state: FL

facility_name: residential alternative for mentally challenged

summary: PREA - FINAL

raw_content:
Prison Rape Elimination Act (PREA) Audit Report
Juvenile Facilities
☐ ☒
Interim Final
Date of Report January 31, 2018
Auditor Information
Name: Cheryl M. Anderson Email: thechandegroup@gmail.com
Company Name: Correctional Management and Communications Group, LLC
Mailing Address: PO Box 502 City, State, Zip: Blythewood, SC 29016
Telephone: 803-240-1209 Date of Facility Visit: January 11, 2018
Agency Information
Name of Agency Governing Authority or Parent Agency (If Applicable)
Twin Oaks Juvenile Development, Inc.
Physical Address: 2930 Kerry Forrest Parkway City, State, Zip: Tallahassee, FL 32309
Suite #101
Mailing Address: Same as above City, State, Zip: Same as above
Telephone: (850) 536-6225 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: To provide quality services that promote the development of successful, responsible,
productive and accountable citizens by fulfilling the social, emotional, physical, and spiritual needs in
a caring and supportive environment.
Agency Website with PREA Information: www.twinoaksfl.org
Agency Chief Executive Officer
Name: Donald B. Read Title: Chief Executive Officer
Email: dread@twinoaksfl.org Telephone: (850) 643-7698
Agency-Wide PREA Coordinator
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Name: Charles Chervanik Title: COO - Agency PREA Coordinator
Email: cchervanik@twinoaksfl.org Telephone: 850- 643-8049
PREA Coordinator Reports to: Number of Compliance Managers who report to the
PREA Coordinator 3
Chief Executive Officer
Facility Information
Name of Facility: Residential Alternative for the Mentally Challenged (RAMC)
Physical Address: 742 SW Greenville Hills Road, Greenville, FL 32331
Mailing Address (if different than above):
Telephone Number: 850-948-1226
The Facility Is: ☐ ☐ ☒
Military Private for Profit Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Facility Type: ☐ ☐ ☐ ☒
Detention Correction Intake Other
Facility Mission: To provide quality services that promote the development of successful,
responsible, productive and accountable citizens by fulfilling the social, emotional, physical, and
spiritual needs in a caring and supportive environment.
Facility Website with PREA Information: www.twinoaksfl.org
☒ ☐
Is this facility accredited by any other organization? Yes No
Facility Administrator/Superintendent
Name: Ron Matthews Title: Program Director
Email: rmatthews@twinoaksfl.org Telephone: (850) 643-8226
Facility PREA Compliance Manager
Name: Ron Matthews Title: Program Director/PREA Compliance Manager
Email: rmatthews@twinoaksfl.org Telephone: (850) 643-8226
Facility Health Service Administrator
Name: Michelle Miller Title: Director of Nursing
Email: mmiller@twinoaksfl.org Telephone: (850) 973-0064
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Facility Characteristics
Designated Facility Capacity: 42 Current Population of Facility: 34
Number of residents admitted to facility during the past 12 months 66
Number of residents admitted to facility during the past 12 months whose length of stay in 66
the facility was for 10 days or more:
Number of residents admitted to facility during the past 12 months whose length of stay in 66
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 9-18
Population:
Average length of stay or time under supervision: 9-12 mos.
Facility Security Level: Non-secure
Resident Custody Levels: Moderate Risk
Number of staff currently employed by the facility who may have contact with residents: 54
Number of staff hired by the facility during the past 12 months who may have contact with 6
residents:
Number of contracts in the past 12 months for services with contractors who may have 3
contact with residents:
Physical Plant
Number of Buildings: 5 Number of Single Cell Housing Units: 0
Number of Multiple Occupancy Cell Housing Units: 3
Number of Open Bay/Dorm Housing Units: 0
Number of Segregation Cells (Administrative and 0
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 facility is equipped with a video surveillance system which includes 17 cameras. The monitors
are located in the Main Control room in the administrative area. The monitoring data will be
maintained for at least 30 days or until review of data is complete, whichever occurs first.
Medical
Type of Medical Facility: Nurse station with weekly on-site visits from
Physician.
Forensic sexual assault medical exams are conducted Madison County Memorial Hospital
at:
Other
Number of volunteers and individual contractors, who may have contact with residents, 3
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 Residential Alternative for the Mentally Challenged (RAMC) facility, located in Greenville,
Florida, is operated by Twin Oaks Juvenile Development, Inc. through a contract with the
Florida Department of Juvenile Justice (DJJ). The facility’s first PREA audit was conducted in
January 2015. The current audit was attained and assigned to the Auditor by Correctional
Management and Communications Group, LLC of Minneola, Florida.
The current on-site audit was conducted January 11, 2018. In preparation for the on-site audit,
a conference call was conducted with the Florida Department of Juvenile Justice (FDJJ)
Statewide PREA Coordinator, the facility’s Program Director, who also serves as the PREA
Compliance Manager, identified staff from the facility and the parent agency, and this Auditor
to discuss the audit process and data gathering. During the conference call, introductions
were made and the audit process and requested documentation were reviewed. The pre-audit
preparation phase included a review of all documentation, materials, and data submitted by the
facility in the completed Pre-Audit Questionnaire (PAQ). The documentation reviewed included
agency policies and procedures; forms; organizational charts; PREA related posters,
brochures; training documentation for staff, volunteers and contractors; and interagency
collaborative agreements.
The notifications of the on-site audit were posted in various parts of the facility at least six
weeks prior to the site visit. Photographs were taken of the various sites where the notices had
been posted and the photographs were electronically sent to this Auditor, noting their
locations. The Pre-Audit Questionnaire and the supporting documentation were uploaded to a
flash drive, which was received approximately three weeks prior to the on-site audit. During the
review of the information on the flash drive, communication was maintained with the facility
and agency staff and additional information was provided or clarified as requested. The Chief
Operating Officer (COO) for Twin Oaks Juvenile Development, Inc. serves as the agency’s
PREA Coordinator.
An entrance meeting was held with the Program Director, COO/PREA Coordinator, and an
administrative staff from the corporate office. Following the meeting, a comprehensive tour of
the facility was provided by the Program Director, accompanied by the staff that was present
during the entrance meeting. During the tour, direct-care staff was observed to be supervising
and interacting with the residents. During the tour, observations were made by the Auditor
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that PREA signage was not displayed in areas that are frequented by the residents; therefore,
the Auditor recommended that this facility post additional PREA signage and ensure that it
has bold print and is child friendly. Corrective actions were taken to rectify this issue. Photos
of the additional signage were sent to the Auditor to verify the actions taken.
The Auditor reviewed staff, contractor and volunteer training records to ensure all required
training had been completed. The Auditor also reviewed staff personnel files related to
completed investigations and disciplinary actions taken regarding PREA related allegations.
Additional information for the audit process was provided upon request and in a timely manner
while on-site. A close-out meeting was held at the conclusion of the site visit and an
opportunity for questions and a review of the on-site audit process were provided to the facility
and agency staff in attendance.
With the necessary corrective action addressed, the facility was found to be in compliance with
all applicable standards as indicated below and detailed throughout this report.
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 RAMC is a non-secure, moderate risk facility that serves male juvenile offenders between
the ages of 9-18. The average length of stay is approximately 9-12 months. The facility’s
rated capacity is 42. The program is housed on a spacious campus and consists of a main
building that houses the administrative area of offices, entrance lobby and the control room.
The facility is equipped with a video surveillance system which includes 17 cameras. The
main building also contains the cafeteria and kitchen; classrooms; medical clinic; and the
RAMC Cafe that serves as the setting for the operations of the culinary arts vocational
program. There are three dormitories, and each contains a day room area and offices.
Located on the campus is also a building that houses the Boys and Girls Club.
During the onsite audit, the current population was 34 residents. The agency reported 66
residents had been admitted to the facility in the past 12 months. The agency reported 54 staff
employed at the facility during the past 12 months. The agency reported three contracts with
contractors who might have contact with residents and three volunteers and contractors
currently authorized to enter the facility.
Twelve Random staff, seven specialized staff and ten residents were interviewed during the
on-site audit process. Overall, the interviews revealed staff members are knowledgeable of
PREA standards and were able to articulate their responsibilities. The interviews revealed the
residents were informed of their right to be free from sexual abuse and sexual harassment
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and how to report sexual abuse and sexual harassment. The interview selections were
randomly made from rosters provided by the facility. The training records of staff interviewed,
and the files of residents interviewed were reviewed along with policies and other secondary
documentation.
The facility provides supervision of residents in a safe, secure and humane environment. Full
bathrooms are in each dormitory and provide a reasonable amount of privacy for the residents.
The outside grounds contain a basketball court, ample space for additional recreation and
other activities, and an attractive gazebo.
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)
Specific corrective actions taken to address the deficiencies identified during the review and
on-site visit are summarized in this report under the related standard.
Standard 115.333 Resident Education
PREVENTION PLANNING
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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
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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RAMC meets the requirements of this standard based upon the following evidence:
The facility adheres to the Twin Oaks Juvenile Development, Inc. Prison Rape Elimination Act
(PREA) Policy. It affords guidelines for implementing the agency’s approach to complying with
the requirements of the PREA standards. The Policy provides for a zero tolerance approach
regarding all forms of sexual abuse and sexual harassment. It contains definitions of the
prohibited behaviors and sanctions for those who participate in such behaviors. The agency’s
PREA Policy and the facility’s operating procedures are aligned with the Florida Department of
Juvenile Justice PREA Policy (FDJJ 1919).
Agency polices addressed "Preventing" sexual abuse and sexual harassment through the
designation of a PREA Coordinator and PREA Compliance Manager; Criminal History
Background Checks and Child Abuse Registry Checks (Staff, Contractors, and Volunteers, as
applicable); Training (Staff, Volunteers, and Contractors); Staffing; Intake Screening;
Classification; Resident Education; Posting of Signage (PREA Posters, etc.); and Contract
Monitoring. The policies addressed "Detecting" sexual abuse and sexual harassment through
Training (Staff, Volunteers, and Contractors), and Intake Screening. The polices addressed
"Responding" to allegations of sexual abuse and sexual harassment through Reporting;
Investigations; Victim Services; Medical and Mental Health Services; Disciplinary Sanctions for
Staff (including notification of licensing agencies); Incident Review Teams; and Data
Collections and Analysis.
Based on staff interviews and a review of practices, it was noted staff closely monitor for
resident-on-resident sexual misconduct in accordance with the PREA standards.
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
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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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility does not contract with other facilities for the confinement of 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
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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:
Generally accepted juvenile detention and correctional/secure residential practices?
☒ 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
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
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▪ 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)
▪ 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
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▪ 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
☐
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy and practices provide for the implementation of a staffing plan with
adequate staffing levels to protect residents against sexual abuse and provides that the
staffing ratios are per the current program contract. According to the staffing plan and staff
interviews the ratios within the facility are 1:6 during the awake hours and 1:8 during the
sleeping hours.
The assessment of the staffing plan determines whether adjustments are needed in
accordance with the standard. The staffing plan details the methodology that ensures
adherence to the staffing ratios. Documentation of the annual review of the staffing plan dated
August 13, 2017 was reviewed and found in compliance with all elements contained in (d)-1
of this standard. The state-wide PREA Coordinator and the Program Director reviewed the
staffing plan to determine if adjustments are needed however no adjustments were made
during the review.
Unannounced rounds of the facility for the maintenance of a safe environment are conducted
and documented by members of the management team. Policy and practice provide staff
members are prohibited from alerting other staff regarding unannounced rounds occurring. An
Interview with a higher- level staff member confirmed the practice.
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Standard 115.315: Limits to cross-gender viewing and searches
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
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
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information as part of a broader medical examination conducted in private by a medical practitioner?
☒ Yes ☐ No
115.315 (f)
▪ 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.
RAMC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 and RAMC FOP PREA prohibit cross-gender strip searches, or pat down
searches of residents, except in exigent circumstances and there have been no such
searches conducted by direct care staff in the past 12 months as verified by random staff
and random resident interviews.
The facility’s PREA Policy states body cavity searches requires the Program Director’s
authorization and must be conducted by licensed medical personnel in a medical
establishment. There were no body cavity searches of residents in the past 12 months
The PREA Policy states the facility must be configured to allow residents to shower, perform
bodily functions and change clothing without staff of the opposite sex viewing their bodies.
Staff and resident interviews confirm there is no cross-gender viewing. Observation of the
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bathrooms revealed all shower stalls have shower curtains to allow privacy while taking
showers.
FDJJ Policy 1919 PREA and the facility’s PREA Policy require opposite sex staff, volunteers
and contractors entering housing units to announce themselves. Resident interviews verified
this is done on consistent basis.
FDJJ Policy 1919 and the facility’s PREA Policy prohibit the search of a transgender or
intersex resident solely for the purpose of determining the resident’s genital status and staff
interviews verified compliance.
One hundred percent of direct care staff have received training on cross-gender pat down
searches and searches of transgender and intersex residents. The training was verified
during interviews of random staff. Training curriculum and training logs were reviewed and
confirmed compliance.
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,
PREA Audit Report Page 15 of 80 Facility Name – double click to change
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
▪ 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
PREA Audit Report Page 16 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.
RAMC meets the requirements of this standard based upon the following evidence:
RAMC’s PREA Policy, Residents with Disabilities and Limited English Proficiencies, require
steps to be taken to ensure residents with disabilities or who are limited English proficient are
provided meaningful access to all aspects of the facility’s efforts to prevent, protect and
respond to sexual abuse and sexual harassment. This Policy also states the facility will not
rely on resident interpreter, resident readers or any kind of resident assistants except when a
delay in obtaining interpreters services could jeopardize a residents’ safety.
FDJJ’s North Region has a blanket purchase order with Language Line Services, Inc. to
provide interpreter services for facilities in the North Region.
A letter from Madison County School District confirms their ability to provide services for
hearing-impaired, visually impaired and other residents on an as needed basis to provide them
with 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. Mental Health
professionals are also trained to provide appropriate explanations regarding PREA to
residents, when needed.
Random staff interviews verified the facility does not use resident assistants and there
were no instances of resident interpreter or readers being used in the past 12 months.
Written material used to ensure effective communication about PREA with residents with
disabilities and residents who are limited English proficient are available for use when
needed.
Standard 115.317: Hiring and promotion decisions
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
PREA Audit Report Page 17 of 80 Facility Name – double click to change
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
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
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▪ 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
▪ 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
PREA Audit Report Page 19 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.
RAMC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1800 Background Screening, FDJJ Policy 1919 PREA and the facility’s PREA
Policy, Hiring and Promotions, address hiring and promotion processes and decisions,
including the requirement for background checks for new hires. The collective Policies and
interview with the Human Resource staff member revealed information regarding the hiring
process, completion of background checks, and the grounds for termination. The Policies are
aligned with the requirements of the standard and provide that background checks are
conducted every five years. A review of a sample of personnel files confirmed compliance.
A pre-hire form requires applicants to provide information regarding previously related sexual
misconduct allegations and convictions. The policies prohibit hiring or promoting anyone who
may have contact with residents and prohibit enlisting the services of any contractor who may
have contact with residents who engaged in previous sexual misconduct.
According to the Human Resource staff, the facility considers any incidents of sexual abuse or
sexual harassment in determining whether to hire a person, contract for services, or whether to
promote an employee. Policies FDJJ 1800 and FDJJ 1919 and an interview with the Human
Resource staff provide staff has a continuing duty to report misconduct and provide omissions
of misconduct or providing false information will be grounds for termination.
The PREA Coordinator provided documentation that Florida State law does not allow
FDJJ or other agencies to contact the abuse registry for the purpose of screening
applicants.
A review of personnel files for a sample of staff hired in the past 12 months revealed all had
criminal records checks and a sample review of personnel files of current staff employed for
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more than 5 years revealed all have had criminal background checks conducted every five
years.
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.
RAMC meets the requirements of this standard based upon the following evidence:
RAMC has not acquired any new facilities or updated surveillance technology since August 20,
PREA Audit Report Page 21 of 80 Facility Name – double click to change
2012. The video monitoring system was assessed during the annual review of the staffing
plan, dated August 23, 2017, to determine if upgrades were needed to enhance the facility’s
ability to protect residents from sexual abuse. No blind spots were identified during the review.
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
PREA Audit Report Page 22 of 80 Facility Name – double click to change
▪ Has the agency documented its efforts to provide SAFEs or SANEs? ☒ Yes ☐ No
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)
PREA Audit Report Page 23 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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy addresses this standard and states that staff is expected to
cooperate in investigations conducted by the FDJJ Office of the Inspector General (OIG).
Administrative investigations are conducted by OIG and criminal investigations are conducted
by the Florida Department of Children and Families and local law enforcement. The PREA
Policy states that upon the arrival of law enforcement investigators, a copy of the PREA
Compliance Form will be provided to them which contain the PREA standards requirements
regarding investigations.
The facility’s PREA Policy further provides for forensic medical examinations to be completed
at no financial cost to the victim. There have been no forensic examinations conducted during
this audit period. The agency has a written Agreement with Tammy Williams, Forensic Nurse
Specialist, for the provision of forensic medical examinations for residents when needed as
verified during the PREA Compliance Manager’s interview.
Documentation was provided showing attempts to make arrangements for advocacy services
through the community resources of the Sheriff’s Department and the rape crisis center. The
facility has a written Professional Services Agreement with an agency staff member who is a
Licensed Mental Health Counselor that will be able to provide supportive services to residents
as needed.
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
PREA Audit Report Page 24 of 80 Facility Name – double click to change
▪ 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
▪ 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.
RAMC meets the requirements of this standard based upon the following evidence:
PREA Audit Report Page 25 of 80 Facility Name – double click to change
The facility’s PREA Policy and FDJJ 1919 provide staff report all allegations of sexual abuse
and sexual harassment and the appropriate investigative entity be contacted when allegations
of sexual abuse are made. There was one allegation from a resident at this facility that was
reported during this audit period and it was investigated according to policy. A review of the
documentation and an interview with the Program Director revealed that the incident was
reported and documented as required. The investigation was closed by the Florida
Department of Children and Families and local law enforcement, with no findings. The
incident was determined to be unfounded.
The Twin Oaks Juvenile Development, Inc. website contains information regarding the referral
of allegations for investigations of sexual abuse and it has related information posted, which is
accessible to the public. The website is very informative and educational to the public as well
as the staff.
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
PREA Audit Report Page 26 of 80 Facility Name – double click to change
▪ 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
▪ 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
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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.
RAMC meets the requirements of this standard based upon the following evidence:
FDJJ provides PREA training through SkillPro, an online E-Learning training system. At the end
of the PREA course, staff are tested and receive a score based upon their comprehension of
the material provided.
Facility Policy and FDJJ 1919 address PREA related training for staff. The policies, training
materials, staff interviews, and a review of training rosters verify staff training occurs. 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.
The Facility Trainer coordinates and assigns training and maintains the staff training records.
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
PREA Audit Report Page 28 of 80 Facility Name – double click to change
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
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.
RAMC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and RAMC’s PREA Policy require volunteers and contracted
providers who have contact with residents to be trained on their responsibilities on sexual
misconduct prevention, detection, reporting and responding to sexual abuse, assault or sexual
harassment. The level and type training provided to contract providers and volunteers is based
upon the service they provide and the level of contact they have with residents, but at a
minimum all contract providers and volunteers will be informed of FDJJ’s policy on zero-
tolerance against sexual abuse and sexual harassment as well as informed on how to report
incidents.
The facility’s PREA Policy contains information regarding the training of volunteers and
contractors who have contact with residents. Receipt of the training is documented, and it
contains a review of the agency’s zero tolerance (PREA) policy. An interview with the Program
Director verified this information.
Standard 115.333: Resident education
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.333 (a)
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▪ 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
▪ 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
PREA Audit Report Page 30 of 80 Facility Name – double click to change
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)
☐
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.
RAMC meets the requirements of this standard based upon the following evidence:
A review of the facility’s PREA Policy, other documentation and interviews with residents and
staff confirm residents receive information about the contents of the Policy, including how to
report incidents of sexual abuse or sexual harassment. According to the facility’s PREA Policy,
the facility will provide support services in accessible formats for residents who are limited
English proficient, deaf, visually impaired, or otherwise disabled.
As a corrective action, the Program Director has displayed additional and youth friendly
postings of PREA information in areas frequented by the residents. Photographs have been
provided to this Auditor to verify additional postings.
Standard 115.334: Specialized training: Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.334 (a)
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▪ 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)
▪ 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
PREA Audit Report Page 32 of 80 Facility Name – double click to change
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.
RAMC meets the requirements of this standard based upon the following evidence:
FDJJ 1919 and the facility’s PREA Policy state that staff in the OIG will be trained on the
related policies and procedures regarding the handling of sexual misconduct incidents and
reports. Training is provided to investigative staff regarding conducting investigations in the
facility settings.
Facility staff does not conduct administrative nor criminal investigations into allegations of
sexual abuse and sexual harassment.
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 does not conduct forensic exams.) ☐ Yes ☐ No ☒ NA
115.335 (c)
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▪ 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)
☒
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.
RAMC meets the requirements of this standard based upon the following evidence:
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.
A review of training documentation and staff interviews confirm the specialized training
occurs for medical and mental health staff. Forensic examinations are not conducted by
the facility’s medical staff as verified during the medical staff interview. Forensic
examinations are conducted at the local hospital by SANE or SAFE certified examiners.
SCREENING FOR RISK OF SEXUAL VICTIMIZATION
AND ABUSIVENESS
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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)
▪ 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
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▪ 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
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
PREA Audit Report Page 36 of 80 Facility Name – double click to change
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy and FDJJ 1919 address this standard. The screening for risk of
sexual abuse victimization or sexual abusiveness toward other residents is being conducted on
each resident. The initial screening is done during the intake process and the facility’s PREA
Policy states the treatment teams should continually review the resident’s adjustment.
Interviews with residents and staff and a review of documentation confirmed the practices.
A review of VSAB forms in residents’ files and resident interviews revealed risk screenings
are being conducted or reviewed by Intake staff upon arrival. The VSAB form includes each
component contained in section (c) of this standard.
Resident interviews indicated they were asked whether they identify with being gay, bi-
sexual, transgender or intersex, if they think they are in danger of sexual abuse and if they
have any disabilities. Random resident interviews verified they were asked the same
questions by mental health staff during their initial interview.
Completed VSAB forms are maintained in residents’ medical and Intake files and are available
to staff only on a need to know basis.
Standard 115.342: Use of screening information
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
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
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▪ 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
▪ 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
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▪ 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
▪ 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)
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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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy prohibits placing gay, bisexual, transgender, or intersex residents in
particular housing based solely on such identification or status. Housing and program
assignments will be made for each transgender or intersex resident on a case by case basis
and the resident’s view regarding safety will be seriously considered. According to the facility’s
PREA Policy, the facility prohibits considering gay, bisexual, transgender, or intersex
identification or status as an indicator of the likelihood of being sexually abusive.
Random staff interviews indicated protective measures would be taken immediately if it was
determined that a resident was at risk or imminent sexual abuse and responses included
separating residents and alerting the supervisor of the situation. An interview with the Program
Director indicated his expectations for protective measures to be taken immediately.
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)
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▪ 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)
▪ 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.
PREA Audit Report Page 41 of 80 Facility Name – double click to change
RAMC meets the requirements of this standard based upon the following evidence:
According to the facility’s PREA Policy, there are internal ways a resident may report
allegations of sexual abuse; sexual harassment; retaliation for reporting; and staff neglect or
other violations that lead to abuse. A resident may place a note or grievance form in the Sick
Call/PREA Box; complete a form requesting to see a specific staff member; talk to a staff
member; and third parties may report allegations to staff or through the Florida abuse hotline.
Interviews with staff and residents and a review of documentation support the practices.
PREA related information is posted in each dormitory. Residents are provided access to a
telephone to report allegations of sexual abuse and sexual harassment to the abuse reporting
hotline. The abuse reporting hotline number is posted in the dormitories. Interviews revealed
that staff members are aware of their responsibility to report sexual abuse and sexual
harassment. They are also aware that they may accept reports of sexual abuse and sexual
harassment made verbally, in writing, anonymously, and from third parties.
A resident may also call or write his/her parent(s) or guardian or call or write his/her attorney or
legal representative.
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
▪ 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)
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▪ 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
▪ 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
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▪ 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)
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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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy prohibits the use of an informal grievance process regarding
allegations of sexual abuse and sexual harassment. The facility considers resident grievances
regarding sexual abuse to be an allegation of sexual abuse and when such a complaint is
received, the procedures regarding reporting allegations are initiated.
Residents may place written allegations of sexual abuse or sexual harassment in the
Grievance/PREA Box which is accessible to all residents. Residents may also give a written
complaint to a staff member who is not the subject of the complaint. The facility’s PREA and
Grievance Policies provide the timeline for the response to the complaints.
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 assessable 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
▪ 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)
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▪ 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.
RAMC meets the requirements of this standard based upon the following evidence:
The PREA Policy requires the facility to provide the residents with access to outside victim
advocacy services. The facility has documentation showing their efforts to obtain outside
victim advocacy services. A written Professional Services Agreement exists with a Licensed
PREA Audit Report Page 46 of 80 Facility Name – double click to change
Mental Health Counselor who is employed with the agency but does not work within the
facility.
Residents are allowed to see their parents at visitation on a specified day and may talk to
them one-two times per week. Attorneys or other legal representation may visit residents in a
confidential manner.
Random resident interviews helped to verify this standard.
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
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy provides guidelines regarding third-party reporting. The agency
website and the DJJ website provide the public with information regarding the reporting of
abuse. Parents and other visitors are informed about reporting incidents of sexual abuse
through information posted in the facility.
PREA Audit Report Page 47 of 80 Facility Name – double click to change
Resident interviews revealed their awareness of reporting sexual abuse or sexual
harassment to others outside of the facility including their parents/legal guardians.
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)
▪ 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
PREA Audit Report Page 48 of 80 Facility Name – double click to change
▪ 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)
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 49 of 80 Facility Name – double click to change
According to the facility’s PREA Policy, all staff members are mandated reporters. Staff
members are to immediately report any knowledge, suspicion or information they receive
regarding sexual abuse, sexual harassment; retaliation against residents or staff who report
any incidents; or any staff neglect or violation of responsibilities that may have contributed to
an incident. All staff members interviewed are aware of their reporting duties.
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)
☒
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy provides when it is learned a resident is subject to substantial risk of
imminent sexual abuse, immediate action is taken to protect the resident. There have been no
incidents in the last 12 months where the facility took any action in regards to a resident being
in substantial risk of imminent sexual abuse.
There were no residents identified as being at risk for sexual abuse in the past 12 months, as
revealed in interviews with the Program Director and random staff.
Standard 115.363: Reporting to other confinement facilities
PREA Audit Report Page 50 of 80 Facility Name – double click to change
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
☐
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy and FDJJ 1919 address this standard. Upon receiving an allegation
that a resident was sexually abused while confined in another facility, the Program Director will
notify the Central Communications Center (CCC) and the Department of Children and Families
PREA Audit Report Page 51 of 80 Facility Name – double click to change
of the allegation. Additionally, the facility head of the other facility will be notified. The
notifications will be made within 72 hours of receipt of the allegation.
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,
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
PREA Audit Report Page 52 of 80 Facility Name – double click to change
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy and FDJJ 1919 guide the response to this standard. The Policies
provide direction to staff in responding to allegations of sexual abuse. Staff training has been
provided.
Random staff interviews revealed considerable knowledge of actions to be taken upon learning
a resident alleges being sexually abused.
Standard 115.365: Coordinated response
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
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.
RAMC meets the requirements of this standard based upon the following evidence:
PREA Audit Report Page 53 of 80 Facility Name – double click to change
The facility plan, Coordinated Response, is detailed in its guidance to staff regarding steps to
take in the event of an incident or 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.
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility does not maintain any collective bargaining agreements.
Standard 115.367: Agency protection against retaliation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
PREA Audit Report Page 54 of 80 Facility Name – double click to change
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
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
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▪ 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.
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy supports protection against retaliation for residents and staff who
report allegations of sexual abuse or sexual harassment. A facility staff member has been
PREA Audit Report Page 56 of 80 Facility Name – double click to change
identified to monitor for the occurrence of retaliation. The Policy identifies areas to monitor
regarding possible retaliation of residents and staff.
The Program Director serves as the Retaliation Monitor and the interview revealed he is
knowledgeable of the position’s responsibilities. He articulated multiple measures available for
victims, abusers and staff such as housing changes, transfers, reassign staff, etc. FDJJ has
developed a form to document monitoring.
There was no retaliation monitoring in 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)
☒
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility does not use segregated housing; however, staff interviews revealed that
protective measures may be used that include one to one supervision by staff and assigning
the resident to another dormitory. The rooms in the dormitories vary from housing one to four
residents.
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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
▪ 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
PREA Audit Report Page 58 of 80 Facility Name – double click to change
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)
▪ 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.
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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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy and FDJJ 1919 address this standard. Administrative investigations
are conducted by the FDJJ Office of Inspector General and criminal investigations are
conducted by the Department of Children and Families and local law enforcement. Both
Policies direct facility staff to cooperate with investigations.
According to FDJJ 1919, an investigation is not terminated solely because the source of the
investigation recants the allegation. Substantiated allegations of conduct that appear to be
criminal are referred for prosecution.
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
PREA Audit Report Page 60 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.
RAMC meets the requirements of this standard based upon the following evidence:
The OIG, responsible for administrative investigations, imposes 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)
▪ 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
PREA Audit Report Page 61 of 80 Facility Name – double click to change
▪ 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)
▪ 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)
PREA Audit Report Page 62 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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy and FDJJ 1919 provides the process for notifying residents,
following an investigation, of whether an allegation has been determined to be substantiated,
unsubstantiated, or unfounded.
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)
▪ 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
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▪ 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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy provides for disciplinary sanctions for staff to be up to and including
termination for violation of the sexual abuse and sexual harassment policies. The Policy
requires the violation be reported to local law enforcement and provides for contacting relevant
licensing bodies. In the past 12 months, no staff has been terminated or has resigned for
violating PREA related 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)
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▪ 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.
RAMC meets the requirements of this standard based upon the following evidence:
An incident regarding sexual abuse by a contractor or volunteer will be reported as required,
including to relevant licensing bodies, according to the facility’s PREA Policy. The facility will
prohibit future contact with residents in the case of any violation of the facility’s PREA related
policies. During the past 12 months, no contractor or volunteer has been reported to law
enforcement or any investigative entity for allegations of sexual abuse.
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
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▪ 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
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
PREA Audit Report Page 66 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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy provides that any resident found in violation of the Policy may be
subject to disciplinary action, following a formal process. The resident may be transferred to
another facility following an administrative or criminal finding of resident-on-resident sexual
abuse. During the past 12 months there have been no incidents of resident-on-resident sexual
abuse.
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
PREA Audit Report Page 67 of 80 Facility Name – double click to change
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
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy addresses the elements of this standard. The policy indicates
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.
Residents who disclose a history of sexual abuse or who disclose previously perpetrating
sexual abuse will be offered a follow-up meeting with a medical or mental health practitioner
within 14 days of the intake screening. Medical and mental health staff interviewed confirmed
awareness of the policy and the requirements of the standard.
PREA Audit Report Page 68 of 80 Facility Name – double click to change
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)
▪ 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
PREA Audit Report Page 69 of 80 Facility Name – double click to change
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
RAMC meets the requirements of this standard based upon the following evidence:
According to the facility’s PREA Policy, timely and unimpeded access to emergency medical
treatment and crisis intervention services for victims of sexual abuse will be provided. The
nature and scope of the services are determined by medical and mental health practitioners
according to their professional judgment. Interviews confirmed what is stated in the facility’s
PREA Policy.
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)
▪ 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)
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▪ 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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy provides for ongoing medical and mental health care for sexual
abuse victims. It also provides for medical and mental health evaluations and appropriate
treatment in accordance with the standard. According to staff interviews and a review of
documentation, health care is consistent with the community level of care.
DATA COLLECTION AND REVIEW
Standard 115.386: Sexual abuse incident reviews
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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
▪ 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
PREA Audit Report Page 72 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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy will serve as the guide for staff in conducting incident reviews. The
Policy details the requirements of the standard and states the incident review will occur within
30 days of the conclusion of the investigation. The incident review team has been identified.
The Program Director’s interview indicated familiarity with the role of the incident review team
regarding incidents of sexual abuse.
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)
▪ 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)
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▪ 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.
RAMC meets the requirements of this standard based upon the following evidence:
The agency’s PREA Policy requires the collection of accurate, uniform data for every allegation
of sexual abuse. The agency uses a system called TRENDSTAT for their facilities to collect,
analyze and submit monthly data to the corporate leadership team. The agency has developed
a data collection instrument that includes the required data.
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 the U.S. Department of Justice with data as requested.
Standard 115.388: Data review for corrective action
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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)
☒
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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy and FDJJ 1919 address this standard. Part of the process in
analyzing the data is to identify trends and/or problem areas and to develop corrective actions
where indicated. The Policies require the review of data with the goal of improving the
effectiveness of the agencies’ PREA initiatives in the areas of prevention; protection and
response policies; practices; and training.
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)
▪ 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)
PREA Audit Report Page 76 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.
RAMC meets the requirements of this standard based upon the following evidence:
The facility’s PREA Policy requires that data is collected and securely retained for 10 years,
unless otherwise required by law. The aggregated PREA data is reviewed and all personal
identifiers are removed. The agency has a report posted on its website.
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
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)
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▪ 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.
RAMC meets the requirements of this standard based upon the following evidence:
Since August 20, 2013, FDJJ has ensured one-third of all operated detention centers and all
contracted residential facilities have been audited as evidenced by the Final Audit reports
provided on the Agency’s website.
The Auditor was provided complete access to the facility and observed all areas of the
facility’s buildings and grounds. Additionally, all relevant documents were provided
upon request.
The facility made space available for private staff and resident interviews. Residents were
provided information on the “Notice of the Auditor’s On-site Visit” regarding how to send
confidential information to the Auditor.
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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 has 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.
RAMC meets the requirements of this standard based upon the following evidence:
A review of the FDJJ’s website revealed PREA Audit Reports dating back to 2014 through
2017 for detention centers operated by FDJJ and residential facilities contracted by FDJJ are
posted and can be downloaded.
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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.
Cheryl M. Anderson January 31, 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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source: DJJ

report_type: PREA

status: FINAL