state: FL

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY
REPORT JUVENILE FACILITIES
Name of Facility: AMIkids Big Cypress
Physical Address: 25959 Turner River Road, Ochopee, FL 34141
Date report submitted: February 24, 2016
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: February 2, 2016
Facility Information
Facility Mailing Address: Same as Physical Address
Telephone Number: 239-695-1001
The Facility is: Military County Federal
Private for profit Municipal State
X Private not for profit
Facility Type: Detention Correction X Other: Residential
Name of PREA Compliance Manager: Marvin Ferrell Title: Executive Director
Email Address: bigcypress-ed@amikids.org Telephone Number:
239-695-1001
Agency Information
Name of Agency: AMIkids Big Cypress, Inc.
Governing Authority or Parent Agency:
Physical Address: 5915 Benjamin Center Drive, Tampa, FL 33634
Mailing Address: Same as Above
Telephone Number: 813-887-3300
Agency Chief Executive Officer
Name: O. B. Stander Title: CEO/President
Telephone 813-887-3300
Email Address: obs@amikids.org
Number:
Agency Wide PREA Coordinator
Name: Wendell Watson Title: Regional Director
Email Address: WLW@amikids.org Telephone Number: 3 2 1 - 8 6 3 - 1 4 9 7
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AUDIT FINDINGS
NARRATIVE:
The AMIkids Big Cypress residential program is located on the Big Cypress National Preserve in
Ochopee, Florida and is operated through a contract with the Florida Department of Juvenile Justice
(DJJ). The facility serves low and moderate risk male juvenile offenders between the ages of 13 and
18. The length of stay is three to nine months and the facility capacity is 30. Risk and needs
assessments are completed on each resident in order to develop individualized plans that combine
behavior modification, education and treatment. This comprehensive approach addresses mental
health issues; addiction; family issues; academic problems; and legal consequences.
Medical services are provided on-site by a full-time Registered Nurse who is the Lead Nurse and
there is a part-time Registered Nurse. The contract physician visits the facility at least weekly and is
on-call. Mental health services are provided by on-site staff through the Director of Treatment, two
full-time therapists and one contract therapist. A contract psychiatrist visits the facility every two
weeks. Each resident participate in individual and group counseling; residents have the opportunity to
learn to develop skills to resolve issues regarding anger management, substance abuse, alcohol abuse;
and other mental health issues.
Education services include academic and remedial work, GED preparation, and Post GED courses.
The education services also include the teaching of employability skills and independent living skills.
Community activities such as service projects, group work projects and incentive trips are available to
each resident as he progresses through the program. Through experiential education the facility
provides opportunities for residents to participate in life experiences that they may not have been
exposed to if it was not for this program. The facility offers a vocational program in construction
which is supported by an accreditation organization, National Center for Construction & Education
Research (NCCER). A vocational program is also offered in food service, where residents may earn
ServSafe food handler certification from the National Restaurant Association. The facility uses a
point system as a part of behavior management techniques. The number of points a resident earns is
based on their participation and behavior throughout each day. Achieving a certain number of points
for the level the resident is on affords him the opportunity to participate in the Bid Store, special
programs and special activities on campus.
DESCRIPTION OF FACILITY CHARACTERISTICS:
There are six primary buildings that make up the Big Cypress program: administration; dorm 1; dorm
2; education; kitchen/dining area; and vocation. The administrative building consists of a reception
area, administrative offices; conference room; and the medical clinic. The dormitories have
aesthetically screened porches and ramps leading into them which represent the work completed by
the residents under staff supervision. The set-up of the dorms and strategically placed staff afford
residents a reasonable amount of privacy during showers within their housing units. The education
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building has a screened front porch area where staff members are stationed, three classrooms, and
two bathrooms. A shelter is attached to the education building that serves as a physical fitness area
which contains related equipment. The kitchen building comprises ample space for the cooking and
dining areas. The vocation building is a large structure located beyond the group of other buildings.
The grounds also contain a greenhouse, several picnic tables which the residents built, and storage
sheds. A “Bikes for Tykes” portable structure is on the grounds and is used by the residents and staff
in repairing bikes that are later donated to children and adults in need. The grounds provide ample
space for various outside large muscle exercises, recreation and other activities.
Thirty-five staff members who may have contact with residents are currently employed at the
facility. Seventy-six youth were admitted to the facility during the past 12 months. Seventy-six
residents have been admitted to the facility in the past 12 months.
SUMMARY OF AUDIT FINDINGS:
The notifications of the on-site audit were posted in various parts of the facility 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. Telephone conversations were held
with the Executive Director and other AMIkids staff and the DJJ statewide PREA Coordinator to
review the PREA audit processes. The facility policies and supporting documentation were
uploaded to a flash drive, which was received by the Auditor prior to the on-site visit. After
reviewing the information, notes were sent to staff to seek clarity of information and to note the
additional documents needed. In response to the issues noted, additional information was provided
and discussed during the site visit.
The on-site visit was conducted February 2, 2016. An entrance meeting was held and a
comprehensive tour of the facility was conducted by a resident accompanied by the Executive
Director and the Director of Case Management from another AMIkids facility, Melbourne Center
for Personal Growth. During the tour, staff members were observed to be actively engaged in
supervising and interacting with the residents. There were 18 residents at the facility on the date of
the audit and interviews were conducted with randomly selected residents. Interviews were
conducted with direct care staff from all shifts and staff identified in the specialized areas. The staff
members interviewed were knowledgeable of the related policies and their duties and
responsibilities as they relate to PREA compliance. At the conclusion of the audit, a summary of the
findings were provided in a close-out meeting with the Executive Director and the Director of Case
Management from the Melbourne Center for Personal Growth, who provided technical support to
the Big Cypress program.
Number of Standards Exceeded: 0
Number of Standards Met: 39
Number of Standards Not Met: 0
Number of Standards Not Applicable: 2
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Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
AMIkids Big Cypress has developed a collection of policies and procedures that directly
address the PREA standards. The policies are aligned and used interchangeably with the
overarching Florida Department of Juvenile Justice PREA policy and procedures, FDJJ 1919.
The policies and procedures provide guidelines for implementing the facility’s and the
agency’s approach to complying with the requirements of the PREA standards including zero-
tolerance toward all forms of sexual abuse and sexual harassment. Policy 6.11 contains
definitions of the prohibited behaviors and sanctions for those who participate in such
behaviors. The Executive Director, who manages the facility, has been identified as the PREA
Compliance Manager and he reports to the Regional Director.
Standard 115.312 Contract With Other Entities for the Confinement of Residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
The facility does not contract with other agencies for the confinement of residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.13 states the required staff ratio of 1:10 during the waking hours and 1:12 during the
sleeping hours and further states that the plan is predicated on a population of 30 residents.
An annual staffing plan assessment had been conducted, as required, by the DJJ statewide
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PREA Coordinator. The facility has also developed forms for conducting internal annual
staffing assessments. The Policy states that when the required ratios are not met due to
limited and discrete exigent circumstances, the deviation from the plan will be documented in
the facility logbook.
The Policy identifies the management staff responsible for conducting unannounced rounds
to deter sexual abuse. The staff interviewed stated that the unannounced visits occur on all
shifts, as evidenced by documentation, and that staff members are knowledgeable of and
practice not alerting other staff when such visits occur. The facility reports that there have
been no deviations from the staffing plan that is based on the current contract requirements,
during the past 12 months. An interview with the Executive Director revealed how the work
schedules are reviewed to ensure that the ratios are met. He also shared that the facility is
currently involved in implementing the hiring process to increase the number of direct care
staff to meet the staffing ratio requirement of the standard. PREA drills are conducted based
on scenarios that include the completion of a document that considers steps that were taken to
protect the victim; steps to preserve evidence; staff ratio at the scene of the incident; proper
notifications; etc.
Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 6.15, staff members are prohibited from searching a transgender or
intersex resident to determine the resident’s genital status and no type searches have occurred
in the past 12 months. Staff interviews revealed that they are knowledgeable of this
requirement. The Policy also prohibits cross-gender strip and visual body cavity searches and
cross-gender pat-down searches which staff and resident interviews validated as practice. The
viewing of residents by opposite gender staff while they are showering, changing clothes, and
performing bodily functions is not permitted, unless there are exigent circumstances.
According the Policy, signs posted and interviews with staff and residents, female staff
members announce themselves upon entering the dorms or other areas where residents may
be performing bodily functions. Staff and resident interviews support that female staff
members do not provide supervision to residents during shower time or when they are using
the toilet. Supervision practices provide residents with a reasonable amount of privacy and
ensure no cross gender viewing. Training documentation shows and interviews confirm that
staff has received training on conducting searches in a professional and respectful manner,
including searches of transgender and intersex residents.
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Standard 115.316 Residents With Disabilities and Residents Who are Limited English
Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.16 addresses the tenets of this standard including providing that the facility will not
rely on resident interpreters, resident readers or any kind of resident assistance except when
a delay in obtaining interpreter services would jeopardize a resident’s safety, performance of
first responder duties, or an investigation. In such cases, it must be documented by staff in
the logbook according to policy. The staff interviews and documentation show that the
facility has the capability to provide residents with support services from staff and by
contracting with individuals from a list of certified providers. In the past 12 months, there
have been no instances where residents have been used as interpreters, readers or any other
type assistants as verified in staff interviews.
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 6.17 and FDJJ 1919 address the hiring and promotion process including the
requirement of obtaining background checks on all employees and require consideration of
any incidents of sexual harassment in hiring or promotions or in obtaining services of a
contractor. The Policies prohibit hiring or promoting anyone who has engaged in sexual
abuse in prison, jail, juvenile facility, or other institution; convicted of engaging or
attempting to engage in sexual activity by force, threat or coercion; or has been adjudicated
to have engaged in such behavior. Applicants and employees are asked about previous
misconduct and sign the acknowledgment form, Self-Declaration of Sexual Abuse/Sexual
Harassment, as to whether or not any of the actions have occurred. A review of
documentation in personnel files and interviews with staff confirmed that prior to the hiring
of an employee or contractor, background checks are conducted. The Policies and reviewed
documented practices and interviews support that criminal background checks are conducted
every five years and that omissions about misconduct or providing false information are
grounds for termination. The facility reports that during the past 12 months, all individuals
hired have received background checks.
6
Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility uses direct and engaged supervision in ensuring the safety of residents. A camera
system was installed in 2013 to enhance staffs’ supervision and monitoring of the residents.
There has not been a substantial expansion or modification to the facility since August 20,
2012.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policies 6.21 and FDJJ 1919 and staff interviews, the facility is not responsible
for conducting administrative or criminal investigations. The DJJ Office of the Inspector
General (OIG) is responsible for conducting administrative investigations; the Florida
Department of Children and Families (DCF) is responsible for conducting allegations of child
abuse and they are also contacted; and the local law enforcement agency, Collier County
Sheriff’s Office, is responsible for conducting criminal investigations. All of the agencies
follow the requirements of the standards regarding administrative and criminal investigations.
Document review included a draft Memorandum of Understanding (MOU) between the
facility and the Collier County Sheriff’s Office for the investigation of alleged sexual abuse
or attempted sexual abuse occurring at the facility. The draft MOU states that the Sheriff’s
Office will follow uniform evidence protocols that maximize the potential for obtaining
usable physical evidence for administrative proceedings and criminal prosecutions. It further
states that the Sheriff’s Office, as appropriate will utilize protocols of the most recent edition
of “A National Protocol for Sexual Assault Medical Forensic Examinations,
Adult/Adolescents or similar protocols developed after 2011. Information regarding the
administration and location of forensic examinations is also included in the draft document,
which is still in the process of being finalized with all the appropriate signatures. The DJJ
provides each facility with an information sheet that is to be shared with local law
enforcement which provides information regarding protocols related to the investigation of
allegations that are criminal in nature.
7
Policy 6.21 provide that victim advocacy services will be provided and at no cost to the
victim. The facility has a MOU with a rape crisis center, Project Help, Inc. When requested, a
qualified staff member from Project Help will provide support services that include provision
for a forensic examination; accompany the victim through the forensic medical examination
process; access to 24/7 rape crisis hotline, staffed by certified victim advocates; counseling;
information and referral services; and follow-up support. The provision of services to be
provided was confirmed through interviews, including a representative from Project Help,
Inc. There has not been a need for a forensic medical examination during this audit period.
Information is posted in the dorms and other areas of the facility regarding the reporting of
sexual abuse and sexual harassment. In the dining room, there is a poster for Project Help that
provides the information about services and how to make contact and it has an added
convenience of tear-away contact numbers at the bottom of the poster so that anyone
(resident, staff or visitor) may take the number with them when they leave the area.
Standard 115. 322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.22 and FDJJ 1919 identify the agencies that will conduct the criminal and
administrative investigations. Policy instructs the facility staff to cooperate with the OIG
investigations and ensures that an administrative or criminal investigation is completed for all
allegations of sexual abuse and sexual harassment. During the past 12 months, there was one
allegation of sexual abuse that received an administrative investigation. It was determined
that the allegations were Unsubstantiated, according to the reviewed reports and staff
interviews.
The policy regarding the referral of allegations of sexual abuse or sexual harassment for a
criminal investigation, as required by the standard, is available to the public on the DJJ
website. Information regarding reporting sexual abuse is included in the packet provided to
the residents’ parents/legal guardians. All random staff interviews confirmed that allegations
of sexual abuse and sexual harassment are documented.
Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
Policy 6.31 provides for the PREA training outlined in the standard. The staff training covers
the areas referenced in the standard and includes the facility’s and agency’s zero-tolerance
policies. A review of the training documentation and interviews with staff confirms that the
initial training is provided and refresher training is provided annually and as needed. All staff
receives the PREA training and the training is tailored to meet the needs of the population
served. A review of a sample of staff training records and staff interviews support that initial
training and refresher training occurs. The training is a combination of the Florida DJJ
training provided online through Skill-Pro and in-house training.
Standard 115. 332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 6.32 and FDJJ 1919 contain the requirements regarding the training of volunteers
and contractors who have contact with residents. The training covers their responsibilities
regarding the zero-tolerance of sexual assault and sexual harassment and how to report any
allegations or incidents. All vendors visiting the facility are required to read and sign the
Vendor Acknowledgement Statement that includes prohibited behavior, including sexual
contact or sexual conversation with residents. The vendors are also required to read the
Prison Rape Elimination Act Acknowledgement form which includes an overview of PREA,
definitions of sexual abuse, and how to report allegations.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.33 requires that residents receive information about the zero-tolerance policy and
how to report incidents or suspicions of sexual abuse or sexual harassment. During the intake
process residents are provided an age-appropriate education session regarding PREA. A
signed acknowledgement statement by the resident of his having received the training is kept
9
in the case management file. Residents transferring from another facility will also receive the
PREA education during the intake process as verified by staff. Acknowledgement statements
were reviewed in the files; the intake staff articulated how she ensures that each admission
receives the PREA education; and all residents interviewed stated their participation in
PREA education. The facility reports that all 76 admissions during this audit period
participated in education sessions. A new resident was admitted during the on-site visit and
the admission process was observed. Staff took care to put the resident at ease and explain
the rules of the facility and what each step would contain at each step of the intake process.
There were coordinated efforts and cooperation by intake, case management, medical,
mental health, and direct care staffs in service delivery. PREA education is provided to
residents during the intake process.
PREA education would also involve providing the information through accessible formats if
needed for residents who are limited English proficient, deaf, visually impaired, or otherwise
disabled. Support services may be provided through local certified providers; identified
facility staff who speak the prominent languages of residents who are limited English
proficient; and other facility staff. Information regarding PREA and emotional support
services for victims are posted throughout the facility and flyers about the rape crisis center
are also maintained on the desk in the reception area and all of the posted information is
available to residents, staff and visitors. The Student Handbook contains information about
abuse and how to report it.
The interviews with the residents revealed a general uncertainty regarding the specific
services that would be provided to a victim of sexual abuse from the rape crisis center,
although information was posted. The facility had been in communication with the rape
crisis center regarding services but finalized the MOU just prior to the on-site visit and had
not yet provided detailed information about specific services to the residents. A corrective
action was implemented to provide updated training to residents regarding the services that
will be available and confidentiality practices of Project Help, Inc. The subsequent receipt of
a training roster where residents wrote their names and further discussion with staff support
that the updated training has been provided. The flyer from Project Help will continue to be
reviewed in the PREA education sessions and given to the resident as it was done during an
intake that was conducted during the on-site visit.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 states 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 DJJ settings. The draft MOU,
10
between the facility and the Collier County Sheriff’s Office states that the Sherriff’s Office
agrees to comply with the PREA standards regarding the investigative process and will follow
the prescribed protocols. The document has been reviewed by the involved parties. The DJJ
also provides facilities with an information sheet for local law enforcement investigators
regarding protocols for investigations that are criminal in nature.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.35 addresses the elements of this standard. The medical and mental health staff
members received the on-line specialized training through Skill-Pro, provided by DJJ. The
training documentation was reviewed and the interviews with medical and mental health
staff members indicated that they have received the general and specialized PREA training.
Forensic medical examinations are not conducted at the facility.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 2.04/05/06 and 6.41 address this standard. Included in the facility’s classification
process is the use of the Screening for Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) instrument. It is completed on each resident and is an
objective instrument required by DJJ. Staff and resident interviews and a review of
completed VSABs confirm that screening for risk of sexual abuse victimization or sexual
abusiveness toward other residents is being conducted. Policy 6.41 requires that the VSAB is
completed within 72 hours of admissions; however, the staff and resident interviews and a
review of a sample of documents revealed that the practice is that it is completed on the day
of admission. Residents are reclassified, where indicated, during their stay in the program.
The facility reports that 76 residents, all that were admitted during this audit period, were
involved in the classification process and a VSAB was completed.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
11
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.42 provides that information gleaned from the classification process, including
application of the VSAB, is used to guide the decisions regarding bed, education, work and
other program assignments for residents. The facility’s policy addresses isolation in general
and includes the PREA standards’ requirements; however, the practice of the facility and the
agency is that isolation is not used. The facility does not have an isolation room or
segregated housing. The Policy does say that isolating any resident will be done only as a
last resort when less restrictive measures are inadequate to keep the resident or others safe.
Policy 6.42 prohibits placing gay, bisexual, transgender, or intersex residents into
confinement based solely on such identification or status. Housing and program assignments
require determinations on each transgender or intersex resident on a case by case basis. The
Policy, which staff members are familiar with, prohibits considering gay, bisexual,
transgender, or intersex identification or status as an indicator of likelihood of being sexually
abusive. There have been no residents isolated in the last 12 months because he or she was at
risk of sexual victimization.
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 6.51, interviews and observations, there are several internal ways a
resident may report allegations of sexual abuse; sexual harassment; retaliation for reporting;
and staff neglect or other violation(s) that lead to abuse. A resident may talk to any staff
member; put the information in writing and give it to any staff member; the DJJ and the rape
crisis center abuse hotline numbers are available and may be called by residents; and third
parties may report allegations to the facility or use the hotline numbers. The Policy directs
staff to accept reports of sexual abuse and sexual harassment made verbally, in writing,
anonymously, and from third parties; staff interviews reflected knowledge of this mandate.
Interviews with staff and Policy afford staff with methods to privately report allegations
through the use of the abuse hotline and talking to management staff; the methods are
covered in staff training and PREA policies are also reviewed.
Staff interviews were also aligned with the Policy requirement of calling in allegations of
sexual abuse and sexual harassment to the DJJ Central Communications Center within two
hours and documenting the report within eight hours. The resident grievance system may also
12
be used to report allegations of sexual abuse or sexual harassment by completing a grievance
form and placing it in the locked grievance box. Through observations and resident
interviews it was determined that residents have access to writing tools to complete a
grievance form.
.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 6.52 and staff interviews, the facility considers resident grievances
regarding sexual abuse to be an allegation of sexual abuse and when such a complaint is
received, the reporting policies and procedures are initiated. The Policy states that
allegations of sexual harassment grievances will be addressed through the facility’s
grievance system. The facility makes the current grievance process another method for
internal reporting of allegations of sexual harassment and a resident may report allegations
of sexual abuse using the grievance system. The facility staff does not investigate allegations
of sexual abuse or sexual harassment; once the alert is made to staff through the grievance
system, the allegations are reported and the OIG or appropriate investigative entity will
follow-up regarding the investigation. The facility does not have administrative procedures
to address grievances regarding sexual abuse due to them being considered an allegation of
sexual abuse and addressed through reporting and investigation policies. There have been no
grievances alleging sexual abuse filed in the past 12 months.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.53 supports the residents having access to outside victim advocacy services. A MOU
has been obtained with the local rape crisis center. Project Help, Inc. Posters are displayed
regarding the services and contact information. Flyers are also maintained at the front desk in
the reception area, available to staff, visitors and also residents. The details of the MOU were
recently completed and a written document was developed. The details of the services had not
yet been thoroughly reviewed with the residents prior to the site visit. A corrective action was
13
implemented after the site visit where a PREA education session was conducted with all
residents receiving a review of the specific services and the confidentiality practices of the
facility and Project Help, based on the written materials received from the agency. A roster of
the residents, where they had written their names, was submitted to the auditor with additional
discussion with staff regarding the PREA training. While on site it was discussed how the
specific information would be incorporated in the PREA education session that is provided
with each resident during the intake process. Interviews with staff stated that reasonable
privacy is given to residents regarding reporting allegations of sexual abuse and would be
provided during any instance that a resident contacts Project Help.
Policy 6.53 provides for reasonable and confidential access to attorneys and other court or
agency staff. The Policy also provide for the residents to have reasonable access to parents or
legal guardians. All of the residents interviewed could verbalize how they are able to receive
visitors and make phone calls and confirmed that contact may occur with attorneys or other
legal representatives and with their parents, legal guardians or someone else. Visitation
information is also provided in the Student Handbook.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.54 provides information regarding third-party reporting of sexual abuse. Pamphlets
regarding reporting sexual abuse and sexual harassment are available at the reception desk in
the administration building and other related information is posted throughout the facility.
The sign-in book for vendors visiting or performing a service at the facility contains
acknowledgement forms to be signed indicating they have received information regarding
conduct expectations, overview of PREA, and how to report allegations of sexual abuse or
sexual harassment. Posters containing reporting information are displayed in various areas of
the facility, including areas that are accessible to the public.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
14
Policies 6.61 and FDJJ 1919 and the Florida Administrative Code Rule 63F-11 address this
standard. All staff members are required to report any allegation of sexual misconduct or
resident-on-resident sexual activity to the Central Communications Center. The Policy states
that staff members are prohibited from revealing any related information to anyone other than
is necessary. The Policy requires that staff members are to immediately report any
knowledge, suspicion or information they receive regarding sexual abuse and sexual
harassment; and retaliation against residents or staff who report any incidents, staff neglect,
or violation of responsibilities that may have contributed to an incident or retaliation. A
review of the incident/investigation reports and staff interviews revealed that staff members
are aware of the requirement regarding their reporting duties and understand that they are
mandated reporters.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.62 addresses this standard and provides steps to take when staff learns that a
resident is subject to substantial risk of imminent sexual abuse. The staff is instructed to take
immediate action to protect the resident, such as make dorm, classroom, work, and other
program re-assignments. There have been no actions in the last 12 months where the facility
took any of these actions due to a resident being in substantial risk of imminent sexual abuse.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.63 requires that upon receiving an allegation that a resident was sexually abused
while confined in another facility, the Executive Director or his designee will notify the head
of that facility as soon as possible but no later than 72 hours and the appropriate investigative
agency, which begins with the call to the Central Communication Center. The Policy also
requires that the notification be documented within 72 hours of receiving the allegation. The
OIG operations and FDJJ policy ensure that allegations received from other agencies or
15
facilities are investigated in accordance with the PREA standards. The facility reports that
during this audit period, there has not been an allegation of sexual abuse occurring to a
resident while he was in another facility. The interview with the Executive Director revealed
his knowledge of the Policies and how to implement the procedures.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.64 outlines the first responder duties and responses which are generally to separate
the victim from the abuser; preserve and protect the scene; and request that the alleged
victim and alleged abuser do not take any action that would destroy physical evidence. Initial
training and refresher training was conducted with staff through a combination of online
statewide DJJ courses and in-house training courses. The Policy directs that if the employee
first responder is not direct care staff, the responder requests that physical evidence is
preserved and direct care staff should be notified. Staff interviews revealed that they are
aware of the steps to take if they are the first responder. There has been one allegation of
sexual abuse or sexual harassment within the last 12 months, which was investigated by the
FDJJ and was determined to be Unsubstantiated. The allegations were reported through a
survey and did not require direct intervention from security or non-security staff. The staff
interviews confirmed that they are knowledgeable of their duties as a first responder.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The coordinated response is incorporated in the facility’s Policy 6.65 and is aligned with the
requirements of FDJJ 1919. The facility’s sexual abuse response plan has been developed in
checklist format and includes the coordinated actions for staffs to take that include first
responders, medical and mental health practitioners, and management staff. Interviews with
staff support that an institutional plan in response to an incident of sexual abuse has been
developed and that they are familiar with their roles. Drills are also conducted by staff using
various PREA related scenarios and they are documented, using the specific form, for
management review.
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Standard 115.366 Preservation of Ability to Protect Residents from Contact with Abusers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
This standard is not applicable. The facility does not maintain any collective bargaining
agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 6.67, the Operations Department Shift Supervisors, under the
supervision of the Director of Operations, will be directly responsible for ensuring all
residents and staff members who report sexual abuse or sexual harassment are protected from
any retaliation occurring. The Director of Operations is responsible for reporting any possible
retaliation to the Executive Director. Staff members found to have engaged in retaliation will
receive disciplinary action up to and including termination. Residents engaging in retaliation
will receive disciplinary work details and loss of privileges. If the retaliation conduct is
identified, the monitoring would be conducted for no less than 90 days and longer if
indicated. The form, PREA Retaliation Monitoring Report, has been created to document the
monitoring activities.
There has been one allegation of sexual abuse within the last 12 months and the retaliation
monitoring found no incidents of retaliation occurring. Interviews with staff and a review of
the Administrative Review Report revealed that the allegations were Unsubstantiated. The
retaliation monitor interview revealed that the monitoring considers a review of resident point
cards, interactions between staff and resident, and behavior of staff and residents and he was
able to discuss remedies that could be taken if retaliation is suspected or determined.
Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
17
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Although the practice is that segregation or isolation is not used at the facility, Policy 3.62
includes that a resident may be isolated from others only when less restrictive measures are
inadequate and until other arrangements can be made. The facility does not have segregated
or isolation rooms. Staff interviews revealed that there is no practice of isolation; however,
removing a resident temporarily from the other residents until he can be placed in another
program or his return to regular placement is safe, may require the resident remaining in an
area with staff away from other residents, such as the medical clinic. The Policy and staff
interviews support that the rights of the resident such as education services and large muscle
exercise will not be violated. During this audit period, there has not been a situation where a
resident has been temporarily removed from the general population due to his need for
protection from sexual abuse, sexual harassment or retaliation.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 6.71 and FDJJ 1919 address this standard. Administrative investigations are
conducted by the DJJ Office of Inspector General (OIG) and criminal investigations are
conducted by the local law enforcement agency, Collier County Sheriff’s Office. The Florida
Department of Children and Families (DCF) are also called when there is an allegation of
sexual abuse. Both Policies direct facility staff to cooperate with the investigations. An
investigation is not terminated solely because the source of the allegation recants the
allegation. This is evident through staff interviews and the review of investigation reports.
The investigation by DCF and a DJJ administrative review were conducted although the
allegations were recounted and an apology provided by the resident. The allegations were
also referred to the Sheriff’s Office; however, it was determined that they would not conduct
an investigation. FDJJ 1919, staff interview and the draft MOU, as well as the
understanding with the Collier County Sheriff’s Office also ensure that allegations of
conduct that appear to be criminal are referred for prosecution.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
18
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 6.72 and FDJJ address this standard. The OIG, responsible for administrative
investigations, imposes a standard of a preponderance of the evidence for determining whether
allegations are substantiated. The draft MOU document with the Collier County Sheriff’s
Office states that the Sheriff’s Office will follow the appropriate protocols as required by the
standards. The Department of Children and Families is a state agency with a responsibility of
investigating allegations of child abuse.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.73 and FDJJ 1919 address this standard. The facility’s policy provides for staff to
notify the resident when an investigation has been completed and that the notification be
documented. There is documentation indicating that the resident was verbally informed of
the results of the investigation. During the course of the investigation of the one allegation of
abuse reported during this audit period, the resident recanted the allegations made on a
survey and apologized for his actions.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.76 provides for disciplinary sanctions for staff to be up to and including dismissal
for violation of the facility’s zero-tolerance policies against sexual abuse and sexual
harassment. In the past 12 months, no staff member has been terminated or has resigned for
19
violating the facility’s PREA policies. Personnel policies and FDJJ 1919 provide that
sanctions for violations of facility/agency policies relating to sexual abuse, other than actually
engaging in the act, and sexual harassment are appropriate to the circumstances of the
incident; staff’s disciplinary history; and the sanctions for similar cases of other staff.
During the past 12 months, no staff member has been disciplined for violation of agency
sexual abuse or sexual harassment policies or reported to law enforcement by the facility for
violating such policies. Agency policy provide that terminations or resignations by staff who
would have been terminated if not for the resignation, are reported to local law enforcement if
the situation appeared to be criminal in nature and to relevant licensing bodies. The staff
interviewed revealed his knowledge of the personnel policies, procedures and practices.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 6.77 and FDJJ 1919 address the corrective actions regarding any contractor or
volunteer engaging in sexual abuse of residents. They will be reported to local law
enforcement and to relevant licensing bodies and would be prohibited from having contact
with residents. Sexual activity between residents and between residents and volunteers and
contracted personnel is prohibited. During the past 12 months, no contractor or volunteer has
been reported to law enforcement or any investigative agency for allegations of sexual abuse.
During this audit period, there have been no allegations of sexual assault or sexual harassment
regarding a contractor or volunteer.
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.78 addresses this standard. Any resident found in violation of the facility’s zero
tolerance policy regarding sexual abuse, sexual assault, sexual misconduct or sexual
harassment against another resident will receive disciplinary sanctions after a formal
administrative process. A resident may also be referred to law enforcement for charges and
possible removal from the facility regarding resident-on-resident abuse. Sexual activity
between residents is prohibited and administrative or court processes and sanctions occur
20
when it has been determined that the sexual activity was coerced. The Policy also states that
the facility may discipline a resident for sexual contact with staff only upon finding that the
staff did not consent to such contact.
The Policy addresses a resident receiving counseling or other interventions to address the
underlying reasons or motivations for the resident-on-resident abuse; this information is also
provided in the Student Handbook. There has been no incident of resident-on-resident sexual
abuse in the past 12 months. The facility does not use isolation as a disciplinary sanction.
Interviews with mental health and medical staffs support that counseling or other interventions
will be offered to address and correct the underlying reasons or motivations for abuse when
the resident remains in or returns to the facility after an incident. The staff members
interviewed stated that any type interventions used would not be dependent on the resident’s
participation in the behavior management system, education or other programs or services.
FDJJ 1919 provides that anyone reporting in good faith shall be exempt from any civil or
criminal liability. During the past 12 months there have been no administrative findings or
criminal findings of guilt regarding resident-on-resident sexual abuse that occurred at the
facility.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.81 provides that residents who disclose a history of sexual abuse or who disclose
previously perpetrating sexual abuse during an intake screening will be offered a follow-up
meeting with a medical or mental health practitioner within 14 days of the intake screening.
Staff interviewed confirmed awareness of the policy and the requirements of the standard
and stated that their process affords the practice of the meetings to occur sooner. Staff also
reported that where indicated, specific services may be provided through a contract
specialist. The facility and staff interviews report that no residents disclosed prior
victimization or previously being a perpetrator during this audit period during the medical or
mental health screening.
Policy 6.81 supports that information related to sexual victimization or abusiveness that
occurred in an institutional setting is limited to medical and mental health practitioners. A
review of files showed that medical and mental health staff members maintain documentation
of the services they provide to the residents. Interviews and the review of files show that staffs
are knowledgeable of the importance of documenting and there would not be issues in
documenting the delivery of services related to mental health or medical screenings regarding
a resident’s history of sexual abuse. Medical and mental health staffs discussed their
knowledge of informed consent regarding how informed consent is used for residents18 years
old and older; consent forms are contained in the medical files.
21
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 address the sections of this standard. The Policies require that treatment services
to every victim be provided at no cost to the victim and verified by staff and the
representative from the rape crisis center. According to the Policies, services will be
provided regardless of whether or not the victim names the abuser or cooperates with any
investigation due to the incident. Staff interviews confirmed that the nature and scope of the
medical and mental health services are determined by medical and mental health
practitioners based on their professional judgment. Staff interviews, as well as a review of
records and documented practices revealed that crisis intervention services will be
documented and maintained by medical and mental health staff as required.
Observations of files show that medical and mental health staff members maintain secondary
materials that document services to residents and in an incident of sexual abuse the
requirement of the standards will be met as demonstrated through interviews and the files
reviewed. Mental health and medical staffs articulated that a victim would receive timely and
unimpeded access to emergency medical treatment and crisis intervention services. The staff
interviews supported that a victim would be provided medically appropriate information and
care based on professionally accepted standards of care.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.83 addresses ongoing medical and mental health care for sexual abuse victims and
abusers. It also provides for the appropriate tests to be provided. The facility will obtain a
mental health evaluation within 60 days of learning of resident-on-resident abuse and offer
treatment deemed appropriate by a contract mental health practitioner. The referral process
for the treatment will be documented and was explained during the mental health staff
interview. Mental health and medical staffs relayed through interviews their awareness of the
Policy and how it would be implemented and the services provided. Additional interchanges
with staff, document review, and observations of responses to residents revealed that medical
and mental health services are consistent with the community level of care.
22
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 6.86 and FDJJ 1919 state that the sexual abuse incident review team will assess the
incident within 30 days of the completion of an investigation unless it determines that the
allegation was Unfounded. According to the policies and staff interview, the sexual abuse
incident review team includes upper-level management; supervisors; medical or mental
health practitioner; and allow for input from investigators. Representatives from DJJ also
participate on the team. The meetings are documented using the Sexual Abuse Incident
Review Report form.
There have not been any criminal investigations conducted at the facility in the last 12
months. One administrative investigation was conducted during this audit period and it was
determined that the allegations were Unsubstantiated. The Policies and the incident review
report process allows for the inclusion of written findings and recommendations and the
completed report to be provided to the Facility Administrator, who also serves as the PREA
Compliance Manager. The Policies and an interview with one of the identified team members
revealed that he was knowledgeable of the role of the team. A review of documentation
revealed that incident reviews are conducted.
Standard 115.387 Data collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 and interviews with staff confirmed that DJJ collects incident-based, uniform and
aggregated data regarding allegations of sexual abuse at facilities under its direct control
using a standardized instrument and set of definitions. Policy requires the collection of
accurate, uniform data for every allegation of sexual assault. The agency provides the U. S.
Department of Justice (DOJ) with data as requested. The format used for DJJ facilities and its
contractors capture the information required to complete the most recent version of the
Survey of Sexual Violence conducted by the DOJ and the information is provided as
requested. The agency maintains and collects various types of identified data and related
documents regarding sexual abuse incidents. FDJJ aggregates the sexual abuse data annually
that culminates into an annual report, which has been reviewed by this Auditor.
23
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 addresses this standard. The statewide PREA Coordinator along with other agency
management staff reviews the collected and aggregated data to assess and improve the
effectiveness of the PREA related efforts and initiatives by identifying problem areas;
developing and implementing corrective actions as needed; and preparing an annual report
based on the collected data. The Policy also states that an annual report will be prepared that
will provide an assessment of the agency’s progress in addressing sexual misconduct. A
review of the current documentation and interviews with facility and agency staffs confirm
this practice and the comparative review to the previous report is also confirmed. The annual
report is approved as required.
It is obvious from staff interviews, observations, and document review that the agency has
compared the results of the annual reports and used them to continuously improve policies;
procedures; practices; and training on a statewide basis. The annual report has been reviewed
by this Auditor and the report is accessible to the public through the agency’s website. The
report does not contain any personal identifying information.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According FDJJ 1919, it is required that data is collected and securely retained for 10 years
after the initial collection date, unless statutes require otherwise. The aggregated PREA data
from all facilities including contractors is reviewed, all personal identifiers are removed, and
the report is made readily available to the public through the agency’s website. A review of
the reports and interviews with the facility staff and the DJJ statewide PREA Coordinator
confirmed the practice.
24
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
February 24. 2016
Auditor Signature Date
25

source: DJJ