.
Provision (g):
Transgender and intersex residents shall be given the opportunity to shower
separately from other residents.
Transgender or intersex residents are given the opportunity to shower separately
from other residents which is also supported by the interviews and policy. There
were no targeted interviewees in the facility during the onsite audit phase.
Provision (h):
If a resident is isolated pursuant to paragraph (b) of this section, the facility shall
clearly document:
(1) The basis for the facility’s concern for the resident’s safety; and
(2) The reason why no alternative means of separation can be arranged.
The provisions of this standard will be implemented if such occurs however the
practice is that isolation is not used in this facility. No residents were determined at-
risk of sexual victimization during the 12 months preceding the audit.
Provision (i):
Every 30 days, the facility shall afford each resident described in paragraph (h) of
this section a review to determine whether there is a continuing need for separation
from the general population.
Isolation is not used in this facility as the practice.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.351 Resident reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 1-5, Provision of Abuse Free Environment
Facility Policy 5-19, PREA
Agency Policy, Chapter 63F-11, Central Communications Center
Youth and Parent Program Handbook
Grievance Form
Request to Speak Form
Sick Call Form
Training Plans
Training Curricula
Staff Meeting Minutes
Brochure
Multilingual Posters
General Counsel Memorandum
Interviews:
Residents
Random Staff
PREA Coordinator
Provision (a):
The agency shall provide multiple internal ways for residents to privately report
sexual abuse and sexual harassment, 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.
Policy provides for internal ways a resident may report allegations of sexual abuse
and sexual harassment, including how to privately report sexual abuse and sexual
harassment; retaliation for reporting; and staff neglect or violations of
responsibilities that may have contributed to such. Residents may report allegations
of sexual abuse or sexual harassment by telephone through the 24-hour Florida
abuse reporting hotline. Telephones are made accessible to residents for reporting
allegations of sexual abuse and sexual harassment. Staff members are required to
make the use of the telephone accessible for residents to report allegations of
sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents. The reporting
information is posted by the telephones.
Policies, posters, brochures, and the Youth & Parent Program Handbook collectively
provide telephone numbers and instructions for reporting allegations of sexual
abuse and sexual harassment. In addition to accessing a telephone, residents are
also informed in the PREA education sessions, determined from the interviews, that
they may tell staff; submit a complaint in writing utilizing the Grievance form; or use
the hotline regarding allegations of sexual abuse or sexual harassment. The posters
are graphic and easy to read and understand. The messaging is consistent
regarding the provision of PREA information and how to report and seek assistance.
Other forms that may be used to obtain staff assistance is the Sick Call form and
Request to Speak Form. The Sick Call form may be placed in the sick call box and
only medical staff has a key. The request may be made for medical care, mental
health care or dental care. The resident is able to describe his problem on the form.
The Request to Speak form may be given to staff or also placed in the locked box
where designated staff has a key. The resident may request to speak with the
Superintendent, Assistant Superintendent, Clinical Director, Director of Case
Management, Case Manager, or Therapist. The resident may provide a brief
description of the request if they choose to. The help request forms (Grievance, Sick
Call, Request to Speak) are accessible to residents, posted on each housing unit.
The residents interviewed identified someone who did not work at the facility they
could report to about sexual abuse or sexual harassment. The random staff and
resident interviews collectively revealed residents may use a telephone, submit a
complaint in writing, or talk to staff to privately report allegations of sexual abuse
and sexual harassment. The resident is provided the hotline number in writing
throughout the facility, including in the, resident handbook, brochures, and posted
information. According to interviews and informal conversations, residents have
access to use the telephone to report allegations and to communicate with
approved contacts on the outside.
Residents have access to writing utensils; help request forms; and locked boxes for
receipt of the forms which are accessible to all residents for reporting allegations of
sexual abuse and sexual harassment. Written notes or letters and other completed
forms may also be given to staff or placed in the secure grievance or sick call box. If
a grievance form is used to make a written allegation of sexual abuse or sexual
harassment, the reporting procedures will be implemented in accordance with
policy. PREA information is posted and each resident is provided a handbook which
contains reporting and other PREA related information. Staff members receive
information on how to report allegations of sexual abuse or sexual harassment
through policies and procedures, training, shift briefings, staff meetings, and State
statutes.
Provision (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 detained solely for civil immigration purposes shall be
provided information on how to contact relevant consular officials and relevant
officials at the Department of Homeland Security.
The Florida abuse reporting hotline may be used by residents and staff to report
allegations of sexual abuse and sexual harassment. The interviews revealed
familiarity with policy and posted information on how to report allegations.
Telephones are accessible to all staff and are made accessible to residents by staff;
a resident may remain anonymous upon request. The telephone hotline was tested;
the telephone was in working order and attended by an operator who explained the
routing of the calls. An allegation may also be reported in Spanish by following the
recorded prompt on the hotline. The reports of sexual abuse or sexual harassment
are accepted and referred for an investigation. The facility does not detain residents
solely for civil immigration purposes according to written communication from the
Department of Juvenile Justice's legal department.
Provision (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 reports made anonymously, third-party reports and to document verbal
reports. The resident interviews collectively indicated awareness of reporting either
in person, in writing, by telephone, or through a third-party. The residents may
remain anonymous by not recording their names if an allegation is made in writing.
Interviewed staff members were aware of their duty to receive and document the
receipt of verbal reports. PREA related information is stored in lockable cabinets
behind locked doors within the key control system. Electronic records are password
protected and staff access identified.
Provision (d):
The facility shall provide residents with access to tools necessary to make a written
report.
Interviews and observations revealed writing materials are available for residents to
complete a help request form or write a note. Each resident is provided a handbook
which contains information regarding reporting by a written method. The interviews,
review of documents and facility practices revealed alignment with the agency and
facility policies. All residents have access to writing tools as confirmed by interviews
and observations by the Auditor. The facility also has a process and space for
writing letters. The facility has a process for mailing letters and the distribution of
received letters.
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and
sexual harassment of residents.
The staff interviews revealed staff can privately report allegations of sexual abuse
and sexual harassment through a call to the Florida abuse reporting hotline or
Department of Juvenile Justice, Central Communications Center, and/or speak
directly to a supervisor or a member of the management team, including
Superintendent and Assistant Superintendent. Random staff were able to walk
through the processes for the methods they provided for reporting allegations of
abuse.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.352 Exhaustion of administrative remedies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Grievance Form
Youth and Parent Program Handbook
Interviews:
Random Staff
Residents
Superintendent
Provision (a):
An agency shall be exempt from this standard if it does not have administrative
procedures to address resident grievances regarding sexual abuse.
When an emergency grievance is received that contains an allegation of sexual
abuse or sexual harassment, the policy and procedures for reporting allegations of
sexual abuse or sexual harassment are initiated and a report is made as required by
agency policy. The grievance system does not include a process for the facility staff
to investigate or resolve allegations of sexual abuse or sexual harassment. The
content of the grievance is reported and an investigation will be conducted by the
Department of Juvenile Justice (DJJ)/Office of Inspector General (OIG), Florida
Department of Children and Families (DCF), and/or law enforcement. The resident-
on-resident allegation of sexual abuse was reported on a grievance form. The
allegation was immediately reported to the OIG through the DJJ Central
Communications Center.
Provision (b):
(1) The agency shall not impose a time limit on when a resident may submit a
grievance regarding an allegation of sexual abuse.
(2) The agency may apply otherwise-applicable time limits on any portion of a
grievance that does not allege an incident of sexual abuse.
(3) The agency shall not require a resident to use any informal grievance process, or
to otherwise attempt to resolve with staff, an alleged incident of sexual abuse.
(4) Nothing in this section shall restrict the agency’s ability to defend against a
lawsuit filed by a resident on the ground that the applicable statute of limitations
has expired.
Policy provides there is no time limit for completing a Grievance Form to report
allegations of sexual abuse. Residents are not required to use an informal process or
give the Grievance Form to any staff member regarding allegations of sexual abuse.
Locked boxes are located in the common areas for residents to deposit grievances,
other help request forms, or notes if they choose. The Grievance Form informs
residents they do not have to talk to staff if the complaint is PREA related. Residents
are also informed they may put the Grievance Form in one of the locked boxes or
give it to staff if they choose. Policy does not restrict the facility’s ability to defend
against a lawsuit filed by a resident on the ground that the applicable statute of
limitations has expired.
Provision (c):
The agency shall ensure that—
(1) A resident who alleges sexual abuse may submit a grievance without submitting
it to a staff member who is the subject of the complaint, and
(2) Such grievance is not referred to a staff member who is the subject of the
complaint.
The grievance system does not include investigating allegations of sexual abuse
and sexual harassment. Residents are not required to use an informal process or
give the Grievance Form to any staff member regarding allegations of sexual abuse.
The staff member involved in the grievance will not be involved in reporting the
allegation stated in the complaint. To assist in the prompt and proper handling of
the allegation of sexual abuse or sexual harassment, youth may put the completed
Grievance Form in the locked box or give to staff if they choose.
The Florida abuse reporting hotline and the contact information is provided and
accessible to all residents through postings, handbook, and brochures. The residents
are informed that they will have unhindered access to a telephone. The locked
boxes for depositing help request forms are located in the common areas for
depositing help request forms or notes. The handbook explains the regular
grievance system and contains information regarding reporting allegations of sexual
abuse and sexual harassment. The Grievance Form informs residents that they do
not have to give the Form to any staff member and it may be placed in the box.
Provision (d):
(1) The agency shall issue a final agency decision on the merits of any portion of a
grievance alleging sexual abuse within 90 days of the initial filing of the grievance.
(2) Computation of the 90-day time period shall not include time consumed by
residents in preparing any administrative appeal.
(3) The agency may claim an extension of time to respond, of up to 70 days, if the
normal time period for response is insufficient to make an appropriate decision. The
agency shall notify the resident in writing of any such extension and provide a date
by which a decision will be made.
(4) At any level of the administrative process, including the final level, if the resident
does not receive a response within the time allotted for reply, including any properly
noticed extension, the resident may consider the absence of a response to be a
denial at that level.
Initial response to the grievance is required within 48 hours to inform the resident of
receipt of the grievance containing an allegation of sexual abuse and that it has
been referred for investigation. All Grievance Forms that contain an allegation of
sexual abuse or sexual harassment will be referred for an investigation in
accordance with policy. The purpose of the submission of a PREA related complaint
on a Grievance Form provides residents and staff another avenue for ensuring the
reporting of allegations and provides management staff with the opportunity to
protect the resident.
Provision (e):
(1) Third parties, including fellow residents, staff members, family members,
attorneys, and outside advocates, shall be permitted to assist residents in filing
requests for administrative remedies relating to allegations of sexual abuse, and
shall also be permitted to file such requests on behalf of residents.
(2) 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.
(3) If the resident declines to have the request processed on his or her behalf, the
agency shall document the resident’s decision.
(4) A parent or legal guardian of a juvenile shall be allowed to file a grievance
regarding allegations of sexual abuse, including appeals, on behalf of such juvenile.
Such a grievance shall not be conditioned upon the juvenile agreeing to have the
request filed on his or her behalf.
When third-party reports of allegations of sexual abuse or sexual harassment are
received, the policies and procedures for reporting allegations of sexual abuse or
sexual harassment are initiated and a report is made as required by policy. The
grievance system does not include a process for facility staff to investigate or
resolve allegations of sexual abuse or sexual harassment. The allegation on the
Grievance Form is reported and an investigation will be conducted by the
investigative entity as appropriate.
Provision (f):
(1) The agency shall establish procedures for the filing of an emergency grievance
alleging that a resident is subject to a substantial risk of imminent sexual abuse.
(2) After receiving an emergency grievance alleging a resident is subject to a
substantial risk of imminent sexual abuse, the agency shall 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, shall provide an initial response within 48 hours, and shall issue a final
agency decision within five calendar days. The initial response and final agency
decision shall document the agency’s determination whether the resident is in
substantial risk of imminent sexual abuse and the action taken in response to the
emergency grievance.
Policy provides for emergency grievances to be responded to within 48 hours. The
response is to inform the resident of the receipt of the grievance and the referral for
an investigation. If a Grievance Form alleging sexual abuse is received, it is reported
by staff to the appropriate investigative entity. The response to the emergency
grievance will include measures to ensure safety and also include but not limited to
determining an immediate corrective action that would be implemented within 48
hours where applicable to ensure the safety of the resident. Policy also supports
that in the case of imminent sexual abuse, the facility final response regarding the
allegation will be issued in five days. There has not been a grievance submitted
alleging sexual abuse during this audit period.
Provision (g):
The agency may discipline a resident for filing a grievance related to alleged sexual
abuse only where the agency demonstrates that the resident filed the grievance in
bad faith.
Residents will not be punished for filing a complaint. The grievance system does not
include a process for facility staff to investigate or resolve allegations of sexual
abuse. Once a Grievance Form alleging sexual abuse is received, the allegation is
reported to the appropriate investigative entities and an investigation will be
conducted by the DJJ/ Office of Inspector General, Florida Department of Children
and Families, and/or local law enforcement. There has not been a Grievance Form
submitted alleging sexual abuse during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
Posted PREA Information
Youth and Parent Program Handbook
Posted Information Re: US Citizenship and Immigration Services
Communication Re: Memorandum of Understanding (MOU)
Interviews:
Residents
Superintendent/PREA Compliance Manager
Advocacy Agency Representative
Provision (a):
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.
The interview with the representative from the Nancy J. Cotterman Center (NJCC)
and the Superintendent confirmed the current efforts for the development of a
comprehensive MOU. There is correspondence and meetings have been held to
finalize a MOU which is now in draft stage and under review by management staff at
the detention center. The NJCC representative confirmed the services that will be
provided as needed include accompaniment for the forensic medical examination,
interview, and court hearing. There are 24-hour hotline services, counseling, and
information and referrals. Forensic medical examinations are also conducted at the
NJCC by a Nurse Practitioner that is trained and/or certified as a Sexual Assault
Nurse Examiner. The representative provided that the lack of a formal MOU with the
detention center will not interfere with the provision of services to the residents. The
facility Superintendent and the advocacy agency representative confirmed the draft
MOU is under review by the advocacy agency.
The interviews and the written content about the NJCC confirmed a forensic medical
examination may be conducted at the NJCC. The NJCC is a certified sexual assault
program and accredited children's advocacy center and child protection team. It is
certified by the Florida Council Against Sexual Violence and accredited by the
National Children's Alliance. The services provided are accessible to all residents
detained or confined in the facility. Services are available in English, Spanish and
Creole. Flyers are available in the facility, accessible to residents, that are easy to
read and graphic. The calls are free and policy and practice provides staff must let
residents use the telephone upon request and there is guidance to staff on the
provision of privacy by keeping resident within the line of sight but not within
earshot as they use the telephone. All staff receive training regarding confidentiality
of information.
Provision (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.
Policy, facility staff interviews and PREA education sessions provide there will be
adherence to confidentiality measures and this information is shared with residents
during PREA education sessions. PREA signage is placed at varying eye levels and
are colorful and graphic with consistent and easily read messages. The interviews
with the residents revealed nine out of 12 residents were not familiar with the
advocacy services but the questioning revealed they know where to find information
on the walls if they need it. The interviews confirmed the PREA information is always
on the walls. PREA information is located in the housing areas; common areas for
staff, residents, contractors, volunteers, and visitors; lobby; and offices.
Provision (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 interviews with the advocacy agency representative and Superintendent and
flyers document the availability of advocacy services including but not limited to
emotional support; accompaniment through the forensic medical examination,
investigative interview and court hearing. The services are activated by an
investigation by the Florida Department of Children and Families or law enforcement
and the hotline number is accessible to the residents. The interview with the
representative from NJCC and the facility Superintendent confirmed the current
efforts for the development of a comprehensive MOU. There is correspondence
regarding the review of the draft MOU being in process. The NJCC representative
confirmed the services that will be provided as needed include accompaniment for
the forensic medical examination, interview, and court hearing. There are a 24-hour
hotline service, counseling, and information and referrals. Forensic medical
examinations are also conducted at the NJCC by a Nurse Practitioner that is trained
and/or certified as a Sexual Assault Nurse Examiner. The representative provided
that the lack of a formal MOU with the detention center will not interfere with the
provision of services to the residents.
Provision (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 residents have reasonable and confidential access to attorneys and court
workers and reasonable access to their parents/legal guardians which is supported
by policy, resident handbook, and resident interviews. During the comprehensive
site review, the Auditor observed areas of visitation for parents/guardians and
private areas for attorneys, court workers, child welfare workers, etc. All residents
interviewed confirmed communication opportunities occur with parents, guardians,
court workers and attorneys. All visitors must sign in upon entry into the facility and
document the reason for the visit.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility meets this standard.
115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Facility Policy 1-5, Provision of an Abuse Free Environment
Third Party Reporting Information Sheet
Agency Website
Multilingual Posters
Multilingual Pamphlets
Interviews:
Random Staff
Residents
Provision (a):
The agency shall establish a method to receive third-party reports of sexual abuse
and sexual harassment and shall distribute publicly information on how to report
sexual abuse and sexual harassment on behalf of a resident.
The Florida Department of Juvenile Justice's website provides the public with
information regarding third-party reporting and the contact information for such of
sexual abuse or sexual harassment. Resident interviews revealed their awareness of
reporting sexual abuse or sexual harassment to others they have contact with
outside of the facility including their parents/legal guardians.
The agency policy addresses third-party reporting and interviews revealed random
staff members are aware third-party reporting of sexual abuse and sexual
harassment can be done and stated they will be accepted, reported, and
subsequently investigated. Staff members also stated they are to immediately
document all verbal reports received. The interviews revealed reports of allegations
may be made privately, anonymously, and as a third-party through the use of the
abuse reporting hotline, contact with facility or agency staff, and/or completion of a
PREA or other help request form maintained in the facility.
All residents interviewed stated they knew someone who did not work at the facility
they could report to regarding allegations of sexual abuse and that person could
make a report for them. The interviews with the residents revealed their knowledge
of third-party reporting. The residents identified the methods within the facility in
which they may make third party reports such as complete an emergency grievance
or other help request form, report to staff or a family member, or utilize the abuse
reporting hotline telephone or number.
An abundance of information regarding reporting allegations of sexual abuse and
sexual harassment is provided through observed postings and other printed
materials are located in various areas of the facility accessible to visitors, residents,
staff, contractors and volunteers. The posted information is on the walls at varying
eye-levels with a consistent message which is easy to read, throughout the facility.
Third-party reporting information is also posted in the lobby accessible to visitors,
contractors, and staff. There were no third- party reports received during this audit
period.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the standard.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Florida Administrative Code, Rule 63F-11
Interviews:
Random Staff
Superintendent
Mental Health Staff
Medical Staff
Provisions (a) and (b):
(a): The agency shall require all staff to report immediately and 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; 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. (b): The agency shall also require all staff
to comply with any applicable mandatory child abuse reporting laws.
The Administrative Code and policy support that all staff report any knowledge,
suspicion, information, or receipt of information regarding an incident or allegation
of sexual abuse, sexual harassment or incidents of retaliation. Staff members are
deemed as mandated reporters by the State. Trained agency investigators conduct
administrative investigations and allegations that are criminal in nature are
investigated by trained law enforcement investigators. The facility and agency
policies provide guidance to staff on reporting allegations of sexual abuse and
sexual harassment and the duties of the first responder. The two allegations of
sexual abuse during this audit period were reported in accordance with policy and
the standard.
Provision (c):
Apart from reporting to designated supervisors or officials and designated State or
local services agencies, staff shall be 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.
Policies collectively address confidentiality of information and the conditions for
providing information. Once allegations have been appropriately reported, staff will
keep the information confidential regarding what was reported except when
necessary for the investigation and treatment and management decisions. Staff
receives training regarding confidentiality of information.
Provision (d):
(1) Medical and mental health practitioners shall be required to report 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.
(2) Such practitioners shall be required to inform residents at the initiation of
services of their duty to report and the limitations of confidentiality.
The clinical staff interviewed indicated residents are informed at the initiation of
services of the limitations of confidentiality and the duty of the staff members to
report. The clinical staff members are also mandated reporters and required by the
State to report allegations received regarding sexual abuse and sexual harassment,
in accordance with policy and State requirements.
Provision (e):
(1) Upon receiving any allegation of sexual abuse, the facility head or his or her
designee shall promptly report the allegation to the appropriate agency office and
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.
(2) If the alleged victim is under the guardianship of the child welfare system, the
report shall be made to the alleged victim’s caseworker instead of the parents or
legal guardians.
(3) If a juvenile court retains jurisdiction over the alleged victim, the facility head or
designee shall also report the allegation to the juvenile’s attorney or other legal
representative of record within 14 days of receiving the allegation.
Reports of allegations are made as soon as possible to the investigative entities,
including the Department of Juvenile Justice (DJJ) Central Communications Center,
and parents/legal guardians. Policy and interview with the Superintendent confirmed
a resident’s caseworker rather than a parent would be notified where indicated by
the resident being under the guardianship of the Florida Department of Children and
Families. The resident’s attorney would be notified of an allegation of sexual abuse
within 14 days, where applicable and accordance with policy. Timelines and
directions to staff for reporting allegations are provided in policy.
Provision (f):
The facility shall report all allegations of sexual abuse and sexual harassment,
including third-party and anonymous reports, to the facility’s designated
investigators.
Policy and interviews provide for all allegations to be reported and include the Office
of the Inspector General (OIG) through the Central Communications Center.
Administrative investigations are conducted by a DJJ/OIG Investigator. Sexual abuse
and sexual harassment allegations that are criminal in nature are referred for
investigation to law enforcement. Third-party and anonymous reports received must
be reported and documented by staff as confirmed through interviews. The
interviews confirmed all allegations are reported to the DJJ Central Communications
Center, Florida Department of Children and Families, and to law enforcement when
an allegation is criminal in nature.
Conclusion:
The review of evidence and interviews indicate the facility is in compliance with this
standard.
115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 2-1, Admission and Orientation
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Grievance Form
Sick Call Form
Request to Speak Form
Interviews:
Superintendent
Random Staff
Agency Head Designee
Provision (a):
When an agency learns that a resident is subject to a substantial risk of imminent
sexual abuse, it shall take immediate action to protect the resident.
The staff is required to protect the residents through implementing protective
measures. Administration of the risk screening instrument provides information that
assists and guide staff in keeping residents safe through housing and program
assignments. Additional assessment instruments provide information which offer
supporting information in determining the risk level of each resident. The interviews
revealed protective measures include but are not limited to separating youth; one-
on-one supervision; and contacting administrators, supervisors and other staff.
The help request forms (Grievance, Sick Call Request, Request to Speak) are
displayed for residents to complete to report any problems and/or gain assistance.
The facility environment encourages residents to complete a help request form, talk
to a trusted staff member, talk to a parent/guardian or other approved outside
contact, or make a report using the abuse reporting hotline regarding allegations of
sexual abuse and sexual harassment.
The expectation is that any action to protect a resident is taken immediately as
deemed from interviews. During the intake process, residents are asked about how
they feel about their safety as part of the inquiries by staff completing the primary
sexual safety instrument, VSAB. No resident was identified to be at substantial risk
of imminent sexual abuse in the past 12 months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.363 Reporting to other confinement facilities
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 1-6, Incident Reporting
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Interview:
Superintendent
Provisions (a)-(d):
(a): Upon receiving an allegation that a resident was sexually abused while confined
at another facility, the head of the facility that received the allegation shall notify
the head of the facility or appropriate office of the agency where the alleged abuse
occurred and shall also notify the appropriate investigative agency. (b): Such
notification shall be provided as soon as possible, but no later than 72 hours after
receiving the allegation. (c): The agency shall document that it has provided such
notification. (d): The facility head or agency office that receives such notification
shall ensure that the allegation is investigated in accordance with these standards.
The policies and interview provide that when an allegation of sexual abuse is
received that a resident was sexually abused while confined at another facility, the
facility administrator will notify the head of the facility or appropriate office of the
agency where the alleged abuse occurred. The notification will be made as soon as
possible and within 72 hours and documented in policy.
The Superintendent is also required to make a report to the Central Communications
Center. Policy and the interview support allegations of sexual abuse or sexual
harassment from a resident regarding their stay in another facility will be reported
and investigated as required. In the past 12 months, there were no allegations
reported of sexual abuse occurring at another facility.
Conclusion:
Based upon the information received and interviews, the Auditor determined the
facility is compliant with this standard.
115.364 Staff first responder duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Facility Coordinated Response Plan for Reports of Sexual Abuse
Interviews:
Random Staff
Superintendent
Provision (a):
Upon learning of an allegation that a resident was sexually abused, the first staff
member to respond to the report shall be required to:
(1) Separate the alleged victim and abuser;
(2) Preserve and protect any crime scene until appropriate steps can be taken to
collect any evidence;
(3) If the abuse occurred within a time period that still allows for the collection of
physical evidence, 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; and
(4) If the abuse occurred within a time period that still allows for the collection of
physical evidence, 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.
The interviews and review of the Facility Coordinated Response Plan for Reports of
Sexual Abuse support the familiarity with appropriate intervention. There were two
allegations of sexual abuse in the last 12 months. Policy and training provide that
upon learning of an allegation that a resident was sexually abused the general staff
response would basically include but not be limited to the following:
a. Separate the victim and alleged abuser.
b. Preserve and protect the scene until appropriate steps can be taken to collect any
evidence.
c. Request that the alleged victim not take any actions that could destroy physical
evidence.
d. Take actions to ensure the alleged abuser does not take any actions that could
destroy physical evidence.
e. Ensure the safety of the victim.
f. Make the required notifications.
The victim and perpetrator were separated when staff learned of the allegations.
There was no crisis intervention indicated for either case.
Provision (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, and then notify security staff.
The non-security staff who may act as a first responder will request that physical
evidence be preserved and contact direct care staff for assistance. There were two
allegations of sexual abuse and there was no non-security staff involved in either
case that had to act as a first responder in the last 12 months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Facility Coordinated Response Plan for Reports of Sexual Abuse
Interviews:
Random Staff
Superintendent
Provision (a):
The facility shall develop a written institutional plan to coordinate actions taken in
response to an incident of sexual abuse among staff first responders, medical and
mental health practitioners, investigators, and facility leadership.
The Facility Coordinated Response Plan for Reports of Sexual Abuse to be
implemented in the event of an allegation or incident of sexual abuse outlines the
actions of the identified staff members in general and the plan’s format identifies
each step and roles such as the first responder; supervisors; medical; mental health;
and management staff; and when to contact such. Policy provides guidance to staff
regarding the actions to take when there is an alleged incident of sexual abuse.
Staff members interviewed were familiar with their role regarding the response to
an allegation of sexual abuse. There were two allegations of sexual abuse during
this audit period. One was an allegation of resident-on-resident sexual abuse and
the other was staff-on-resident sexual abuse. The allegation regarding staff-on-
resident has been deemed unfounded.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with the standard.
Preservation of ability to protect residents from contact with
115.366
abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Interviews:
Superintendent
Agency Head Designee
Provisions (a) and (b):
(a): Neither the agency nor any other governmental entity responsible for collective
bargaining on the agency’s behalf shall enter into or renew any collective
bargaining agreement or other agreements that limits the agency’s ability to
remove alleged staff sexual abusers form contact with residents pending the
outcome of an investigation or of a determination of whether and to what extent
discipline is warranted.
(b): Nothing is this standard shall restrict the entering into on renewal of
agreements that govern:
(1) The conduct of the disciplinary process, at long as such agreements are not
inconsistent with the provisions of §115.372 and §115.376; or
(2) Whether a no-contact assignment that is imposed pending the outcome of an
investigation shall be expunged from or retained in the staff member’s personnel
file following a determination that the allegation of sexual abuse is not
substantiated.
The facility is not involved in any collective bargaining agreements.
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Youth & Parent Handbook
Retaliation Monitoring Forms
Interviews:
Retaliation Monitor
Superintendent
Random Staff
PREA Coordinator/Agency Head Designee
Provision (a):
The agency shall establish a policy to protect all residents and staff who report
sexual abuse or sexual harassment or cooperate with sexual abuse or sexual
harassment investigations from retaliation by other residents or staff and shall
designate which staff members or departments are charged with monitoring
retaliation.
Policy supports protecting residents and staff who report sexual abuse or sexual
harassment, or cooperate with sexual abuse or sexual harassment investigations
from retaliation by other residents, or staff. The message is prominent in the facility
as to the staff member responsible for retaliation monitoring. The picture of the
retaliation monitor is posted on each living unit and the common areas. A dedicated
form is used to document retaliation monitoring.
The retaliation monitor is familiar with the role of retaliation monitor and its
purpose. A sample of Retaliation Monitoring forms were reviewed by the Auditor.
The form documents whether the individual has been threatened or been treated
unfairly. Any reported maltreatment must be described on the form. The written
policy also provides for the review of housing changes and removal of alleged staff
or residents from contact with victims.
Provision (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 that fear retaliation for reporting sexual abuse or sexual harassment or for
cooperating with investigations.
Protective measures were generally identified during the interviews with random
staff, PREA Coordinator, Superintendent, and retaliation monitor and were aligned
with policy. According to the interviews the collective protective measures include
housing changes for resident victims or abusers; removing alleged staff or resident
abusers from contact with victims; changes in shift or other assignments for staff;
single room status for residents; and transferring resident or staff, if needed. The
retaliation monitoring is documented on the dedicated monitoring form and follow-
up checks with the parties involved ensure safe feelings and identifies whether
retaliation is occurring. The interviews and documented checks confirmed the
measures to protect residents and staff from retaliation by others.
Provision (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.
Policy and practice provide that the monitoring occurs for at least 90 days to see if
there are any changes that may suggest possible retaliation is occurring. The
monitoring period may last longer if needed, according to the retaliation monitor
and policy. The interview identified items that are monitored to assess retaliation
occurring included but were not limited to program and housing changes; shift
assignments; review of behavior points; call-outs; staff and resident interactions;
resident to resident interactions; and the demeanors of staff and/or residents.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
Policy and the interview with the retaliation monitor indicate status checks will occur
as a part of retaliation monitoring where there is face-to-face contact. The dedicated
monitoring form and the interview with the retaliation monitor revealed that initial
contact is made and there are follow-up checks; all are documented.
Provision (e):
If any other individual who cooperates with an investigation expresses a fear of
retaliation, the agency shall take appropriate measures to protect that individual
against retaliation.
Policy encompasses those who cooperate with an investigation if there is a concern
regarding retaliation. The interview with the retaliation monitor indicated the
appropriate measures are taken to protect any related individuals against
retaliation.
Provision (f):
An agency’s obligation to monitor shall terminate if the agency determines that the
allegation is unfounded.
The obligation to monitor for retaliation terminates, in accordance with policy, if it is
determined the allegation is unfounded. The interview determined familiarity with
the requirements regarding retaliation monitoring policy.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.368 Post-allegation protective custody
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Agency Policy FDJJ 1919
Interviews:
Superintendent
Medical Staff
Mental Health Staff
Provision (a):
The use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse shall be subject to the requirements of §115.342.
Segregated housing is not used in the facility to protect residents who alleged to
have suffered sexual abuse. The interviews were aligned with this premise. No
segregated area was observed or identified during the comprehensive site review.
Conclusion:
Based upon the review of Policy, interviews, and observations, the Auditor
determined the facility is compliant with this standard.
115.371 Criminal and administrative agency investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Facility Policy 5-19, PREA
Facility Policy 1-5, Provision of Abuse Free Environment
Training Curriculum
PREA Compliance Form
Investigation Reports
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinator
Investigative Staff
Provision (a):
When the agency conducts its own investigations into allegations of sexual abuse
and sexual harassment, it shall do so promptly, thoroughly, and objectively for all
allegations, including third-party and anonymous reports.
The administrative investigations are conducted by the investigators with the
Florida Department of Juvenile Justice (DJJ), Office of Inspector General (OIG). Based
on policies, incident reports, and interviews, trained investigators conduct
administrative investigations as prescribed by agency policy. Allegations that are
criminal in nature are referred to local law enforcement and the Florida Department
of Children and Families and all allegations are reported through the Central
Communications Center for residents 17 and under. A management review by the
agency occurs for all allegations. The agencies’ policy provides for the training of
investigators.
Provisions (b) and (c):
(b): Where sexual abuse is alleged, the agency shall use investigators who have
received special training in sexual abuse investigations involving juvenile victims
pursuant to §115.334. (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.
The DJJ investigative staff is trained through the OIG. The DJJ Investigator will turn
over any evidence found to law enforcement investigators since they generally do
not handle direct evidence. The DJJ investigators will assist law enforcement and
among other activities, may review video; gather witness statements; and review
logs during the administrative investigation of the allegation. The law enforcement
investigator and/or qualified medical practitioner are responsible for collecting direct
physical and DNA evidence.
The facility staff and DJJ investigators are trained on how to assist in preserving
general evidence. The agency, DJJ, provides each facility with the PREA Form which
is provided to law enforcement investigators referencing the PREA standards
regarding conducting investigations in accordance with the standards. The DJJ
investigators follow the OIG guidelines governing PREA related investigations, in
accordance with agency policy.
Provision (d):
The agency shall not terminate an investigation solely because the source of the
allegation recants the allegation.
The interview with investigative staff and agency policy confirm the provision that
an investigation is not terminated if the source recants an allegation of sexual abuse
or sexual harassment.
Provision (e):
When the quality of evidence appears to support criminal prosecution, the agency
shall conduct compelled interviews only after consulting with prosecutors as to
whether compelled interviews may be an obstacle for subsequent criminal
prosecution.
The DJJ agency Investigators do not conduct compelled interviews.
Provision (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.
The credibility of an alleged victim, suspect, or witness is assessed on an individual
basis and is not determined by the person’s status as a resident or staff as
supported by the interviews of the investigative staff, training, and in accordance
with policy. According to the investigative staff, credibility may be influenced by
past history; what can be verified; what other evidence can corroborate the
information; body language; and/or whether or not the person is answering
questions or being dismissive. No resident who alleges sexual abuse will be
subjected to a polygraph examination or other truth telling device as a condition for
proceeding with the investigation of the allegation.
Provisions (g) and (h):
(g): Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act
contributed to the abuse.
(2) 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.
(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.
The interviews support that PREA investigations include an effort to determine
whether staff actions or failures to act contributed to the abuse. Investigations in all
facilities are completed with written reports that include a description of the
evidence and investigative facts and findings as gleaned from the interview with the
investigative staff. The report also contains information regarding the initial call or
allegation; list of interviews; list of exhibits; logbook information; critique of any
video; and a host of other information as described by the investigative staff.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be referred for
prosecution.
The DJJ agency investigators do not conduct criminal investigations. It is the
responsibility of law enforcement personnel to refer cases for prosecution.
Provision (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.
The written investigative reports are maintained for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years as stated in agency policy.
Provision (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.
The interview with the investigative staff and administrators confirmed that upon
the start of an investigation, it will not end until the investigation has been
completed. The departure of the alleged abuser or victim from the employment or
control of the facility will not terminate the investigation.
Provision (l):
Any State entity or Department of Justice component that conducts such
investigations shall do so pursuant to the above requirements.
The investigative agencies are aware of the PREA standards requirements through
the initial sharing of PREA information, PREA Compliance Form, and subsequent
interactions.
Provision (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.
Policy, reports and interviews indicate that staff cooperate with investigators and
that the agency/facility is kept informed of the progress of an investigation. The
Superintendent maintains contact with the investigator from the applicable
investigative entity and will also be updated through the statewide PREA
Coordinator who maintains direct contact with the OIG.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Agency Policy FDJJ 1919
Incident Reports
Interview:
Investigative Staff
Provision (a):
The agency shall impose no standard higher than a preponderance of the evidence
in determining whether allegations of sexual abuse or sexual harassment are
substantiated.
The Florida Department of Juvenile Justice/Office of Inspector General, responsible
for administrative investigations, imposes a standard of a preponderance of the
evidence for determining whether allegations are substantiated. The interview,
reports and policy were aligned.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the
facility is compliant with this standard.
115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Notification Form
Interview:
Superintendent/PREA Compliance Manager
Provision (a):
Following an investigation into a resident’s allegation of sexual abuse suffered in an
agency facility, the agency shall inform the resident as to whether the allegation
has been determined to be substantiated, unsubstantiated, or unfounded.
It is required that the resident be informed when a sexual abuse investigation is
completed and the outcome of the investigation provided in writing. The results of
such investigations are documented and provided to the resident. The interview and
notification revealed awareness of the requirement. One resident had been notified
of the results of the investigation and was was still open during the onsite audit
phase which was later closed.
Provision (b):
If the agency did not conduct the investigation, it shall request the relevant
information from the investigative agency in order to inform the resident.
The Superintendent remains abreast of an investigation conducted by law
enforcement or the DJJ Investigator and will be provided a copy of completed
investigations. The results of the investigation are provided to the resident by the
Superintendent.
Provision (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.
The Superintendent is familiar with policy requirements. Policy and the dedicated
form used require that following a resident’s allegation that a staff member
committed sexual abuse against a resident, the resident will be informed of the
following, unless it has been determined that the allegation is unfounded,
whenever:
a. The staff member is no longer posted within the resident’s housing unit;
b. The staff member is no longer employed at the facility;
c. The staff member has been indicted on a charge related to sexual abuse in the
facility; and/or
d. The staff member has been convicted on a charge related to sexual abuse in the
facility.
Provision (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.
Policy provides that following a resident’s allegation of being sexually abused by
another resident the alleged victim shall be informed whenever:
a. The alleged abuser is criminally charged related to the sexual abuse.
b. The alleged abuser is adjudicated on a charge related to sexual abuse within the
facility.
The Superintendent is familiar with the requirements of the policy and the dedicated
form. There were no criminal investigation related to this allegation.
Provision (e):
All such notifications or attempted notifications shall be documented.
Policy provides for the notification to the resident be documented. The
Superintendent utilizes the dedicated form and process as prescribed in agency
policy. During the site visit one allegation of sexual abuse was still open; the
notification of the results is pending.
Provision (f):
An agency’s obligation to report under this standard shall terminate if the resident is
released from the agency’s custody.
The FDJJ Policy provides that the agency’s obligation to report under this standard
terminates if the resident is released from the agency’s custody. All notifications or
attempted notifications are documented.
Conclusion:
The interviews and review of Policy and other documentation confirmed the facility
is compliant with this standard.
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Interview:
Superintendent
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for
violating agency sexual abuse or sexual harassment policies.
Policy and the interview support staff be subject to disciplinary sanctions up to and
including termination for violating facility sexual abuse and sexual harassment
policies. There were no violations by staff during this audit period.
Provision (b):
Termination shall be the presumptive disciplinary sanction for staff who has
engaged in sexual abuse.
Termination is the presumptive disciplinary sanction for staff who has engaged in
sexual abuse with a resident. There was no staff member that violated policy
regarding sexual abuse or sexual harassment during this audit period.
Provision (c):
Disciplinary sanctions for violations of agency policies relating to sexual abuse or
sexual harassment shall be 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.
Any staff with findings other than actually engaging in sexual abuse will be subject
to termination, and other measures appropriate to the circumstance of the incident
and the other components of the provision and remedial in-service if permitted to
return to work. Disciplinary sanctions for violations of policies relating to sexual
abuse or sexual harassment (other than engaging in sexual abuse) will be
commensurate with the act committed, the staff member’s disciplinary history, and
the similar history of other staff.
Provision (d):
All terminations for violations of agency sexual abuse or sexual harassment policies,
or resignations by staff who would have been terminated if not for their resignation,
shall be reported to law enforcement agencies, unless the activity was clearly not
criminal, and to any relevant licensing bodies.
Policy provides that terminations for violations of the facility’s sexual abuse or
sexual harassment policies or resignations by staff that would have been terminated
if not for their resignation, will be reported to law enforcement, unless the activity is
clearly not criminal. In addition, such will be reported to relevant licensing bodies,
where applicable. Notification to a licensing body will occur where indicated.
Conclusion:
Based upon the review of documentation and the interview, the Auditor determined
the facility is compliant with this standard.
115.377 Corrective action for contractors and volunteers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Acknowledgement Statement
Interviews:
Superintendent
Contractors
Volunteers
Provision (a):
Any contractor or volunteer who engages in sexual abuse shall 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.
Policy provides for contractors and volunteers who engage in sexual abuse with a
resident to be reported to law enforcement and to relevant licensing bodies. The
interviews confirmed a clear understanding that sexual misconduct with a resident
is prohibited. Any contractor or volunteer who violates the agency’s sexual abuse or
sexual harassment policies is prohibited from contact with residents. During this
audit period, there have been no allegation of sexual abuse and no allegation of
sexual harassment regarding a contractor or volunteer. The volunteers and
contractors provide programming services.
Provision (b):
The facility shall take appropriate remedial measures, and shall consider whether to
prohibit further contact with residents, in the case of any other violation of agency
sexual abuse or sexual harassment policies by a contractor or volunteer.
Policy provides that appropriate remedial measures will be taken and include
prohibiting further contact with residents in the case of any violation of the sexual
abuse and sexual harassment policies by a contractor or volunteer. The
Superintendent provided that the services will be immediately terminated. In the
past 12 months, no contractor or volunteer was reported for allegations of sexual
abuse or sexual harassment.
Conclusion:
Based upon the review of the documentation and interviews, the Auditor
determined the facility is compliant with this standard.
115.378 Interventions and disciplinary sanctions for residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Youth & Parent Program Handbook
Interviews:
Superintendent
Mental Health Staff
Medical Staff
Provision (a):
A resident may be subject to disciplinary sanctions only pursuant to a formal
disciplinary process following an administrative finding that the resident engaged in
resident-on-resident sexual abuse or following a criminal finding of guilt for resident-
on-resident sexual abuse.
An administrative process exists for dealing with violations and hold residents
accountable for their actions. Residents may be subject to disciplinary sanctions
only after formal proceedings regarding resident-on-resident sexual abuse.
Residents found in violation of facility rules are subject to sanctions pursuant to a
formal process. The consequences will be administered through the administrative
system, encompassing the behavior management system. Allegations of sexual
abuse are referred for an investigation to the appropriate investigative entities and
may result in charges being filed and the resident being removed from the facility.
Sexual activity between residents is prohibited.
Provision (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.
In the event a disciplinary sanction results in the isolation of a resident, agencies
shall not deny the resident daily large-muscle exercise or access to any legally
required educational programming or special education services. Residents in
isolation shall receive daily visits from a medical or mental health care clinician.
Residents shall also have access to other programs and work opportunities to the
extent possible.
Disciplinary sanctions, applicable to the offense, are commensurate with the nature
and circumstances of the offense committed; considers resident’s disciplinary
history; considers similar disciplinary history of other residents. The interview with
the Superintendent and review of policy supported there is consideration of mental
disabilities or mental illness contributing to the behavior. PREA related violations
may result in charges filed and the resident transported to a detention facility based
on the circumstances of the incident. Allegations of sexual abuse are referred for an
investigation to the appropriate investigative entities. Isolation is not used as a
disciplinary sanction.
Provision (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.
Disciplinary and other processes consider whether a resident’s mental disabilities or
mental illness contributed to a resident’s behavior regarding the application of
disciplinary measures. The interviews with the Superintendent and mental health
staff were aligned with this provision.
Provision (d):
If the facility offers therapy, counseling, or other interventions designed to address
and correct underlying reasons or motivations for the abuse, the facility shall
consider whether to offer the offending resident participation in such interventions.
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.
Consideration would be given regarding offering a perpetrator intervention services
that are designed to address and correct underlying reasons or motivations for
abuse participation. The facility would not require participation in such interventions
as a condition for participation in the behavior management system or to access
general programming or education. Staff members within the mental health unit are
equipped to develop treatment planning and interventions to address underlying
reasons or motivations for abuse with alleged victims and offending residents.
Provision (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.
Policy provides that a resident may be disciplined for sexual contact with staff only
upon a finding that the staff member did not consent to such contact.
Provision (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.
Any resident reporting in good faith shall be immune from any civil or criminal
liability. A report of sexual abuse made in good faith based on the belief that the
alleged incident occurred does not constitute falsely reporting an incident or lying,
even if an investigation does not establish evidence sufficient to substantiate the
allegation.
Provision (g):
An agency may, in its discretion, prohibit 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.
Policy prohibits any sexual conduct between residents. All such conduct is subject to
disciplinary action as a rule violation. Referrals are made to the investigative
entities and court processes occur after determination the sexual activity was
coerced.
Conclusion:
Based on the available evidence and interviews, the Auditor concluded the facility is
compliant with the standard.
115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
Medical Staff
Mental Health Staff
Provisions (a) and (b):
(a): If the screening pursuant to §115.341 indicates that a resident has experienced
prior sexual victimization, whether it occurred in an institutional setting or in the
community, staff shall ensure that the resident is offered a follow-up meeting with a
medical or mental health practitioner within 14 days of the intake screening. (b): If
the screening pursuant to §115.341 indicates that a resident has previously
perpetrated sexual abuse, whether it occurred in an institutional setting or in the
community, staff shall ensure that the resident is offered a follow-up meeting with a
mental health practitioner within 14 days of the intake screening.
Policy and practice provide that a resident be referred to mental health or medical
staff within 14 days if identified as having been a victim or perpetrator of sexual
abuse. The interviews with clinical staff and review of documents revealed when the
issues are identified upon admission, the documented referral is routinely made the
same day, always well within 14 days, and the resident seen by mental health staff
within 24 hours.
Provision (c):
Any information related to sexual victimization or abusiveness that occurred in an
institutional setting shall be strictly limited to medical and mental health
practitioners and other staff, as necessary, to inform treatment plans and security
and management decisions, including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local law.
Policy supports that no information is to be shared with other staff unless it is
required for security and management decisions regarding sexual abuse history.
Information related to sexual victimization or abusiveness that occurred in an
institutional setting is limited to clinical and treatment staff and to other staff, based
on their need to know, to make effective management decisions. During the onsite
review, the files were observed to be maintained in a secure manner in locked file
cabinets within the locked clinic. The clinic also has a small foyer upon entrance to
the clinic, where the records are not kept. Electronic records are password protected
and the agency has a virtual private network which is also password protected with
limited and identified access. The keys to the clinic are within the key control
system with limited access.
Provision (d):
Medical and mental health practitioners shall obtain informed 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.
Policy addresses informed consent being obtained for residents 18 years or over
prior to clinical personnel reporting information disclosed about prior sexual
victimization that did not occur in an institutional setting. The mental health and
medical staff interviewed expressed an understanding of the use of informed
consent. The use of informed consent will be documented in the case notes or
nurse's notes.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.382 Access to emergency medical and mental health services
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Facility Coordinated Response for Reports of Sexual Abuse
Interviews:
Mental Health Staff
Medical Staff
Provision (a):
Resident victims of sexual abuse shall receive timely, unimpeded 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.
The interviews and policies support the alleged victim will receive timely and
unimpeded access to emergency medical treatment and crisis intervention services.
The interviews were aligned with the the policies including that the nature and
scope of their services are determined according to their professional judgment.
Residents are informed of clinical services and meet with those practitioners and are
provided services during the intake process and throughout their stay in the facility.
An alleged victim will get services within the facility as well as timely services in the
community. An alleged victim will be transported to the local hospital or Nancy J.
Cotterman Center for a forensic medical examination that will be conducted by a
Sexual Assault Nurse Examiner (SANE). The examination will be performed at no
cost to the victim, in accordance with policy, in response to an allegation of sexual
abuse. Observations revealed that medical and mental health staff members
maintain secondary materials and documentation of encounters with residents at
the facility.
Provision (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.
Interviews and the Facility Coordinated Response Plan for Reports of Sexual Abuse
revealed residents have access to unimpeded access to emergency services. The
policies provide guidance to staff in protecting residents and for contacting the
appropriate staff and agencies regarding allegations or incidents of sexual abuse,
including contacting treatment staff and investigative entities.
A review of the documentation; observations of the interactions among residents
and staff during the onsite audit phase; and the interviews indicated unimpeded
medical and crisis intervention services are available to an alleged victim of sexual
abuse. Staff training also prepare staff members to properly report sexual abuse,
protect the alleged victim and notify the appropriate staff and investigative entities.
Provision (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.
Policy, review of documentation and interviews confirmed processes and services
are in place for an alleged victim to receive timely access to sexually transmitted
infection prophylaxis, where medically appropriate. If needed after an incident,
follow-up services may be provided by the facility’s medical and mental health staff
members to provide support, including community services, coordinated by staff as
needed. The standard of care within the facility ensures the appropriate medical and
mental health follow-up as needed and continuity of care.
Provision (d):
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.
The interviews and policies provide that treatment services will be provided to the
victim without financial cost to the victim regardless of whether the victim names
the abuser, or cooperates with any investigation arising out of the incident.
Conclusion:
Based on the evidence reviewed and interviews, the Auditor determined the facility
is compliant with this standard.
Ongoing medical and mental health care for sexual abuse victims
115.383
and abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Agency Policy FDJJ 1919
Interviews:
Medical Staff
Mental Health Staff
Provision (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.
Policy and interviews support that medical and mental health evaluation and
treatment will be offered to resident victims of sexual abuse. Follow-up services will
be provided that include but are not limited to adjustments to mental health
treatment plan; development of a medical treatment plan; increased meetings with
therapists; assessments; and referral services as needed. Health education sessions
are conducted with the residents by nursing staff, unrelated to sexual abuse
allegations.
Provision (b):
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 and documentation of encounters confirm on-going medical and mental
health care will be provided as appropriate and will include but not be limited to
treatment planning; evaluations, and clinical follow-up and referrals as needed.
Specialized treatment may also be provided by clinicians on site and through
contract and referral services. The medical staff manager will ensure the medical
discharge orders are followed.
Provision (c):
The facility shall provide such victims with medical and mental health services
consistent with the community level of care.
Review of policy, interviews and observations during the site review indicated
medical and mental health services are consistent with the community level of care.
Treatment services may be provided by facility staff and contract services if needed.
The interviews and observations during the site review emphasized the treatment
services at the facility are consistent with the community level of care with a variety
of services provided including community resources to address the unique needs of
the juvenile population.
Provision (d):
Resident victims of sexually abusive vaginal penetration while incarcerated shall be
offered pregnancy tests.
The facility has an all male population.
Provision (e):
If pregnancy results from conduct specified in paragraph (d) of this section, such
victims shall receive timely and comprehensive information about and timely access
to all lawful pregnancy-related medical services.
The facility has a male population.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for
sexually transmitted infections as medically appropriate.
The interviews and policy ensure victims of sexual abuse will be provided tests for
sexually transmitted infections (STI) as medically appropriate as confirmed by
medical staff. There were two allegations of sexual abuse during this audit period.
Tests for STIs was not required intervention regarding the circumstances of the two
allegations.
Provision (g):
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.
All treatment services will be provided at no cost to the victim and whether or not
the victim names the abuser of cooperates with the investigation, according to
policy and the interviews.
Provision (h):
The facility shall attempt to conduct a mental health evaluation of 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.
A resident will get a mental health evaluation within 60 days upon staff learning of
resident-on-resident abuse history and offer appropriate treatment in accordance
with the interview with mental health staff. Policy provides for the mental health
evaluation to be conducted within 60 days. Additionally, medical and mental health
evaluations and treatment will be offered to resident victims of sexual abuse.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the facility is compliant with this standard.
115.386 Sexual abuse incident reviews
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interviews:
Incident Review Team Member
Superintendent/PREA Compliance Manager
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion of every
sexual abuse investigation, including where the allegation has not been
substantiated, unless the allegation has been determined to be unfounded.
The facility is required to conduct a sexual abuse incident review at the conclusion
of an investigation, unless the allegation was unfounded. The interviews reflected
an understanding of the role of the incident review team. A review of policies,
documentation and interviews confirmed incident reviews will be conducted
regarding the investigation of an allegation of sexual abuse, unless unfounded and
in accordance with the policy and standard. The statewide PREA Coordinator
facilitates the incident review team meetings. There was one resident-on-resident
allegation of sexual abuse and one staff-on-resident allegation of sexual abuse. The
resident-on-resident allegation was determined as Information Only as the result of
an administrative investigation. The staff-on-resident allegation was determined
unsubstantiated as a result of the administrative investigation. Both cases received
an incident review.
Provision (b):
Such review shall ordinarily occur within 30 days of the conclusion of the
investigation.
Policy requires that the review occurs within 30 days of the conclusion of the
investigation. The interviews confirmed incident reviews will occur. The interviews
revealed knowledge of the purpose of the incident review process and the timeline.
Both incident reviews were beyond the 30-day period due to inclement weather in
the State of Florida. A review of previous incident review meeting minutes indicate
the meetings are held ordinarily within 30 days of the completion of the
investigation.
Provision (c):
The incident review team shall include upper-level management officials, with input
from line supervisors, investigators, and medical or mental health practitioners.
Policy and interviews collectively identify members of the incident review team. The
statewide PREA Coordinator facilitates the incident review team meeting. Members
of the team are identified, in accordance with policy. There will also be input from
line supervisors and other staff as needed. The Department of Juvenile Justice/Office
of Inspector General investigator may also participate in the incident review as
needed. Additional staff members will attend the meeting as needed, related to the
incident.
Provision (d):
The review team shall:
(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.
The policies and interviews collectively outline the requirements of the standard for
the areas to be assessed by the incident review team. The interviews and review of
policies confirmed the incident review team is charged with considering the factors
identified in this standard provision regarding the results of the investigation. The
incident review process is documented and is facilitated by the statewide PREA
Coordinator. The written report may also include any recommendations for
improvement confirmed by the agency's documented practice.
The meeting minutes indicate a meaningful discussion occurred. The meeting
minutes note that appropriate notifications were made after the allegation was
reported. The meeting minutes also stated a risk assessment was administered to
the alleged victim and notes that retaliation monitoring occurs. There were no
recommendations during the meetings for both cases.
Provision (e):
The facility shall implement the recommendations for improvement, or shall
document its reasons for not doing so.
Policy indicates the reasons for not following recommendations will be documented
in accordance with policy. The interviews revealed familiarity with policy
requirements. The incident review process allows for the assessment of the
circumstances surrounding the incident. A format for documenting the incident
review process has been developed by the DJJ statewide PREA Coordinator and
includes recommendations where indicated as determined from a review of
documentation of reports from other facilities. There were no recommendations
during the review team meetings.
Conclusion:
Based upon the review of policy and other documentation and interviews, the
Auditor determined the facility is compliant with this standard.
115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Facility Policy 5-19
Agency Policy FDJJ 1919
Agency Policy FDJJ 2020, Incident Operations Center and Incident Reviews
Agency Data Logs
Interviews:
Superintendent
PREA Coordinator
Provisions (a) & (c):
(a): The agency shall collect accurate, uniform data for every allegation of sexual
abuse at facilities under its direct control using a standardized instrument and set of
definitions. (c): The incident-based data collected shall include, at a minimum, the
data necessary to answer all questions from the most recent version of the Survey
of Sexual Violence conducted by the Department of Justice.
Policies provide for the collection of accurate and uniform data for every allegation
of sexual abuse from incident-based documents. The agency collects the data and
completes an annual report with the compilation of data gleaned from the facilities
through the central reporting system. Agency Policy FDJJ 2020 contains a
standardized set of definitions and provides support for the collection of accurate
and uniform data. The agency maintains incident-based data complete enough to
complete the most recent version of the instrument formerly identified as the
Survey of Sexual Violence and now identified as the Survey of Sexual Victimization.
A request for data has not been received from the Department of Justice (DOJ)
during this audit period.
Provision (b):
The agency shall aggregate the incident-based sexual abuse data at least annually.
The agency aggregates the incident-based, uniform data regarding allegations of
sexual abuse and sexual harassment. The aggregated data contributes to the
development of the annual reports for the agency which is supported by the
reviewed data and policy.
Provision (d):
The agency shall maintain, review, and collect data as needed from all available
incident-based documents, including reports, investigation files, and sexual abuse
incident reviews.
The data is collected and various types of data are identified and related documents
regarding PREA information as applicable. Policy requires that statistical information
is maintained for various service areas and occurrences, including major incidents
and medical and mental health emergencies. The agency collects and maintains
data for state-run and contract facilities and aggregates the data which culminates
into the agency’s annual report.
Provision (e):
The agency also shall obtain incident-based and aggregated data from every private
facility with which it contracts for the confinement of its residents.
The agency collects and maintains data for state-run and contract facilities and
aggregates the data which culminates into the annual report. The data is collected
from the contract facilities and is included in the agency’s annual reports. The data
is aggregated at the agency’s central office level.
Provision (f):
Upon request, the agency shall provide all such data from the previous calendar
year to the Department of Justice no later than June 30.
Upon request, the facility completes all such data from the previous calendar year
and submits to the Department of Justice in a timely manner based on the year of
the most recent version of the Survey of Sexual Victimization. A request has not
been received from DOJ during this audit period.
Conclusion:
Based upon the review and analysis of the documentation and the interviews, the
Auditor determined the facility is compliant with this standard.
115.388 Data review for corrective action
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919
Annual Reports
Interviews:
Superintendent
PREA Coordinators
Agency Head Designee
Provision (a):
The agency shall 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:
(1) Identifying problem areas;
(2) Taking corrective action on an ongoing basis; and
(3) Preparing an annual report of its findings and corrective actions for each facility,
as well as this agency as a whole.
The interviews support the review of data and its use to improve the agency’s PREA
efforts. The interviews and review of documentation revealed the collection of
various types of data, including PREA related information. Data is reviewed to
assess and improve the effectiveness of prevention, detection and response within
the agency as well as individual facilities. The data is also primary to preparing
annual reports.
Provisions (b)-(d):
(b): Such report shall include a comparison of the current year’s data and corrective
actions with those from prior years and shall provide an assessment of the agency’s
progress in addressing sexual abuse. (c): The agency’s report shall be approved by
the agency head and made readily available to the public through its website or, if it
does not have one, through other means. (d): The agency may redact specific
material from the reports when publication would present a clear and specific threat
to the safety and security of a facility, but must indicate the nature of the material
redacted.
The annual report is prepared by the Department of Juvenile Justice statewide PREA
Coordinator for the agency and includes data from all state-run and contract
facilities within the agency. The annual reports are approved by the DJJ agency
head/designee. There are no personal identifiers in the report. The annual report
contains PREA related data that represents previous calendar years allowing for the
comparison of data. The overarching and inclusive annual report for the agency is
posted on the agency’s website, accessible to the public.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the agency is compliant with this standard.
115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy FDJJ 1919, PREA
Agency Policy FDJJ 1316, Records and Information Management Procedures
Annual Reports
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinator
Provisions (a)-(d):
(a): The agency shall ensure that data collected pursuant to §115.387 are securely
retained. (b): The agency shall make all aggregated sexual abuse data, from
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. (c): Before making aggregated sexual abuse data
publicly available, the agency shall remove all personal identifiers. (d): The agency
shall maintain sexual abuse data collected pursuant to §115.387 for at least 10
years after the date of its initial collection unless Federal, State, or local law requires
otherwise.
All data collected is securely stored and maintained for at least 10 years after the
date of collection unless a law requires otherwise, in accordance with agency policy.
Personal identifiers are removed from aggregated data before making the data
publicly available. The annual reports are available to the public through the
Department of Juvenile Justice (DJJ) agency website. A review of the annual report
verified there are no personal identifiers. All facility and agency records such as
medical, mental health, allegations, risk screenings are securely stored in locked
cabinets behind locked doors within the facility's key control system through
assigned and limited access keys. Electronic records are password protected with
identified and limited access on the agency's website. The agency has a virtual
private network website. The DJJ Bureau of Information of Technology provides
hardware and software standards for agency users.
Conclusion:
Based upon the review and analysis of the documentation, interviews and
observations, the Auditor determined the facility is compliant with this standard.
115.401 Frequency and scope of audits
Auditor Overall Determination: Meets Standard
Auditor Discussion
The previous audit was conducted in 2021. The PREA Pre-Audit Questionnaire and
supporting documentation was provided to the Auditor by uploading the information
into the automated online system. The Auditor was provided additional information
by email or onsite, as requested. The Department of Juvenile Justice ensured the
completion of PREA audits for each state-run and contract facility as required,
including this facility.
The site review was led by the facility assistant superintendent; all areas of the
facility where residents go were included. The areas containing posted information
were observed, including the areas where group and private visitation occur. The
Superintendent, Assistant Facility Administrator, facility management and other
staff were cooperative in providing information and participating in or assisting in
coordinating the interviews.
All interviews were conducted in private onsite and privacy was ensured for those
supervisors and managers interviewed by telephone due to accommodating
Hurricane Milton. The PREA notices provided the general information and included
instructions and Auditor contact information regarding how to provide confidential
information to the Auditor. The facility has a process in place for confidential
correspondence for the residents however no correspondence was received by the
Auditor from residents or staff. Additionally, no PREA related information was
received by a contractor, volunteer or community stakeholder.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Annual Reports
Interviews:
Superintendent
Statewide PREA Coordinator
Provision (f):
The agency shall ensure that the auditor’s final report is published on the agency’s
website if it has one, or is otherwise made readily available to the public.
The posted PREA reports do not contain any personal identifying information other
than names and job titles in the general information sections. The facility and
agency policies and additional documentation, practices and interviews with the
Superintendent, Assistant Superintendent and other staff were reviewed regarding
compliance with the standards and have been identified in the reports. The
interview with the Superintendent and communication with the statewide PREA
Coordinator confirm the final audit reports are posted on the agency website.
The audit findings were based on a review of policies, procedures, supporting
documentation, observations, and interviews. There were no conflicts of interest
regarding the completion of this audit. This report does not contain any personal
identifying information other than names and job titles of facility and agency
management and leadership staff.
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, yes
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 yes
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 yes
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 yes
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 yes
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 yes
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 yes
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 yes
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 no
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 yes
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, yes
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 na
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 § na
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 na
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 na
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 yes
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

file_name: Florida_Broward Youth Treatment Center_Year3Cycle4.pdf

program_name_raw: Broward Youth Treatment Center