facility_name: centralpascogirls

summary: PREA

raw_content:
Prison Rape Elimination Act (PREA) Audit Report
Juvenile Facilities
☐ ☒
Interim Final
Date of Report January 14, 2018
Auditor Information
Name: Shirley L. Turner Email: shirleyturner3199@comcast.net
Company Name: Correctional Management and Communications Group
Mailing Address: 3199 Kings Bay Circle City, State, Zip: Decatur, GA 30034
Telephone: 678-895-2829 Date of Facility Visit: December 3-4, 2017
Agency Information
Name of Agency Governing Authority or Parent Agency (If Applicable)
TrueCore Behavioral Solutions, LLC
Physical Address: 6302 Benjamin Road City, State, Zip: Tampa, FL 33634
Mailing Address: City, State, Zip:
Telephone: 813-514-6275 Is Agency accredited by any organization? ☐ Yes ☒ No
The Agency Is: ☐ ☒ ☐
Military Private for Profit Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Agency mission: Helping the children in our care overcome their obstacles and discover the true
potential that lies within them.
Agency Website with PREA Information: www. djj.state.fl.us/partners/prison-rape-elimination-act-(prea)
Agency Chief Executive Officer
Name: Martin Favis Title: Chief Executive Officer
Email: martin.favis@truecorebehavioral.com Telephone: 813-514-6275
Agency-Wide PREA Coordinator
Name: Bobbi Pohlman-Rodgers Title: JJDPA/PREA Compliance Director
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Email: bobbi.pohlman@truecorebehavioral.com Telephone: 813-514-6275
PREA Coordinator Reports to: Number of Compliance Managers who report to the
Peter Plant, Sr. Vice President PREA Coordinator 26
Facility Information
Name of Facility: Central Pasco Girls Academy
Physical Address: 2953 Wilson Road, Land O’Lakes, FL 34638
Mailing Address (if different than above):
Telephone Number: 813-909-7800
The Facility Is: ☐ ☒ ☐
Military Private for Profit Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Facility Type: ☐ ☒ ☐ ☒
Detention Correction Intake Other
Facility Mission: Helping the children in our care overcome their obstacles and discover the true
potential that lies within them.
Facility Website with PREA Information: www. djj.state.fl.us/partners/prison-rape-elimination-act-(prea)
☐ ☒
Is this facility accredited by any other organization? Yes No
Facility Administrator/Superintendent
Name: Christina Roberts Title: Facility Administrator
Email: Telephone: 813-476-3319
christina.roberts@truecorebehavioral.com
Facility PREA Compliance Manager
Name: Christina Roberts Title: Facility Administrator
Email: Telephone: 813-476-3319
christina.roberts@truecorebehavioral.com
Facility Health Service Administrator
Name: Vanessa Speight Title: Regional Health Services Administrator
Email: Telephone: 813-618-6552
vanessa.speight@truecorebehavioral
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Facility Characteristics
Designated Facility Capacity: 32 Current Population of Facility: 28
Number of residents admitted to facility during the past 12 months 51
Number of residents admitted to facility during the past 12 months whose length of stay in 51
the facility was for 10 days or more:
Number of residents admitted to facility during the past 12 months whose length of stay in 51
the facility was for 72 hours or more:
Number of residents on date of audit who were admitted to facility prior to August 20, 0
2012:
Age Range of 13-18
Population:
Average length of stay or time under supervision: 7 Months
Facility Security Level: Non-Secure
Resident Custody Levels: Moderate
Number of staff currently employed by the facility who may have contact with residents: 31
Number of staff hired by the facility during the past 12 months who may have contact with 18
residents:
Number of contracts in the past 12 months for services with contractors who may have 6
contact with residents:
Physical Plant
Number of Buildings: 5 Number of Single Cell Housing Units: 0
Number of Multiple Occupancy Cell Housing Units: 2
Number of Open Bay/Dorm Housing Units: 0
Number of Segregation Cells (Administrative and 1
Disciplinary:
Description of any video or electronic monitoring technology (including any relevant information about where
cameras are placed, where the control room is, retention of video, etc.): The control room is located in the front of
the main building and contains monitors. The Facility Administrator can monitor the cameras from her laptop computer
and the Assistant Facility Administrator can also view the cameras from her desktop computer. Four cameras have been
added to the administration building and two at the back of each housing unit since the last PREA audit. The facility has a
total of 26 cameras.
Medical
Type of Medical Facility: Medical Clinic Onsite
Forensic sexual assault medical exams are conducted Crisis Center of Tampa Bay
at:
Other
Number of volunteers and individual contractors, who may have contact with residents, 29
currently authorized to enter the facility:
Number of investigators the agency currently employs to investigate allegations of 0
sexual abuse:
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Audit Findings
Audit Narrative
The auditor’s description of the audit methodology should include a detailed description of the following
processes during the pre-onsite audit, onsite audit, and post-audit phases: documents and files reviewed,
discussions and types of interviews conducted, number of days spent on-site, observations made during the
site-review, and a detailed description of any follow-up work conducted during the post-audit phase. The
narrative should describe the techniques the auditor used to sample documentation and select interviewees,
and the auditor’s process for the site review.
The Central Pasco Girls Academy is a 32-bed facility for female juvenile offenders and provides intensive
mental health treatment services, as well as cognitive behavioral treatment. The facility is located in Land
O’Lakes, Florida and the average length of stay is seven months. The program is operated by TrueCore
Behavioral Solutions, LLC through a contract with the Florida Department of Juvenile Justice (FDJJ). The
facility received its first PREA audit in 2014.
During this cycle, the audit was conducted through the Correctional Management and Communications
Group, LLC. In preparation for the onsite portion of the audit, a conference call was held with the Facility
Administrator who also serves as the PREA Compliance Manager and the FDJJ statewide PREA
Coordinator. The conference call included introductions and a review of the audit process and data
gathering. A printed sign announcing the audit which contained the Auditor’s contact information were sent
to the FDJJ PREA Coordinator who forwarded it to the facility for posting. Announcement notices were
subsequently posted in conspicuous areas of the facility and pictures were taken and sent to the Auditor via
email. The areas of the postings were identified and accessible to residents, staff and visitors.
The PREA Pre-Audit Questionnaire, policies, and supporting documentation were uploaded to a flash drive
and mailed to the Auditor. After an assessment of the information provided, a written review was sent to the
Facility Administrator/PREA Compliance Manager, requesting additional documents and clarification of
information. The additional documentation was provided onsite. There was communication with the Facility
Administrator during the document review process prior to the site visit.
The site visit was conducted December 3-4, 2017. A comprehensive tour was conducted by the Facility
Administrator and included all areas of the facility and outside grounds. During the comprehensive facility
tour, the printed notifications of the PREA site visit were observed to be posted in the areas previously
identified with the pictures sent earlier to the Auditor. Posted signs were also observed regarding general
PREA information; victim advocacy; and the abuse reporting hotline number. During the tour and beyond,
residents were observed in recreation, leisure and education activities with direct supervision being provided
by staff. The PREA staff ratio was observed to be met during these times.
A total of 11 residents were interviewed, including residents from both living units. Twelve specialized staff
interviews were conducted and included a contractor. Ten direct care staff members were interviewed,
covering all shifts, based on the size of the facility and the staffing schedule. The interviews with staff
members, residents, and contractor indicated the receipt of PREA training which was also verified by a
review of documentation. Secondary documentation was reviewed onsite and included but was not limited to
various forms; staff background checks; risk and other screening instruments; education and training
acknowledgement forms; training records; logbooks; and other documentation.
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Upon completion of all interviews and the site visit process, an exit conference was held with the Facility
Administrator. She was provided the opportunity to ask additional questions about the PREA audit process
and the timelines for the submission of the PREA reports were reviewed.
Facility Characteristics
The auditor’s description of the audited facility should include details about the facility type, demographics
and size of the inmate, resident or detainee population, numbers and type of staff positions, configuration
and layout of the facility, numbers of housing units, description of housing units including any special
housing units, a description of programs and services, including food service and recreation. The auditor
should describe how these details are relevant to PREA implementation and compliance.
The Central Pasco Girls Academy is a non-secure residential commitment program. The residents receive
individual, group, and family therapy, as well as testing and psychiatric evaluation services. The program
provides gender-responsive services utilizing a specific curriculum tailored to the unique needs of the
population served. An individualized treatment plan is developed with each resident and goals are identified.
Gender-specific treatment areas address sexual abuse, substance abuse, domestic violence, trauma, and
crime specific topics. The average length of stay is seven months and depends upon the resident’s pace of
success in completing her individualized treatment plan and goals. Education services are provided by the
Pasco County School District and include English; Mathematics; Science; Social Studies; Reading; and one
elective course.
Each resident receives case management services and is assigned a Therapist. Court sanctions may be
completed by residents while they are in the program. All court sanctions are identified at intake and are
incorporated into the resident’s treatment plan. Court sanctions include: community service hours which
may include dietary chores and housekeeping; apology letters/essays that a resident may complete to the
victim; and assistance may be provided by staff in planning for the payment of restitution upon release. The
resident’s court and parents are informed of the resident’s progress in the program through periodic
submission of reports from the Case Manager.
Mental health services are provided onsite by the Clinical Director and four full-time Therapists. A
psychologist and psychiatrist visit the facility weekly. Supportive mental health services are provided as
scheduled and as needed by a contract Licensed Mental Health Counselor and a contract Licensed Clinical
Social Worker. The Health Services Administrator and a full-time Nurse provide medical services with
assistance from one part-time Nurse and as needed by one additional Nurse. A physician visits the facility
weekly. The Director of Case Management and Case Manager perform duties in collaboration with all
disciplines regarding the planning, facilitation and coordination of services in efforts to meet the
comprehensive needs of the residents. Direct care staff members are responsible for the supervision of the
residents and manage the residents during their daily activities. The comprehensive tour of the facility
revealed staff members provide direct supervision of the residents.
The campus consists of five buildings including administration; two education buildings; medical;
maintenance; and the main building which contains housing units, cafeteria and small control room
surrounded by a perimeter fence. Visitors to the facility check in the main building at the outside window of
the control room. The administration building contains offices of the administrators, human resources and
treatment staff and has a conference room.
There are two housing units located in the main building with four rooms on each unit, housing four females
per room. Residents are provided a reasonable amount of privacy when they shower, change clothes and
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use the toilet. Each living unit has a dayroom area. Attached to the medical building is an area used as the
library and for conducting groups and treatment team and other meetings.
During the tour, PREA notices, advocacy agency information, and signs for males to announce their
presence when entering the housing units were observed posted. A basketball court is located on the
outside grounds and there is ample space for other activities.
Summary of Audit Findings
The summary should include the number of standards exceeded, number of standards met, and number of
standards not met, along with a list of each of the standards in each category. If relevant, provide a
summarized description of the corrective action plan, including deficiencies observed, recommendations
made, actions taken by the agency, relevant timelines, and methods used by the auditor to reassess
compliance.
Auditor Note: No standard should be found to be “Not Applicable” or “NA”. A compliance determination
must be made for each standard.
Number of Standards Exceeded: 0
Click or tap here to enter text.
Number of Standards Met: 41
Click or tap here to enter text.
Number of Standards Not Met: 0
Click or tap here to enter text.
Summary of Corrective Action (if any)
Corrective actions are discussed in standards 115.332 and 115.351.
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PREVENTION PLANNING
Standard 115.311: Zero tolerance of sexual abuse and sexual harassment;
PREA coordinator
All Yes/No Questions Must Be Answered by The Auditor to Complete the Report
115.311 (a)
▪ Does the agency have a written policy mandating zero tolerance toward all forms of sexual
abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the written policy outline the agency’s approach to preventing, detecting, and responding
to sexual abuse and sexual harassment? ☒ Yes ☐ No
115.311 (b)
▪ Has the agency employed or designated an agency-wide PREA Coordinator? ☒ Yes ☐ No
▪ Is the PREA Coordinator position in the upper-level of the agency hierarchy? ☒ Yes ☐ No
▪ Does the PREA Coordinator have sufficient time and authority to develop, implement, and
oversee agency efforts to comply with the PREA standards in all of its facilities? ☒ Yes ☐ No
115.311 (c)
▪ If this agency operates more than one facility, has each facility designated a PREA compliance
manager? (N/A if agency operates only one facility.) ☒ Yes ☐ No ☐ NA
▪ Does the PREA compliance manager have sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards? (N/A if agency operates only one facility.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
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The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The methods for sustaining zero-tolerance regarding all forms of sexual abuse and sexual harassment
are found in facility Policy 10-25, Prison Rape Elimination Act, PREA. It outlines the approach for
preventing, detecting, and responding to allegations of sexual abuse and sexual harassment.
Additionally, the Florida Department of Juvenile Justice Policy 1919 (FDJJ 1919) serves as the
supportive policy for the contract facilities.
The policies outline the strategies for addressing the components of the PREA Standards and include
prevention and responsive planning; training and education; risk screening; reporting; official response
following a resident report; investigations; discipline; medical and mental health care; and data
collection and review. Both policies also contain definitions of the prohibited behaviors and address
sanctions to be used when the PREA related policies are violated.
The Facility Administrator serves as the PREA Compliance Manager and indicated during the interview,
she has the time and authority required to fulfill PREA related duties. A review of facility Policy 10-25
and the organizational chart verified the role of the Facility Administrator as the PREA Compliance
Manager. Interviews conducted with all staff revealed their awareness of the role of the PREA
Compliance Manager. The Facility Administrator discussed in the interview the facility’s efforts towards
achieving compliance.
Standard 115.312: Contracting with other entities for the confinement of
residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.312 (a)
▪ If this agency is public and it contracts for the confinement of its 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.) ☐ Yes ☐ No ☒ NA
115.312 (b)
▪ Does any new contract or contract renewal signed on or after 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".) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
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☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The facility does not contract with other facilities for the confinement of its residents.
Standard 115.313: Supervision and monitoring
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.313 (a)
▪ Does the agency ensure that each facility has developed a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility has implemented a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility has documented a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into 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? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into 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?
☒ Yes ☐ No
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▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
judicial findings of inadequacy? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into 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? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into 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? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into 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)? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: The
composition of the resident population? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: The
number and placement of supervisory staff? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring:
Institution programs occurring on a particular shift? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into 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? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
other relevant factors? ☒ Yes ☐ No
115.313 (b)
▪ Does the agency comply with the staffing plan except during limited and discrete exigent
circumstances? ☒ Yes ☐ No
▪ In circumstances where the staffing plan is not complied with, does the facility document all
deviations from the plan? (N/A if no deviations from staffing plan.) ☐ Yes ☐ No ☒ NA
115.313 (c)
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▪ Does the facility maintain staff ratios of a minimum of 1:8 during resident waking hours, except
during limited and discrete exigent circumstances? (N/A only until October 1, 2017.)
☒ Yes ☐ No ☐ NA
▪ Does the facility maintain staff ratios of a minimum of 1:16 during resident sleeping hours,
except during limited and discrete exigent circumstances? (N/A only until October 1, 2017.)
☒ Yes ☐ No ☐ NA
▪ Does the facility fully document any limited and discrete exigent circumstances during which the
facility did not maintain staff ratios? (N/A only until October 1, 2017.) ☒ Yes ☐ No ☐ NA
▪ Does the facility ensure only security staff are included when calculating these ratios? (N/A only
until October 1, 2017.) ☒ Yes ☐ No ☐ NA
▪ Is the facility obligated by law, regulation, or judicial consent decree to maintain the staffing
ratios set forth in this paragraph? ☐ Yes ☒ No
115.313 (d)
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed,
determined, and documented whether adjustments are needed to: The staffing plan established
pursuant to paragraph (a) of this section? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator,
assessed, determined, and documented whether adjustments are needed to: Prevailing staffing
patterns? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator,
assessed, determined, and documented whether adjustments are needed to: The facility’s
deployment of video monitoring systems and other monitoring technologies? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the 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? ☒ Yes ☐ No
115.313 (e)
▪ Has the facility implemented 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? (N/A for non-secure facilities) ☒ Yes ☐ No ☐ NA
▪ Is this policy and practice implemented for night shifts as well as day shifts? (N/A for non-secure
facilities) ☒ Yes ☐ No ☐ NA
▪ Does the facility have a policy prohibiting 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? (N/A for non-secure facilities) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
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☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 addresses staffing, supervision, monitoring, and unannounced rounds. The Policy
outlines the considerations for staffing and provides guidance to staff in adhering to the staffing ratios of
the contract which provide for more staff during the waking hours and the sleeping hours. The work
schedules and observations during the comprehensive facility tour revealed the adherence to the PREA
staffing ratios of 1:8 during the waking hours and 1:16 during the sleeping hours. The staffing plan
provides for the PREA staffing ratios to be met and a hold-over system of direct care staff ensures
adherence to the staffing plan. The interview with the Facility Administrator indicated her awareness of
the factors to consider for ensuring adequate staff coverage.
The annual Staffing Plan Assessment was completed on May 13, 2017 by the FDJJ statewide PREA
Coordinator in conjunction with the Facility Administrator and includes but is not limited to a review of
the following: staffing plan; monitoring system; resources available and committed to ensure adherence
to the staffing plan; and the occurrence of unannounced rounds. The form summarizes the review and
contained the recommendation for male staff to be identified on the work schedules. PREA information
was observed posted throughout the facility.
The documentation reviewed, including the annual Staffing Plan Assessment, interview with Facility
Administrator; indicated the facility complies with the PREA staffing ratios. The facility policy and FDJJ
1919 provide for compliance to the staffing plan except during limited and exigent circumstances and
the deviations be documented. The facility reports there were no deviations from the staffing plan and
this was also documented on the Staffing Plan Assessment.
Unannounced rounds are conducted and are documented in the logbook. A review of a sample of
documented unannounced rounds and the Policies support unannounced rounds are conducted by
intermediate level and higher level staff. The unannounced rounds are conducted to identify and deter
sexual abuse and sexual harassment. The Assistant Facility Administrator, interviewed for conducting
unannounced, ensures staff members do not alert other staff members regarding the visits.
Standard 115.315: Limits to cross-gender viewing and searches
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
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115.315 (a)
▪ Does the facility always refrain from conducting any cross-gender strip or cross-gender visual
body cavity searches, except in exigent circumstances or by medical practitioners?
☒ Yes ☐ No
115.315 (b)
▪ Does the facility always refrain from conducting cross-gender pat-down searches in non-exigent
circumstances? ☒ Yes ☐ No ☐ NA
115.315 (c)
▪ Does the facility document and justify all cross-gender strip searches and cross-gender visual
body cavity searches? ☒ Yes ☐ No
▪ Does the facility document all cross-gender pat-down searches? ☒ Yes ☐ No
115.315 (d)
▪ Does the facility 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? ☒ Yes ☐ No
▪ Does the facility require staff of the opposite gender to announce their presence when entering
a resident housing unit? ☒ Yes ☐ No
▪ In facilities (such as group homes) that do not contain discrete 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) ☒ Yes ☐ No ☐ NA
115.315 (e)
▪ Does the facility always refrain from searching or physically examining transgender or intersex
residents for the sole purpose of determining the resident’s genital status? ☒ Yes ☐ No
▪ If a resident’s genital status is unknown, does the facility determine genital status during
conversations with the resident, by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted in private by a medical practitioner?
☒ Yes ☐ No
115.315 (f)
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▪ Does the facility/agency train security staff in how to conduct cross-gender pat down searches
in a professional and respectful manner, and in the least intrusive manner possible, consistent
with security needs? ☒ Yes ☐ No
▪ Does the facility/agency train security staff in how to conduct searches of transgender and
intersex residents in a professional and respectful manner, and in the least intrusive manner
possible, consistent with security needs? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 10-25 and 10-3 address the type of searches to be conducted. Cross-gender strip and
cross-gender visual body cavity searches are prohibited at the facility. Cross-gender pat-down
searches are not permitted, except in exigent circumstances. The interviews with direct care staff
members, residents and Facility Administrator support the premise cross-gender searches are not
conducted. All random staff interviewed and the Facility Administrator stated cross-gender searches are
prohibited.
Conducting searches was a part of the 2017 Annual Training Plan. The random staff has received
training regarding searches of transgender and intersex residents as indicated through interviews with
staff and the Facility Administrator. The interviews also indicated staff’s familiarity with the facility policy
prohibiting staff from searching or physically examining a transgender or intersex resident 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 reports cross-gender searches and searches of transgender or
intersex youth have not been conducted during this audit period.
The facility has implemented procedures, guiding staff and ensuring residents are able to shower,
change clothes and perform bodily functions without being viewed by staff of the opposite gender.
Direct care staff and resident interviews, observations, and policy and procedures confirmed the
practice for residents being provided reasonable privacy as they perform bodily functions and change
clothes. Facility Policy 10-25, posted signs, and staff and resident interviews confirmed males
announce their presence upon entering the dorms.
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Standard 115.316: Residents with disabilities and residents who are limited
English proficient
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.316 (a)
▪ Does the agency take appropriate steps to ensure that residents 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? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents 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? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents 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? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents 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? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents 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? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents 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.) ☒ Yes ☐ No
▪ Do such steps include, when necessary, ensuring effective communication with residents who
are deaf or hard of hearing? ☒ Yes ☐ No
▪ Do such steps include, when necessary, providing access to interpreters who can interpret
effectively, accurately, and impartially, both receptively and expressively, using any necessary
specialized vocabulary? ☒ Yes ☐ No
▪ Does the agency 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? ☒ Yes ☐ No
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▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Have
limited reading skills? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Are
blind or have low vision? ☒ Yes ☐ No
115.316 (b)
▪ Does the agency 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? ☐ Yes ☐ No
▪ Do these steps include providing interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any necessary specialized vocabulary?
☐ Yes ☐ No
115.316 (c)
▪ Does the agency always refrain from relying 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?
☐ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 9-2, Classification and Orientation, and FDJJ 1919 address the provision of
accommodations for disabled residents. The facility staff has access to resources to access interpreters
and other support services, including services for the hearing impaired, intellectual disabilities, and
based on the individual need of the resident. The Director of Case Management is responsible for
securing the services needed which may include the assistance of facility staff and providing a resident
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a copy of the information in the dominant language other than English. The facility has access to PREA
brochures in various languages. In addition to English, PREA information was posted in the cafeteria
and housing areas in Spanish and Creole. Resources available to the facility include Registered Court
Interpreters for the Florida State Court System and internal interpreting staff within the TrueCore
agency.
The facility Policy provides residents with disabilities and who are limited English proficient be provided
with the support services that would enable the identified residents to participate in or benefit from all
aspects of the PREA education sessions with the goal of preventing, detecting, and responding to
sexual abuse and sexual harassment. The direct care staff interviews revealed no use of resident
interpreters, resident readers or any type of resident assistants for the provision of PREA information
during the past 12 months. The resident handbook contains information regarding reporting allegations
of sexual abuse and sexual harassment.
Standard 115.317: Hiring and promotion decisions
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.317 (a)
▪ Does the agency prohibit the hiring or promotion of anyone 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)? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone 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? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who: Has been civilly or administratively adjudicated to have engaged in the activity
described in the question immediately above? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any 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)?
☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any 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? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact
with residents who: Has been civilly or administratively adjudicated to have engaged in the
activity described in the question immediately above? ☒ Yes ☐ No
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115.317 (b)
▪ Does the agency 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? ☒ Yes ☐ No
115.317 (c)
▪ Before hiring new employees, who may have contact with residents, does the agency: Perform
a criminal background records check? ☒ Yes ☐ No
▪ Before hiring new employees, who may have contact with residents, does the agency: Consult
any child abuse registry maintained by the State or locality in which the employee would work?
☒ Yes ☐ No
▪ Before hiring new employees, who may have contact with 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? ☒ Yes ☐ No
115.317 (d)
▪ Does the agency perform a criminal background records check before enlisting the services of
any contractor who may have contact with residents? ☒ Yes ☐ No
▪ Does the agency consult applicable child abuse registries before enlisting the services of any
contractor who may have contact with residents? ☒ Yes ☐ No
115.317 (e)
▪ Does the agency 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? ☒ Yes ☐ No
115.317 (f)
▪ Does the agency 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? ☒ Yes ☐ No
▪ Does the agency ask all applicants and employees who may have 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? ☒ Yes ☐ No
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▪ Does the agency impose upon employees a continuing affirmative duty to disclose any such
misconduct? ☒ Yes ☐ No
115.317 (g)
▪ Does the agency consider material omissions regarding such misconduct, or the provision of
materially false information, grounds for termination? ☒ Yes ☐ No
115.317 (h)
▪ Unless prohibited by law, does the agency 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? (N/A if providing
information on substantiated allegations of sexual abuse or sexual harassment involving a
former employee is prohibited by law.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 3-16, Employee Recruitment and Selection; FDJJ 1800 and FDJJ 1919 address this
standard. The Policies afford guidance regarding hiring and promotion processes, hiring decisions and
background checks. A review of the Policies and the interview with Human Resources/Administrative
Assistant provided details about the hiring process, completion of background checks, and the grounds
for termination. The interview and a review of documentation supported the policy requirement of all
employees having a background check completed every five years.
All staff members have a continuing duty to report related misconduct as indicated in the Employee
Handbook and confirmed by the Administrative Assistant. Staff members are also aware that omissions
of such conduct or providing false information will be grounds for termination.
Completion of a pre-hire form obtains information from applicants regarding previously related sexual
misconduct allegations and convictions as reviewed by the Auditor and explained by the Administrative
Assistant. The Policies prohibit hiring or promoting anyone or enlisting contract services of anyone who
may have contact with residents who has engaged in previous sexual misconduct. The interview and
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review of a sample of personnel files confirmed the facility considers any incidents of sexual abuse or
sexual harassment in determining whether to hire a person, contract for services, or promote an
employee.
Standard 115.318: Upgrades to facilities and technologies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.318 (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?
(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.)
☐ Yes ☐ No ☒ NA
115.318 (b)
▪ If the agency installed or updated a video monitoring system, 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.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The camera system supplements direct supervision provided to residents by staff. Since the last PREA
audit in 2014, four cameras were added to the administration building and one camera on the back of
PREA Audit Report Page 20 of 80 Facility Name – double click to change
the hallway for each housing unit. The placement of the additional cameras were explained by the
Facility Administrator and pointed out during the comprehensive tour of the facility. There has not been
a significant expansion of the physical structure since the last PREA audit.
RESPONSIVE PLANNING
Standard 115.321: Evidence protocol and forensic medical examinations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.321 (a)
▪ If the agency is responsible for investigating allegations of sexual 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.)
☐ Yes ☐ No ☒ NA
115.321 (b)
▪ Is this protocol developmentally appropriate for youth where applicable? (N/A if the
agency/facility is not responsible for conducting any form of criminal OR administrative sexual
abuse investigations.) ☐ Yes ☐ No ☒ NA
▪ Is this protocol, as appropriate, 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? (N/A if the agency/facility is
not responsible for conducting any form of criminal OR administrative sexual abuse
investigations.) ☐ Yes ☐ No ☒ NA
115.321 (c)
▪ Does the agency 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? ☒ Yes ☐ No
▪ Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual
Assault Nurse Examiners (SANEs) where possible? ☒ Yes ☐ No
▪ If SAFEs or SANEs cannot be made available, is the examination performed by other qualified
medical practitioners (they must have been specifically trained to conduct sexual assault
forensic exams)? ☒ Yes ☐ No
▪ Has the agency documented its efforts to provide SAFEs or SANEs? ☒ Yes ☐ No
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115.321 (d)
▪ Does the agency attempt to make available to the victim a victim advocate from a rape crisis
center? ☒ Yes ☐ No
▪ If a rape crisis center is not available to provide victim advocate 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? ☒ Yes ☐ No
▪ Has the agency documented its efforts to secure services from rape crisis centers?
☒ Yes ☐ No
115.321 (e)
▪ As requested by the victim, does the victim advocate, qualified agency staff member, or
qualified community-based organization staff member accompany and support the victim
through the forensic medical examination process and investigatory interviews? ☒ Yes ☐ No
▪ As requested by the victim, does this person provide emotional support, crisis intervention,
information, and referrals? ☒ Yes ☐ No
115.321 (f)
▪ If the agency itself is not responsible for investigating allegations 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/facility is responsible for conducting criminal AND
administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA
115.321 (g)
▪ Auditor is not required to audit this provision.
115.321 (h)
▪ If the agency uses a qualified agency staff member or a qualified 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.) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
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☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919 and staff interviews confirmed facility staff members are not
responsible for conducting administrative or criminal investigations. Facility Policy 10-25 and FDJJ
1919 state the Florida Department of Juvenile Justice Office of the Inspector General (OIG) is
responsible for conducting administrative investigations; the Florida Department of Children and
Families (DCF) is responsible for conducting allegations of child abuse; and local law enforcement is
responsible for conducting criminal investigations. The Facility Administrator serves as the contact
person with the law enforcement agency, OIG and DCF.
The OIG provides each facility written information regarding PREA related investigations and
comprehensive uniform evidence protocols developed after 2011 that is to be shared with their local
law enforcement agency who investigate allegations that are criminal in nature. Documentation, Prison
Rape Elimination Act Agreement, was reviewed demonstrating the continued services of the provision
of victim advocacy services by the Crisis Center of Tampa Bay and at no cost to the victim. There has
not been a situation requiring a forensic examination during this audit period.
Standard 115.322: Policies to ensure referrals of allegations for
investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.322 (a)
▪ Does the agency ensure an administrative or criminal investigation is completed for all
allegations of sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure an administrative or criminal investigation is completed for all
allegations of sexual harassment? ☒ Yes ☐ No
115.322 (b)
▪ Does the agency have a policy and practice in place 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? ☒ Yes ☐ No
▪ Has the agency published such policy on its website or, if it does not have one, made the policy
available through other means? ☒ Yes ☐ No
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▪ Does the agency document all such referrals? ☒ Yes ☐ No
115.322 (c)
▪ If a separate entity is responsible for conducting criminal 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).]
☒ Yes ☐ No ☐ NA
115.322 (d)
▪ Auditor is not required to audit this provision.
115.322 (e)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919, interviews with staff and Facility Administrator ensure allegations
of sexual abuse and sexual harassment are investigated. Administrative investigations are conducted
by the FDJJ Office of Inspector General (OIG) trained investigators and sexual abuse allegations are
referred for an investigation to local law enforcement and the Florida Department of Children and
Families is also contacted.
Collectively, the Policies direct staff to report all allegations of sexual abuse and sexual harassment and
to document the reports. Staff members are aware of the Policy requirements as verified through
interviews and a review of documentation. During the past 12 months five allegations were received
and all were reported by the facility as required. Three of the five cases remain open and are being
investigated by the FDJJ OIG; one case was closed by law enforcement and no criminal actions were
taken and also closed by FDJJ OIG as Information Only; and one case was determined unfounded.
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The FDJJ website provides the information and policy for reporting allegations of sexual abuse and
reporting information is also posted in various areas of the facility, accessible to residents, staff,
contractors, volunteers, and visitors.
TRAINING AND EDUCATION
Standard 115.331: Employee training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.331 (a)
▪ Does the agency train all employees who may have contact with residents on: Its zero-tolerance
policy for sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to fulfill their
responsibilities under agency sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: Residents’ right
to be free from sexual abuse and sexual harassment ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The right of
residents and employees to be free from retaliation for reporting sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The dynamics of
sexual abuse and sexual harassment in juvenile facilities? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The common
reactions of juvenile victims of sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with 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? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to avoid
inappropriate relationships with residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to
communicate effectively and professionally with residents, including lesbian, gay, bisexual,
transgender, intersex, or gender nonconforming residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to comply
with relevant laws related to mandatory reporting of sexual abuse to outside authorities?
☒ Yes ☐ No
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▪ Does the agency train all employees who may have contact with residents on: Relevant laws
regarding the applicable age of consent? ☒ Yes ☐ No
115.331 (b)
▪ Is such training tailored to the unique needs and attributes of residents of juvenile facilities?
☒ Yes ☐ No
▪ Is such training tailored to the gender of the residents at the employee’s facility? ☒ Yes ☐ No
▪ Have employees received additional training if reassigned from a facility that houses only male
residents to a facility that houses only female residents, or vice versa? ☒ Yes ☐ No
115.331 (c)
▪ Have all current employees who may have contact with residents received such training?
☒ Yes ☐ No
▪ Does the agency 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? ☒ Yes ☐ No
▪ In years in which an employee does not receive refresher training, does the agency provide
refresher information on current sexual abuse and sexual harassment policies? ☒ Yes ☐ No
115.331 (d)
▪ Does the agency document, through employee signature or electronic verification, that
employees understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
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Facility Policy 10-25 and FDJJ 1919 address PREA related training for staff. The policies, an array of
training materials, staff interviews, and a review of documented training verify staff training occurs and
address the requirements of the standard. All staff members interviewed were familiar with the PREA
information regarding the primary components of preventing, detecting and responding to sexual abuse
or sexual harassment. Electronic records documenting training through the FDJJ training system,
SkillPro, also exists.
Staff training considers the needs of the population served. Refresher training is provided for staff
annually and when needed, according to training records and staff interviews. The direct care, medical
and mental health staff interviewed reported receiving the PREA training.
Standard 115.332: Volunteer and contractor training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.332 (a)
▪ Has the agency ensured 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? ☒ Yes ☐ No
115.332 (b)
▪ Have all volunteers and contractors who have contact with 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)? ☒ Yes ☐ No
115.332 (c)
▪ Does the agency maintain documentation confirming that volunteers and contractors
understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
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The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25, FDJJ 1919 and review of training records document the training occurs. The
training includes a review of the zero-tolerance strategies regarding sexual abuse and sexual
harassment. The facility has acknowledgement statements for training recipients to sign regarding the
training.
The PREA training informs the participants of their role in reporting allegations of sexual abuse and
sexual harassment. Participants are informed of their responsibilities regarding sexual abuse
prevention, detection, and response to a PREA allegation.
Abuse reporting training is provided to the education staff through the Pasco County School District as
indicated by the interview with a contractor. The Facility Administrator implemented a corrective action
to provide additional training to the education staff specifically regarding the facility’s zero-tolerance
protocols toward sexual abuse and sexual harassment. The Facility administrator submitted signed
and dated acknowledgement statements containing the training information and submitted a document
for each education contractor.
Standard 115.333: Resident education
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.333 (a)
▪ During intake, do residents receive information explaining the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ During intake, do residents receive information explaining how to report incidents or suspicions
of sexual abuse or sexual harassment? ☒ Yes ☐ No
▪ Is this information presented in an age-appropriate fashion? ☒ Yes ☐ No
115.333 (b)
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Their rights to be free from sexual abuse
and sexual harassment? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Their rights to be free from retaliation for
reporting such incidents? ☒ Yes ☐ No
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▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Agency policies and procedures for
responding to such incidents? ☒ Yes ☐ No
115.333 (c)
▪ Have all residents received such education? ☒ Yes ☐ No
▪ Do residents 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?
☒ Yes ☐ No
115.333 (d)
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are limited English proficient? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are deaf? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are visually impaired? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are otherwise disabled? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Have limited reading skills? ☒ Yes ☐ No
115.333 (e)
▪ Does the agency maintain documentation of resident participation in these education sessions?
☒ Yes ☐ No
115.333 (f)
▪ In addition to providing such education, does the agency ensure that key information is
continuously and readily available or visible to residents through posters, resident handbooks,
or other written formats? ☐ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
PREA Audit Report Page 29 of 80 Facility Name – double click to change
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facilities Policies 9-2, Classification and Orientation, and 10-25 and FDJJ 1919 collectively ensure all
residents admitted receive general and PREA information. PREA education involves directions to
residents about how to report allegations of sexual abuse and sexual harassment; and the right to be
free from retaliation for reporting. The resident handbook provides information to residents on how to
report allegations of sexual harassment and sexual abuse.
PREA education sessions are conducted by case management staff during the intake process. The
Case Manager described the process for ensuring residents receive the information, including the
resident signing a form designated to acknowledge receipt of the training. Interviews with the Case
Manager and residents indicated PREA education sessions occur. The residents were aware of their
PREA related rights, how to report allegations of sexual abuse and sexual harassment, and they would
not be punished for reporting such. The facility refresher training for the residents is provided as
needed. The PREA related information is provided to staff in policies, training and staff meetings.
The facility has the capability of providing the PREA education in formats accessible to all residents
including those who may be limited English proficient; deaf; visually impaired, or otherwise disabled,
and to residents who have limited reading skills. The Pasco County School District may provide
services for identified disabled residents and interpreters, in addition to facility and agency staff. The
facility has the PREA related information posted in the housing units and other areas accessible to
residents, staff, visitors, contractors and volunteers. The PREA information is posted in various
languages in the cafeteria. Staff interviews confirmed residents are not used as translators or readers
for other residents.
Standard 115.334: Specialized training: Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.334 (a)
▪ In addition to the general training provided to all employees 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).] ☐ Yes ☐ No ☒ NA
115.334 (b)
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▪ Does this specialized training include: Techniques for interviewing 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).] ☐ Yes ☐ No ☒ NA
▪ Does this specialized training include: Proper use of Miranda and Garrity warnings? [N/A if the
agency does not conduct any form of administrative or criminal sexual abuse investigations.
See 115.321(a).] ☐ Yes ☐ No ☒ NA
▪ Does this specialized training include: Sexual abuse evidence 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).] ☐ Yes ☐ No ☒ NA
▪ Does this specialized training include: The criteria and evidence 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).] ☐ Yes ☐ No ☒ NA
115.334 (c)
▪ Does the agency maintain documentation that agency 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).]
☐ Yes ☐ No ☒ NA
115.334 (d)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The facility does not conduct administrative or criminal investigations.
PREA Audit Report Page 31 of 80 Facility Name – double click to change
Standard 115.335: Specialized training: Medical and mental health care
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.335 (a)
▪ Does the agency ensure that all full- and part-time medical and 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? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How to preserve physical evidence of
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and 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? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and 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? ☒ Yes ☐ No
115.335 (b)
▪ If medical staff employed by the agency conduct forensic 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.) ☐ Yes ☐ No ☒ NA
115.335 (c)
▪ Does the agency maintain documentation that medical and mental health practitioners have
received the training referenced in this standard either from the agency or elsewhere?
☒ Yes ☐ No
115.335 (d)
▪ Do medical and mental health care practitioners employed by the agency also receive training
mandated for employees by §115.331? ☒ Yes ☐ No
▪ Do medical and mental health care practitioners contracted by and volunteering for the agency
also receive training mandated for contractors and volunteers by §115.332? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
PREA Audit Report Page 32 of 80 Facility Name – double click to change
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919 provide medical and mental health staff members receive the
regular PREA training and the specialized training available online through the SkillPro training system
provided by FDJJ. The mental health and medical staff completed the general training that is provided
for all staff members which is also available through the SkillPro training system. Forensic medical
examinations will not be conducted by the facility medical personnel. The examinations will be
conducted at the Crisis Center of Tampa Bay. A review of the training records and interviews with
medical and mental health staff revealed their completion of the specialized training.
SCREENING FOR RISK OF SEXUAL VICTIMIZATION
AND ABUSIVENESS
Standard 115.341: Screening for risk of victimization and abusiveness
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.341 (a)
▪ Within 72 hours of the resident’s arrival at the facility, does the agency obtain and use
information about each resident’s personal history and behavior to reduce risk of sexual abuse
by or upon a resident? ☒ Yes ☐ No
▪ Does the agency also obtain this information periodically throughout a resident’s confinement?
☒ Yes ☐ No
115.341 (b)
▪ Are all PREA screening assessments conducted using an objective screening instrument?
☒ Yes ☐ No
115.341 (c)
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▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Prior sexual victimization or abusiveness? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does 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? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Current charges and offense history? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Age? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Level of emotional and cognitive development? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Physical size and stature? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Mental illness or mental disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Intellectual or developmental disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Physical disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: The resident’s own perception of vulnerability? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does 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? ☒ Yes ☐ No
115.341 (d)
▪ Is this information ascertained: Through conversations with the resident during the intake
process and medical mental health screenings? ☒ Yes ☐ No
▪ Is this information ascertained: During classification assessments? ☒ Yes ☐ No
▪ Is this information ascertained: By reviewing court records, case files, facility behavioral records,
and other relevant documentation from the resident’s files? ☒ Yes ☐ No
PREA Audit Report Page 34 of 80 Facility Name – double click to change
115.341 (e)
▪ Has the agency implemented 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? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 9-1, Intake and Screening Process and FDJJ 1919 ensure all new admissions to the
facility are properly screened. Staff and resident interviews and a review of documentation confirmed
residents are screened for risk of victimization and abusiveness. This vulnerability screening occurs
within 24 hours of intake, whether transferred from another facility or a new admission. The screening is
conducted using the FDJJ objective instrument, Screening for Vulnerability, Victimization and Sexuality
Aggressive Behavior (VSAB). The VSAB is used to obtain the information required by the standard,
including but not limited to prior sexual victimization or abusiveness; the youth’s self-identification;
current charges and offense history; and intellectual or developmental disabilities.
Resident interviews, a review of documentation and the interview with a Therapist confirmed the VSAB
is administered. Information for completing the VSAB is also obtained by talking to parents/guardians
and reviewing the court packet which contains a comprehensive mental health evaluation. Additional
screening and assessment tools are used to obtain information to aid staff in meeting the individual
needs of residents.
The residents interviewed were able to identify specific areas that are inquired about in the
administration of the VSAB. Facility Policy 9-2 addresses the occurrence and criteria regarding formal
reassessments of residents. The completed risk assessment instruments are accessible to the clinical
staff. The files were observed to be maintained in a confidential manner in a locked file room.
Standard 115.342: Use of screening information
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
PREA Audit Report Page 35 of 80 Facility Name – double click to change
115.342 (a)
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Housing
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Bed
assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Work
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Education
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Program
Assignments? ☒ Yes ☐ No
115.342 (b)
▪ Are residents 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? ☐ Yes ☒ No
▪ During any period of isolation, does the agency always refrain from denying residents daily
large-muscle exercise? ☐ Yes ☒ No
▪ During any period of isolation, does the agency always refrain from denying residents any
legally required educational programming or special education services? ☐ Yes ☒ No
▪ Do residents in isolation receive daily visits from a medical or mental health care clinician?
☐ Yes ☒ No
▪ Do residents also have access to other programs and work opportunities to the extent possible?
☐ Yes ☒ No
115.342 (c)
▪ Does the agency always refrain from placing: Lesbian, gay, and bisexual residents in particular
housing, bed, or other assignments solely on the basis of such identification or status?
☒ Yes ☐ No
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▪ Does the agency always refrain from placing: Transgender residents in particular housing, bed,
or other assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from placing: Intersex residents in particular housing, bed, or
other assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from considering lesbian, gay, bisexual, transgender, or
intersex identification or status as an indicator or likelihood of being sexually abusive?
☒ Yes ☐ No
115.342 (d)
▪ When deciding whether to assign a transgender or intersex 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)? ☒ Yes ☐ No
▪ When making housing or other program assignments for 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? ☒ Yes ☐ No
115.342 (e)
▪ Are placement and programming assignments for each transgender or intersex resident
reassessed at least twice each year to review any threats to safety experienced by the resident?
☒ Yes ☐ No
115.342 (f)
▪ Are each transgender or intersex resident’s own views with respect to his or her own safety
given serious consideration when making facility and housing placement decisions and
programming assignments? ☒ Yes ☐ No
115.342 (g)
▪ Are transgender and intersex residents given the opportunity to shower separately from other
residents? ☒ Yes ☐ No
115.342 (h)
▪ If a resident is isolated pursuant to paragraph (b) of this section, 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?) ☐ Yes ☐ No ☒ NA
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▪ If a resident is isolated pursuant to paragraph (b) of this section, 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?) ☐ Yes ☐ No ☒ NA
115.342 (i)
▪ In the case of each resident who is isolated as a last resort when 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? ☐ Yes ☒ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 8-14, Lesbian, Gay, Bisexual, Transgender, Intersex (LGBTI) Youth and 9-2 and FDJJ
1919 address this standard and provide guidance to staff regarding the information from the VSAB and
other risk screening instruments and outline how the information is to be used. The information
obtained through the administration of the screening instruments assists in determining bed, education
and other program assignments with the goal of keeping all residents safe and meeting needs of each
resident.
Staff members responsible for administering the VSAB participate in required training per review of the
training curriculum. Alleged victims of sexual abuse are not held in isolation. Random staff and Facility
Administrator interviews indicated protective measures would be taken immediately if it was determined
a resident was at risk for imminent sexual abuse and responses included talking to the alleged victim,
separating residents and alerting the supervisor of the situation.
Facility Policy 8-14 prohibits placing lesbian, bisexual, transgender, or intersex residents in specific
housing or making other assignments solely based on how the residents identify or their status. The
Policy prohibits staff from considering the identification as an indicator that these residents may be
more likely to be sexually abusive. Facility and agency policies and interviews support housing and
program assignments for transgender or intersex residents would be made on a case-by-case basis to
ensure the resident’s health and safety. The Therapist and Facility Administrator are aware of the
policies that would be implemented when there are transgender or intersex residents within the
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population. The resident’s concern for her own safety is currently taken into account through responses
obtained from the administration of the VSAB and as confirmed through resident interviews.
REPORTING
Standard 115.351: Resident reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.351 (a)
▪ Does the agency provide multiple internal ways for residents to privately report: Sexual abuse
and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report: Retaliation by
other residents or staff for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report: Staff neglect or
violation of responsibilities that may have contributed to such incidents? ☒ Yes ☐ No
115.351 (b)
▪ Does the agency also provide at least one way for residents to report sexual abuse or sexual
harassment to a public or private entity or office that is not part of the agency? ☒ Yes ☐ No
▪ Is that private entity or office able to receive and immediately forward resident reports of sexual
abuse and sexual harassment to agency officials? ☒ Yes ☐ No
▪ Does that private entity or office allow the resident to remain anonymous upon request?
☒ Yes ☐ No
▪ Are residents detained solely for civil immigration purposes provided information on how to
contact relevant consular officials and relevant officials at the Department of Homeland Security
to report sexual abuse or harassment? ☒ Yes ☐ No
115.351 (c)
▪ Do staff members accept reports of sexual abuse and sexual harassment made verbally, in
writing, anonymously, and from third parties? ☒ Yes ☐ No
▪ Do staff members promptly document any verbal reports of sexual abuse and sexual
harassment? ☒ Yes ☐ No
115.351 (d)
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▪ Does the facility provide residents with access to tools necessary to make a written report?
☒ Yes ☐ No
▪ Does the agency provide a method for staff to privately report sexual abuse and sexual
harassment of residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 1-5, Incident Reporting; 8-3, Abuse and Neglect Reporting; 10-25; and FDJJ 1919
provide multiple internal ways a resident may report, including how a resident may privately report
sexual abuse; 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 to the Florida abuse hotline. A dedicated phone is provided for
residents in the cafeteria.
The resident handbook contains information for reporting allegations of sexual abuse and sexual
harassment of residents. According to the Facility Administrator, the Crisis Center of Tampa Bay may
be contacted regarding an incident of sexual abuse. The Agreement was provided acknowledging the
services to be provided by the victim advocacy agency who has served as the resource regarding
victim services since 2014.
Direct care staff interviews revealed residents may use the abuse hotline to privately report sexual
abuse and sexual harassment of residents. The staff also revealed they could use the abuse hotline for
that same purpose. Internal ways a resident may report include completing a Chatty Cathy or grievance
form; talking to a trusted staff member; completing a sick call form; and third parties may report
allegations either in writing or through the abuse hotline. The residents and staff were aware that third-
party reports could be made and that reports could be made anonymously. The majority of the
residents interviewed stated they would report allegations of sexual abuse or sexual harassment to staff
or through the use of the Florida Abuse Hotline.
The residents interviewed stated they have contact with someone who does not work at the facility such
as a family member, who they could report abuse to if needed. Policies and staff interviews indicate
staff members are required to immediately document all verbal reports. Staff members receive
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information on how to report allegations of sexual abuse or sexual harassment through policies and
procedures, training, and staff meetings. Information about reporting allegations of sexual abuse and
sexual harassment is posted in the housing units and other areas of the facility. Residents and staff are
aware of the methods a resident may report allegations of sexual abuse or sexual harassment.
Residents are not detained in the facility for civil immigration purposes.
Facility Policy 8-4 and FDJJ 1919 and the resident handbook provide that a grievance form may be
used to report allegations of sexual abuse or sexual harassment. The form may be completed and
submitted to staff or placed in the locked grievance box at any time. The practice is residents are not
required to handle an emergency grievance informally by attempting to resolve the situation with staff.
Access to writing tools is provided for residents so that they are able to complete the forms.
A review of the resident handbook revealed more clarity was needed regarding the use of a grievance
form to report an allegation of sexual abuse or sexual harassment. The Facility Administrator
implemented a corrective action with a revision to the handbook which makes it clear, in writing to
residents that the steps of the regular grievance system are not required when the resident is using the
grievance form to report allegations of sexual abuse or sexual harassment. The form may be placed
directly in the grievance box and the modification to the handbook is now aligned with the practice. The
residents are aware of how to use a grievance form to report a PREA related allegation.
A corrective action was also implemented by posting the grievance forms on the wall in the cafeteria
under the grievance box, eliminating the resident having to request a form from staff. The resident
handbook was revised to reflect this change also. The third corrective action taken was regarding the
abuse reporting phone in the cafeteria. When tested by the Auditor, the phone was found not to be
functioning as intended. The Facility Administrator reported the problem and it was discovered the
phone was malfunctioning. The original phone was replaced with a new one.
Standard 115.352: Exhaustion of administrative remedies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.352 (a)
▪ Is the agency exempt from this standard? 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. ☐ Yes ☐ No ☒ NA
115.352 (b)
▪ Does the agency permit residents to submit a grievance regarding 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.) ☐ Yes ☐ No ☒ NA
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▪ Does the agency always refrain from requiring a resident to use 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.) ☐ Yes ☐ No ☒ NA
115.352 (c)
▪ Does the agency ensure that: A resident who alleges sexual abuse 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.) ☐ Yes ☐ No ☒ NA
▪ Does the agency ensure that: Such grievance is not referred to a staff member who is the
subject of the complaint? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (d)
▪ Does the agency 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? (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.) ☐ Yes ☐ No ☒ NA
▪ If the agency determines that the 90-day timeframe is insufficient 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.) ☐ Yes ☐ No ☒ NA
▪ 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,
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.) ☐ Yes ☐ No ☒ NA
115.352 (e)
▪ Are third parties, including fellow residents, staff members, family 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.)
☐ Yes ☐ No ☒ NA
▪ Are those third parties also permitted to file such requests on 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.) ☐ Yes ☐ No ☒ NA
▪ If the resident declines to have the request processed on his or her behalf, does the agency
document the resident’s decision? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
PREA Audit Report Page 42 of 80 Facility Name – double click to change
▪ Is a parent or legal guardian of a juvenile allowed to file a grievance regarding allegations of
sexual abuse, including appeals, on behalf of such juvenile? (N/A if agency is exempt from this
standard.) ☐ Yes ☐ No ☒ NA
▪ If a parent or legal guardian of a juvenile files a grievance (or an 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.) ☐ Yes ☐ No ☒ NA
115.352 (f)
▪ Has the agency established procedures for the filing of an 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.) ☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance alleging a resident is 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.).
☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance described above, does the agency provide an initial
response within 48 hours? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance described above, does the agency issue a final agency
decision within 5 calendar days? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ Does the initial response and final agency decision document the agency’s determination
whether the resident is in substantial risk of imminent sexual abuse? (N/A if agency is exempt
from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the initial response document the agency’s action(s) taken in response to the emergency
grievance? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency’s final decision document the agency’s action(s) taken in response to the
emergency grievance? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (g)
▪ If the agency disciplines a resident for filing a grievance related to 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.) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
PREA Audit Report Page 43 of 80 Facility Name – double click to change
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
When a grievance is received regarding sexual abuse or sexual harassment, it is immediately provided
to the Facility Administrator/designee. The policies and procedures for reporting allegations of sexual
abuse or sexual harassment are initiated and a report is made as required by policies. The grievance
system does not include a process for facility staff to investigate or resolve allegations of sexual abuse
or sexual harassment. The content of the grievance is reported and an investigation may be conducted
by the FDJJ Office of Inspector General; Florida Department of Children and Families; or local law
enforcement when the allegation is criminal in nature.
The purpose of the submission of a PREA related grievance provides residents and staff another
method for ensuring the reporting of allegations and provides management staff with the opportunity to
protect the resident. There is a response from staff within 48 hours informing the resident of receipt of
the grievance and that it has been referred for investigation. The facility and agency policies provide a
resident may be disciplined when it has been determined a report alleging sexual abuse has been
made in bad faith.
Residents understand they will not be punished if a report is made in good faith, as determined through
the interviews. The residents and staff interviewed identified the use of a grievance form as one of the
methods that may be used to report allegations of sexual abuse or sexual harassment and the
residents are aware of how grievances are handled regarding sexual abuse and sexual harassment.
Standard 115.353: Resident access to outside confidential support services
and legal representation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.353 (a)
▪ Does the facility provide residents with access to outside victim advocates for emotional support
services related to sexual abuse by providing, posting, or otherwise making assessible mailing
addresses and telephone numbers, including toll-free hotline numbers where available, of local,
State, or national victim advocacy or rape crisis organizations? ☒ Yes ☐ No
PREA Audit Report Page 44 of 80 Facility Name – double click to change
▪ Does the facility provide persons detained solely for civil immigration purposes mailing
addresses and telephone numbers, including toll-free hotline numbers where available of local,
State, or national immigrant services agencies? ☐ Yes ☒ No
▪ Does the facility enable reasonable communication between residents and these organizations
and agencies, in as confidential a manner as possible? ☒ Yes ☐ No
115.353 (b)
▪ Does the facility 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? ☒ Yes ☐ No
115.353 (c)
▪ Does the agency 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? ☒ Yes ☐ No
▪ Does the agency maintain copies of agreements or documentation showing attempts to enter
into such agreements? ☒ Yes ☐ No
115.353 (d)
▪ Does the facility provide residents with reasonable and confidential access to their attorneys or
other legal representation? ☒ Yes ☐ No
▪ Does the facility provide residents with reasonable access to parents or legal guardians?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
PREA Audit Report Page 45 of 80 Facility Name – double click to change
Facility Policy 10-25 and FDJJ 1919 address the residents’ access to outside confidential support
services and communication with parents/guardians and legal representation. The parent agency has
renewed the Prison Rape Elimination Act Agreement for victim advocacy services with the Crisis
Center of Tampa Bay. The confirmed services include but are not limited to the provision of forensic
examinations, follow-up meetings, and hotline services. Contact information for the Crisis Center of
Tampa Bay is posted in the facility. The Center has been used as a resource since 2014.
During the comprehensive tour of the facility, the posted information was observed. The interview with
the Facility Administrator and the TrueCore Behavioral Solutions PREA Coordinator; review of the
correspondence and Policies; and posted information also support advocacy services will be provided
upon contact with the Crisis Center of Tampa Bay.
Facility Policies, 8-5 Telephone Access; 8-6 Visitation; and 8-7 Correspondence address contact with
visitors. Resident and Facility Administrator interviews and observations during the comprehensive tour
support residents are provided confidential access to their attorney or other legal representative and
reasonable access to their parents/legal guardian. All residents interviewed stated the facility allows for
family visits and they were aware of the days and times for visitation and phone calls. Residents also
revealed they have contact with someone on the outside to report allegations of sexual abuse to if
needed.
Standard 115.354: Third-party reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.354 (a)
▪ Has the agency established a method to receive third-party reports of sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Has the agency distributed publicly information on how to report sexual abuse and sexual
harassment on behalf of a resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
PREA Audit Report Page 46 of 80 Facility Name – double click to change
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
FDJJ 1919 addresses third-party reporting and interviews revealed residents are aware third-party
reporting of sexual abuse or sexual harassment can be done. All residents interviewed stated they
knew someone who did not work at the facility they could report to regarding allegations of sexual
abuse. Staff interviews revealed their knowledge of third-party reporting and that they can receive
allegations from third parties. Information regarding reporting is provided through observed postings
located in areas of the facility accessible to visitors, residents and staff members. The FDJJ website
contains information regarding third-party reporting of allegations of sexual abuse.
Interviews with direct care staff revealed they are aware of their obligation to receive and submit
reported allegations from others. They are aware staff may report privately through the use of the
hotline. Staff members are also aware they are to document all verbal reports. Interviews with residents
confirmed their knowledge of the meaning of third-party reporting. The methods within the facility in
which residents may make third-party reports include completing and submitting a Chatty Cathy or
grievance form, talking to staff, and utilizing the abuse reporting hotline.
OFFICIAL RESPONSE FOLLOWING A RESIDENT REPORT
Standard 115.361: Staff and agency reporting duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.361 (a)
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding an incident of sexual abuse or sexual
harassment that occurred in a facility, whether or not it is part of the agency? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding retaliation against residents or staff who
reported an incident of sexual abuse or sexual harassment? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding any staff neglect or violation of responsibilities
that may have contributed to an incident of sexual abuse or sexual harassment or retaliation?
☒ Yes ☐ No
115.361 (b)
▪ Does the agency require all staff to comply with any applicable mandatory child abuse reporting
laws? ☒ Yes ☐ No
115.361 (c)
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▪ Apart from reporting to designated supervisors or officials and 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? ☒ Yes ☐ No
115.361 (d)
▪ Are medical and mental health practitioners 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? ☒ Yes ☐ No
▪ Are medical and mental health practitioners required to inform residents of their duty to report, and
the limitations of confidentiality, at the initiation of services? ☒ Yes ☐ No
115.361 (e)
▪ Upon receiving any allegation of sexual abuse, does the facility head or his or her designee
promptly report the allegation to the appropriate office? ☒ Yes ☐ No
▪ Upon receiving any allegation of sexual abuse, does the facility 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?
☒ Yes ☐ No
▪ If the alleged victim is under the guardianship of the child welfare 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.) ☒ Yes ☐ No ☐ NA
▪ If a juvenile court retains jurisdiction over the alleged victim, does 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? ☒ Yes ☐ No
115.361 (f)
▪ Does the facility report all allegations of sexual abuse and sexual harassment, including third-
party and anonymous reports, to the facility’s designated investigators? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
PREA Audit Report Page 48 of 80 Facility Name – double click to change
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 1-5, Incident Reporting; 8-3, Abuse and Neglect Reporting; 10-25 and FDJJ 1919
collectively address the standard and inform all staff to immediately report any knowledge, suspicion,
information, or receipt of information regarding an incident or allegation of sexual abuse, sexual
harassment or incidents of retaliation and according to mandatory reporting laws. The facility does not
conduct administrative or criminal investigations. All allegations of sexual abuse and sexual harassment
are reported to the FDJJ Central Communications Center (CCC).
Policy 10-25 prohibits staff from revealing any related information to anyone other than to the extent
necessary to make treatment, investigation and other security and management decisions. The CCC
will make appropriate notification to senior FDJJ management who will make notification to
management overseeing the facility where the alleged abuse occurred. Policy 10-25 requires the
Facility Administrator to notify the alleged victim’s parents or legal guardians. If the resident is under
Department of Children and Families (DCF) custody, the DCF Case Worker will be notified and if
applicable, the attorney of record will be notified of the allegation within 14 days of receipt of the
allegation, according to the Policy.
Random Staff, mental health and medical staff revealed through interviews their awareness of the
requirements regarding reporting duties and acknowledged they are mandated reporters and must
immediately report all allegations of sexual abuse and complete a written follow-up report. The direct
care staff members interviewed provided the reporting requirements and that staff is expected to
document verbal reports immediately. The facility staff members are also required by policy to report
allegations that were made anonymously or by a third-party. The mental health and medical staff
indicated residents are informed at the initiation of services of the limitations of confidentiality and the
duty of the staff to report.
Standard 115.362: Agency protection duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.362 (a)
▪ When the agency learns that a resident is subject to a substantial risk of imminent sexual
abuse, does it take immediate action to protect the resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
PREA Audit Report Page 49 of 80 Facility Name – double click to change
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919 require staff to protect the residents through immediately
implementing protective measures. The interviews of the direct care staff and the Facility Administrator
revealed protective measures will be immediately implemented when needed. The interviews with the
residents indicated that during their stay in the facility, their feelings about their safety are part of the
inquiries by staff periodically. The facility reports that during the past 12 months, no residents were
identified as being subject to substantial risk of imminent sexual abuse.
Standard 115.363: Reporting to other confinement facilities
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.363 (a)
▪ Upon receiving an allegation that a resident was sexually abused 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? ☒ Yes ☐ No
▪ Does the head of the facility that received the allegation also notify the appropriate investigative
agency? ☒ Yes ☐ No
115.363 (b)
▪ Is such notification provided as soon as possible, but no later than 72 hours after receiving the
allegation? ☒ Yes ☐ No
115.363 (c)
▪ Does the agency document that it has provided such notification? ☒ Yes ☐ No
115.363 (d)
▪ Does the facility head or agency office that receives such notification ensure that the allegation
is investigated in accordance with these standards? ☒ Yes ☐ No
Auditor Overall Compliance Determination
PREA Audit Report Page 50 of 80 Facility Name – double click to change
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919 and interview with Facility Administrator provide for notification to
the facility administrator where the alleged abuse occurred, upon receipt of an allegation a resident was
sexually abused while confined in another facility. Notification must be made as soon as possible but no
later than 72 hours after receipt of the allegation. The Facility Administrator must also notify the Central
Communications Center to report the incident for an investigation.
Facility Policy 10-25 requires the Facility Administrator/designee to notify the facility head where the
alleged incident occurred. The facility reports during this audit period, there has not been a report about
an incident of abuse occurring while the resident was confined in another facility. The Facility
Administrator is aware of the policy and the required duties regarding reporting to other confinement
facilities and the requirement that allegations received from other facilities must be investigated.
Standard 115.364: Staff first responder duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.364 (a)
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Separate the alleged victim and abuser?
☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually 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? ☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually 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,
PREA Audit Report Page 51 of 80 Facility Name – double click to change
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? ☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually 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? ☒ Yes ☐ No
115.364 (b)
▪ If the first staff responder is not a security staff member, is the responder required to request
that the alleged victim not take any actions that could destroy physical evidence, and then notify
security staff? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919 require that any staff acting as a first responder must separate the
alleged victim from the alleged abuser; call for help; and take the appropriate steps for the preservation
and collection of any evidence. The Policy directs the first responder to request the alleged victim does
not wash; brush their teeth; change clothes; wash or do anything that may destroy evidence.
The Policies instruct non-security staff who may act as a first responder to request that physical
evidence be preserved and to contact direct care staff for assistance. Staff members who would serve
as first responders are aware of their duties. There was no allegation or incident of sexual abuse
during this audit period.
Standard 115.365: Coordinated response
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
PREA Audit Report Page 52 of 80 Facility Name – double click to change
115.365 (a)
▪ Has the facility developed a written institutional plan to coordinate actions among staff first
responders, medical and mental health practitioners, investigators, and facility leadership taken
in response to an incident of sexual abuse? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The facility has a written institutional plan, Sexual Abuse Incident Coordinated Response Plan, to be
implemented in the event of an allegation or incident of sexual abuse. The Plan outlines the actions of
the identified staff members such as the first responder; supervisors; medical; mental health; and
management. This coordinated response to an incident of sexual abuse is also aligned with facility
policy 10-25 and FDJJ 1919. Staff members interviewed were familiar with their role regarding the
response to an allegation of sexual abuse.
Standard 115.366: Preservation of ability to protect residents from contact
with abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.366 (a)
▪ Are both the agency and any other governmental entities 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? ☐ Yes ☒ No
115.366 (b)
▪ Auditor is not required to audit this provision.
PREA Audit Report Page 53 of 80 Facility Name – double click to change
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The facility is not involved in collective bargaining.
Standard 115.367: Agency protection against retaliation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.367 (a)
▪ Has the agency established 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? ☒ Yes ☐ No
▪ Has the agency designated which staff members or departments are charged with monitoring
retaliation? ☒ Yes ☐ No
115.367 (b)
▪ Does the agency employ multiple protection measures for 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? ☒ Yes ☐ No
115.367 (c)
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
PREA Audit Report Page 54 of 80 Facility Name – double click to change
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? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of 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? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of 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? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Resident
housing changes? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Resident
program changes? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Negative
performance reviews of staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor:
Reassignments of staff? ☒ Yes ☐ No
▪ Does the agency continue such monitoring beyond 90 days if the initial monitoring indicates a
continuing need? ☒ Yes ☐ No
115.367 (d)
▪ In the case of residents, does such monitoring also include periodic status checks?
☒ Yes ☐ No
115.367 (e)
▪ If any other individual who cooperates with an investigation expresses a fear of retaliation, does
the agency take appropriate measures to protect that individual against retaliation?
☒ Yes ☐ No
115.367 (f)
▪ Auditor is not required to audit this provision.
PREA Audit Report Page 55 of 80 Facility Name – double click to change
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919 provide protection to residents and staff from retaliation. The
interview with the Facility Administrator, retaliation monitor, revealed she understands the role of the
retaliation monitor and the discharge of those duties assist in preventing retaliation against residents
and staff who report sexual abuse, sexual harassment or who cooperate with an investigation. Facility
Policy 10-25 requires the following be monitored to determine if retaliation is occurring: youth
disciplinary reports; status checks; housing or program changes; negative performance review; or
reassignment of staff.
The Facility Administrator discussed and the Policies support things which would be considered in
detecting retaliation include monitoring complaints made by residents, review residents’ journals, and
instances of reassignment of staff. The interviews and the policies support measures which may be
taken when retaliation is detected include housing changes and status checks for continued safety. A
Retaliation Monitoring form may be used to document the monitoring for retaliation. The Facility
Administrator reported no incidents of retaliation during the past 12 months. .
Standard 115.368: Post-allegation protective custody
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.368 (a)
▪ Is any and all use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse subject to the requirements of § 115.342? ☐ Yes ☒ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
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☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Segregated housing is not used to protect residents who are alleged to have suffered sexual abuse.
INVESTIGATIONS
Standard 115.371: Criminal and administrative agency investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.371 (a)
▪ When the agency conducts its own investigations into allegations of sexual abuse and sexual
harassment, does it do so promptly, thoroughly, and objectively? [N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.
See 115.321(a).] ☐ Yes ☐ No ☒ NA
▪ Does the agency conduct such investigations for all allegations, including third party and
anonymous reports? [N/A if the agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations. See 115.321(a).]
☐ Yes ☐ No ☒ NA
115.371 (b)
▪ Where sexual abuse is alleged, does the agency use investigators who have received
specialized training in sexual abuse investigations involving juvenile victims as required by
115.334? ☒ Yes ☐ No
115.371 (c)
▪ Do investigators gather and preserve direct and circumstantial evidence, including any available
physical and DNA evidence and any available electronic monitoring data? ☒ Yes ☐ No
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▪ Do investigators interview alleged victims, suspected perpetrators, and witnesses?
☒ Yes ☐ No
▪ Do investigators review prior reports and complaints of sexual abuse involving the suspected
perpetrator? ☒ Yes ☐ No
115.371 (d)
▪ Does the agency always refrain from terminating an investigation solely because the source of
the allegation recants the allegation? ☒ Yes ☐ No
115.371 (e)
▪ When the quality of evidence appears to support criminal 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? ☒ Yes ☐ No
115.371 (f)
▪ Do agency investigators assess the credibility of an alleged victim, suspect, or witness on an
individual basis and not on the basis of that individual’s status as resident or staff?
☒ Yes ☐ No
▪ Does the agency investigate allegations of sexual abuse without requiring a resident who
alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a
condition for proceeding? ☒ Yes ☐ No
115.371 (g)
▪ Do administrative investigations include an effort to determine whether staff actions or failures to
act contributed to the abuse? ☒ Yes ☐ No
▪ Are administrative investigations documented in written reports that include a description of the
physical evidence and testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings? ☒ Yes ☐ No
115.371 (h)
▪ Are criminal investigations documented in a written report that contains a thorough description
of the physical, testimonial, and documentary evidence and attaches copies of all documentary
evidence where feasible? ☒ Yes ☐ No
115.371 (i)
▪ Are all substantiated allegations of conduct that appears to be criminal referred for prosecution?
☒ Yes ☐ No
115.371 (j)
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▪ Does the agency retain all written reports referenced in 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?
☒ Yes ☐ No
115.371 (k)
▪ Does the agency ensure that the departure of an alleged abuser or victim from the employment
or control of the agency does not provide a basis for terminating an investigation?
☒ Yes ☐ No
115.371 (l)
▪ Auditor is not required to audit this provision.
115.371 (m)
▪ When an outside entity investigates sexual abuse, does the facility 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).) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919, staff interviews, and a review of documentation indicate
administrative investigations are conducted by the FDJJ Office of the Inspector General and criminal
investigations are conducted by law enforcement. Sustained allegations as a result of a criminal
investigation will be referred for prosecution. The Florida Department of Children and Families are also
called when there is an allegation of sexual abuse.
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The Policies direct facility staff to cooperate with investigations and the documentation reviewed
indicates such. FDJJ 1919 provides an investigation is not terminated because the source recants the
allegation. The Office of Inspector General follows protocols in conducting administrative investigations
in FDJJ settings and the investigators receive training on the related agency policies. The investigative
reports include descriptions and investigative facts and findings.
Standard 115.372: Evidentiary standard for administrative investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.372 (a)
▪ Is it true that the agency does not impose a standard higher than a preponderance of the
evidence in determining whether allegations of sexual abuse or sexual harassment are
substantiated? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The policy and practice of the FDJJ Office of Inspector General, responsible for administrative
investigations, impose a standard of a preponderance of the evidence for determining whether
allegations are substantiated.
Standard 115.373: Reporting to residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.373 (a)
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▪ Following an investigation into a resident’s allegation that he or she suffered sexual abuse in an
agency facility, does the agency inform the resident as to whether the allegation has been
determined to be substantiated, unsubstantiated, or unfounded? ☒ Yes ☐ No
115.373 (b)
▪ If the agency did not conduct the investigation into a resident’s 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.) ☒ Yes ☐ No ☐ NA
115.373 (c)
▪ Following a resident’s allegation that a staff member has 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? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has 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? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has 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? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has 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? ☒ Yes ☐ No
115.373 (d)
▪ Following a resident’s allegation that he or she has been sexually 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?
☒ Yes ☐ No
▪ Following a resident’s allegation that he or she has been sexually 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?
☒ Yes ☐ No
115.373 (e)
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▪ Does the agency document all such notifications or attempted notifications? ☒ Yes ☐ No
115.373 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919 address this standard. The victim is to be informed when the
investigation is completed and the PREA Compliance Manager/Facility Administrator notifies the
alleged victim of the outcome of the investigation and it is documented. Following an allegation of
sexual abuse committed by staff, the resident is informed when the staff member is no longer posted in
the unit or employed in the facility and of the staff member’s indictment or conviction. Following an
allegation of sexual abuse committed by another resident, the alleged victim is informed if the alleged
abuser has been indicted, charged, or convicted which will is documented. The Youth Notification of
Investigation Outcome (PREA) form is used to inform residents of the outcomes of investigations and
perpetrators. The Facility Administrator remains abreast of an investigation conducted by investigative
entities through serving as the primary contact person.
DISCIPLINE
Standard 115.376: Disciplinary sanctions for staff
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.376 (a)
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▪ Are staff subject to disciplinary sanctions up to and including termination for violating agency
sexual abuse or sexual harassment policies? ☒ Yes ☐ No
115.376 (b)
▪ Is termination the presumptive disciplinary sanction for staff who have engaged in sexual
abuse? ☒ Yes ☐ No
115.376 (c)
▪ Are disciplinary sanctions for violations of agency policies relating 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? ☒ Yes ☐ No
115.376 (d)
▪ Are 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, reported to:
Law enforcement agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Are 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, reported to:
Relevant licensing bodies? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 3-3, Employee Standards of Conduct, 10-25 and the Employee Handbook provide for
disciplinary sanctions, up to and including termination for those staff violating the facility’s sexual abuse
and sexual harassment zero-tolerance policy. The facility reports that during this audit period, no staff
member violated facility or agency policy regarding sexual abuse or sexual harassment. Disciplinary
sanctions for violations of facility/agency policies relating to sexual abuse, other than actually engaging
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in the act, and sexual harassment are appropriate to the circumstances of the incident, staff’s
disciplinary history, and the sanctions for similar cases of other staff.
Policies provide terminations or resignations by staff that would have been terminated if not for their
resignation are reported to law enforcement if the situation appears to be criminal in nature and to
relevant licensing bodies. The interviews with the Human Resources/Administrative Assistant and the
Facility Administrator support the Policies.
Standard 115.377: Corrective action for contractors and volunteers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.377 (a)
▪ Is any contractor or volunteer who engages in sexual abuse prohibited from contact with
residents? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Law enforcement
agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Relevant licensing
bodies? ☒ Yes ☐ No
115.377 (b)
▪ In the case of any other violation of agency sexual abuse or sexual harassment policies by a
contractor or volunteer, does the facility take appropriate remedial measures, and consider
whether to prohibit further contact with residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
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Facility Policy 10-25 and FDJJ 1919 address this standard. Any contractor or volunteer who engages in
sexual abuse is prohibited from contact with residents. The Policies also provide for contractors and
volunteers who engage in sexual abuse to be reported to law enforcement and to relevant licensing
bodies. The documentation and interviews revealed the facility takes measures to provide volunteers
and contractors a clear understanding that sexual misconduct with a resident is strictly prohibited and is
a serious breach of conduct.
Interviews with a contractor and a volunteer, review of related documentation demonstrate the PREA
training occurs and the contractor’s and volunteer’s awareness of the zero-tolerance policy and how to
report allegations of sexual abuse or sexual harassment of residents. During this audit period, there
have been no allegations of sexual abuse or sexual harassment related to a contractor or volunteer.
Standard 115.378: Interventions and disciplinary sanctions for residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.378 (a)
▪ Following an administrative finding that a resident engaged in 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?
☒ Yes ☐ No
115.378 (b)
▪ Are disciplinary sanctions 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? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident is not denied daily large-muscle exercise? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident is not denied access to any legally required educational programming or special
education services? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident receives daily visits from a medical or mental health care clinician? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the resident also
have access to other programs and work opportunities to the extent possible? ☒ Yes ☐ No
115.378 (c)
▪ When determining what types of sanction, if any, should be imposed, does the disciplinary
process consider whether a resident’s mental disabilities or mental illness contributed to his or
her behavior? ☒ Yes ☐ No
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115.378 (d)
▪ If the facility offers therapy, counseling, or other interventions 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? ☒ Yes ☐ No
▪ If the agency requires participation in such interventions as a 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? ☒ Yes ☐ No
115.378 (e)
▪ Does the agency discipline a resident for sexual contact with staff only upon a finding that the
staff member did not consent to such contact? ☒ Yes ☐ No
115.378 (f)
▪ For the purpose of disciplinary action does a report of sexual 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? ☒ Yes ☐ No
115.378 (g)
▪ Does the agency always refrain from considering non-coercive sexual activity between residents
to be sexual abuse? (N/A if the agency does not prohibit all sexual activity between residents.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
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Policy FDJJ 1919 and facility disciplinary policy address an administrative process for dealing with
violations, including resident-on-resident sexual abuse. According to the Facility Administrator, a
resident may also be referred by law enforcement for charges and possible removal from the facility
regarding resident-on-resident abuse. Policy 10-25 provides sexual activity between residents is
prohibited and court or administrative processes and sanctions occur after determination that the
sexual activity was coerced.
According to the Policies, residents may be disciplined for sexual contact with staff only when it has
been determined that the staff member did not consent to the sexual contact. Policy 10-25 states
anyone reporting in good faith shall be immune from any civil or criminal liability. The facility reports
during the past 12 months there have been no administrative findings or criminal findings of guilt
regarding resident-on-resident sexual abuse.
Facility Policy 10-25 and FDJJ 1919 and interviews with mental health staff support counseling or other
interventions will be offered to address and correct the underlying reasons or motivations for abuse
when the resident remains in or returns to the facility after an incident. Any type interventions or
treatment services provided are not as a condition for the resident to access education or other
programs.
MEDICAL AND MENTAL CARE
Standard 115.381: Medical and mental health screenings; history of sexual
abuse
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.381 (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, 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? ☒ Yes ☐ No
115.381 (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, do staff ensure
that the resident is offered a follow-up meeting with a mental health practitioner within 14 days
of the intake screening? ☒ Yes ☐ No
115.381 (c)
▪ Is any information related to sexual victimization or abusiveness 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?
☒ Yes ☐ No
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115.381 (d)
▪ Do medical and mental health practitioners 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? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 7-3 Health Care Admission Screening and Evaluation; 7-8 Informed Consent; 7-28
Medical Files, Transitional Planning & Reporting; 10-25; and FDJJ 1919 collectively address this
standard. There is the provision for a follow-up meeting with a medical or mental health practitioner
within 14 days when the resident discloses any prior incidents of sexual abuse as a victim or
perpetrator. Interviews with medical and mental health staff and a review of general documentation
confirmed the practice of residents being provided services by treatment staff.
According to resident interviews and documentation, residents are generally seen by medical and
mental health staff on the same day of admission as part of the intake process. Facility Policy 10-25
indicate information related to sexual victimization or abusiveness which occurred in an institutional
setting is limited to medical and mental health practitioners and other staff, based on their need to
know. Medical and mental health staff discussed their knowledge of informed consent during their
interviews. No information is shared with other staff unless it is required for security and management
decisions regarding a resident’s sexual abuse history.
Standard 115.382: Access to emergency medical and mental health
services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.382 (a)
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▪ Do resident victims of sexual abuse 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? ☒ Yes ☐ No
115.382 (b)
▪ If no qualified medical or mental health practitioners are on duty 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? ☒ Yes ☐ No
▪ Do staff first responders immediately notify the appropriate medical and mental health
practitioners? ☒ Yes ☐ No
115.382 (c)
▪ Are resident victims of sexual abuse 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? ☒ Yes ☐ No
115.382 (d)
▪ Are treatment services 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?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 7-30 Sexual Assault Reporting and 10.25 and FDJJ 1919 address this standard. Staff
interviews revealed emergency medical care and crisis intervention services will be provided by
medical and mental health staff. Processes and services are in place for a victim to receive timely
access to sexually transmitted infection prophylaxis, where medically appropriate, at the Crisis Center
of Tampa Bay and with follow-up as needed by the facility’s medical staff. Observations of current files
and practices indicate secondary materials are maintained and documentation of resident encounters.
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The medical and mental health staff interviews revealed they are knowledgeable of actions to take
regarding an incident of sexual abuse. It is documented through policies and understood by the medical
and mental health staff that treatment services will be provided at no cost to the victim, whether or not
the victim names the abuser, or whether or not the victim cooperates with the investigation. The
interviews with the medical and mental health staff revealed residents have access to unimpeded
access to emergency services and medical and mental health services are determined according to the
professional judgment of the practitioner.
The Policies, procedures and written coordinated response plan exist for protecting residents and for
contacting the appropriate staff regarding allegations or incidents of sexual abuse, including contacting
medical and mental health staff. The interviews confirmed timely information would be provided to a
victim regarding sexually transmitted infection prophylaxis and legal pregnancy services. The
observations of the interactions among residents, medical and mental health practitioners, and other
staff interviews indicate that unimpeded medical and crisis intervention services will be available to a
victim of sexual abuse.
Standard 115.383: Ongoing medical and mental health care for sexual
abuse victims and abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.383 (a)
▪ Does the facility 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? ☒ Yes ☐ No
115.383 (b)
▪ Does the evaluation and treatment of such victims 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? ☒ Yes ☐ No
115.383 (c)
▪ Does the facility provide such victims with medical and mental health services consistent with
the community level of care? ☒ Yes ☐ No
115.383 (d)
▪ Are resident victims of sexually abusive vaginal penetration while incarcerated offered
pregnancy tests? (N/A if all-male facility.) ☐ Yes ☐ No ☒ NA
115.383 (e)
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▪ If pregnancy results from the conduct described in paragraph § 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.) ☐ Yes ☐ No ☒ NA
115.383 (f)
▪ Are resident victims of sexual abuse while incarcerated offered tests for sexually transmitted
infections as medically appropriate? ☒ Yes ☐ No
115.383 (g)
▪ Are treatment services 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?
☒ Yes ☐ No
115.383 (h)
▪ Does the facility 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? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policies 7-13 Periodic Evaluations and Ongoing Treatment; 9-3 Risk Assessment; 9-5
Assessment; and 10-25 address this standard. Interviews with the medical and mental health staff
confirmed on-going medical and mental health care will be provided for sexual abuse victims and
abusers, as appropriate. Staff interviews supported on-going services would include collaboration
among medical and mental health staff providing services and referrals as needed. All treatment
services will be provided at no cost to the victim.
Policy 10-25; staff interviews; and observations revealed medical and mental health services are
consistent with the community level of care. The Policies and interviews support medical and mental
PREA Audit Report Page 71 of 80 Facility Name – double click to change
health evaluations and treatment will be offered to all residents who have been victimized by sexual
abuse in any facility. Policy 10-25 provides for a mental health practitioner to conduct a mental health
evaluation within 60 days on a resident who discloses resident-on-resident abuse.
DATA COLLECTION AND REVIEW
Standard 115.386: Sexual abuse incident reviews
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.386 (a)
▪ Does the facility 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? ☒ Yes ☐ No
115.386 (b)
▪ Does such review ordinarily occur within 30 days of the conclusion of the investigation?
☒ Yes ☐ No
115.386 (c)
▪ Does the review team include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners? ☒ Yes ☐ No
115.386 (d)
▪ Does the review team: Consider whether the allegation or investigation indicates a need to
change policy or practice to better prevent, detect, or respond to sexual abuse? ☒ Yes ☐ No
▪ Does the review team: Consider whether the incident or allegation was motivated by race;
ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or
perceived status; gang affiliation; or other group dynamics at the facility? ☒ Yes ☐ No
▪ Does the review team: Examine the area in the facility where the incident allegedly occurred to
assess whether physical barriers in the area may enable abuse? ☒ Yes ☐ No
▪ Does the review team: Assess the adequacy of staffing levels in that area during different
shifts? ☒ Yes ☐ No
▪ Does the review team: Assess whether monitoring technology should be deployed or
augmented to supplement supervision by staff? ☒ Yes ☐ No
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▪ Does the review team: Prepare a report of its findings, including 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?
☒ Yes ☐ No
115.386 (e)
▪ Does the facility implement the recommendations for improvement, or document its reasons for
not doing so? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Facility Policy 10-25 and FDJJ 1919 provide for an incident review to be conducted within 30 days of
the completion of an investigation in accordance with the standard. The Policies outline the
requirements of the standard for the areas to be assessed by the incident review team. The Policies
also identify the positions that comprise the team. The Facility Administrator is knowledgeable of the
purpose of the incident review process. One incident review meeting was conducted due to the findings
being Information Only by FDJJ. A format has been developed for documenting the incident review
team meeting, including allowing for the assessment of the circumstances surrounding the incident and
recommendations made by the team.
Standard 115.387: Data collection
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.387 (a)
▪ Does the agency collect accurate, uniform data for every allegation of sexual abuse at facilities
under its direct control using a standardized instrument and set of definitions? ☒ Yes ☐ No
115.387 (b)
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▪ Does the agency aggregate the incident-based sexual abuse data at least annually?
☒ Yes ☐ No
115.387 (c)
▪ Does the incident-based data 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? ☒ Yes ☐ No
115.387 (d)
▪ Does the agency maintain, review, and collect data as needed from all available incident-based
documents, including reports, investigation files, and sexual abuse incident reviews?
☒ Yes ☐ No
115.387 (e)
▪ Does the agency also obtain incident-based and aggregated data 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.) ☐ Yes ☐ No ☒ NA
115.387 (f)
▪ Does the agency, upon request, provide all such data from the previous calendar year to the
Department of Justice no later than June 30? (N/A if DOJ has not requested agency data.)
☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
FDJJ 1919 and a review of reports confirm that FDJJ collects incident-based, uniform data regarding
allegations of sexual abuse at facilities under its direct control, including contractors, using a
standardized instrument and specific guidelines. The format used for FDJJ facilities and contractors
capture the information required to complete the most recent version of the Survey of Sexual Violence
conducted by the U. S. Department of Justice (DOJ).
PREA Audit Report Page 74 of 80 Facility Name – double click to change
Florida DJJ maintains and collects various types of identified data and related documents regarding
sexual abuse incidents. The facility collects and maintains data in accordance with directives by FDJJ
and FDJJ aggregates the sexual abuse data which culminates into an annual report. The agency
provides DOJ with data as requested
Standard 115.388: Data review for corrective action
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.388 (a)
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Identifying problem areas? ☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Taking corrective action on an ongoing basis?
☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Preparing an annual report of its findings and
corrective actions for each facility, as well as the agency as a whole? ☒ Yes ☐ No
115.388 (b)
▪ Does the agency’s annual report include a comparison of the current year’s data and corrective
actions with those from prior years and provide an assessment of the agency’s progress in
addressing sexual abuse ☒ Yes ☐ No
115.388 (c)
▪ Is the agency’s annual report 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? ☒ Yes ☐ No
115.388 (d)
▪ Does the agency indicate the nature of the material redacted 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? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
PREA Audit Report Page 75 of 80 Facility Name – double click to change
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
FDJJ 1919 provides guidance regarding this standard. The collected and aggregated data is reviewed
to assess and improve the effectiveness of the PREA related efforts and initiatives by identifying
problem areas; developing and implementing corrective actions as needed; and preparing an annual
report based on the collected data. The Policy also states that an annual report will be prepared that
will provide an assessment of the agency’s progress in addressing sexual misconduct.
The annual report is approved as required. The report reflects that that the agency has compared the
results of annual reports and used them to continuously improve policies; procedures; practices; and
training on a statewide basis. The annual report has been reviewed and the report is accessible to the
public through the FDJJ website. There are no personal identifiers on the annual reports.
Standard 115.389: Data storage, publication, and destruction
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.389 (a)
▪ Does the agency ensure that data collected pursuant to § 115.387 are securely retained?
☒ Yes ☐ No
115.389 (b)
▪ Does the agency 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? ☒ Yes ☐ No
115.389 (c)
▪ Does the agency remove all personal identifiers before making aggregated sexual abuse data
publicly available? ☒ Yes ☐ No
115.389 (d)
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▪ Does the agency maintain sexual abuse data collected pursuant to § 115.387 for at least 10
years after the date of the initial collection, unless Federal, State, or local law requires
otherwise? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
FDJJ 1919 provide that all data collected will be securely stored and maintained for at least 10 years
after the initial collection date, unless statutes require otherwise. According to the policy, the
aggregated sexual abuse data from all facilities will be readily available to the public through the
agency’s website; the practice is that the report is posted on the agency’s website. A review of the
annual report verified that there are no personal identifiers, as required.
AUDITING AND CORRECTIVE ACTION
Standard 115.401: Frequency and scope of audits
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.401 (a)
▪ During the three-year period starting on August 20, 2013, and during each three-year period
thereafter, did the agency ensure that each facility operated by the agency, or by a private
organization on behalf of the agency, was audited at least once? (N/A before August 20, 2016.)
☒ Yes ☐ No ☐ NA
115.401 (b)
▪ During each one-year period starting on August 20, 2013, did the agency 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? ☒ Yes ☐ No
PREA Audit Report Page 77 of 80 Facility Name – double click to change
115.401 (h)
▪ Did the auditor have access to, and the ability to observe, all areas of the audited facility?
☒ Yes ☐ No
115.401 (i)
▪ Was the auditor permitted to request and receive copies of any relevant documents (including
electronically stored information)? ☒ Yes ☐ No
115.401 (m)
▪ Was the auditor permitted to conduct private interviews with inmates, residents, and detainees?
☒ Yes ☐ No
115.401 (n)
▪ Were residents permitted to send confidential information or correspondence to the auditor in
the same manner as if they were communicating with legal counsel? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The FDJJ ensured the completion of PREA audits for each facility as required for the initial three-year
period, including this facility. The agency has embarked on fulfilling the auditing requirements for this
second three-year period. The facilities have provided the auditors with the required documentation
which the auditors have maintained as required by the standards and the auditing process.
A comprehensive tour of the facility was provided to the auditor during the site visit and additional
documentation was reviewed by the auditor during the site visit. The facility staff members and the
parent agency’s PREA Coordinator were cooperative in providing additional documentation as
requested. The Facility Administrator provided appropriate work space which included conditions for
conducting interviews in private with the residents and staff.
PREA Audit Report Page 78 of 80 Facility Name – double click to change
Standard 115.403: Audit contents and findings
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.403 (f)
▪ The agency has published on its agency website, if it has one, or has otherwise made publicly
available, all Final Audit Reports within 90 days of issuance by auditor. The review period is for
prior audits completed during the past three years PRECEDING THIS AGENCY AUDIT. In the
case of single facility agencies, the auditor shall ensure that the facility’s last audit report was
published. 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 that there has never been a
Final Audit Report issued.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all 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 the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
This facility was previously audited in 2014 and the Auditor confirmed the audit report was posted on
the agency’s website as is the practice with FDJJ. This report does not contain any personal identifying
information and there were no conflicts of interest regarding the completion of the audit. The facility and
agency policies were reviewed regarding compliance with the standards and have been identified in the
report. The audit findings were based on a review of policies and procedures and supporting
documentation; interviews with staff and residents; and observations.
PREA Audit Report Page 79 of 80 Facility Name – double click to change
AUDITOR CERTIFICATION
I certify that:
☐ 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, and
☐ I have not included in the final report any personally identifiable information (PII)
about any resident or staff member, except where the names of administrative
personnel are specifically requested in the report template.
Auditor Instructions:
Type your full name in the text box below for Auditor Signature. This will function as your official
electronic signature. Auditors must deliver their final report to the PREA Resource Center as a
searchable PDF format to ensure accessibility to people with disabilities. Save this report document
into a PDF format prior to submission.1 Auditors are not permitted to submit audit reports that have
been scanned.2 See the PREA Auditor Handbook for a full discussion of audit report formatting
requirements.
Shirley L. Turner January 14, 2018
Auditor Signature Date
1 See additional instructions here: https://support.office.com/en-us/article/Save-or-convert-to-PDF-d85416c5-7d77-4fd6-
a216-6f4bf7c7c110 .
2 See PREA Auditor Handbook, Version 1.0, August 2017; Pages 68-69.
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report_type: PREA

program_name_raw: centralpascogirls