summary: PREA - Year 2 Cycle 3

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Marion Regional Juvenile Detention Center
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 02/19/2021
Auditor Certification
The contents of this report are accurate to the best of my knowledge.
No conflict of interest exists with respect to my ability to conduct an audit of the agency
under review.
I have not included in the final report any personally identifiable information (PII) about any
inmate/resident/detainee or staff member, except where the names of administrative
personnel are specifically requested in the report template.
Auditor Full Name as Signed: CHERYL ANDERSON Date of Signature: 02/19/2021
AUDITOR INFORMATION
Auditor name: Anderson, Cheryl
Email: thechandegroup@gmail.com
Start Date of On-Site 01/11/2021
Audit:
End Date of On-Site 01/13/2021
Audit:
FACILITY INFORMATION
Facility name: Marion Regional Juvenile Detention Center
Facility physical 3040 NW 10th St., Ocala, Florida - 34475
address:
Facility Phone
Facility mailing
address:
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Primary Contact
Name: Forrest Hallam
Email Address: Forrest.Hallam@djj.state.fl.us
Telephone Number: 352-732-1450
Superintendent/Director/Administrator
Name: Forrest Hallam
Email Address: forrest.Hallam@djj.state.fl.us
Telephone Number: 352-732-1450
Facility PREA Compliance Manager
Name: Forrest Hallam
Email Address: forrest.hallam@djj.state.fl.us
Telephone Number: O: 352-132-1450
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Facility Characteristics
Designed facility capacity: 60
Current population of facility: 25
Average daily population for the past 12 526
months:
Has the facility been over capacity at any point No
in the past 12 months?
Which population(s) does the facility hold? Both females and males
Age range of population: 9-11 = 2, 12-14 = 64, 15-17 = 330, 18-20 =165,
21=1
Facility security levels/resident custody levels: Secure
Number of staff currently employed at the 50
facility who may have contact with residents:
Number of individual contractors who have 19
contact with residents, currently authorized to
enter the facility:
Number of volunteers who have contact with 8
residents, currently authorized to enter the
facility:
AGENCY INFORMATION
Name of agency: Florida Department of Juvenile Justice
Governing authority
or parent agency (if
applicable):
Physical Address: 2737 Centerview Dr., Tallahassee, Florida - 32399
Mailing Address:
Telephone number:
3
Agency Chief Executive Officer Information:
Name:
Email Address:
Telephone Number:
Agency-Wide PREA Coordinator Information
Name: Jeff Wenhold Email Address: jeff.wenhold@djj.state.fl.us
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AUDIT FINDINGS
Narrative:
The auditor’s description of the audit methodology should include a detailed description of the following
processes during the pre-audit, on-site 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 Marion Regional Juvenile Detention Center (Marion RJDC) is located in Ocala, Florida and is
operated by the Florida Department of Juvenile Justice (FDJJ). The onsite audit phase of the Prison
Rape Elimination Act (PREA) audit was conducted on January 11-13, 2021 by Cheryl Anderson, a
certified U. S. Department of Justice PREA Auditor. The facility’s last PREA audit was completed with a
written report on February 19, 2018. The current audit was attained and assigned to the Auditor by
Correctional Management and Communications Group, LLC of Minneola, Florida.
The Marion RJDC is a 60 bed hardware secure facility and houses male and female residents 9-21 years
old. The facility serves youth detained by various circuit court(s). Youth are detained pending
adjudication, disposition or placement in commitment facility. The services provided at the facility include
mental health, medical, education; and substance abuse. The mental health services include counseling,
screenings, and crisis intervention and stabilization. Residents participate in daily structured
programming and recreation activities. Religious services are provided by volunteers and residents may
attend on a voluntary basis. The contracted staff consists of a Physician, an Advanced Registered Nurse
Practitioner, Registered Nurses and Licensed Practical Nurses as well as a Licensed Mental Health
Counselor. Educational services are funded by the Department of Education through Marion County
Public Schools.
There are no known existing conflicts of interest with the Auditor and the facility and there were no
barriers in completing any phase of the audit.
Audit Methodology
Pre-Onsite Audit Phase
In preparation for the on-site audit, a conference call was conducted with the Florida Department of
Juvenile Justice (FDJJ) Statewide PREA Coordinator, North Region Staff, and the facility’s
Superintendent who also serves as the PREA Compliance Manager. During the conference call, an
overview of the audit process was discussed and requested documentation was reviewed. There were
also discussions concerning access to the facility and staff, the audit process, logistics for the onsite
phase of the audit, and goals and expectations prior to the site visit. The notifications of the on-site audit
which provided Auditor contact information were posted six weeks prior to the audit. The postings of the
notices were verified by photographs received electronically from the facility’s Superintendent. The
photographs indicated notices were posted in various locations throughout the facility including the
housing areas, educational areas, dining areas, and administrative areas. The audit notice was posted
using color and large print that was easy to see and read. The notices were strategically placed
throughout the facility, accessible to residents, staff, visitors, and volunteers. The posted audit notices
contained the Auditor’s contact information and included information regarding confidentiality. No
correspondence was received during any phase of the audit. Further verification of their placement was
made through observations during the site tour. The original notice was provided to the facility by the
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FDJJ PREA Coordinator and had previously been provided by the Auditor to the FDJJ PREA Coordinator.
The notice was posted in English and Spanish at eye levels easy for a person to see either standing or
sitting. All residents in the facility during the time of the site visit spoke and read English.
The Pre-Audit Questionnaire (Online Audit System), completed December 4, 2020, policies and
supporting documentation were completed within an adequate time frame prior to the scheduled onsite
visit for review. Any additional information needed was discussed with the Superintendent/PREA
Compliance Manager and was received within a timely manner or available for review during the onsite
visit.
The Superintendent/PREA Compliance Manager had been previously provided a document by the
Auditor titled, “Information Requested to Determine Staff and Residents to be Interviewed During the On-
Site PREA Audit.” The document was completed and returned to the Auditor. The document requested
the identification of the staff members who served and performed in specific PREA related specialized
roles within the facility, including volunteers and contractors who have contact with residents. The
document requested a list of direct care staff and their shift assignments and a resident population roster.
Additionally, the request included information regarding residents who may be in vulnerable categories
such as disabled; limited English proficient; intersex, gay, lesbian, bisexual and/or transgender residents;
and residents housed in isolation.
The Auditor communicated with the Superintendent/PREA Compliance Manager to confirm schedules
and to clarify specialized PREA roles. A current resident roster was also provided to the Auditor. As a
result of the information received, the Auditor developed an interview schedule of specialized and
random staff and residents, including targeted resident interviews. The facility provided the lists and
information before and during the site visit that assisted with the following determinations and interview
selections:
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Lists/Information Comments
Complete Resident Roster An up-to -date roster was provided prior to the
site visit.
Youthful residents/detainees Youthful residents/detainees identified on
interview document sent to the facility.
Residents with disabilities None were identified
Residents who are Limited English Proficient None were identified
LGBTI Residents None were identified
Residents in segregated housing None were identified
Residents in Isolation None were identified
Residents who reported sexual abuse None were identified
Residents who reported sexual victimization None were identified
during risk screening.
Staff roster for the time of the site visit. The roster was provided during the pre-onsite
phase of the audit
Specialized Staff Specialized staff was identified on interview
document sent to the facility
Contractors who have contact with the residents Contractor was identified on interview document
sent to the facility
Volunteers who has contact with the residents Volunteer was not available for interview
All grievances/allegations made in the 12 months None
preceding the audit
All allegations of sexual abuse and sexual None
harassment reported for investigation in the 12
months preceding the audit
Hotline calls made during the 12 months None
preceding the audit
Detailed list of number of sexual abuse and The facility reported there were no allegations of
sexual harassment allegations in the 12 months sexual abuse or sexual harassment in the 12
preceding the audit months preceding the audit
The Auditor reviewed the lists/documents provided and conferred with the Superintendent/PREA
Compliance Manager in development of the interview schedule to ensure clarity regarding specialized
PREA roles among staff.
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Internet research of the facility revealed no indication of litigation, U. S. Department of Justice
involvement, or federal consent decrees. General and specific information about the facility and the
programs and services provided are detailed on the facility’s website. An array of information, pictures of
the facility and contact information may be accessed from the informative page. The facility’s website also
contains PREA information including but not limited to the zero-tolerance and coordinated response
policies. The PREA audit report for the last audit in February 2018 is located on the website and it also
contains the third-party reporting form.
Onsite Audit Phase
During the pre-audit phase, the Auditor was provided a diagram of the physical plant which provided
familiarity with the layout of the facility.
Upon arriving at the facility, an entrance meeting was held. Formal introductions were made and a review
of the audit process, site visit activities and the itinerary were reviewed. Following the entrance meeting
with the Superintendent, two Captains, and North Region Office Representative, a comprehensive tour of
the facility was conducted, guided by the Superintendent. During the tour, youth were observed to be
under constant supervision of the staff while involved in various activities. PREA signage (in bold and
colorful print) was displayed in all areas frequented by the residents. The tour included all areas of the
facility which included but was not limited to Intake, all housing units, medical, food services, industry
areas, programming, and education areas. The facility was clean and well maintained. Staff announced
themselves prior to entering the housing area of the opposite gender.
Signage was observed on doors indicating youth are not allowed in the room/area or only allowed with
staff supervision. Observation of community bathrooms revealed shower stall openings have shower
curtains to allow residents privacy when taking showers. The shower procedures are printed and posted
at the entrance of the bathroom on each unit. Also, residents have toilets in their single cell unit to allow
for privacy when using the toilet. Observation of the surveillance system monitors revealed cameras do
not capture showers, toilets or inside residents’ rooms.
The signage posted includes instructions on accessing the 24/7 hotline for reporting allegations and
requesting advocacy services for the Ocala Domestic Violence and Sexual Assault Center (rape crisis
center) in Ocala, Florida. A Memorandum of Understanding (MOU) exists with the Ocala Domestic
Violence and Sexual Assault Center to receive allegations of sexual abuse and sexual harassment and
for the provision of advocacy services upon request. The advocacy service was contacted and
interviewed by phone and confirmed the advocacy services to be provided in accordance with the MOU.
Documentation and interviews with the Nurse and Superintendent confirmed forensic medical
examinations will be performed at the Ocala Domestic Violence and Sexual Assault Center or a local
hospital. The hospital’s Sexual Assault Policy provides that a Sexual Assault Nurse Examiner (SANE) will
conduct the examinations. According to the Ocala Domestic Violence and Sexual Assault Center’s written
Policy, when a SANE is not available, the Emergency Department Physician and Emergency Department
Nurse will assume care of the patient and follow the protocols outlined in the Policy.
Questions were answered by staff during informal interviews regarding resident activities and program
services as the tour progressed throughout the facility. The site visit also included the outside grounds.
During the tour, the intake process was described, and the daily scheduled activities and staff supervision
were discussed by the PREA Compliance Manager. There were no new admissions during the site visit.
Staff readily explained activities as different facility areas were visited.
Staff of the opposite gender, must announce their presence when entering the housing unit or any area
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where a resident shower, change clothes, or perform bodily functions. All residents interviewed stated the
staff members announce their presence prior to entering the housing unit. This practice was experienced
and observed during the tour.
Medical Request Forms, PREA/grievance forms, and the locked boxes for each are posted in the
common area, accessible to all residents, staff and visitors. All residents have access to writing utensils
needed for completing the forms. The doors to closets and storage rooms are kept locked.
Interviews
Fifty staff members are currently employed at the facility that may have contact with residents. During the
three-day, on-site visit, 12 random direct care staff from the three shifts and 15 specialized staff were
interviewed. The interviews revealed staff are knowledgeable of PREA standards and were able to
articulate their responsibilities in the PREA roles. Although 11 individuals were identified for specialized
interviews, the specialized interviews conducted totaled 15 due to staff members in this category serving
in more than one PREA related specialized role. Ten residents were also interviewed after randomly
selecting the names from the facility population report, considering each housing unit and information
regarding the make-up of the population. The interviews revealed the residents were informed of their
right to be free from sexual abuse and sexual harassment and how to report sexual abuse and sexual
harassment. The resident population on the first day of the on-site audit was 21. A previous inquiry was
made regarding vulnerable categories within the resident population related to the selection of targeted
interviews. There were no targeted residents identified to be interviewed at this facility during this auditing
cycle.
The training records of staff interviewed, and the files of residents interviewed were reviewed along with
policies and other secondary documentation. The Auditor reviewed staff, contractor and volunteer
training records to ensure that 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. There were no allegations of sexual abuse and/or sexual harassment within the facility in the
past 12 months.
The Auditor conducted ten resident interviews in the following categories during the onsite phase of the
audit:
Category of Residents Number of Interviews
Random Residents 10
Targeted Residents 0
The Auditor conducted the following number of specialized staff interviews during the onsite phase of the
audit:
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Category of Staff Number of Interviews
PREA Coordinator 1
PREA Compliance Manager 1
Agency Contract Administrator 1
Intermediate or Higher-level Facility Staff (unannounced 1
rounds)
Medical Staff 1
Mental Health Staff 1
Administrative (Human Resources) Staff 1
SAFE/SANE staff 1
Volunteer/Contractor who have contact with residents Not available for interview
Investigative Staff 1
Staff who Perform Screening for Risk of Victimization and 1
Abusiveness
Supervise Residents in Isolation 1
Staff on the Incident Review Team 1
Designated Staff Member Charged with Monitoring 1
Retaliation
First Responder All staff are 1st responders (1)
Intake Staff 1
********************************************************* ****************************************
Number of Specialized Staff Interviews 15
Number of Random Staff Interviews 12
Total Random and Specialized Interviews 27
Onsite Documentation Review
The Auditor received many examples of documentation from resident and staff files as part of the Pre-
Onsite Audit Phase. During the Pre-Onsite Audit Phase and the Onsite Audit Phase, the auditor reviewed
a sample of personnel files of the staff selected to be interviewed, including documentation of criminal
background checks occurring. The PREA Pre-Audit Questionnaire and facility policies, procedures and
supporting documentation were reviewed prior to the site visit and while onsite for interviewees and
persons not interviewed. The secondary documentation reviewed included but was not limited to
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Vulnerability Assessments; PREA/Grievance Form; Medical Request Form; PREA education and training
acknowledgement forms; training records; checklists; sexual abuse coordinated response plan; annual
staffing plan assessment; staffing plan; staff schedules; unannounced rounds reports; retaliation
monitoring form; organization chart; and other documentation. The facility reports there were no
allegations of sexual abuse or sexual harassment in the past 12 months.
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 on-site audit with the North Region Office
Representative, Superintendent, and two Captains to allow the opportunity for questions and to review
the on-site audit process. The timelines for the submission of PREA audit reports were reviewed.
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AUDIT FINDINGS
Facility Characteristics:
The auditor’s description of the audited facility should include details about the facility type, demographics
and size of the inmate or resident 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 Marion RJDC is a 60-bed hardware secure facility which provides short-term care and custody for
male and female residents as ordered by the courts pending adjudication, disposition and/or placement
in a residential confinement facility. Located in Ocala, Florida, the facility is operated by the FDJJ and
serves Marion County. The OAS facility information incorrectly shows that the average daily population is
526; however, the average daily population is 53 and the average length of stay for residents is
approximately 14 days.
The Marion RJDC physical plant consists of one building which contains administrative offices, a dining
hall and food preparation area, and three housing modules (two for males and one for females). Each
module has a community bathroom with sinks and showers. The dining hall also serves as the visitation
area for families. Visitation is conducted on Sundays and Tuesdays. Also, there is a large courtyard for
the youth to play basketball, football, etc. and an adjacent area for various other activities. The facility is
equipped with a video surveillance system which includes 89 operating cameras.
Eight hundred fifty-one residents have been admitted to the Marion RJDC facility in the past 12 months.
The number of residents admitted to the facility during the past 12 months whose length of stay was for
72 hours or more is 506. The number of residents admitted to the facility during the past 12 months
whose length of stay was for 10 days or more is 442. The number of staff employed at the facility in the
past 12 months who may have contact with residents is 93. In the past 12 months there have been two
contract for services with contractors who might have contact with residents and there are eight
volunteers who may have contact with residents. There were 21 residents in the facility during the first
day of the on-site visit.
The facility operates with a total of 51 full-time employees that includes Superintendent, Assistant
Superintendent, Administrative Staff, Maintenance Staff, Food Support Staff, Juvenile Detention Officer
Supervisors, and Juvenile Detention Officers (line staff).
The facility provides supervision of residents in a safe, secure and humane environment. Services
include education, mental health, and substance abuse and health care services. Medical services are
contracted through Maxim Healthcare Services and Mental Health services are contracted through
Camelot Community Care and these services are available to the youth seven days a week. Contracted
staff consist of a physician, a nurse practitioner, a registered nurse, a licensed practical nurse and a
medical records clerk.
Educational services are funded by the Florida Department of Education through the Marion County
School Board. The educational program is part of the facility's behavior management system and youth
have the opportunity to earn points through their participation in school and completion of assignments
as well as through pro-social behavior. Direct care staff members/random staff are responsible for the
daily and direct supervision of residents and manage them during their daily activities. The staff to
resident ratio was observed to be met in all areas of the facility during the on-site tour. The camera
monitoring system, in addition to mirrors, support the direct supervision provided by staff. The cameras
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were observed to be constantly monitored.
There is a host of management, supervisory, support and contract staff members who provide oversite of
or participation in processes and activities that contribute to the facility operations. Allegations that are
criminal in nature are investigated by the Ocala Police Department as confirmed through interviews.
The resident interviews, documentation and observations confirmed the provision of the programs and
services described. The residents indicated they could communicate with their parents/guardians through
telephone calls and visits. Observations during the tour revealed adequate space for conducting the
programs and services described. There is enough space to accommodate visitation and meetings in
private, as needed.
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AUDIT FINDINGS
Summary of Audit Findings:
The OAS will automatically calculate the number of standards exceeded, number of standards met, and
the number of standards not met based on the auditor's compliance determinations. If relevant, the
auditor should provide the list of standards exceeded and/or the list of standards not met (e.g. Standards
Exceeded: 115.xx, 115.xx..., Standards Not Met: 115.yy, 115.yy ). Auditor Note: In general, no standards
should be found to be "Not Applicable" or "NA." A compliance determination must be made for each
standard. In rare instances where an auditor determines that a standard is not applicable, the auditor
should select "Meets Standard” and include a comprehensive discussion as to why the standard is not
applicable to the facility being audited.
Number of standards exceeded: 0
Number of standards met: 43
Number of standards not met: 0
Post Onsite Audit Phase
The Auditor contacted the Superintendent regarding clarity of information. The final report was concluded
on the posted date. The Auditor determined the information and documentation received and reviewed
and the results of the site visit confirmed all the standards were met as indicated below and detailed
throughout this report. The report was submitted to the FDJJ PREA Coordinator to be reviewed and
subsequently forwarded to the facility.
With the necessary corrective actions addressed, the facility was found to be in compliance with all
applicable standards.
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Standards
Auditor Overall Determination Definitions
Exceeds Standard
(Substantially exceeds requirement of standard)
Meets Standard
(substantial compliance; complies in all material ways with the stand for the relevant review period)
Does Not Meet Standard
(requires corrective actions)
Auditor Discussion Instructions
Auditor discussion, including the evidence relied upon in making the compliance or non-compliance
determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion must
also include corrective action recommendations where the facility does not meet standard. These
recommendations must be included in the Final Report, accompanied by information on specific
corrective actions taken by the facility.
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115.311 Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documentation Reviewed: PREA Pre-Audit Questionnaire, Agency Policy (FDJJ Policy
1919), Prison Rape Elimination Act (PREA), Facility Operating Procedures (FOP) 3.09
PREA, Organizational Chart, 2019 Annual Report
Interviews: PREA Coordinator, PREA Compliance Manager, Random Staff, Residents
Provision (a): An agency shall have a written policy mandating zero tolerance toward all
forms of sexual abuse and sexual harassment and outlining the agency’s approach to
preventing, detecting, and responding to such conduct.
The FDJJ PREA Policy 1919 and Marion RJDC Facility Operating Procedure (FOP)-PREA,
mandate zero-tolerance of sexual abuse and sexual harassment and outlines how the facility
carries out its approach to preventing, detecting and responding to sexual abuse and sexual
harassment. The Policy and FOP includes definitions of prohibited behaviors and sanctions for
those found to have participated in prohibited behaviors. The Policy and FOP also provides
strategies and responses for reducing and preventing sexual abuse and harassment.
Provision (b): An agency shall employ or designate an upper-level, agency-wide PREA
Coordinator with sufficient time and authority to develop, implement, and oversee agency
efforts to comply with the PREA standards in all of its facilities.
Marion RJDC is a juvenile detention facility governed and operated by the FDJJ which
employs an agency-wide PREA Coordinator who is in an upper-level management position
within the agency. An interview with the PREA Coordinator revealed he has sufficient time and
authority to develop, implement, and oversee the agency’s efforts to comply with the PREA
standards in all operated and contracted facilities.
Provision (c): Where an agency operates more than one facility, each facility shall designate
a PREA compliance manager with sufficient time and authority to coordinate the facility’s
efforts to comply with the PREA standards.
The facility’s Superintendent also serves as the PREA Compliance Manager as indicated on
the facility’s organizational chart. An interview with the PREA Compliance Manager revealed
he has sufficient time to oversee the facility’s PREA compliance efforts and to perform his
other duties.
Conclusion: Based upon the review and analysis of the available documentation, the Auditor
has determined the facility is compliant with this standard requiring a zero-tolerance policy
toward sexual abuse and sexual harassment and the designation of a PREA Coordinator.
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115.312 Contracting with other entities for the confinement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: PREA Pre-Audit Questionnaire, Agency Policy (FDJJ 1919), Prison
Rape Elimination Act (PREA) Facility Operating Procedures (FOP) 3.09 PREA
Interview: Superintendent, Agency Contract Administrator
Provision (a): A public agency that contracts for the confinement of its residents with private
agencies or other entities, including other government agencies, shall include in any new
contract or contract renewal the entity’s obligation to adopt and comply with the PREA
standards.
Currently, FDJJ has 82 contracts with providers for the confinement of juveniles in residential
facilities throughout the State of Florida.
Provision (b): Any new contract or contract renewal shall provide for agency contract
monitoring to ensure that the contractor is complying with the PREA standards.
A review of a signed contract revealed provider’s agreement to comply with all requirements
and standards of the Prison Rape Elimination Act 28 CFR Part 115 as outlined in FDJJ Policy
1919.
Based upon the review and analysis of the available documentation, the Auditor has
determined all contracts require FDJJ to monitor the contractor’s compliance with PREA
standards as verified during the FDJJ Contract Administrator’s interview.
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115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA) Facility Operating Procedures (FOP) 3.09 PREA, Staffing Plan, Staffing Plan
Assessment, Resident Daily Rosters, PREA Pre-Audit Questionnaire
Interviews: Superintendent, PREA Compliance Manager, PREA Coordinator, Random
Staff, Random Residents
Provision (a): The agency shall ensure that each facility it operates shall develop, implement,
and document a staffing plan that provides for adequate levels of staffing, and, where
applicable, video monitoring, to protect residents against sexual abuse. In calculating
adequate staffing levels and determining the need for video monitoring, facilities shall take into
consideration:
(1) Generally accepted juvenile detention and correctional/secure residential practices; (2) Any
judicial findings of inadequacy; (3) Any findings of inadequacy from Federal investigative
agencies; (4) Any findings of inadequacy from internal or external oversight bodies; (5) All
components of the facility’s physical plant (including “blind spots” or areas where staff or
residents may be isolated); (6) The composition of the resident population; (7) The number
and placement of supervisory staff; (8) Institution programs occurring on a particular shift; (9)
Any applicable State or local laws, regulations, or standards; (10) The prevalence of
substantiated and unsubstantiated incidents of sexual abuse; and (11) Any other relevant
factors.
FDJJ Policy 1919 and Marion RJDC FOP-PREA require the facility to develop, implement and
document an approved staffing plan. Superintendent and Compliance Manager interviews
verified the development of the facility’s staffing plan, the continual assessment of adequate
staffing levels and the need for video monitoring.
Provision (b): The agency shall comply with the staffing plan except during limited and
discrete exigent circumstances and shall fully document deviations from the plan during such
circumstances.
The staffing plan is based upon the facility’s capacity of 60 residents. Marion RJDC FOP-
PREA requires the facility to document deviations from the staffing plan; however, due to the
facility’s hold-over policy, there were no deviations from the plan to review.
Provision (c): Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8
during resident waking hours and 1:16 during resident sleeping hours, except during limited
and discrete exigent circumstances, which shall be fully documented. Only security staff shall
be included in these ratios. Any facility that, as of the date of publication of this final rule, is not
already obligated by law, regulation, or judicial consent decree to maintain the staffing ratios
set forth in this paragraph shall have until October 1, 2017, to achieve compliance.
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The Superintendent’s interview confirmed there is no law, regulation or judicial decree to
maintain staffing ratios of 1:8 staff to resident ratio during waking hours or a 1:16 staff to
resident ratio during sleeping hours; however, the facility’s staffing plan does reflect the
required ratios. Observation during the tour revealed the staff to residents’ ratio requirements
are met.
Provision (d): Whenever necessary, but no less frequently than once each year, for each
facility the agency operates, in consultation with the PREA coordinator required by § 115.311,
the agency shall assess, determine, and document whether adjustments are needed to: (1)
The staffing plan established pursuant to paragraph (a) of this section; (2) Prevailing staffing
patterns; (3) The facility’s deployment of video monitoring systems and other monitoring
technologies; and (4) The resources the facility has available to commit to ensure adherence
to the staffing plan.
Documentation of the annual assessment of the staffing plan dated March 11, 2020 was
reviewed and found to be in compliance with all elements contained in (d)-1 of this standard.
The FDJJ Statewide PREA Coordinator and the Superintendent reviewed the staffing plan to
determine if adjustments are needed; however, no adjustments were made during the review.
Marion RJDC utilizes video monitoring combined with direct staff supervision to protect
residents from sexual abuse and sexual harassment. The facility has a total of 89 cameras
throughout the facility. The annual assessment of the staffing plan indicated no
recommendations.
Provision (e): Each secure facility shall implement a policy and practice of having
intermediate-level or higher-level supervisors conduct and document unannounced rounds to
identify and deter staff sexual abuse and sexual harassment. Such policy and practice shall be
implemented for night shifts as well as day shifts. Each secure facility shall have a policy to
prohibit staff from alerting other staff members that these supervisory rounds are occurring,
unless such announcement is related to the legitimate operational functions of the facility.
FDJJ Policy 1919 and Marion RJDC FOP PREA requires intermediate or higher-level staff to
conduct unannounced rounds to deter and identify staff sexual abuse and sexual harassment.
An interview with a higher-level staff member and a review of unannounced rounds
documentation revealed over time unannounced rounds are conducted on three shifts in all
areas of the facility.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is in compliance with this standard regarding supervision and
monitoring.
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115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, PREA Pre-Audit
Questionnaire, Training Curriculum, Training Acknowledgement Statements, Training Sign-in
Sheet, Posted Signs
Interviews: Superintendent, PREA Coordinator, Random Staff, Random Residents
Provision (a): The facility shall not conduct cross-gender strip searches or cross-gender
visual body cavity searches (meaning a search of the anal or genital opening) except in
exigent circumstances or when performed by medical practitioners.
FDJJ Policy 1919 and Marion RJDC FOP PREA prohibit cross-gender strip searches, or pat
down searches of youth, 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.
Provision (b): The agency shall not conduct cross-gender pat-down searches except in
exigent circumstances.
Marion RJDC FOP Searches states body cavity searches require the Superintendent’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 as
verified by Superintendent’s interview.
Provision (c): The facility shall document and justify all cross-gender strip searches, cross-
gender visual body cavity searches, and cross-gender pat-down searches.
The Policy prohibits cross-gender strip searches and cross-gender visual body cavity
searches. Cross-gender pat-down searches may be conducted only in exigent circumstances
which random staff interviews summarized as an extreme emergency. The Policy indicates
that in the event a cross-gender search is warranted pursuant to an emergency circumstance;
it must be approved by the Superintendent and the justification for the search documented.
Such searches will be documented on a form currently used for all searches which have been
used for same sex searches. The form requires the staff to record the reason for the search.
The evidence shows the facility is prepared to document and justify all cross-gender pat-down
searches. Based on the review of the Pre-audit questionnaire, staff and resident interviews,
and staff training materials, the facility follows this provision of the standard.
Provision (d): The facility shall implement policies and procedures that enable residents to
shower, perform bodily functions, and change clothing without nonmedical staff of the opposite
gender viewing their breasts, buttocks, or genitalia, except in exigent circumstances or when
such viewing is incidental to routine cell checks. Such policies and procedures shall require
staff of the opposite gender to announce their presence when entering a resident housing
20
unit. In facilities (such as group homes) that do not contain discrete housing units, staff of the
opposite gender shall be required to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions, or changing clothing.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require opposite sex staff, volunteers
and contractors entering housing units to announce themselves. Resident interviews verified
this is done on consistent bases.
Marion RJDC FOP PREA 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 bathrooms revealed all shower stalls have shower coverings to allow privacy while taking
showers. Staff members of the opposite gender are required to announce themselves upon
entering the unit. This practice was confirmed through observation of signage indicating such,
observations and interviews with residents and staff. No resident interviewed reported ever
having been naked in full view of opposite gender staff while showering, changing clothing,
and performing bodily functions. Based on the review of the documentation, staff and resident
interviews, and observations, the facility follows this provision of the standard. Additionally,
viewing of the cameras and staff and resident interviews confirmed that residents are not
directly viewed by staff when showering, using the toilet or changing clothes. The shower
procedures are printed and posted at the entrance of the bathroom on each unit. Observation
of the surveillance system monitors revealed cameras do not capture showers, toilets or inside
residents’ rooms.
Provision (e): The facility shall not search or physically examine a transgender or intersex
resident for the sole purpose of determining the resident’s genital status. If the resident’s
genital status is unknown, it may be determined during conversations with the resident, by
reviewing medical records, or, if necessary, by learning that information as part of a broader
medical examination conducted in private by a medical practitioner.
FDJJ Policy 1919 and Marion RJDC FOP PREA prohibit the search of transgender or intersex
residents solely for the purpose of determining the residents’ genital status and staff interviews
verified no such searches have occurred in the past 12 months. According to the Policy, if the
resident’s genital status is unknown, it may be determined during conversations with the
resident, by reviewing medical records, or by learning that information as part of a broader
medical examination conducted in private by a medical practitioner. One hundred percent of
direct care staff received the training on conducting cross-gender pat-down searches and
searches of transgender and intersex residents. Staff interviews confirmed they are aware
facility policy prohibits them from conducting a physical examination of transgender or intersex
resident solely for the purpose of determining the resident’s genital status. Based on the
documentation reviewed and staff interviews, the facility meets this provision of the standard.
Provision (f): The agency shall train security staff in how to conduct cross-gender pat-down
searches, and searches of transgender and intersex residents, in a professional and
respectful manner, and in the least intrusive manner possible, consistent with security needs.
FDJJ Policy 1919 and Marion RJDC FOP PREA states that staff shall be trained in how to
conduct cross-gender pat-down searches, and searches of transgender and intersex
residents, in a professional and respectful manner, and in the least intrusive manner possible,
consistent with security needs. The documentation and staff interviews support the training is
21
conducted at least annually. Training participation is documented with sign-in sheets and
training acknowledgement forms. The evidence shows staff are trained in how to conduct
cross-gender pat-down searches, and searches of transgender and intersex residents, in a
professional and respectful manner, and in the least intrusive manner possible, consistent with
security needs.
Conclusion: One hundred percent of direct care staff have received training on cross-gender
pat down searches and searches of transgender and intersex residents as verified during
interviews of random staff. The interviews revealed staff are knowledgeable of PREA
standards and were able to articulate their responsibilities in the PREA roles. Training
curriculum and training logs were reviewed and confirmed compliance. Based on the reviewed
documentation and interviews, the facility follows this provision of the standard.
22
115.316 Residents with disabilities and residents who are limited English proficient
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, FDJJ Special Needs Directives and
Alerts
Interviews: Superintendent, Residents, Random Staff
Provision (a): The agency shall take appropriate steps to ensure that residents with
disabilities (including, for example, residents who are deaf or hard of hearing, those who are
blind or have low vision, or those who have intellectual, psychiatric, or speech disabilities),
have an equal opportunity to participate in or benefit from all aspects of the agency’s efforts to
prevent, detect, and respond to sexual abuse and sexual harassment. Such steps shall
include, when necessary to ensure effective communication with residents who are deaf or
hard of hearing, providing access to interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any necessary specialized vocabulary. In
addition, the agency shall ensure that written materials are provided in formats or through
methods that ensure effective communication with residents with disabilities, including
residents who have intellectual disabilities, limited reading skills, or who are blind or have low
vision. An agency is not required to take actions that it can demonstrate would result in a
fundamental alteration in the nature of a service, program, or activity, or in undue financial and
administrative burdens, as those terms are used in regulations promulgated under title II of
the Americans With Disabilities Act, 28 CFR 35.164.
The Policy and FOP addresses the provision of support services for disabled residents by
providing these residents the equal opportunity to participate in or benefit from all aspects of
the facility’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment.
The Policy and FOP prohibits use of resident interpreters, resident readers, or other types of
resident s except in limited circumstances where an extended delay in obtaining an effective
interpreter could compromise the resident’s safety, performance of first responder duties, or
the investigation of the allegations. Staff interviews confirmed this information. The facility has
a MOU with the School Board of Marion County for supportive services to residents with
disabilities or who may be limited English proficient which was verified through the interview
with the Superintendent.
Provision (b): The agency shall take reasonable steps to ensure meaningful access to all
aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment to residents who are limited English proficient, including steps to provide
interpreters who can interpret effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary.
An Interpreting and Translation Agreement is documented with Language Line Services, Inc.
for services to residents. The evidence shows residents with disabilities and who may be
limited English proficient are provided equal opportunity to participate in or benefit from all
23
aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment. All staff interviewed confirmed residents are not used as interpreters and
understand prior arrangements have been made regarding language interpreters. There are
staff who can speak and translate in other languages in an emergency situation. The evidence
shows the facility ensures access to all aspects of the agency’s efforts to prevent, detect, and
respond to sexual abuse and sexual harassment to residents who are limited English
proficient, including taking steps to provide interpreters who can interpret effectively,
accurately, and impartially, using any necessary specialized vocabulary.
Provision (c): The agency shall not rely on resident interpreters, resident readers, or other
types of resident s 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.
According to Policy and FOP, the facility prohibits the use of resident interpreters, resident
readers or any kind of resident s except when a delay in obtaining interpreter services could
jeopardize a resident’s safety, performance of the first responder duties, or the investigation of
the allegation. Staff interviews confirmed residents have not been used to relate PREA
information to or from other residents in the past 12 months. There were no residents in need
of an interpreter during the site visit.
Conclusion: Based upon the review and analysis of the evidence, the Auditor has determined
the facility is compliant with this standard regarding residents with disabilities and residents
who are limited English Proficient. Residents with disabilities and who are limited English
Proficient are provided equal opportunity to participate in or benefit from all aspects of the
agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment.
24
115.317 Hiring and promotion decisions
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documentation Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) PREA, Personnel Files
Interviews: Administrative (Human Resources) Staff
Provision (a) & (f): (a) The agency shall not hire or promote anyone who may have contact
with residents, and shall not enlist the services of any contractor who may have contact with
residents, who— (1) Has engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997); (2) Has
been convicted of engaging or attempting to engage in sexual activity in the community
facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent
or was unable to consent or refuse; or (3) Has been civilly or administratively adjudicated to
have engaged in the activity described in paragraph (a)(2) of this section. (f) The agency shall
also ask all applicants and employees who may have contact with residents directly about
previous misconduct described in paragraph (a) of this section in written applications or
interviews for hiring or promotions and in any interviews or written self-evaluations conducted
as part of reviews of current employees. The agency shall also impose upon employees a
continuing affirmative duty to disclose any such misconduct.
FDJJ Policy 1919 PREA and Marion RJDC FOP 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.
The Policy is aligned with the requirements of the provisions of the standard and provides
background checks occur prior to employment and every five years thereafter. Initial
background checks and five-year checks were reviewed through a video. Additional personnel
information reviewed during the pre-audit and the onsite audit phases included: Offender
Watch Registry checks; Pre-Hire Interview Questions; New Hire Application Packet;
Applications; results of Diana Screens. The interview with the Superintendent and a review of
Policy and FOP provide details about the hiring process, completion of background checks,
and the grounds for termination in accordance with the PREA standard. According to the
interview, staff has a continuing duty to report related misconduct and omission of sexual
misconduct or providing false information will be grounds for termination. The forms
completed and included in the personnel files are in response to the above provisions of this
standard.
Provision (b): The agency shall consider any incidents of sexual harassment in determining
whether to hire or promote anyone, or to enlist the services of any contractor, who may have
25
contact with residents.
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 that staff has a continuing duty to report misconduct and provide that
omissions of misconduct or providing false information will be grounds for termination.
The Policy and FOP states any incidents of sexual harassment by a staff member will be taken
into consideration if the staff member is eligible for promotion. The interview with the HR Staff
was aligned with the standard. The interview questions for employment also address previous
misconduct. The evidence shows the facility considers 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. Based on the review of the personnel files, records
provided during the pre-audit phase, and the interview with the Superintendent, the facility
follows this provision of the standard.
Provisions (c) & (d): (c) Before hiring new employees or (d) contractors who may have
contact with residents, the agency shall: (1) Perform a criminal background records check; (2)
Consult any child abuse registry maintained by the State or locality in which the employee
would work; and (3) Consistent with Federal, State, and local law, make its best efforts to
contact all prior institutional employers for information on substantiated allegations of sexual
abuse or any resignation during a pending investigation of an allegation of sexual abuse.
The policy requires background checks to occur prior to residents receiving services from
contractors and volunteers and confirmed by the Superintendent’s interview. Additionally, best
efforts should be made 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. Based on the review of documentation and interview with the
Superintendent, the facility follows this provision of the standard.
Provision (e): The agency shall either conduct criminal background records checks at least
every five years of current employees and contractors who may have contact with residents or
have in place a system for otherwise capturing such information for current employees.
The Policy and FOP is aligned with the requirements of the provisions of the standard and
provides background checks occur prior to employment and every five years thereafter. Initial
background checks and five-year checks were reviewed while onsite and during the pre-audit
phase. This was also confirmed during the Superintendent’s interview. Based on the review of
documentation and the interview, the evidence shows the facility practices are aligned with the
provisions of this standard.
A review of personnel files for a sample of staff hired in the past 12 months revealed that all
had criminal records checks and a sample review of personnel files of current staff employed
for more than 5 years revealed that all have had criminal background checks conducted every
five years.
Provision (g): Material omissions regarding such misconduct, or the provision of materially
false information, shall be grounds for termination.
FOP states material omissions regarding such misconduct, or the provision of materially false
26
information, shall be grounds for termination. Based on the review of the documentation and
the interview with the Superintendent, the evidence shows the facility follows this provision of
the standard.
Provision (h): Unless prohibited by law, the agency shall provide information on substantiated
allegations of sexual abuse or sexual harassment involving a former employee upon receiving
a request from an institutional employer for whom such employee has applied to work.
The interview with the Superintendent confirmed the facility would provide this information if
requested to do so. Policy and FOP states the information would be provided when requested
unless it is prohibited by law to provide the information.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with the provisions of the standard regarding hiring and
promotion decisions.
27
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Marion RJDC FOP PREA requires when installing or updating a video monitoring system,
electronic surveillance system or other monitoring technology, the facility will consider how
such technology may enhance the ability to protect residents from sexual abuse.
Policy and FOP states that when there is substantial expansion to the facility, the ability to
protect residents and staff from sexual abuse will be reviewed and ensured.
Documentation of the annual staffing plan assessment referenced 89 operating cameras in
the facility. No blind spots were identified at that time.
During the on-site tour, the video surveillance system was observed, and all cameras were
pointed out by staff. The video monitoring system was assessed during the annual review of
the staffing plan.
The interview with the Superintendent and according to the Pre-Audit Questionnaire, Marion
RJDC has not acquired any new facilities since August 20, 2012.
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115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Inspector General Directive, FDJJ
Evidence Protocol, Memorandum of Understanding (MOU), Kimberly Cottage, Staff Training
Certificate, Resident Handbook
Interviews: Direct Care Staff, Superintendent, PREA Compliance Manager
Provisions (a) & (b): (a) To the extent the agency is responsible for investigating allegations
of sexual abuse, the agency shall follow a uniform evidence protocol that maximizes the
potential for obtaining usable physical evidence for administrative proceedings and criminal
prosecutions. (b) The protocol shall be developmentally appropriate for youth and, as
appropriate, shall be adapted from or otherwise based on the most recent edition of the U.S.
Department of Justice’s Office on Violence Against Women publication, “A National Protocol
for Sexual Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly
comprehensive and authoritative protocols developed after 2011.
Policy and FOP provides for the uniform FDJJ Protocols to be followed. The Protocol is
outlined regarding appropriateness for youth and adults. The FDJJ Protocol, developed by
related professionals, addresses but is not limited to interviewing; evidence collection; victim
services; notifications; and prosecution of sexual assault cases. The agency-based
investigators conduct administrative investigations and the Ocala Police Department
investigate sexual abuse allegations that are criminal in nature. The Ocala PD agrees to follow
the FDJJ Protocol. Staff interviews confirmed an understanding of the facility’s protocol for
obtaining usable physical evidence if a resident alleges sexual abuse and knowledge of the
entities responsible for conducting investigations.
Provision (c): The agency shall offer all residents who experience sexual abuse access to
forensic medical examinations whether on-site or at an outside facility, without financial cost,
where evidentiary or medically appropriate. Such examinations shall be performed by Sexual
Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs) where
possible. If SAFEs or SANEs cannot be made available, the examination can be performed by
other qualified medical practitioners. The agency shall document its efforts to provide SAFEs
or SANEs.
The Policy states forensic medical examinations will be conducted at the Kimberly Cottage
who employs Sexual Assault Nurse Examiners (SANE) and Sexual Assault Forensic
Examiners. The Sexual Assault Policy of the Kimberly Cottage states that the medical forensic
examination will be conducted by a SANE or SAFE. The facility Policy states that the services
will be provided at no cost to the victim. The Nurse’s interview was aligned with the facility
Policy.
Provisions (d) & (e): (d) The agency shall attempt to make available to the victim a victim
advocate from a rape crisis center. If a rape crisis center is not available to provide victim
29
advocate services, the agency shall make available to provide these services a qualified staff
member from a community-based organization or a qualified agency staff member. Agencies
shall document efforts to secure services from rape crisis centers. For the purpose of this
standard, a rape crisis center refers to an entity that provides intervention and related
assistance, such as the services specified in 42 U.S.C. 14043g(b)(2)(C), to victims of sexual
assault of all ages. The agency may utilize a rape crisis center that is part of a governmental
unit as long as the center is not part of the criminal justice system (such as a law enforcement
agency) and offers a comparable level of confidentiality as a nongovernmental entity that
provides similar victim services. (e) As requested by the victim, the victim advocate, qualified
agency staff member, or qualified community-based organization staff member shall
accompany and support the victim through the forensic medical examination process and
investigatory interviews and shall provide emotional support, crisis intervention, information,
and referrals.
The facility has a MOU with the Kimberly Cottage for victim advocacy services. According to
the MOU, the supportive services to victims include access to 24-hour reporting and contact
for advocacy service; emotional support; accompaniment through forensic examination and
investigative interview upon request; and provision of information and resources. The
Superintendent confirmed that advocacy services will be provided in accordance with the
MOU. The interview with the Superintendent confirmed the resident and/or facility staff
members are able to utilize the victim service hotline to request a victim advocate.
Provisions (f), (g) & (h): (f) To the extent the agency itself is not responsible for investigating
allegations of sexual abuse, the agency shall request that the investigating agency follow the
requirements of paragraphs (a) through (f) of this section. (g) The requirements of paragraphs
(a) through (f) of this section shall also apply to: (1) Any State entity outside of the agency that
is responsible for investigating allegations of sexual abuse in juvenile facilities; and (2) Any
Department of Justice component that is responsible for investigating allegations of sexual
abuse in juvenile facilities. (h) For the purposes of this standard, a qualified agency staff
member or a qualified community-based staff member shall be an individual who has been
screened for propriateness to serve in this role and has received education concerning sexual
assault and forensic examination issues in general.
Marion RJDC FOP PREA requires staff to report allegations of sexual abuse to the Ocala
Police Department for criminal investigations and to the Florida Central Abuse Hotline and
FDJJ’s Central Communication Center (CCC). Marion RJDC does not have a Memorandum of
Understanding (MOU) however the policy states when the Ocala Police Department arrives at
the facility to conduct an investigation, facility staff will provide and request the investigative
agency to follow the DJJ Inspector General Directive 3-05 (uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for criminal prosecution and
appropriate for youth).
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is in compliance with the provisions of this standard.
30
115.322 Policies to ensure referrals of allegations for investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) PREA, PREA Pre-Audit Questionnaire
Interviews: Random Staff, Superintendent, PREA Coordinator
Provision (a): The agency shall ensure that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment.
The Policy directs staff to report all allegations of sexual abuse and sexual harassment and to
document the reports. Staff members are aware of the Policy requirements as verified through
their interviews. The facility reports no allegation of sexual abuse and sexual harassment. The
facility Policy ensures the cooperation between the facility staff and the Ocala Police
Department.
Provision (b): The agency shall have in place a policy to ensure that allegations of sexual
abuse or sexual harassment are referred for investigation to an agency with the legal authority
to conduct criminal investigations, unless the allegation does not involve potentially criminal
behavior. The agency shall publish such policy on its website or, if it does not have one, make
the policy available through other means. The agency shall document all such referrals.
Provision (c): If a separate entity is responsible for conducting criminal investigations, such
publication shall describe the responsibilities of both the agency and the investigating entity.
The facility’s website provides the information and related policies for reporting allegations of
sexual abuse. A third-party reporting form is also on the website. Reporting information is also
posted in various areas of the facility including but not limited to living units. The posted
information is accessible to residents, staff, contractors and visitors. The Policy and interviews
confirmed allegations of sexual abuse and sexual harassment are investigated. Administrative
investigations are conducted by the trained agency investigators and sexual abuse allegations
that are criminal in nature are investigated by the Ocala PD.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard regarding policies to ensure referrals of
allegations for investigations.
31
115.331 Employee training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA); Facility Operating Procedures (FOP) 3.09 PREA; Staff SkillPro PREA
Curriculum; Training Attendance Record (Sign-in Sheets); PREA Training Acknowledgement
Statements
Interviews: Random Staff; Superintendent; PREA Compliance Manager
Provisions (a) and (c): (a)The agency shall train all employees who may have contact with
residents on: (1) Its zero-tolerance policy for sexual abuse and sexual harassment; (2) How to
fulfill their responsibilities under agency sexual abuse and sexual harassment prevention,
detection, reporting, and response policies and procedures; (3) Residents’ right to be free
from sexual abuse and sexual harassment; (4) The right of residents and employees to be
free from retaliation for reporting sexual abuse and sexual harassment; (5) The dynamics of
sexual abuse and sexual harassment in juvenile facilities; (6) The common reactions of
juvenile victims of sexual abuse and sexual harassment; (7) How to detect and respond to
signs of threatened and actual sexual abuse and how to distinguish between consensual
sexual contact and sexual abuse between residents; (8) How to avoid inappropriate
relationships with residents; (9) How to communicate effectively and professionally with
residents, including lesbian, gay, bisexual, transgender, intersex, or gender nonconforming
residents; and (10) How to comply with relevant laws related to mandatory reporting of sexual
abuse to outside authorities; (11) Relevant laws regarding the applicable age of consent. (c)
All current employees who have not received such training shall be trained within one year of
the effective date of the PREA standards, and the agency shall provide each employee with
refresher training every two years to ensure that all employees know the agency’s current
sexual abuse and sexual harassment policies and procedures. In years in which an employee
does not receive refresher training, the agency shall provide refresher information on current
sexual abuse and sexual harassment policies.
The agency Policy and FOP addresses PREA related training for staff. All interviewed staff
members were familiar with the PREA information regarding primary components of
preventing, detecting and responding to sexual abuse or sexual harassment. However, staff
interviews revealed staff are knowledgeable of PREA standards and were able to articulate
their responsibilities in the PREA roles. However, staff interviewed were not aware of their
ability to report privately to the Kimberly Cottage. The Superintendent conducted a PREA
refresher education session for the staff. Documentation of the session conducted was
provided to the auditor which included a roster signed by the staff. PREA training is provided
to staff, as indicated by a review of Policy and training documents. The documents and staff
interviews support refresher training is also conducted and is documented.
The direct care staff interviewed and the PREA Compliance Manager reported the training is
provided as required. All direct care staff members interviewed, and document review verified
the general topics below were included in the training: 1. Zero-tolerance PREA related
32
policies. 2. Staff responsibilities and how to fulfill them regarding allegations or incidents of
sexual abuse or sexual harassment. 3. Residents’ right to be free from sexual abuse and
sexual harassment. 4. The right for staff and residents to be free from retaliation for reporting
allegations or cooperating in an investigation. 5. Dynamics of sexual abuse and sexual
harassment in juvenile facilities. 6. Residents and employees rights to be free from retaliation
for reporting sexual abuse and sexual harassment. 7. How to avoid inappropriate relationships
with residents. 8. Common reactions of sexual abuse and sexual harassment by juvenile
victims. 9. Communicating effectively and professionally with residents, including lesbian, gay,
bisexual, transgender, intersex, or gender non-conforming residents. 10. Mandatory
reporting. 11. Relevant laws regarding the applicable age of consent.
The Policy and FOP, training materials, staff interviews, review of the trainings log and
acknowledgement statements verify the staff training occurs. Training is conducted annually,
and refresher training is provided as needed. Staff interviews confirmed they have received
training on the 11 required topics. The interviews revealed staff are knowledgeable of PREA
standards and were able to articulate their responsibilities in the PREA roles.
Provision (b): Such training shall be tailored to the unique needs and attributes of residents
of juvenile facilities and to the gender of the residents at the employee’s facility. The employee
shall receive additional training if the employee is reassigned from a facility that houses only
male residents to a facility that houses only female residents, or vice versa.
The facility houses male and female and the training considers the needs of the population as
determined by a review of training curricula and interviews with random staff. The Policy state
the training shall be tailored to the needs and attributes to the population served.
Provision (d): The agency shall document, through employee signature or electronic
verification that employees understand the training they have received.
The Policy and FOP provides all training be documented. Staff members sign training rosters
and training acknowledgement statements. A checklist is utilized for orientation training for all
new employees and contains the elements of PREA training. The facility provided the Auditor
with several examples for verification of the training occurring and the training was verified
through staff interviews. The facility follows this provision of the standard.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is in compliance with the provisions of this standard.
33
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA); Facility Operating Procedures (FOP) 3.09 PREA; Volunteer and Contractor Training
Curriculum; PREA Notification/Acknowledgement Statement
Interviews: Education Staff; Superintendent
Provision (a): The agency shall ensure that all volunteers and contractors who have contact
with residents have been trained on their responsibilities under the agency’s sexual abuse and
sexual harassment prevention, detection, and response policies and procedures.
The Policy and FOP require volunteers and contractors who have contact with residents, be
trained on PREA and their responsibilities regarding sexual assault prevention, detection, and
response to allegations of sexual abuse and sexual harassment. A review of training records
and interviews document the training occurs.
Provision (b): The level and type of training provided to volunteers and contractors shall be
based on the services they provide and level of contact they have with residents, but all
volunteers and contractors who have contact with residents shall be notified of the agency’s
zero-tolerance policy regarding sexual abuse and sexual harassment and informed how to
report such incidents.
The interviews revealed the PREA training informs the participants of their role in reporting
allegations of sexual abuse and sexual harassment. The participants are informed of their
responsibilities regarding sexual abuse prevention, detection, and response to a PREA
allegation. The training is based on the services provided by the contractors and volunteers.
The education staff member stated the training includes a review of the zero-tolerance policy
regarding sexual abuse and sexual harassment of residents.
Provision (c): The agency shall maintain documentation confirming that volunteers and
contractors understand the training they have received.
The PREA Notification document contains the information reviewed with the contractor and
volunteer. The document also serves as the training acknowledgement statement containing
the signature of the participant and the date, confirming their understanding of the PREA
information.
The review of training records revealed volunteers and contract providers are given a
downloaded version of the SkillPro on-line PREA training, asked to read it and given the
opportunity to ask questions prior to signing acknowledging they understand the contents of
the documents regarding PREA.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with the provisions of this standard regarding volunteer and
34
contractor training.
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115.333 Resident education
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, PREA Safety
Brochure, Acknowledgement Statements, PREA Posters
Interviews: Residents, Intake Staff
Provisions (a) and (b): During the intake process, residents shall receive information
explaining, in an age appropriate fashion, the agency’s zero tolerance policy regarding sexual
abuse and sexual harassment and how to report incidents or suspicions of sexual abuse or
sexual harassment. Provision (b): Within 10 days of intake, the agency shall provide
comprehensive age-appropriate education to residents either in person or through video
regarding their rights to be free from sexual abuse and sexual harassment and to be free from
retaliation for reporting such incidents, and regarding agency policies and procedures for
responding to such incidents.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA provides all residents admitted receive
information about the facility, including PREA education. Residents receive directions on how
to report allegations of sexual abuse and sexual harassment; and the right to be free from
retaliation for reporting. According to the Intake staff who provides PREA education to
residents and the residents interviewed, an orientation is provided to residents during the
intake process. Policy provides that residents receive a comprehensive age-appropriate PREA
education session within 10 days of admission to the facility. The results of the staff and
resident interviews indicated the information provided to the residents is comprehensive and
age-appropriate.
The intake staff’s interview revealed she ensures residents are educated regarding their rights
to be free from sexual abuse and sexual harassment, and to be free from retaliation for
reporting such incidents. The PREA education sessions include a review of the PREA
Brochure. The residents sign acknowledgement statements confirming their receipt of the
PREA information. A review of documentation showing dates and indicating residents’
participation in PREA education sessions confirmed the PREA education sessions occur;
however, the residents were not aware of the services provided by the victims’ advocacy
services. Staff conducted an education session to review the services provided by the
Kimberly Cottage. Documentation of the session conducted was provided to the auditor which
included a roster signed by the residents. The PREA related information is provided to staff in
policies and procedures, training and staff meetings.
Provision (c): Current residents who have not received such education shall be educated
within one year of the effective date of the PREA standards and shall receive education upon
transfer to a different facility to the extent that the policies and procedures of the resident’s
new facility differ from those of the previous facility.
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Provision (d): The agency shall provide resident education in formats accessible to all
residents, including those who are limited English proficient, deaf, visually impaired, or
otherwise disabled, as well as to residents who have limited reading skills.
The facility has the capability to provide the PREA education in formats accessible to all
residents including those who may be hearing impaired; Deaf; have intellectual, psychiatric
and speech disabilities; low vision; blind; limited reading, limited English proficient, and based
on the individual need of the resident. Documentation was reviewed of a MOU between the
facility and Marion County Board of Education for the provision of accommodations and
supportive services for residents in the aforementioned areas. Posted PREA information is in
English and Spanish accessible to residents, staff, contractors, volunteers, and visitors. The
facility also has a MOU with Language Line Solutions for interpreting and translating services.
Staff interviews confirmed residents are not used as translators or readers for other residents.
Provision (e): The agency shall maintain documentation of resident participation in these
education sessions.
A sample of signed acknowledgement statements were reviewed which supported the
residents’ involvement in PREA education sessions. The residents were aware of PREA
information, including their rights regarding PREA, how to report allegations and that they
would not be punished for reporting allegations of sexual abuse or sexual harassment. The
Intake staff was interviewed regarding PREA education for residents. She ensures residents’
receipt of the information, including the resident signing the acknowledgement form.
Provision (f): In addition to providing such education, the agency shall ensure that key
information is continuously and readily available or visible to residents through posters,
resident handbooks, or other written formats.
The PREA education materials provide residents information on how to report allegations of
sexual harassment and sexual abuse. A brochure is provided to each resident to eliminate
incidents of sexual abuse and sexual harassment. The brochure provides educational
information regarding sexual abuse and victims. The residents revealed they can report
allegations of sexual abuse or sexual harassment by telling a staff member; telling a family
member who may report the allegation for them; access to the hotline to report allegations of
sexual abuse or sexual harassment; or complete a PREA/grievance form. Each resident is
provided a Safety Brochure.
Staff present the PREA information in a manner that is accessible to all residents. If needed,
the facility has internal and external resources to provide translation services through staff or
Language Line Solutions, Inc. for residents who may be limited English proficient or through
Marion County Schools for hearing and visual impairment services and for residents with other
disabilities.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with the provision of this standard.
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115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documentation Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA),
Facility Operating Procedures (FOP) 3.09 PREA, Inspector General Directive, Training
Curriculum, PREA Compliance Form
Interviews: Superintendent
Provision (a) & (b): In addition to the general training provided to all employees pursuant to
§115.331, the agency shall ensure that, to the extent the agency itself conducts sexual abuse
investigations, its investigators have received training in conducting such investigations in
confinement settings. Provision (b): Specialized training shall include techniques for
interviewing juvenile sexual abuse victims, proper use of Miranda and Garrity warnings, sexual
abuse evidence collection in confinement settings, and the criteria and evidence required to
substantiate a case for administrative action or prosecution referral.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA provides for investigations of
allegations of sexual abuse that are criminal in nature to be conducted by the Ocala Police
Department. The Policy and FOP provides for the investigators to be trained.
Provision (c): The agency shall maintain documentation that agency investigators have
completed the required specialized training in conducting sexual abuse investigations.
FDJJ Policy 1919 PREA states local law enforcement agencies and the Florida Department of
Children and Families Services conduct criminal investigations into allegations of sexual
abuse. FDJJ’s Office of Inspector General (OIG) conducts administrative and management
reviews, separate and apart from any criminal investigation. The policy further states the OIG
staff will be trained on the policies and procedures for the Department policies and procedures
related to handling of sexual misconduct incidents and reports.
Provision (d): Any State entity or Department of Justice component that investigates sexual
abuse in juvenile confinement settings shall provide such training to its agents and
investigators who conduct such investigations.
Facility staff does not conduct administrative nor criminal investigations into allegations of
sexual abuse and sexual harassment.
Conclusion: Based upon the review and analysis of the available evidence, the auditor has
determined the facility is compliant with this standard regarding specialized training for
investigations.
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115.335 Specialized training: Medical and mental health care
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documentation Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Contractor Training
example, PREA-Mental Health and Medical Professional Training example, Power Point
Training Modules
Interviews: Nurse, Counselor
Provision (a): The agency shall ensure that all full- and part-time medical and mental health
care practitioners who work regularly in its facilities have been trained in: (1) How to detect
and assess signs of sexual abuse and sexual harassment; (2) How to preserve physical
evidence of sexual abuse; (3) How to respond effectively and professionally to juvenile victims
of sexual abuse and sexual harassment; and (4) How and to whom to report allegations or
suspicions of sexual abuse and sexual harassment.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA provide medical and mental health staff
members receive the regular PREA training as well as the specialized training. Training
records document specialized training for medical and mental health staff members.
Specialized medical and mental health training is provided through SkillPro, FDJJ’s online E-
Learning system. Documentation of specialized training was reviewed for all medical and
mental health staff and confirmed during interviews of medical and mental health staff. The
interviews with the Nurse and Counselor and a review of training certificates, curricula, and
training logs confirmed completion of training which includes the provisions of the standard.
Provision (b): If medical staff employed by the agency conduct forensic examinations, such
medical staff shall receive the appropriate training to conduct such examinations.
Forensic examinations are not conducted by the facility’s medical staff as verified during the
medical staff interview. Forensic examinations are conducted at the Ocala Domestic Violence
and Sexual Assault Center by SANE or SAFE certified examiners.
Provision (c): The agency shall maintain documentation that medical and mental health
practitioners have received the training referenced in this standard either from the agency or
elsewhere.
The training documents, including training certificates and the interviews with medical and
mental health staff confirmed receipt of the required training.
Provision (d): Medical and mental health care practitioners shall also receive the training
mandated for employees under Standard 115.331 or for contractors and volunteers under
Standard 115.332, depending upon the practitioner’s status at the agency.
Medical and mental health staff completed the general training that is provided for all staff
members as documented by training documentation.
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Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard regarding specialized training for medical
and mental health care.
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115.341 Obtaining information from residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA); Facility Operating Procedures (FOP) 3.09 PREA; Sample of Vulnerability
Assessment: Risk of Victimization and/or Sexual Aggression
Interviews: Superintendent; PREA Compliance Manager; Staff Responsible for Risk
Screening; Residents
Provision (a): Within 72 hours of the resident’s arrival at the facility and periodically
throughout a resident’s confinement, the agency shall obtain and use information about each
resident’s personal history and behavior to reduce the risk of sexual abuse by or upon a
resident. The Policy provides a risk screening occurs within 72 hours upon arrival to the
facility. The Intake Coordinator will interview the resident at intake to obtain information about
the residents’ personal history and behavior in order to reduce the risk of sexual abuse by or
upon a resident. The resident’s risk level is reassessed periodically.
Marion RJDC FOP PREA requires staff to complete the FDJJ’s Vulnerability to Victimization
and Sexually Aggressive Behavior (VSAB) form if youth arrive from the Juvenile Assessment
Center (JAC) without a completed form or is returning from a residential program. JAC staff
and Intake staff obtain information from court records, current charges, and interviews with the
resident and his/her parents. The Intake staff interview confirmed compliance with 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.
Disclosure of prior victimization or perpetrated sexual abuse is addressed during the time of
disclosure. The information is related to mental health personnel following the disclosure of
the information. There was no resident in the facility who had disclosed prior victimization. A
review of documentation, interviews with residents and staff confirmed the Vulnerability
Assessment is administered. The information for the instrument may be obtained by asking
questions from the form, medical and mental health screenings and other methods. All
residents interviewed could identify specific areas inquired about in the administration of the
Vulnerability Assessment. Reassessments are conducted periodically. PREA Education and
Screening log was reviewed and it is maintained indicating the administration of the initial
assessment and the completion of the follow-up assessments.
The facility provided the Auditor with examples of the screening tool. The Intake staff,
responsible for risk screening, confirmed residents are screened whether a new admission or
transfer from another facility for risk of sexual abuse victimization or sexual abusiveness
toward the other residents. The risk screening occurs within 72 hours of intake, usually on the
first day. Risk levels are reassessed periodically per the Intake Coordinator and a review of
41
documents. All residents interviewed entered the facility within the past 12 months. They
confirmed they were asked questions like the following examples at intake: (1) Have you have
ever been sexually abused? (2) Do you identify with being gay, bisexual or transgender? (3)
Do you have any disabilities? (4) Do you think you might be in danger of sexual abuse at the
facility?
Based on the review of the Pre-audit questionnaire, review of resident records, interview with
the staff responsible for risk screening, and resident interviews, the evidence shows that
resident’s risk levels are assessed during intake, but no later than 72 hours of their arrival at
the facility. Additionally, risk levels are reassessed periodically. The facility follows this
provision of the standard.
Provision (b): Such assessments shall be conducted using an objective screening
instrument.
The Vulnerability Assessment is used to obtain the information required by the standard,
including but not limited to prior sexual victimization or abusiveness; self-identification; current
charges and offense history; intellectual or developmental disabilities; and a resident’s
concern regarding his own safety. The interview and review of Policy and FOP revealed how
the objective instrument is administered to obtain information to assist staff in keeping
residents safe. The responses on the instrument accumulate a score and the risk level is
determined by definition and the corresponding number to that definition. The Policy and FOP
states residents will be screened within 72 hours of admission however interviews with
residents indicated it is also administered earlier.
Provision (c): At a minimum, the agency shall attempt to ascertain information about: (1)
Prior sexual victimization or abusiveness; (2) Any gender nonconforming appearance or
manner or identification as lesbian, gay, bisexual, transgender, or intersex, and whether the
resident may therefore be vulnerable to sexual abuse; (3) Current charges and offense
history; (4) Age; (5) Level of emotional and cognitive development; (6) Physical size and
stature; (7) Mental illness or mental disabilities; (8) Intellectual or developmental
disabilities; (9) Physical disabilities; (10) The residents own perception of vulnerability;
and (11) Any other specific information about individual residents that may indicate heightened
needs for supervision, additional safety precautions, or separation from certain other
residents.
The Auditor reviewed the Vulnerability Assessment: Risk of Victimization and/or Sexual
Aggression screening instrument and determined all factors required by this provision of the
standard are included. The interview with the Intake staff confirmed he is aware of the
elements of the risk screening instrument. The resident interviews also confirmed the
administration of the screening instrument.
Provision (d): This information shall be ascertained through conversations with the resident
during the intake process and medical and mental health screenings; during classification
assessments; and by reviewing court records, case files, facility behavioral records, and other
relevant documentation from the resident’s files.
The FDJJ Policy 1919 PREA and Marion RJDC FOP PREA states the information shall be
ascertained through conversations with the resident during the intake process and medical
and mental health screenings; during classification assessments; and by reviewing court
42
records, case files, facility behavioral records, and other relevant documentation from the
resident’s file. The staff and resident interviews are aligned with the Policy and FOP and this
provision of the standard. The review of the instrument and interview with the Intake staff
responsible for risk screening confirmed the information is ascertained through conversations
with the residents using the Vulnerability Assessment: Risk of Victimization and/or Sexual
Aggression screening instrument. Resident interviews also revealed the instrument is used.
Additional screening instruments are used and based on the needs of the resident.
Provision (e): The agency shall implement appropriate controls on the dissemination within
the facility of responses to questions asked pursuant to this standard in order to ensure that
sensitive information is not exploited to the resident’s detriment by staff or other residents.
The Policy and FOP provides for appropriate controls be taken to ensure that sensitive
information is protected and not exploited. The interview with the PREA Compliance Manager
revealed the completed VSAB forms are maintained in residents’ medical and Intake files and
are available to staff only on a need to know bases. The Auditor observed the files to be
maintained in a secure manner. The evidence shows the facility follows this provision of the
standard.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is fully compliant with this standard regarding screening for risk of
victimization and abusiveness.
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115.342 Placement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA); Facility Operating Procedures (FOP) 3.09 PREA; Sample of Vulnerability Assessment:
Risk of Victimization and/or Sexual Aggression (VSAB); FOP Admissions; FOP
Classification; FOP Alerts; VSAB Curriculum
Interviews: Superintendent; PREA Compliance Manager; Staff Responsible for Risk
Screening/Intake Staff; Residents; Random Staff
Provision (a): The agency shall use all information obtained pursuant to § 115.341 and
subsequently to make housing, bed, program, education, and work assignments for residents
with the goal of keeping all residents safe and free from sexual abuse.
Marion RJDC FOP PREA requires victimization screening information to be used to determine
a resident’s room assignment and room’s proximity to direct care staff to ensure resident’s
safety. The PREA Compliance Manager interview confirmed the facility’s compliance with this
standard. The facility also utilizes the Classification Alerts to ensure that direct-care staff are
advised if the resident is identified as being at-risk for victimization or posing a risk.
The facility Policy provides guidance to staff regarding the use of the information obtained
from the Vulnerability Assessment: Risk for Victimization and/or Sexual Aggressiveness. The
staff interviews and information obtained through the administration of the screening
instrument assist in determining bed, education and other program assignments with the goal
of keeping all residents safe and meeting the needs of each resident. This information was
verified through a review of specific samples of the aforementioned completed screening
instrument. The facility also uses additional screening instruments.
Provision (b): Residents may be isolated from others only as a last resort when less
restrictive measures are inadequate to keep them and other residents safe, and then only until
an alternative means of keeping all residents safe can be arranged. During any period of
isolation, agencies shall not deny residents daily large-muscle exercise and any legally
required educational programming or special education services. Residents in isolation shall
receive daily visits from a medical or mental health care clinician. Residents shall also have
access to other programs and work opportunities to the extent possible.
The Policy states any use of segregated housing to protect a resident who is alleged to have
suffered sexual abuse shall comply with § 115.342 and the provision (a). At no time will any
client be denied any legally required educational programs, special education services, daily
large-muscle exercise, or medical/mental health care. At risk residents may only be placed in
isolation in an emergency situation, and only as a last resort if less restrictive measures are
inadequate to keep the resident safe.
No residents at risk of sexual victimization were placed in isolation in the 12 months preceding
the audit. The interview with the Superintendent confirmed the facility has not used isolation
44
for this purpose. The policy is inclusive of this provision if there were to be an emergency
situation. The use of isolation would be documented. The residents’ rights to daily large-
muscle exercise and any legally required educational programming or special education
services would be provided. Based on the review of the Pre-audit questionnaire, related
documents and interview with the Superintendent, the evidence shows the facility follows this
provision of the standard.
Provision (c): Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in
particular housing, bed, or other assignments solely on the basis of such identification or
status, nor shall agencies consider lesbian, gay, bisexual, transgender, or intersex
identification or status as an indicator of likelihood of being sexually abusive.
Marion RJDC FOP PREA precludes lesbian, gay, bi-sexual, transgender and intersex
residents from being placed in a particular module and states LGBTI identification or status is
not an indicator of likelihood of being sexually abusive. Transgender or intersex resident’s own
view with respect to his/her safety will be given serious consideration. The PREA Compliance
Manager’s interview also verified compliance with this standard.
During the site tour, there were no rooms observed to be reserved for transgender or intersex
residents. A staff interview and observations revealed there is no special housing based on
how a resident identifies.
Provision (d): In deciding whether to assign a transgender or intersex resident to a facility for
male or female residents, and in making other housing and programming assignments, the
agency shall consider on a case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether the placement would present management or
security problems.
The Policy and FOP also provides that housing and program assignments for transgender or
intersex residents would be made on a case-by-case basis and these residents would not be
placed in particular or special housing which was evident from staff interviews. There were no
transgender or intersex residents in the facility during the site visit and this audit period. The
Intake staff’s interview confirmed the facility would consider on a case-by-case basis whether
a placement would ensure the resident’s health and safety, and whether the placement would
present management or security problems.
Provision (e): Placement and programming assignments for each transgender or intersex
resident shall be reassessed at least twice each year to review any threats to safety
experienced by the resident.
The Policy and FOP states placement and programming assignments for each transgender or
intersex resident shall be reassessed at least twice each year. This function would be done to
review any threats to safety experienced by the resident and the Intake staff is aware of the
requirement. The Intake staff confirmed each transgender or intersex resident would be
reassessed at least twice each year to review any threats to safety experienced by the
resident. Based on the review of the Pre-audit Questionnaire and interview with the Intake
staff, the evidence shows the facility follows this provision of the standard.
Provision (f): A transgender or intersex resident’s own views with respect to his or her own
safety shall be given serious consideration.
45
The resident’s concern for his own safety is taken into account through the administration of
the Vulnerability Assessment and this applies to every resident. The residents confirmed in the
interviews, they are asked about their safety concerns. A review of the PREA Education &
Screening Log demonstrated the additional documentation of the screening assessments and
re-assessments completed for each resident. The staff interviews revealed staff members are
aware of the Policy which requires the provision of the standard to be followed.
Provision (g): Transgender and intersex residents shall be given the opportunity to shower
separately from other residents.
Transgender and intersex residents are given the opportunity to shower separately from other
youth. The policy also states isolation or room restriction may be used as a last resort when
less restrictive measures are inadequate to ensure youths safety and only until an alternative
means of keeping all youth safe can be arranged.
Provision (h): If a resident is isolated pursuant to paragraph (b) of this section, the facility
shall clearly document: (1) The basis for the facility’s concern for the resident’s safety; and (2)
The reason why no alternative means of separation can be arranged.
The Policy states if a resident is isolated pursuant to part (B.2.) of this section, the facility shall
document: a. The basis for the facility’s concern for the resident’s safety; and b. The reason
why no alternative means of separation can be arranged.
No residents at risk of sexual victimization were placed in isolation in the 12 months preceding
the audit. Interviews with the Superintendent and PREA Compliance Manager confirmed the
facility has not used isolation for this purpose. The policy is inclusive of this provision if there
were to be an emergency situation. The Isolation/separation would be documented according
to the provisions of the Policy and standard.
Provision (i): Every 30 days, the facility shall afford each resident described in paragraph (h)
of this section a review to determine whether there is a continuing need for separation from
the general population.
The Policy states every thirty (30) days, staff shall afford each resident described in provision
(b) of this section a review to determine whether there is a continuing need for separation
from the general population. No residents at risk of sexual victimization were placed in
isolation in the 12 months preceding the audit. Interviews with the Superintendent and PREA
Compliance Manager confirmed the facility has not used isolation for this purpose. The policy
is inclusive of this provision if there were to be an emergency situation.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is fully compliant with this standard regarding use of screening
information. The facility uses information from the risk screening required by §115.341 to
inform housing, bed, work, education, and program assignments with the goal of keeping all
residents safe and free from sexual abuse. The facility prohibits placing LGBTI residents in
particular housing, bed, or other assignments solely on the basis of such identification or
status and does not consider such identification or status as an indicator of likelihood of being
sexually abusive. The facility is prepared to provide a safe and secure environment and follow
all provisions of this standard.
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115.351 Resident reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA); Facility Operating Procedures (FOP) 3.09 PREA; PREA/Grievance Forms; Medical
Request Form; Third Party Reporting Forms; Safety Brochure; Sample of Incident
Report; Resident Reporting Poster; Multilingual Posters; MOU, Ocala Domestic Violence and
Sexual Assault Center
Interviews: Random Staff, Residents, Superintendent, PREA Compliance Manager
Provision (a): The agency shall provide multiple internal ways for residents to privately report
sexual abuse and sexual harassment, retaliation by other residents or staff for reporting
sexual abuse and sexual harassment, and staff neglect or violation of responsibilities that may
have contributed to such incidents.
Marion RJDC FOP PREA provides multiple internal ways for residents to privately report
sexual abuse and sexual harassment, retaliation and staff neglect including telling a trusted
staff member or filling out a PREA Reporting form and placing it in a secure drop box. Random
resident interviews confirmed their knowledge of this procedure. FOP addresses this standard
and provides for multiple internal ways a resident may report allegations of sexual abuse and
sexual harassment, including how he/she can privately report sexual abuse and sexual
harassment; retaliation for reporting; and staff neglect or violations of responsibilities that may
have contributed to such.
Residents may report allegations of sexual abuse or sexual harassment by telephone through
the 24-hour hotline of an agency not a part of the facility as confirmed by resident interviews,
posters, staff, MOU, and posted phone instructions. Direct care staff interviews revealed
residents may use the telephone, located on each unit, to privately report sexual abuse and
sexual harassment. The victims’ advocacy service, Ocala Domestic Violence and Sexual
Assault Center was contacted to determine the scope of services provided. A live person
responded to the call and indicated no calls have been received from Marion RJDC residents
over the past 12 months.
The residents also identified internal ways a resident may report such as completing a
PREA/grievance form; talking to a trusted staff member; completing a Medical Request Form;
or tell an outside person or family member. There are designated locked boxes and forms on
the living units for depositing the written grievance forms. If a resident uses a grievance form
to report allegations of sexual abuse or sexual harassment, he/she just needs to place his/her
name on the form, check the appropriate space and place it in the grievance box.
The resident receives a Safety Brochure which provides PREA related information, including
how to report allegations of sexual abuse. Posters are located in the living units and other
areas visible to residents, staff, contractors and visitors. Residents revealed they have contact
with someone who does not work at the facility such as a family member or other person they
could report abuse to if needed. Staff members receive information on how to report
47
allegations of sexual abuse or sexual harassment through policies and procedures, training,
and staff meetings
Provision (b): The agency shall also provide at least one way for residents to report abuse or
harassment to a public or private entity or office that is not part of the agency and that is able
to receive and immediately forward resident reports of sexual abuse and sexual harassment
to agency officials, allowing the resident to remain anonymous upon request. Residents
detained solely for civil immigration purposes shall be provided information on how to contact
relevant consular officials and relevant officials at the Department of Homeland Security.
The Marion RJDC FOP PREA requires youth to have one way of reporting sexual abuse and
sexual harassment to a public or private entity or office not a part of the agency. Residents
may call the Florida Abuse Hotline or call the victims’ advocate hotline. Residents may request
to use a telephone with some degree of privacy to call the hotline without having to obtain staff
permission and that mandates staff not to question residents about the reason for the call. A
resident can request writing materials to write and send a letter to one of these
sources. Random residents interviewed were aware of the abuse hotline and were able to
articulate how they could gain access.
Residents may use of the emergency telephone located on each unit. The resident may select
the appropriate line and dial a number to reach a victim advocate at the Ocala Domestic
Violence and Sexual Assault Center to report an allegation of abuse and/or request advocacy
services. Signs are posted explaining how to access Ocala Domestic Violence and Sexual
Assault Center and contains non-emergency numbers for agencies, including the Police
Department. The resident is also instructed on the signage to dial 911 for emergencies. Direct
care staff revealed staff could use the emergency phone to report allegations of abuse.
Allegations of sexual abuse have not been reported during this audit period. The facility does
not detain residents solely for civil immigration purposes.
Provision (c): Staff shall accept reports made verbally, in writing, anonymously, and from
third parties and shall promptly document any verbal reports.
The staff interviews confirmed the methods available to residents for reporting allegations of
sexual abuse and sexual harassment. Staff members are required to accept third-party
reports and to document verbal reports. All residents interviewed revealed they are familiar
with the provisions of the standard. The resident interviews demonstrated their familiarity with
the various ways they may report either in person, in writing, by phone, completing a Request
and Remedy Form, or through a third-party. The residents were aware third-party reports
could be made and that reports can be made anonymously. Staff members interviewed were
aware of their duty to receive and document third-party reports.
Provision (d): The facility shall provide residents with access to tools necessary to make a
written report.
Writing materials are readily available for residents to complete the accessible forms. Prior to
the site visit pictures were sent to the Auditor showing the reporting forms such as Request
and Remedy Forms and the accessibility of writing utensils. During the on-site visit the Auditor
observed the accessibility of writing utensils to the residents.
Provision (e): The agency shall provide a method for staff to privately report sexual abuse
and sexual harassment of residents.
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The staff interviews revealed staff can privately report allegations of sexual abuse. The
interviews collectively identified the following ways a report can be made privately: use of the
telephone on the living units; use of telephone in an office; third-party reporting form online;
report by email to administrative staff; and/or talk to supervisor in private.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard regarding resident reporting. The
residents have multiple internal ways for to privately report. Reports can be made verbally, in
writing, anonymously, and from third parties. A youth may also call or write his/her parent(s) or
guardian or call or write his/her attorney or legal representative. Verbal reports would be
documented immediately. Residents have access to pens and pencils to write a grievance or
complete a Medical Request Form. Staff can privately report sexual abuse and sexual
harassment of residents.
49
115.352 Exhaustion of administrative remedies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Resident Brochure, Inspector
General statement
Interviews: Superintendent, PREA Compliance Manager
Marion RJDC FOP PREA states the facility is exempt from this standard because it does not
have administrative procedures in place for residents to report allegations of sexual abuse and
sexual harassment through the grievance procedure.
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Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, MOU, Ocala Domestic Violence and
Sexual Assault Center, PREA Brochure (Safety Pamphlet), PREA
Notification/Acknowledgement Form, Posted Information
Interviews: Residents, Superintendent, PREA Compliance Manager, Advocate, advocacy
agency
Provision (a): The facility shall provide residents with access to outside victim advocates for
emotional support services related to sexual abuse, by providing, posting, or otherwise making
accessible mailing addresses and telephone numbers, including toll free hotline numbers
where available, of local, State, or national victim advocacy or rape crisis organizations, and,
for persons detained solely for civil immigration purposes, immigrant services agencies. The
facility shall enable reasonable communication between residents and these organizations
and agencies, in as confidential a manner as possible.
Marion RJDC FOP PREA ensures residents are provided access to outside confidential
support services. The facility has made attempts to establish an MOU with the Ocala Domestic
Violence and Sexual Assault Center which provides the following: a 24/7 hotline staffed by
certified victim advocate; certified victim advocates to respond to requests for advocacy and
accompaniment during forensic examination; counselling; follow- up support; and referral for
treatment after release or transfer to another facility. Signs containing the Ocala Domestic
Violence and Sexual Assault Center hotline number and basic information about the service
were observed throughout the facility.
Contact information for advocacy services is a part of the PREA education sessions and is
also provided to each resident in the PREA brochure. Information is also provided through
signs and posters in various parts of the facility including each living unit. However, the
resident interviews revealed that most residents were not aware of the services provided by
the victims’ advocacy services. Staff conducted an education session to review the services
provided by the victims’ advocacy service. Documentation of the session conducted was
provided to the auditor which included a roster signed by the residents. The hotline telephone
was observed in each living unit and the contact information for services from the agencies
was posted. The telephone number was tested and deemed in working order.
Provision (b): The facility shall inform residents, prior to giving them access, of the extent to
which such communications will be monitored and the extent to which reports of abuse will be
forwarded to authorities in accordance with mandatory reporting laws.
The FOP addresses confidentiality of the advocacy support services. The resident receives
information regarding the limitations of confidentiality during the intake process. An
51
acknowledgement statement specific to the review of the reporting and advocacy services
contains information regarding the advocacy services to be provided by The Ocala Domestic
Violence and Sexual Assault Center Samples of acknowledgement statements were reviewed.
Provision (c): The agency shall maintain or attempt to enter into memoranda of
understanding or other agreements with community service providers that are able to provide
residents with confidential emotional support services related to sexual abuse. The agency
shall maintain copies of agreements or documentation showing attempts to enter into such
agreements.
The FOP states the resident may use the phone, located on each living unit, and push the
appropriate number to gain access and speak with a victim advocate. The agency is identified
on the signage along with directions for reporting allegations or requesting advocacy services.
The Superintendent confirmed the availability and accessibility of outside confidential support
services to residents. A staff member of the advocacy agency stated that an advocate would
go to the facility or the hospital upon request.
Provision (d): The facility shall also provide residents with reasonable and confidential access
to their attorneys or other legal representation and reasonable access to parents or legal
guardians.
The interviews confirmed residents have access to attorneys and court workers and
reasonable access to their parents/legal guardians. The site tour revealed areas where
residents could meet privately with a legal representative and the visitation area for visits with
family members. All residents interviewed stated family could visit and they provided the days
and times of visitation and for phone calls.
Residents interviewed confirmed the facility would allow them to see or talk with their lawyer,
another lawyer or a court representative privately. Residents interviewed confirmed the facility
would allow them to see and talk with their parents or someone else, such as a legal guardian.
Visitors to the facility are informed of PREA and an acknowledgement statement is signed. A
sample of PREA Acknowledgement forms were reviewed, including that of an attorney. The
Superintendent confirmed the facility provides residents with reasonable and confidential
access to their attorneys or court representatives and reasonable access to parents or legal
guardians. Based on interviews with residents and the Superintendent, the evidence shows
the facility follows this provision of the standard.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard regarding resident access to outside
confidential support services and legal representation.
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115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Acknowledgement
Statements, Third Party Reporting Form, Multilingual Posters
Interviews: Random Staff, Residents
§115.354 The agency shall establish a method to receive third-party reports of sexual abuse
and sexual harassment and shall distribute publicly information on how to report sexual abuse
and sexual harassment on behalf of a resident.
FDJJ’s website provides the public with information regarding third-party reporting of sexual
abuse or sexual harassment on behalf of a resident. Resident interviews revealed their
awareness of reporting sexual abuse or sexual harassment to others outside of the facility
including their parents/legal guardians.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA addresses third-party reporting and
interviews revealed random staff members are aware third-party reporting of sexual abuse
and sexual harassment can be done and stated they will be accepted and reported. Staff
members also stated they are to immediately document all verbal reports received. The
interviews revealed they may report allegations privately through the use of the abuse
reporting hotline or a third-party reporting form.
All residents interviewed stated they knew someone who did not work at the facility they could
report to regarding allegations of sexual abuse and that person could make a report for them.
The interviews with the residents revealed their knowledge of third-party reporting. The
residents identified the methods within the facility in which they may make third party reports
such as file an emergency grievance, report to staff or a family member, or utilize the abuse
reporting hotline telephone.
Information regarding reporting is provided through observed postings located in various
areas of the facility accessible to visitors, residents, staff, contractors and volunteers. The
facility’s website contains information regarding third-party reporting of allegations of sexual
abuse. The Third-Party Reporting Form is observed to be located on the website. Copies of
the Third-Party Reporting form are maintained in the lobby and the reporting information is
provided to parents/guardians. There were no third- party reports received during this audit
period.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance regarding third-party reporting. The facility provides
various methods for third-party reports of sexual abuse or sexual harassment.
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115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Florida Administrative Code Rule
63F-11, Multilingual Posters
Interviews: Random Staff, Medical Staff/Nurse, Mental Health
Staff/Counselor, Superintendent, PREA Compliance Manager
Provision (a) and (b): The agency shall require all staff to report immediately and according
to agency policy any knowledge, suspicion, or information they receive regarding an incident
of sexual abuse or sexual harassment that occurred in a facility, whether or not it is part of the
agency; retaliation against residents or staff who reported such an incident; and any staff
neglect or violation of responsibilities that may have contributed to an incident or retaliation.
Provision (b): The agency shall also require all staff to comply with any applicable mandatory
child abuse reporting laws.
According to the Marion RJDC FOP PREA and the Florida Administrative Code Rule 63F-11,
all staff members are required to report any allegation of sexual misconduct or youth-on-youth
sexual activity to the Central Communications Center (CCC). The Policy further states that
staff is prohibited from revealing any related information to anyone other than those persons
making treatment, investigation, security, or management decisions. The Policy also states
that staff members are to immediately report any knowledge, suspicion or information they
receive regarding sexual abuse and 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 or retaliation. This information should be reported to the CCC,
Department of Children and Families Abuse Registry, and local law enforcement. Staff
interviews support the standard requirement.
Provision (c): Apart from reporting to designated supervisors or officials and designated
State or local services agencies, staff shall be prohibited from revealing any information
related to a sexual abuse report to anyone other than to the extent necessary, as specified in
agency policy, to make treatment, investigation, and other security and management
decisions.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA supports that after allegations have
been appropriately reported, staff will not be permitted to give out any other information
relating to what was reported except when necessary to obtain treatment for the resident, aid
in the investigation, or help retain the security of the facility. Staff is expected to continue to
abide by the confidentiality requirements of the facility. Interviews with staff indicated their
knowledge of the prohibition of revealing any information related to a sexual abuse report to
anyone other than to the extent necessary to make treatment, investigation, and other security
and management decisions. Based on the review of documentation and interviews with staff, it
is evident the facility follows this provision of the standard.
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Provision (d): (1) Medical and mental health practitioners shall be required to report sexual
abuse to designated supervisors and officials pursuant to paragraph (a) of this section, as well
as to the designated State or local services agency where required by mandatory reporting
laws. (2) Such practitioners shall be required to inform residents at the initiation of services of
their duty to report and the limitations of confidentiality.
The medical and mental health staff interviewed stated residents are informed at the initiation
of services of the limitations of confidentiality and the duty of the staff members to report. The
clinical staff interviewed revealed they are mandated reporters. They also indicated informed
consent would be documented for a resident 18 years old and over regarding reporting
allegations of sexual abuse that did not occur in an institutional setting.
Provision (e): (1) Upon receiving any allegation of sexual abuse, the facility head or his or her
designee shall promptly report the allegation to the appropriate agency office and to the
alleged victim’s parents or legal guardians, unless the facility has official documentation
showing the parents or legal guardians should not be notified. (2) If the alleged victim is under
the guardianship of the child welfare system, the report shall be made to the alleged victim’s
caseworker instead of the parents or legal guardians. (3) If a juvenile court retains jurisdiction
over the alleged victim, the facility head or designee shall also report the allegation to the
juvenile’s attorney or other legal representative of record within 14 days of receiving the
allegation.
Reports of allegations of sexual abuse will be made by the facility Superintendent/designee
which includes but is not limited to the Ocala Police Department. The interview with the
Superintendent confirmed if the resident is under the custody of a child welfare agency, the
Case Worker will be notified. This information was also verified through Policy review and the
interview with the Superintendent.
Provision (f): The facility shall report all allegations of sexual abuse and sexual harassment,
including third-party and anonymous reports, to the facility’s designated investigators.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA states that all allegations of sexual
abuse and sexual harassment information should be reported to the CCC, Department of
Children and Families Abuse Registry, and local law enforcement. Staff interviews support the
standard requirement.
Conclusion: The interviews with random staff, mental health and medical staff and
Superintendent revealed their awareness of the requirements regarding the reporting duties.
All staff interviewed acknowledged they are mandated reporters and a written report must
immediately follow reported allegations or incidents. The random staff interviewed provided
the reporting requirements and that staff is expected to document receipt of verbal reports
immediately. The facility staff members are also required by the Policy to report allegations
that were made anonymously or by a third-party. During this audit period, there were no
allegations of sexual abuse.
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115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Vulnerability
Assessments, Inspector General Directive
Interviews: Superintendent, PREA Compliance Manager, Random Staff, Random Residents
§115.362 When an agency learns that a resident is subject to a substantial risk of imminent
sexual abuse, it shall take immediate action to protect the resident.
The Marion RJDC FOP PREA addresses this standard and provides that when the facility
learns that a resident is subject to substantial risk of imminent sexual abuse, it takes
immediate action to protect the resident. There have been no incidents in the last 12 months
where the facility took any action regarding a resident being in substantial risk of imminent
sexual abuse, as revealed in interviews with the Superintendent and random staff. Policy
guides the response to this standard if it becomes necessary.
The interviews with the residents revealed during the intake process, how they feel about their
safety is part of the inquiries by staff in completing paperwork. A review of a sample of
Vulnerability Assessments supports the information provided by residents. The PREA
Compliance Manager report during the past 12 months, no residents were identified as being
subject to substantial risk of imminent sexual abuse. The Checklists regarding the
investigations of allegations serves to assist the investigator in ensuring the required protocols
are followed.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard and the provisions regarding agency
protection duties.
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115.363 Reporting to other confinement facilities
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA
Interviews: Superintendent
Provisions (a), (b), (c), and (d): Upon receiving an allegation that a resident was sexually
abused while confined at another facility, the head of the facility that received the allegation
shall notify the head of the facility or appropriate office of the agency where the alleged abuse
occurred and shall also notify the appropriate investigative agency. (b) Such notification shall
be provided as soon as possible, but no later than 72 hours after receiving the allegation.
(c)The agency shall document that it has provided such notification. (d) The facility head or
agency office that receives such notification shall ensure that the allegation is investigated in
accordance with these standards.
Agency Policy and Marion RJDC FOP PREA requires the Superintendent to notify the head of
another facility within 72 hours upon receiving an allegation a resident was sexually abused
while confined at another facility. If any allegation is made, the notifications and documentation
of the notifications would be made according to facility policy.
During the past 12 months, there were no allegations received a resident was abused while
confined to another facility nor were there allegations of sexual abuse received by Marion
RJDC from other facilities.
Conclusion: Based upon the information received and interviews, the Auditor has determined
the facility is compliant with this standard regarding reporting to other confinement facilities.
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115.364 Staff first responder duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Marion RJDC Coordinated
Response
Interviews: Random Staff
Provision (a): Upon learning of an allegation that a resident was sexually abused, the first
staff member to respond to the report shall be required to: (1) Separate the alleged victim and
abuser; (2) Preserve and protect any crime scene until appropriate steps can be taken to
collect any evidence; (3) If the abuse occurred within a time period that still allows for the
collection of physical evidence, request that the alleged victim not take any actions that could
destroy physical evidence, including, as appropriate, washing, brushing teeth, changing
clothes, urinating, defecating, smoking, drinking, or eating; and (4) If the abuse occurred
within a time period that still allows for the collection of physical evidence, ensure that the
alleged abuser does not take any actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking,
drinking, or eating.
Agency Policy and Marion RJDC FOP PREA provides that upon learning of an allegation that a
resident was sexually abused, the first security-level staff member to respond to the report
shall be required to: a. Separate the alleged victim and abuser; b. Preserve and protect any
crime scene until appropriate steps can be taken to collect any evidence; c. If the abuse
occurred within a time period that still allows for the collection of physical evidence, request
that the alleged victim not take any actions that could destroy physical evidence.
The interviews with staff confirmed awareness of first responder duties and the training they
had been provided. There were no allegations that a resident was sexually abused in the last
12 months.
Provision (b): If the first staff responder is not a security staff member, the responder shall be
required to request that the alleged victim not take any actions that could destroy physical
evidence, and then notify security staff.
Random staff interviews revealed considerable knowledge of actions to be taken upon
learning a resident alleges being sexually abused.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard regarding staff first responder duties.
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115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Marion RJDC Coordinated
Response
Interviews: Superintendent, Random Staff
§115.365 The facility shall develop a written institutional plan to coordinate actions taken in
response to an incident of sexual abuse among staff first responders, medical and mental
health practitioners, investigators, and facility leadership.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require the development of a written
plan to coordinate actions taken in response to an incident of sexual assault among staff first
responders, medical, and facility leadership. The facility’s coordinated staff response plan was
reviewed and found in compliance with the standard.
Interviews with the Superintendent and random staff revealed they are knowledgeable of their
duties in response to an allegation of sexual abuse. The random staff interviewed was familiar
with the roles regarding the response to an allegation of sexual abuse. The Superintendent
discussed the coordinated actions in response to an incident of sexual abuse which was
parallel to Policy.
Forensic medical examinations will be provided free of charge to the victim at the Ocala
Domestic Violence and Sexual Assault Center by a Sexual Assault Nurse Examiner (SANE).
The Center has 24/7 access to a SANE provider. A qualified medical professional shall
perform a forensic medical examination if there is no SANE available as stated in the Center’s
Sexual Assault Policy. The victim will be provided unimpeded access to crisis intervention and
medical services.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility complies with the provisions of the standard regarding a coordinated
response to an incident of sexual abuse. No allegations of sexual abuse have been reported
during this audit period.
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115.366 Preservation of ability to protect residents from contact with abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
FDJJ is not a collective bargaining agency; therefore, this standard is not applicable as
confirmed by the Superintendent and included in the PREA Pre-Audit Questionnaire.
60
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documentation Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA),
Facility Operating Procedures (FOP) 3.09 PREA, Comprehensive Accountability
Report, Facility Organizational Chart
Interviews: Retaliation Monitor, Superintendent, PREA Compliance Manager
Provision (a): The agency shall establish a policy to protect all residents and staff who report
sexual abuse or sexual harassment or cooperate with sexual abuse or sexual harassment
investigations from retaliation by other residents or staff and shall designate which staff
members or departments are charged with monitoring retaliation.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require the protection of residents and
staff who have reported sexual abuse or harassment or who have cooperated in a sexual
abuse or sexual harassment investigation. The policy requires the monitoring to take place for
a period of 90 days or longer, as needed.
The Superintendent serves as the Retaliation Monitor and his 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.
Provision (b): The agency shall employ multiple protection measures, such as housing
changes or transfers for resident victims or abusers, removal of alleged staff or resident
abusers from contact with victims, and emotional support services for residents or staff who
fear retaliation for reporting sexual abuse or sexual harassment or for cooperating with
investigations.
The Policy identifies measures to protect staff and residents including the following: a.
Initiating housing changes or transfers for resident victims or abusers; b. Removing alleged
staff or resident abusers from contact with victims; and c. Providing emotional support
services.
The interview confirmed the facility would protect residents and staff from retaliation for sexual
abuse and sexual harassment allegations. Protective measures would include housing
changes, transfers, removing alleged abusers, and emotional support services. The PREA
Compliance Manager identified protective measures that are aligned with the FOP and
standard, including separating the alleged abuser from the alleged victim.
Provision (c): For at least 90 days following a report of sexual abuse, the agency shall
monitor the conduct or treatment of residents or staff who reported the sexual abuse and of
residents who were reported to have suffered sexual abuse to see if there are changes that
61
may suggest possible retaliation by residents or staff and shall act promptly to remedy any
such retaliation. Items the agency should monitor include any resident disciplinary reports,
housing, or program changes, or negative performance reviews or reassignments of staff. The
agency shall continue such monitoring beyond 90 days if the initial monitoring indicates a
continuing need.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA requires the monitoring of items
identified in this provision of the standard. The PREA Compliance Manager explained during
the interview how he would discharge those duties, including monitoring the items identified in
the standard and whether a resident filed a grievance alleging sexual abuse or sexual
harassment. Retaliation monitoring would occur for 90 days to see if there are any changes
that may suggest possible retaliation by residents or staff, and shall act promptly to remedy
any such retaliation, according to Policy. The monitoring will continue beyond ninety (90) days,
if the initial monitoring indicates a continuing need. There have been no incidents of retaliation
during the 12 months preceding the audit.
Provision (d): In the case of residents, such monitoring shall also include periodic status
checks.
The PREA Compliance Manager indicated status checks would be initiated with staff and
residents. The FOP states periodic status will occur. The Retaliation Status Checklist would be
used to document the status checks as well as the Retaliation Monitoring Checklist to
document the ongoing motoring and use of the Retaliation Status Checklist.
Provision (e): If any other individual who cooperates with an investigation expresses a fear of
retaliation, the facility shall take appropriate measures to protect that individual against
retaliation.
The FOP states if any other individual who cooperates with an investigation expresses the
occurrence retaliation from another resident or staff member, Marion RJDC shall take
appropriate measures to protect that individual against retaliation.
Provision (f): An agency’s obligation to monitor shall terminate if the agency determines that
the allegation is unfounded.
The FOP states the facility’s obligation to monitor shall terminate if it is determined that the
allegation is unfounded.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard regarding agency protection against
retaliation.
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115.368 Post-allegation protective custody
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA
Interviews: Superintendent, Mental Health Staff, Medical Staff
§115.368 Any use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse shall be subject to the requirements of §115.342.
Marion RJDC FOP PREA requires residents may only be restricted to his/her single room as a
last measure to keep a resident who alleged sexual abuse safe and then only until an
alternative means for keeping the resident safe can be arranged. No residents have alleged
sexual abuse in the past 12 months. The Superintendent’s interview confirmed compliance
with this standard.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA provides that residents may be isolated
from others only as a last resort when less restrictive measures are inadequate to keep them
and other residents safe, and then only until an alternative means of keeping a resident safe
can be arranged. During the isolation period, the resident must have access to daily large
muscle activities and legally required educational programming or special education services.
FOP further provides for daily visits by mental health and medical personnel. Residents shall
also have access to other programs and work opportunities to the extent possible. According
to the Superintendent, isolation or segregated housing has not been used to protect a resident
who alleged sexual abuse. The medical and mental health staff, Nurse and Counselor, stated
they are not aware of an incident regarding sexual abuse or sexual harassment. The clinical
staff confirmed in such case, the resident would be visited at least daily.
Conclusion: Based upon the review and analysis of Policy, interviews and observations, the
Auditor has determined the facility is compliant with this standard regarding post-allegation
protective custody.
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115.371 Criminal and administrative agency investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA
Interviews: Superintendent, PREA Compliance Manager, Random Staff
§115.371 Provision (a): When the agency conducts its own investigations into allegations of
sexual abuse and sexual harassment, it shall do so promptly, thoroughly, and objectively for
all allegations, including third-party and anonymous reports.
Provision (b): Where sexual abuse is alleged, the agency shall use investigators who have
received special training in sexual abuse investigations involving juvenile victims pursuant to §
115.334.
Provision (c): Investigators shall gather and preserve direct and circumstantial evidence,
including any available physical and DNA evidence and any available electronic monitoring
data; shall interview alleged victims, suspected perpetrators, and witnesses; and shall review
prior complaints and reports of sexual abuse involving the suspected perpetrator.
Provision (d): The agency shall not terminate an investigation solely because the source of
the allegation recants the allegation.
Provision (e): When the quality of evidence appears to support criminal prosecution, the
agency shall conduct compelled interviews only after consulting with prosecutors as to
whether compelled interviews may be an obstacle for subsequent criminal prosecution.
Provision (f): The credibility of an alleged victim, suspect, or witness shall be assessed on an
individual basis and shall not be determined by the person’s status as resident or staff. No
agency shall require a resident who alleges sexual abuse to submit to a polygraph
examination or other truth-telling device as a condition for proceeding with the investigation of
such an allegation.
Provision (g): Administrative investigations: 1) Shall include an effort to determine whether
staff actions or failures to act contributed to the abuse; and (2) Shall be documented in written
reports that include a description of the physical and testimonial evidence, the reasoning
behind credibility assessments, and investigative facts and findings.
Provision (h): Criminal investigations shall be documented in a written report that contains a
thorough description of physical, testimonial, and documentary evidence and attaches copies
of all documentary evidence where feasible.
Provision (I): Substantiated allegations of conduct that appears to be criminal shall be
referred for prosecution.
Provision (j): The agency shall retain all written reports referenced in paragraphs (g) and (h)
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of this section for as long as the alleged abuser is incarcerated or employed by the agency,
plus five years, unless the abuse was committed by a juvenile resident and applicable law
requires a shorter period of retention.
Provision (k): The departure of the alleged abuser or victim from the employment or control
of the facility or agency shall not provide a basis for terminating an investigation.
Provision (l): Any State entity or Department of Justice component that conducts such
investigations shall do so pursuant to the above requirements.
Provision (m): When outside agencies investigate sexual abuse, the facility shall cooperate
with outside investigators and shall endeavor to remain informed about the progress of the
investigation.
Marion RJDC FOP PREA states FDJJ does not conduct criminal investigations of residents’
allegations of sexual abuse. The Ocala Police Department and the Florida Department of
Children and Families Services handle criminal investigations. FDJJ’s Office of Inspector
General (OIG) reviews allegations to identify any misconduct by staff related to FDJJ
regulatory guidance. The policy also states the agency does not terminate an investigation
solely because the source of the allegation recants the allegation.
The agency retains all written reports of investigations pertaining to administrative and criminal
investigations.
There have been no substantiated allegations of sexual abuse since the last PREA audit. The
interviews confirmed what the practice will be in accordance with the Policy, FOP, and
standard.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard regarding criminal and administrative
agency investigations.
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115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Inspector General Directive
Interviews: Superintendent, PREA Compliance Manager
§115.372 The agency shall impose no standard higher than a preponderance of the evidence
in determining whether allegations of sexual abuse or sexual harassment are substantiated.
Marion RJDC FOP PREA states the facility shall impose no standard higher than a
preponderance of the evidence in determining whether allegations of misconduct by staff are
substantiated. The interview with the Superintendent and review of the Directive from the OIG
was aligned with the FOP.
Conclusion: Based upon the review and analysis of the available evidence and the
interviews, the Auditor has determined the facility is compliant with this standard regarding
evidentiary standard for administrative investigations.
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115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Comprehensive Accountability
Report, Inspector General Directive
Interviews: Agency PREA Coordinator, Superintendent, PREA Compliance Manager
Provision (a): Following an investigation into a resident’s allegation of sexual abuse suffered
in an agency facility, the agency shall inform the resident as to whether the allegation has
been determined to be substantiated, unsubstantiated, or unfounded.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require at the conclusion of any law
enforcement investigation into sexual abuse, the victim or the victim’s parent(s) or legal
guardian(s) shall be notified the investigation has concluded. The Statewide PREA
Coordinator will send a letter notifying residents/parents /legal guardian of charges and of the
outcome of the investigation including the identification of the investigative entity and state the
findings.
The Superintendent’s interview confirmed his knowledge of the policies and the requirements
of this standard.
There has been no criminal investigation completed during the past 12 months.
Provision (b): If the agency did not conduct the investigation, it shall request the relevant
information from the investigative agency in order to inform the resident.
The Statewide PREA Coordinator will send a letter notifying residents/parents /legal guardian
of charges and of the outcome of the investigation including the identification of the
investigative entity and state the findings.
Provision (c): Following a resident’s allegation that a staff member has committed sexual
abuse against the resident, the agency shall subsequently inform the resident (unless the
agency has determined that the allegation is unfounded) whenever: (1) The staff member is
no longer posted within the resident’s unit; (2) The staff member is no longer employed at the
facility; (3) The agency learns that the staff member has been indicted on a charge related to
sexual abuse within the facility; or (4) The agency learns that the staff member has been
convicted on a charge related to sexual abuse within the facility.
The Policy requires that following a resident’s allegation that a staff member committed sexual
abuse against the resident, the resident will be informed of the following, unless it has been
determined that the allegation is unfounded, whenever: a. The staff member is no longer
assigned within the resident’s housing unit; b. The staff member is no longer employed at the
facility; c. The staff member has been indicted on a charge related to sexual abuse within
Marion RJDC; or d. The staff member has been convicted on a charge related to sexual
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abuse within the facility.
Provision (d): Following a resident’s allegation that he or she has been sexually abused by
another resident, the agency shall subsequently inform the alleged victim whenever: (1) The
agency learns that the alleged abuser has been indicted on a charge related to sexual abuse
within the facility; or (2) The agency learns that the alleged abuser has been convicted on a
charge related to sexual abuse within the facility.
The Policy provides that following a resident’s allegation that he has been sexually abused by
another resident, the alleged victim shall be subsequently informed whenever: a. The alleged
abuser is criminally charged related to the sexual abuse; or b. The alleged abuser is
adjudicated on a charge related to sexual abuse.
Provision (e): All such notifications or attempted notifications shall be documented.
The Statewide PREA Coordinator will send a letter notifying residents/parents /legal guardian
of charges and of the outcome of the investigation including the identification of the
investigative entity and state the findings.
Conclusion: The interviews with the identified staff confirm the Policy requirements and their
knowledge of the process of reporting to a resident regarding the outcomes of an allegation of
sexual abuse. Based on the review and analysis of the available documentation and
interviews, the Auditor has determined the facility is compliant with this standard regarding
reporting to residents.
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115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Employee Handbook
Interview: Superintendent
Provision (a): Staff shall be subject to disciplinary sanctions up to and including termination
for violating agency sexual abuse or sexual harassment policies.
Provision (b): FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require staff disciplinary
sanctions up to and including termination for violating facility’s sexual abuse or harassment
policies. The policies also mandate the violation be reported to law enforcement and states
termination shall be the presumptive disciplinary sanction for staff who engaged in sexual
abuse.
The interview with the Superintendent, who performs personnel duties, confirmed the FOP. No
employees were terminated or disciplined in the past 12 months for violation of the facility’s
sexual abuse or harassment policies. Termination shall be the presumptive disciplinary
sanction for staff who have engaged in sexual abuse.
The FOP states that termination shall be the presumptive disciplinary sanction for staff who
has engaged in sexual abuse with a resident as confirmed by the Superintendent.
Provision (c): Disciplinary sanctions for violations of agency policies relating to sexual abuse
or sexual harassment (other than actually engaging in sexual abuse) shall be commensurate
with the nature and circumstances of the acts committed, the staff member’s disciplinary
history, and the sanctions imposed for comparable offenses by other staff with similar
histories.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA provides that disciplinary sanctions for
violations of Marion RJDC FOP relating to sexual abuse or sexual harassment (other than
actually engaging in sexual abuse) shall be commensurate with the nature and circumstances
of the acts committed, the staff member’s disciplinary history, and the sanctions imposed for
comparable offenses by other staff with similar histories.
Provision (d): All terminations for violations of agency sexual abuse or sexual harassment
policies, or resignations by staff who would have been terminated if not for their resignation,
shall be reported to law enforcement agencies, unless the activity was clearly not criminal, and
to any relevant licensing bodies.
Marion RJDC FOP states all terminations for violations of the facility’s sexual abuse or sexual
harassment policies, or staff resignations related to violations of this policy, shall be reported
to law enforcement, unless the activity is clearly not criminal. In addition, it shall be reported to
relevant licensing bodies.
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Conclusion: Based upon the review of Policy, FOP, and interview, the Auditor has
determined the facility is compliant with this standard regarding disciplinary sanctions for staff.
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115.377 Corrective action for contractors and volunteers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Employee Handbook
Interviews: Superintendent, PREA Compliance Manager
Provision (a): Any contractor or volunteer who engages in sexual abuse shall be prohibited
from contact with residents and shall be reported to law enforcement agencies, unless the
activity was clearly not criminal, and to relevant licensing bodies.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require any contractor or volunteer who
engages in sexual abuse be prohibited from contact with residents. Policies also require
contractors and volunteers who engage in sexual abuse be reported to law enforcement and
to relevant licensing bodies. During the past 12 months, there were no allegations of sexual
abuse or sexual harassment regarding contractors or volunteers.
A review of training acknowledgement statements and training materials revealed the facility
takes measures to provide volunteers and contractors a clear understanding that sexual
misconduct with a resident is strictly prohibited and is a serious breach of conduct. The review
of materials confirmed participation in PREA training and awareness of the zero-tolerance
policy and how to report allegations of sexual abuse or sexual harassment of residents.
Provision (b): The facility shall take appropriate remedial measures and shall consider
whether to prohibit further contact with residents, in the case of any other violation of agency
sexual abuse or sexual harassment policies by a contractor or volunteer.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA states the Superintendent will take
appropriate remedial measures and consider whether to prohibit further contact with residents
in the case of any other violation of the sexual abuse and sexual harassment policies by a
contractor or volunteer.
Conclusion: Based upon the review and analysis of the available documentation, the Auditor
has determined the facility is in compliant with this standard regarding corrective action for
contractors and volunteers.
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115.378 Interventions and disciplinary sanctions for residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Document Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA), Facility
Operating Procedures (FOP) 3.09 PREA, Behavior Management Memo, Florida Administrative
Rule, Multilingual PREA posters
Interviews: Superintendent, PREA Compliance Manager, Nurse
Provision (a): A resident may be subject to disciplinary sanctions only pursuant to a formal
disciplinary process following an administrative finding that the resident engaged in resident-
on-resident sexual abuse or following a criminal finding of guilt for resident-on-resident sexual
abuse.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require an administrative process for
dealing with violations of resident-on-resident sexual abuse. The Superintendent’s interview
confirms the formal disciplinary process however residents may also be referred to law
enforcement for charges regarding resident-on-resident sexual abuse. Sexual activity
between residents is prohibited and court or administrative processes and sanctions occur
after determination the sexual activity was coerced. Residents will be disciplined for sexual
contact with staff only when it has been determined the staff member did not consent to the
sexual contact.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA provide anyone reporting in good faith
will not receive any repercussions. The policies and interview with the mental health staff
confirms 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 a sexual abuse incident. The interview also revealed any type interventions or
treatment services provided are not as a condition for the resident to access participation in
the behavior management system, education services, or other programs.
The Policy addresses an administrative process for dealing with rule violations and references
the policy that deals with discipline. Sanctions are directly related to the seriousness of the
negative behavior. The interview with the Superintendent revealed the process regarding
allegations of resident-on-resident abuse which can include the resident being removed from
the facility and placed in the detention center during the investigation by law enforcement.
Provision (b): Any disciplinary sanctions shall be commensurate with the nature and
circumstances of the abuse committed, the resident’s disciplinary history, and the sanctions
imposed for comparable offenses by other residents with similar histories. In the event a
disciplinary sanction results in the isolation of a resident, agencies shall not deny the resident
daily large-muscle exercise or access to any legally required educational programming or
special education services. Residents in isolation shall receive daily visits from a medical or
mental health care clinician. Residents shall also have access to other programs and work
opportunities to the extent possible.
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Marion RJDC Policy provides that disciplinary sanctions are commensurate with the nature
and circumstances of the abuse committed, the resident’s disciplinary history, and the
sanctions imposed for comparable offenses by other residents with similar histories. In the
extreme event a disciplinary sanction results in the isolation of a resident, Marion RJDC shall
not deny the resident daily large-muscle exercise or access to any legally required educational
programming or special education services. Policy further provides for daily visits by mental
health and medical personnel. Residents shall also have access to other programs and work
opportunities to the extent possible and receive daily visits from medical and mental health
staff, in accordance with FOP.
Provision (c): The disciplinary process shall consider whether a resident’s mental disabilities
or mental illness contributed to his or her behavior when determining what type of sanction, if
any, should be imposed.
The Marion RJDC FOP provides that the disciplinary process considers whether a resident’s
mental disabilities or mental illness contributed to his or her behavior when determining
what type of sanction, if any, should be imposed. This was confirmed by the interview with the
Superintendent.
Provision (d): If the facility offers therapy, counseling, or other interventions designed to
address and correct underlying reasons or motivations for the abuse, the facility shall consider
whether to offer the offending resident participation in such interventions. The agency may
require participation in such interventions as a condition of access to any rewards-based
behavior management system or other behavior-based incentives, but not as a condition to
access to general programming or education.
Marion RJDC FOP provides the facility considers whether to offer the offending resident
therapy, counseling, or other interventions designed to address and correct underlying
reasons or motivations for the abuse participation. The facility may require participation in
such interventions as a condition of access to privileges, but not as a condition to access to
general programming or education.
Provision (e): The agency may discipline a resident for sexual contact with staff only upon a
finding that the staff member did not consent to such contact.
Marion RJDC Policy provides the facility may discipline a resident for sexual contact with staff
only upon finding that the staff member did not consent to such contact.
Provision (f): For the purpose of disciplinary action, a report of sexual abuse made in good
faith based upon a reasonable belief that the alleged conduct occurred shall not constitute
falsely reporting an incident or lying, even if an investigation does not establish evidence
sufficient to substantiate the allegation.
The Marion RJDC FOP states a report of sexual abuse made in good faith based upon a
reasonable belief that the alleged conduct occurred shall not constitute falsely reporting an
incident or lying, even if an investigation does not establish evidence sufficient to substantiate
the allegation.
Provision (g): An agency may, in its discretion, prohibit all sexual activity between residents
and may discipline residents for such activity. An agency may not, however, deem such
activity to constitute sexual abuse if it determines that the activity is not coerced.
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The FOP prohibits any sexual conduct between residents. All such conduct is subject to
disciplinary action. Court processes occur after determination the sexual activity was coerced.
Conclusion: There have been no residents placed in isolation as a disciplinary sanction for
sexual abuse in the past 12 months. Additionally, there have been no administrative or
criminal findings of resident-on-resident sexual abuse in the past 12 months. Based upon the
review and analysis of the available documentation, the Auditor determined the facility is
compliant with this standard regarding interventions and disciplinary sanctions for residents.
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115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documentation Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Youth VSAB Examples, Florida
Administrative Rule, Critical Alerts Curriculum
Interviews: Staff Responsible for Risk Screening, Medical Staff, Mental Health Staff
Provision (a) and (b): If the screening pursuant to § 115.341 indicates that a resident has
experienced prior sexual victimization, whether it occurred in an institutional setting or in the
community, staff shall ensure that the resident is offered a follow-up meeting with a medical or
mental health practitioner within 14 days of the intake screening. Provision (b): If the
screening pursuant to § 115.341 indicates that a resident has previously perpetrated sexual
abuse, whether it occurred in an institutional setting or in the community, staff shall ensure
that the resident is offered a follow-up meeting with a mental health practitioner within 14 days
of the intake screening.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require a follow-up meeting with a
medical or mental health practitioner within 14 days when a resident discloses any prior
incidents of sexual abuse whether victim or perpetrator. Interviews with the medical and
mental health staff and a review of documentation revealed residents are generally seen by
medical and mental health staff on the same day of admission as part of the intake process.
The policies verify information related to sexual victimization or abusiveness which occurred in
an institutional setting is limited to those staff where it is based on their need to know to make
the appropriate management and security decisions.
Interviews with the medical and mental health staff and observations revealed documentation
of the services provided to each resident is maintained in medical and clinical files. Medical
and mental health staff discussed their knowledge of informed consent, in accordance with
policy. The facility utilizes a consent form regarding treatment services for residents 18 years
old and up. The age range of residents admitted to the facility is 9-21 years old. This
information was also confirmed through the interview with the Intake Staff.
Provision (c): Any information related to sexual victimization or abusiveness that occurred in
an institutional setting shall be strictly limited to medical and mental health practitioners and
other staff, as necessary, to inform treatment plans and security and management decisions,
including housing, bed, work, education, and program assignments, or as otherwise required
by Federal, State, or local law.
The FOP supports that any information related to sexual victimization or abusiveness that
occurred in an institutional setting shall be strictly limited to medical and mental health
practitioners and other staff, as necessary, to inform treatment plans and security and
management decisions, including housing, bed, work, education, and program assignments,
or as otherwise required by Federal, State, or local law. The Auditor observed the resident
files maintained in a secure manner. The files are secured in a locked cabinet behind a locked
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door, when the office is unoccupied.
Provision (d): Medical and mental health practitioners shall obtain informed consent from
residents before reporting information about prior sexual victimization that did not occur in an
institutional setting, unless the resident is under the age of 18.
The FOP provides that medical and mental health practitioners shall obtain informed consent
from residents before reporting information about prior sexual victimization that did not occur
in an institutional setting, unless the resident is under the age of 18. The facility has created
the Informed Consent form to document this type of situation.
Conclusion: Based upon the review and analysis of the available evidence, the Auditor has
determined the facility is compliant with this standard regarding medical and mental health
screenings; and history of sexual abuse.
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115.382 Access to emergency medical and mental health services
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documentation Reviewed: Agency Policy (FDJJ 13HS:01.01), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Samples of Acknowledgement of
PREA Education, MOU, the Ocala Domestic Violence and Sexual Assault Center, Medical-
Mental Health Contract
Interviews: Medical Staff, Mental Health Staff, Superintendent
Provision (a): Resident victims of sexual abuse shall receive timely, unimpeded access to
emergency medical treatment and crisis intervention services, the nature and scope of which
are determined by medical and mental health practitioners according to their professional
judgment.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA mandate youth victims of sexual abuse
receive timely and unimpeded access to onsite and offsite emergency medical treatment and
crisis intervention services, the nature and scope as determined by the judgement of medical
and mental health professionals. Medical and mental health staff interviews confirmed
emergency medical care and crisis intervention services will be provided by medical and
mental health staff as required.
Processes and services are in place for a victim to receive timely access to sexually
transmitted infections prophylaxis, where medically appropriate. Observations revealed
medical and mental health staff members maintain secondary materials that document
services to residents and these staff are knowledgeable of what must occur in an incident of
sexual abuse. It is documented through policies and understood by the medical and mental
health staff treatment services will be provided at no cost to the victim, whether or not the
victim cooperates with the investigation.
There have been no resident victims of sexual abuse in the past 12 months.
Residents are provided access to an outside victim advocacy agency for services through a
MOU with the Ocala Domestic Violence and Sexual Assault Center which includes but is not
limited to emotional support and accompaniment through the forensic examination and
investigative interviews. The advocate will go to the facility or the hospital to provide services.
Review of medical files shows that medical and mental health staff members maintain
secondary materials and documentation of resident encounters. There have been no
allegations of sexual abuse during this audit period.
Provision (b): If no qualified medical or mental health practitioners are on duty at the time a
report of recent abuse is made, staff first responders shall take preliminary steps to protect the
victim pursuant to § 115.362 and shall immediately notify the appropriate medical and mental
health practitioners.
The interviews with clinical staff revealed residents have unimpeded access to emergency
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services. The FOP and the written coordinated response plan flow chart provide guidance to
staff in protecting residents and for contacting the appropriate staff regarding allegations or
incidents of sexual abuse, including contacting medical and mental health staff. The on-call
medical list has the names of medical staff and their emergency contact number. The full-time
Nurse is generally on-call 24/7 as determined by the interview. Review of the coordinated
plan; observations of the interactions among residents, medical and mental health
practitioners; and staff interviews indicated unimpeded medical and crisis intervention services
will be available to a victim of sexual abuse. There have been no allegations of sexual abuse
during this audit period.
Provision (c): Resident victims of sexual abuse while incarcerated shall be offered timely
information about and timely access to emergency contraception and sexually transmitted
infections prophylaxis, in accordance with professionally accepted standards of care, where
medically appropriate.
The FOP and interviews confirmed processes and services are in place for a victim to receive
timely access to sexually transmitted infection prophylaxis, where medically appropriate.
Additionally, follow-up services as needed will be provided by the facility’s medical and mental
health staff, according to the interviews with clinical staff. The facility houses females and
males.
Provision (d): Treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any investigation
arising out of the incident.
The FOP states treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any investigation
arising out of the incident. This was also confirmed through staff interviews.
Conclusion: Facility Policy revealed emergency services will be provided by medical and
mental health staff. The medical and mental health staff interviews revealed they are
knowledgeable of actions to take regarding an incident of sexual abuse. It is documented
through FDJJ Policy 1919 PREA and Marion RJDC FOP PREA and understood by the medical
and mental health staff that treatment services will be provided at no cost to the victim. Based
upon the review and analysis of the available evidence, the Auditor has determined the facility
is compliant with this standard regarding access to emergency medical and mental health
services.
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115.383 Ongoing medical and mental health care for sexual abuse victims and abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Florida Administrative
Rule, Medical-Mental Health Contract
Interviews: Medical Staff, Mental Health Staff, Superintendent
Provision (a): The facility shall offer medical and mental health evaluation and, as
appropriate, treatment to all residents who have been victimized by sexual abuse in any
prison, jail, lockup, or juvenile facility.
Marion RJDC FOP PREA requires mental health evaluation and treatment, as determined by
medical/mental health staff, be offered to residents who disclose prior sexual victimization or
perpetrated sexual abuse during intake screening. Treatment services are provided at no cost
to residents.
There have been no sexual assault victims in the past 12 months; however, if needed,
procedures are in place as verified during staff interviews.
The FOP requires that a medical and mental health evaluation and treatment be offered to
resident victims of sexual abuse. According to the interviews, medical and mental health staff
members are aware of the FOP mandates. The FOP and interviews support medical and
mental health evaluations and treatment will be offered to all residents who have been
victimized by sexual abuse. Interviews with the clinical staff and observations confirmed on-
going medical and mental health care will be provided as appropriate, including assessments
and therapy.
Provision (b): The evaluation and treatment of such victims shall include, as appropriate,
follow-up services, treatment plans, and, when necessary, referrals for continued care
following their transfer to, or placement in, other facilities, or their release from custody.
Interviews with the clinical staff and observations confirmed on-going medical and mental
health care will be provided as appropriate and will include but not limited to additional testing
and medical services; medication management, if prescribed; individual counseling; trauma
group; and referrals as needed. The FOP states that follow-up services will be provided.
Provision (c): The facility shall provide such victims with medical and mental health services
consistent with the community level of care.
FOP, staff interviews and observations revealed medical and mental health services are
consistent with the community level of care.
Provision (d): Resident victims of sexually abusive vaginal penetration while incarcerated
shall be offered pregnancy tests.
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Provision (e): If pregnancy results from conduct specified in paragraph (d) of this section,
such victims shall receive timely and comprehensive information about and timely access to all
lawful pregnancy-related medical services.
Provision (f): Resident victims of sexual abuse while incarcerated shall be offered tests for
sexually transmitted infections as medically appropriate.
The Policy and interviews ensure that victims of sexual abuse will be provided tests for
sexually transmitted infections as medically appropriate. Testing would be done at the Ocala
Domestic Violence and Sexual Assault Center and follow-up services may be done at the
facility, as needed.
Provision (g): Treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any investigation
arising out of the incident.
All treatment services will be provided at no cost to the victim, according to FOP and staff
interviews.
Provision (h): The facility shall attempt to conduct a mental health evaluation of all known
resident-on-resident abusers within 60 days of learning of such abuse history and offer
treatment when deemed appropriate by mental health practitioners.
Facility Policy provides for attempts to be made for a mental health practitioner to conduct a
mental health evaluation within 60 days on all known resident-on-resident abusers and offer
appropriate treatment by mental health staff. Services will include but not be limited to
individual, group and family counseling. Additionally, an evaluation or reassessment will be
administered utilizing the Vulnerability Assessment.
Conclusion: Based upon the review and analysis of the documentation, the Auditor has
determined the facility is compliant with this standard regarding ongoing medical and mental
health care for sexual abuse victims and abusers.
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115.386 Sexual abuse incident reviews
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA
Interviews: Superintendent, Incident Review Team Member
Provision (a): The facility shall conduct a sexual abuse incident review at the conclusion of
every sexual abuse investigation, including where the allegation has not been substantiated,
unless the allegation has been determined to be unfounded.
FDJJ Policy 1919 PREA and Marion RJDC FOP PREA require an incident review team
meeting within 30 days of the conclusion of each investigation. The policy mandates review
team participation to include the agency-wide PREA Coordinator, the facility’s PREA
Compliance Manager, regional office staff, facility supervisor, medical and mental health staff.
The FDJJ’s PREA Coordinator will prepare a report of the review team’s findings and submit
the report to the Secretary for Detention Services, regional office staff and the facility’s
Superintendent.
The interview with the Superintendent and a review of the form used to document the incident
review team’s findings indicate the team: consider whether the allegation or investigation
indicates a need to change policy or practice to better prevent, detect, or respond to sexual
abuse considers 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; examine the area in the facility
where the incident allegedly occurred to assess whether physical barriers in the area may
enable abuse; assess the adequacy of staffing levels in that area during different shifts;
assess whether monitoring technology should be deployed or augmented to supplement
supervision by staff.
Provision (b): Such review shall ordinarily occur within 30 days of the conclusion of the
investigation.
The FOP requires that the reviews occur within 30 days of the conclusion of the investigation.
There has been one allegation of sexual abuse, the Superintendent confirmed that the
incident review occurred within 30 days of the conclusion of the investigation in accordance
with facility FOP and the standard.
Provision (c): The review team shall include upper-level management officials, with input
from line supervisors, investigators, and medical or mental health practitioners.
The FOP identifies the incident review team members as administrators with input from line
supervisors, investigators, medical staff, and Counselors. The investigators from the Ocala
Police Department would be invited to the meeting. The interview with the Superintendent
confirmed the FOP requirements.
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Provision (d): The review team shall: (1) Consider whether the allegation or investigation
indicates a need to change policy or practice to better prevent, detect, or respond to sexual
abuse; (2) Consider whether the incident or allegation was motivated by race; ethnicity;
gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or
perceived status; or, gang affiliation; or was motivated or otherwise caused by other group
dynamics at the facility; (3) Examine the area in the facility where the incident allegedly
occurred to assess whether physical barriers in the area may enable abuse; (4) Assess the
adequacy of staffing levels in that area during different shifts; (5) Assess whether monitoring
technology should be deployed or augmented to supplement supervision by staff; and (6)
Prepare a report of its findings, including but not necessarily limited to determinations made
pursuant to paragraphs (d)(1)-(d)(5) of this section, and any recommendations for
improvement and submit such report to the facility head and PREA Compliance Manager.
The interview with the Superintendent and a review of the form used to document the incident
review team’s findings indicate the team: consider whether the allegation or investigation
indicates a need to change policy or practice to better prevent, detect, or respond to sexual
abuse, considers 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; examine the area in the facility
where the incident allegedly occurred to assess whether physical barriers in the area may
enable abuse; assess the adequacy of staffing levels in that area during different shifts;
assess whether monitoring technology should be deployed or augmented to supplement
supervision by staff.
Provision (e): The facility shall implement the recommendations for improvement or shall
document its reasons for not doing so.
The Policy outlines the requirements of the standard for the areas to be assessed by the
incident review team. The interview with the Superintendent, review of FOP and
documentation method confirmed the incident review team is charged with considering the
factors identified in this standard provision regarding the results of the investigation, including:
considering the make-up and vulnerability of the population such as gang affiliation; whether
the resident identifies as gay, bisexual, transgender, or intersex; other group dynamics;
assessment of the area relative to the allegations; and adequacy of staffing.
The FOP requires the meeting to be documented, including recommendations and the
document provided to the Superintendent. The interview with the Incident Review Team
Member confirmed the facility would prepare a report of its findings and any recommendations
for improvement when conducting a sexual abuse incident review. She confirmed the team
would consider all factors required by the standard.
Conclusion: Based upon the review and analysis of the available documentation, the Auditor
has determined the facility is compliant with this standard regarding sexual abuse incident
reviews.
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115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, PREA Data (Annual Report), CCC
Uniform Definitions
Interview: Agency PREA Coordinator, Superintendent, PREA Compliance Manager
Provisions (a) & (c): The agency shall collect accurate, uniform data for every allegation of
sexual abuse at facilities under its direct control using a standardized instrument and set of
definitions. The incident-based data collected shall include, at a minimum, the data necessary
to answer all questions from the most recent version of the Survey of Sexual Violence
conducted by the Department of Justice.
FDJJ has developed a standardized instrument with definitions to collect accurate, uniform
data for every allegation of sexual assault. The instrument includes the data necessary to
answer all questions from the most recent version of the Survey of Sexual violence conducted
by the Department of Justice. FDJJ Policy 1919 PREA requires CCC to collect all data relating
to PREA. FDJJ Policy 1919 requires the collection of data through the CCC for every
allegation of sexual misconduct which occurs in its state-operated detention centers and its
contracted residential facilities. FDJJ’s website includes annual data collected for fiscal years
2013-2014, 2014-2015, 2015-2016, 2016-2017, 2017-2018 and 2018-2019.
Provision (b): The agency shall aggregate the incident-based sexual abuse data at least
annually.
The FOP and review of the annual report and data gathering instrument and other documents
confirm the facility collects incident-based, uniform data regarding allegations of sexual abuse
and sexual harassment. A standardized instrument and specific guidelines and definitions are
used to assist in identifying the data.
Provision (d): The agency shall maintain, review, and collect data as needed from all
available incident-based documents, including reports, investigation files, and sexual abuse
incident reviews.
The facility maintains and collects various types of identified data and related documents
regarding PREA. The facility collects and maintains data in accordance with Policy directives
and FDJJ and aggregates the data which culminates into an annual report.
Provision (e): The agency also shall obtain incident-based and aggregated data from every
private facility with which it contracts for the confinement of its residents.
Marion RJDC does not contract with outside facilities for confinement of its residents.
Provision (f): Upon request, the agency shall provide all such data from the previous
calendar year to the Department of Justice no later than June 30.
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The FOP states that upon request, Marion RJDC shall provide all such data from the previous
calendar year to the Department of Justice no later than June 30. A request was not made for
the previous calendar year.
Conclusion: Based upon the review and analysis of the documentation, the Auditor has
determined the facility is compliant with this standard regarding data collection.
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115.388 Data review for corrective action
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Annual Report
Interviews: PREA Coordinator, Superintendent, PREA Compliance Manager
FDJJ 1919 and the Marion RJDC FOP PREA address this standard. The statewide PREA
Coordinator will review the collected and aggregated data to assess and improve the
effectiveness of the PREA related efforts and initiatives. The Policy also states that an annual
report will be prepared. A review of documentation confirms this practice.
The annual report is approved as required by Policy, per the interviews and a review of the
report was conducted by the Auditor. The annual report reflects a comparison of the results of
annual data, by calendar year. The annual report has been reviewed and the report is
accessible to the public through the facility’s website. There are no personal identifiers on the
annual report.
Conclusion: Based upon the review and analysis of the documentation, the Auditor has
determined the facility is compliant with this standard regarding data review for corrective
action.
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115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC meets the requirements of this standard based upon the following evidence:
Documents Reviewed: Agency Policy (FDJJ 1919), Prison Rape Elimination Act
(PREA), Facility Operating Procedures (FOP) 3.09 PREA, Annual Report
Interviews: Superintendent, PREA Compliance Manager
FDJJ Policy 1919 PREA requires the collection of data though the CCC for every allegation of
sexual misconduct which occurs in its state-operated detention centers and its contracted
residential facilities. All collected data is maintained for a ten-year period as required by the
State of Florida’s records and retention schedule. According to the FOP, the aggregated
sexual abuse data will be readily available to the public through the agency’s website; the
practice is that the report is posted on the agency’s website. A review of the annual report
verified there are no personal identifiers and it was observed posted on the website, as
required. Related documentation in the facility was observed to be securely stored.
Conclusion: Based upon the review and analysis of the documentation, interviews and
observations, the Auditor has determined the facility is compliant with this standard regarding
data storage, publication, and destruction.
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115.401 Frequency and scope of audits
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC 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 Onsite Visit” regarding how to send confidential
information to the Auditor. No correspondence was received by the Auditor.
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115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
Marion RJDC 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
2020 for detention centers operated by FDJJ and residential facilities contracted by FDJJ are
posted and can be downloaded.
This facility was previously audited February 2018 and the Auditor confirmed the audit report
was posted on the agency’s website as is the practice with the facility. This report does not
contain any personal identifying information and there were no conflicts of interest regarding
the completion of the audit. The facility policies and other documentation were reviewed
regarding compliance with the standards and have been identified in the report. The audit
findings were based on a review of policies and procedures and supporting documentation;
interviews with staff, residents, a contractor; and observations.
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Appendix: Provision Findings
115.311 (a) Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
Does the agency have a written policy mandating zero tolerance toward yes
all forms of sexual abuse and sexual harassment?
Does the written policy outline the agency’s approach to preventing, yes
detecting, and responding to sexual abuse and sexual harassment?
115.311 (b) Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
Has the agency employed or designated an agency-wide PREA yes
Coordinator?
Is the PREA Coordinator position in the upper-level of the agency yes
hierarchy?
Does the PREA Coordinator have sufficient time and authority to yes
develop, implement, and oversee agency efforts to comply with the
PREA standards in all of its facilities?
115.311 (c) Zero tolerance of sexual abuse and sexual harassment; PREA coordinator
If this agency operates more than one facility, has each facility yes
designated a PREA compliance manager? (N/A if agency operates only
one facility.)
Does the PREA compliance manager have sufficient time and authority yes
to coordinate the facility’s efforts to comply with the PREA standards?
(N/A if agency operates only one facility.)
115.312 (a) Contracting with other entities for the confinement of residents
If this agency is public and it contracts for the confinement of its yes
residents with private agencies or other entities including other
government agencies, has the agency included the entity’s obligation to
adopt and comply with the PREA standards in any new contract or
contract renewal signed on or after August 20, 2012? (N/A if the agency
does not contract with private agencies or other entities for the
confinement of residents.)
115.312 (b) Contracting with other entities for the confinement of residents
Does any new contract or contract renewal signed on or after August 20, yes
2012 provide for agency contract monitoring to ensure that the
contractor is complying with the PREA standards? (N/A if the agency
does not contract with private agencies or other entities for the
confinement of residents OR the response to 115.312(a)-1 is "NO".)
115.313 (a) Supervision and monitoring
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Does the agency ensure that each facility has developed a staffing plan yes
that provides for adequate levels of staffing and, where applicable, video
monitoring, to protect residents against sexual abuse?
Does the agency ensure that each facility has implemented a staffing yes
plan that provides for adequate levels of staffing and, where applicable,
video monitoring, to protect residents against sexual abuse?
Does the agency ensure that each facility has documented a staffing yes
plan that provides for adequate levels of staffing and, where applicable,
video monitoring, to protect residents against sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: The prevalence of
substantiated and unsubstantiated incidents of sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: Generally accepted
juvenile detention and correctional/secure residential practices?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: Any judicial findings of
inadequacy?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: Any findings of
inadequacy from Federal investigative agencies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: Any findings of
inadequacy from internal or external oversight bodies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: All components of the
facility’s physical plant (including “blind-spots” or areas where staff or
residents may be isolated)?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: The composition of the
resident population?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
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and determining the need for video monitoring: The number and
placement of supervisory staff?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: Institution programs
occurring on a particular shift?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: Any applicable State or
local laws, regulations, or standards?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate staffing levels
and determining the need for video monitoring: Any other relevant
factors?
115.313 (b) Supervision and monitoring
Does the agency comply with the staffing plan except during limited and yes
discrete exigent circumstances?
In circumstances where the staffing plan is not complied with, does the na
facility fully document all deviations from the plan? (N/A if no deviations
from staffing plan.)
115.313 (c) Supervision and monitoring
Does the facility maintain staff ratios of a minimum of 1:8 during resident yes
waking hours, except during limited and discrete exigent circumstances?
(N/A only until October 1, 2017.)
Does the facility maintain staff ratios of a minimum of 1:16 during yes
resident sleeping hours, except during limited and discrete exigent
circumstances? (N/A only until October 1, 2017.)
Does the facility fully document any limited and discrete exigent yes
circumstances during which the facility did not maintain staff ratios? (N/A
only until October 1, 2017.)
Does the facility ensure only security staff are included when calculating yes
these ratios? (N/A only until October 1, 2017.)
Is the facility obligated by law, regulation, or judicial consent decree to yes
maintain the staffing ratios set forth in this paragraph?
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115.313 (d) Supervision and monitoring
In the past 12 months, has the facility, in consultation with the agency yes
PREA Coordinator, assessed, determined, and documented whether
adjustments are needed to: The staffing plan established pursuant to
paragraph (a) of this section?
In the past 12 months, has the facility, in consultation with the agency yes
PREA Coordinator, assessed, determined, and documented whether
adjustments are needed to: Prevailing staffing patterns?
In the past 12 months, has the facility, in consultation with the agency yes
PREA Coordinator, assessed, determined, and documented whether
adjustments are needed to: The facility’s deployment of video monitoring
systems and other monitoring technologies?
In the past 12 months, has the facility, in consultation with the agency yes
PREA Coordinator, assessed, determined, and documented whether
adjustments are needed to: The resources the facility has available to
commit to ensure adherence to the staffing plan?
115.313 (e) Supervision and monitoring
Has the facility implemented a policy and practice of having yes
intermediate-level or higher-level supervisors conduct and document
unannounced rounds to identify and deter staff sexual abuse and sexual
harassment? (N/A for non-secure facilities )
Is this policy and practice implemented for night shifts as well as day yes
shifts? (N/A for non-secure facilities )
Does the facility have a policy prohibiting staff from alerting other staff yes
members that these supervisory rounds are occurring, unless such
announcement is related to the legitimate operational functions of the
facility? (N/A for non-secure facilities )
115.315 (a) Limits to cross-gender viewing and searches
Does the facility always refrain from conducting any cross-gender strip or yes
cross-gender visual body cavity searches, except in exigent
circumstances or by medical practitioners?
115.315 (b) Limits to cross-gender viewing and searches
Does the facility always refrain from conducting cross-gender pat-down yes
searches in non-exigent circumstances?
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115.315 (c) Limits to cross-gender viewing and searches
Does the facility document and justify all cross-gender strip searches yes
and cross-gender visual body cavity searches?
Does the facility document all cross-gender pat-down searches? yes
115.315 (d) Limits to cross-gender viewing and searches
Does the facility implement policies and procedures that enable yes
residents to shower, perform bodily functions, and change clothing
without nonmedical staff of the opposite gender viewing their breasts,
buttocks, or genitalia, except in exigent circumstances or when such
viewing is incidental to routine cell checks?
Does the facility require staff of the opposite gender to announce their yes
presence when entering a resident housing unit?
In facilities (such as group homes) that do not contain discrete housing yes
units, does the facility require staff of the opposite gender to announce
their presence when entering an area where residents are likely to be
showering, performing bodily functions, or changing clothing? (N/A for
facilities with discrete housing units)
115.315 (e) Limits to cross-gender viewing and searches
Does the facility always refrain from searching or physically examining yes
transgender or intersex residents for the sole purpose of determining the
resident’s genital status?
If a resident’s genital status is unknown, does the facility determine yes
genital status during conversations with the resident, by reviewing
medical records, or, if necessary, by learning that information as part of
a broader medical examination conducted in private by a medical
practitioner?
115.315 (f) Limits to cross-gender viewing and searches
Does the facility/agency train security staff in how to conduct cross- yes
gender pat down searches in a professional and respectful manner, and
in the least intrusive manner possible, consistent with security needs?
Does the facility/agency train security staff in how to conduct searches of yes
transgender and intersex residents in a professional and respectful
manner, and in the least intrusive manner possible, consistent with
security needs?
115.316 (a) Residents with disabilities and residents who are limited English proficient
Does the agency take appropriate steps to ensure that residents with yes
disabilities have an equal opportunity to participate in or benefit from all
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aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who are deaf or
hard of hearing?
Does the agency take appropriate steps to ensure that residents with yes
disabilities have an equal opportunity to participate in or benefit from all
aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who are blind or
have low vision?
Does the agency take appropriate steps to ensure that residents with yes
disabilities have an equal opportunity to participate in or benefit from all
aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who have
intellectual disabilities?
Does the agency take appropriate steps to ensure that residents with yes
disabilities have an equal opportunity to participate in or benefit from all
aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who have
psychiatric disabilities?
Does the agency take appropriate steps to ensure that residents with yes
disabilities have an equal opportunity to participate in or benefit from all
aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who have speech
disabilities?
Does the agency take appropriate steps to ensure that residents with yes
disabilities have an equal opportunity to participate in or benefit from all
aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Other? (if "other," please
explain in overall determination notes.)
Do such steps include, when necessary, ensuring effective yes
communication with residents who are deaf or hard of hearing?
Do such steps include, when necessary, providing access to interpreters yes
who can interpret effectively, accurately, and impartially, both receptively
and expressively, using any necessary specialized vocabulary?
Does the agency ensure that written materials are provided in formats or yes
through methods that ensure effective communication with residents with
disabilities including residents who: Have intellectual disabilities?
Does the agency ensure that written materials are provided in formats or yes
through methods that ensure effective communication with residents with
disabilities including residents who: Have limited reading skills?
Does the agency ensure that written materials are provided in formats or yes
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through methods that ensure effective communication with residents with
disabilities including residents who: Who are blind or have low vision?
115.316 (b) Residents with disabilities and residents who are limited English proficient
Does the agency take reasonable steps to ensure meaningful access to yes
all aspects of the agency’s efforts to prevent, detect, and respond to
sexual abuse and sexual harassment to residents who are limited
English proficient?
Do these steps include providing interpreters who can interpret yes
effectively, accurately, and impartially, both receptively and expressively,
using any necessary specialized vocabulary?
115.316 (c) Residents with disabilities and residents who are limited English proficient
Does the agency always refrain from relying on resident interpreters, yes
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?
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115.317 (a) Hiring and promotion decisions
Does the agency prohibit the hiring or promotion of anyone who may yes
have contact with residents who: Has engaged in sexual abuse in a
prison, jail, lockup, community confinement facility, juvenile facility, or
other institution (as defined in 42 U.S.C. 1997)?
Does the agency prohibit the hiring or promotion of anyone who may yes
have contact with residents who: Has been convicted of engaging or
attempting to engage in sexual activity in the community facilitated by
force, overt or implied threats of force, or coercion, or if the victim did not
consent or was unable to consent or refuse?
Does the agency prohibit the hiring or promotion of anyone who may yes
have contact with residents who: Has been civilly or administratively
adjudicated to have engaged in the activity described in the bullet
immediately above?
Does the agency prohibit the enlistment of services of any contractor yes
who may have contact with residents who: Has engaged in sexual abuse
in a prison, jail, lockup, community confinement facility, juvenile facility,
or other institution (as defined in 42 U.S.C. 1997)?
Does the agency prohibit the enlistment of services of any contractor yes
who may have contact with residents who: Has been convicted of
engaging or attempting to engage in sexual activity in the community
facilitated by force, overt or implied threats of force, or coercion, or if the
victim did not consent or was unable to consent or refuse?
Does the agency prohibit the enlistment of services of any contractor yes
who may have contact with residents who: Has been civilly or
administratively adjudicated to have engaged in the activity described in
the two bullets immediately above?
115.317 (b) Hiring and promotion decisions
Does the agency consider any incidents of sexual harassment in yes
determining whether to hire or promote anyone, or to enlist the services
of any contractor, who may have contact with residents?
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115.317 (c) Hiring and promotion decisions
Before hiring new employees who may have contact with residents, does yes
the agency: Perform a criminal background records check?
Before hiring new employees who may have contact with residents, does yes
the agency: Consult any child abuse registry maintained by the State or
locality in which the employee would work?
Before hiring new employees who may have contact with residents, does yes
the agency: Consistent with Federal, State, and local law, make its best
efforts to contact all prior institutional employers for information on
substantiated allegations of sexual abuse or any resignation during a
pending investigation of an allegation of sexual abuse?
115.317 (d) Hiring and promotion decisions
Does the agency perform a criminal background records check before yes
enlisting the services of any contractor who may have contact with
residents?
Does the agency consult applicable child abuse registries before yes
enlisting the services of any contractor who may have contact with
residents?
115.317 (e) Hiring and promotion decisions
Does the agency either conduct criminal background records checks at yes
least every five years of current employees and contractors who may
have contact with residents or have in place a system for otherwise
capturing such information for current employees?
115.317 (f) Hiring and promotion decisions
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct described in
paragraph (a) of this section in written applications or interviews for
hiring or promotions?
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct described in
paragraph (a) of this section in any interviews or written self-evaluations
conducted as part of reviews of current employees?
Does the agency impose upon employees a continuing affirmative duty yes
to disclose any such misconduct?
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115.317 (g) Hiring and promotion decisions
Does the agency consider material omissions regarding such yes
misconduct, or the provision of materially false information, grounds for
termination?
115.317 (h) Hiring and promotion decisions
Unless prohibited by law, does the agency provide information on yes
substantiated allegations of sexual abuse or sexual harassment involving
a former employee upon receiving a request from an institutional
employer for whom such employee has applied to work? (N/A if
providing information on substantiated allegations of sexual abuse or
sexual harassment involving a former employee is prohibited by law.)
115.318 (a) Upgrades to facilities and technologies
If the agency designed or acquired any new facility or planned any na
substantial expansion or modification of existing facilities, did the agency
consider the effect of the design, acquisition, expansion, or modification
upon the agency’s ability to protect residents from sexual abuse? (N/A if
agency/facility has not acquired a new facility or made a substantial
expansion to existing facilities since August 20, 2012, or since the last
PREA audit, whichever is later.)
115.318 (b) Upgrades to facilities and technologies
If the agency installed or updated a video monitoring system, electronic yes
surveillance system, or other monitoring technology, did the agency
consider how such technology may enhance the agency’s ability to
protect residents from sexual abuse? (N/A if agency/facility has not
installed or updated a video monitoring system, electronic surveillance
system, or other monitoring technology since August 20, 2012, or since
the last PREA audit, whichever is later.)
115.321 (a) Evidence protocol and forensic medical examinations
If the agency is responsible for investigating allegations of sexual abuse, yes
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.)
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115.321 (b) Evidence protocol and forensic medical examinations
Is this protocol developmentally appropriate for youth? (N/A if the yes
agency/facility is not responsible for conducting any form of criminal OR
administrative sexual abuse investigations.)
Is this protocol, as appropriate, adapted from or otherwise based on the yes
most recent edition of the U.S. Department of Justice’s Office on
Violence Against Women publication, “A National Protocol for Sexual
Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly
comprehensive and authoritative protocols developed after 2011? (N/A if
the agency/facility is not responsible for conducting any form of criminal
OR administrative sexual abuse investigations. )
115.321 (c) Evidence protocol and forensic medical examinations
Does the agency offer all residents who experience sexual abuse access yes
to forensic medical examinations, whether on-site or at an outside
facility, without financial cost, where evidentiarily or medically
appropriate?
Are such examinations performed by Sexual Assault Forensic Examiners yes
(SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible?
If SAFEs or SANEs cannot be made available, is the examination yes
performed by other qualified medical practitioners (they must have been
specifically trained to conduct sexual assault forensic exams)?
Has the agency documented its efforts to provide SAFEs or SANEs? yes
115.321 (d) Evidence protocol and forensic medical examinations
Does the agency attempt to make available to the victim a victim yes
advocate from a rape crisis center?
If a rape crisis center is not available to provide victim advocate services, yes
does the agency make available to provide these services a qualified
staff member from a community-based organization, or a qualified
agency staff member?
Has the agency documented its efforts to secure services from rape yes
crisis centers?
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115.321 (e) Evidence protocol and forensic medical examinations
As requested by the victim, does the victim advocate, qualified agency yes
staff member, or qualified community-based organization staff member
accompany and support the victim through the forensic medical
examination process and investigatory interviews?
As requested by the victim, does this person provide emotional support, yes
crisis intervention, information, and referrals?
115.321 (f) Evidence protocol and forensic medical examinations
If the agency itself is not responsible for investigating allegations of yes
sexual abuse, has the agency requested that the investigating entity
follow the requirements of paragraphs (a) through (e) of this section?
(N/A if the agency is not responsible for investigating allegations of
sexual abuse.)
115.321 (h) Evidence protocol and forensic medical examinations
If the agency uses a qualified agency staff member or a qualified na
community-based staff member for the purposes of this section, has the
individual been screened for appropriateness to serve in this role and
received education concerning sexual assault and forensic examination
issues in general? (Check N/A if agency attempts to make a victim
advocate from a rape crisis center available to victims per 115.321(d)
above.)
115.322 (a) Policies to ensure referrals of allegations for investigations
Does the agency ensure an administrative or criminal investigation is yes
completed for all allegations of sexual abuse?
Does the agency ensure an administrative or criminal investigation is yes
completed for all allegations of sexual harassment?
115.322 (b) Policies to ensure referrals of allegations for investigations
Does the agency have a policy in place to ensure that allegations of yes
sexual abuse or sexual harassment are referred for investigation to an
agency with the legal authority to conduct criminal investigations, unless
the allegation does not involve potentially criminal behavior?
Has the agency published such policy on its website or, if it does not yes
have one, made the policy available through other means?
Does the agency document all such referrals? yes
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115.322 (c) Policies to ensure referrals of allegations for investigations
If a separate entity is responsible for conducting criminal investigations, na
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))
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115.331 (a) Employee training
Does the agency train all employees who may have contact with yes
residents on: Its zero-tolerance policy for sexual abuse and sexual
harassment?
Does the agency train all employees who may have contact with yes
residents on: How to fulfill their responsibilities under agency sexual
abuse and sexual harassment prevention, detection, reporting, and
response policies and procedures?
Does the agency train all employees who may have contact with yes
residents on: Residents’ right to be free from sexual abuse and sexual
harassment
Does the agency train all employees who may have contact with yes
residents on: The right of residents and employees to be free from
retaliation for reporting sexual abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: The dynamics of sexual abuse and sexual harassment in
juvenile facilities?
Does the agency train all employees who may have contact with yes
residents on: The common reactions of juvenile victims of sexual abuse
and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: How to detect and respond to signs of threatened and
actual sexual abuse and how to distinguish between consensual sexual
contact and sexual abuse between residents?
Does the agency train all employees who may have contact with yes
residents on: How to avoid inappropriate relationships with residents?
Does the agency train all employees who may have contact with yes
residents on: How to communicate effectively and professionally with
residents, including lesbian, gay, bisexual, transgender, intersex, or
gender nonconforming residents?
Does the agency train all employees who may have contact with yes
residents on: How to comply with relevant laws related to mandatory
reporting of sexual abuse to outside authorities?
Does the agency train all employees who may have contact with yes
residents on: Relevant laws regarding the applicable age of consent?
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115.331 (b) Employee training
Is such training tailored to the unique needs and attributes of residents yes
of juvenile facilities?
Is such training tailored to the gender of the residents at the employee’s yes
facility?
Have employees received additional training if reassigned from a facility yes
that houses only male residents to a facility that houses only female
residents, or vice versa?
115.331 (c) Employee training
Have all current employees who may have contact with residents yes
received such training?
Does the agency provide each employee with refresher training every yes
two years to ensure that all employees know the agency’s current sexual
abuse and sexual harassment policies and procedures?
In years in which an employee does not receive refresher training, does yes
the agency provide refresher information on current sexual abuse and
sexual harassment policies?
115.331 (d) Employee training
Does the agency document, through employee signature or electronic yes
verification, that employees understand the training they have received?
115.332 (a) Volunteer and contractor training
Has the agency ensured that all volunteers and contractors who have yes
contact with residents have been trained on their responsibilities under
the agency’s sexual abuse and sexual harassment prevention, detection,
and response policies and procedures?
115.332 (b) Volunteer and contractor training
Have all volunteers and contractors who have contact with residents yes
been notified of the agency’s zero-tolerance policy regarding sexual
abuse and sexual harassment and informed how to report such incidents
(the level and type of training provided to volunteers and contractors
shall be based on the services they provide and level of contact they
have with residents)?
115.332 (c) Volunteer and contractor training
Does the agency maintain documentation confirming that volunteers and yes
contractors understand the training they have received?
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115.333 (a) Resident education
During intake, do residents receive information explaining the agency’s yes
zero-tolerance policy regarding sexual abuse and sexual harassment?
During intake, do residents receive information explaining how to report yes
incidents or suspicions of sexual abuse or sexual harassment?
Is this information presented in an age-appropriate fashion? yes
115.333 (b) Resident education
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through video
regarding: Their rights to be free from sexual abuse and sexual
harassment?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through video
regarding: Their rights to be free from retaliation for reporting such
incidents?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through video
regarding: Agency policies and procedures for responding to such
incidents?
115.333 (c) Resident education
Have all residents received such education? yes
Do residents receive education upon transfer to a different facility to the yes
extent that the policies and procedures of the resident’s new facility differ
from those of the previous facility?
115.333 (d) Resident education
Does the agency provide resident education in formats accessible to all yes
residents including those who: Are limited English proficient?
Does the agency provide resident education in formats accessible to all yes
residents including those who: Are deaf?
Does the agency provide resident education in formats accessible to all yes
residents including those who: Are visually impaired?
Does the agency provide resident education in formats accessible to all yes
residents including those who: Are otherwise disabled?
Does the agency provide resident education in formats accessible to all yes
residents including those who: Have limited reading skills?
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115.333 (e) Resident education
Does the agency maintain documentation of resident participation in yes
these education sessions?
115.333 (f) Resident education
In addition to providing such education, does the agency ensure that key yes
information is continuously and readily available or visible to residents
through posters, resident handbooks, or other written formats?
115.334 (a) Specialized training: Investigations
In addition to the general training provided to all employees pursuant to yes
§115.331, does the agency ensure that, to the extent the agency itself
conducts sexual abuse investigations, its investigators have received
training in conducting such investigations in confinement settings? (N/A if
the agency does not conduct any form of administrative or criminal
sexual abuse investigations. See 115.321(a).)
115.334 (b) Specialized training: Investigations
Does this specialized training include: Techniques for interviewing yes
juvenile sexual abuse victims? (N/A if the agency does not conduct any
form of administrative or criminal sexual abuse investigations. See
115.321(a).)
Does this specialized training include: Proper use of Miranda and Garrity yes
warnings? (N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See 115.321(a).)
Does this specialized training include: Sexual abuse evidence collection yes
in confinement settings? (N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See 115.321(a).)
Does this specialized training include: The criteria and evidence required yes
to substantiate a case for administrative action or prosecution referral?
(N/A if the agency does not conduct any form of administrative or
criminal sexual abuse investigations. See 115.321(a).)
115.334 (c) Specialized training: Investigations
Does the agency maintain documentation that agency investigators have yes
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).)
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115.335 (a) Specialized training: Medical and mental health care
Does the agency ensure that all full- and part-time medical and mental yes
health care practitioners who work regularly in its facilities have been
trained in: How to detect and assess signs of sexual abuse and sexual
harassment? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in its
facilities.)
Does the agency ensure that all full- and part-time medical and mental yes
health care practitioners who work regularly in its facilities have been
trained in: How to preserve physical evidence of sexual abuse? (N/A if
the agency does not have any full- or part-time medical or mental health
care practitioners who work regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and mental yes
health care practitioners who work regularly in its facilities have been
trained in: How to respond effectively and professionally to juvenile
victims of sexual abuse and sexual harassment? (N/A if the agency does
not have any full- or part-time medical or mental health care practitioners
who work regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and mental yes
health care practitioners who work regularly in its facilities have been
trained in: How and to whom to report allegations or suspicions of sexual
abuse and sexual harassment? (N/A if the agency does not have any
full- or part-time medical or mental health care practitioners who work
regularly in its facilities.)
115.335 (b) Specialized training: Medical and mental health care
If medical staff employed by the agency conduct forensic examinations, yes
do such medical staff receive appropriate training to conduct such
examinations? (N/A if agency medical staff at the facility do not conduct
forensic exams or the agency does not employ medical staff.)
115.335 (c) Specialized training: Medical and mental health care
Does the agency maintain documentation that medical and mental yes
health practitioners have received the training referenced in this
standard either from the agency or elsewhere? (N/A if the agency does
not have any full- or part-time medical or mental health care practitioners
who work regularly in its facilities.)
106
115.335 (d) Specialized training: Medical and mental health care
Do medical and mental health care practitioners employed by the yes
agency also receive training mandated for employees by §115.331?
(N/A if the agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
Do medical and mental health care practitioners contracted by and yes
volunteering for the agency also receive training mandated for
contractors and volunteers by §115.332? (N/A if the agency does not
have any full- or part-time medical or mental health care practitioners
contracted by or volunteering for the agency.)
115.341 (a) Obtaining information from residents
Within 72 hours of the resident’s arrival at the facility, does the agency yes
obtain and use information about each resident’s personal history and
behavior to reduce risk of sexual abuse by or upon a resident?
Does the agency also obtain this information periodically throughout a yes
resident’s confinement?
115.341 (b) Obtaining information from residents
Are all PREA screening assessments conducted using an objective yes
screening instrument?
107
115.341 (c) Obtaining information from residents
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Prior sexual victimization
or abusiveness?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Any gender
nonconforming appearance or manner or identification as lesbian, gay,
bisexual, transgender, or intersex, and whether the resident may
therefore be vulnerable to sexual abuse?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Current charges and
offense history?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Age?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Level of emotional and
cognitive development?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Physical size and
stature?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Mental illness or mental
disabilities?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Intellectual or
developmental disabilities?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: Physical disabilities?
During these PREA screening assessments, at a minimum, does the yes
agency attempt to ascertain information about: The resident’s own
perception of vulnerability?
During these PREA screening assessments, at a minimum, does the yes
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?
108
115.341 (d) Obtaining information from residents
Is this information ascertained: Through conversations with the resident yes
during the intake process and medical mental health screenings?
Is this information ascertained: During classification assessments? yes
Is this information ascertained: By reviewing court records, case files, yes
facility behavioral records, and other relevant documentation from the
resident’s files?
115.341 (e) Obtaining information from residents
Has the agency implemented appropriate controls on the dissemination yes
within the facility of responses to questions asked pursuant to this
standard in order to ensure that sensitive information is not exploited to
the resident’s detriment by staff or other residents?
115.342 (a) Placement of residents
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents safe
and free from sexual abuse, to make: Housing Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents safe
and free from sexual abuse, to make: Bed assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents safe
and free from sexual abuse, to make: Work Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents safe
and free from sexual abuse, to make: Education Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents safe
and free from sexual abuse, to make: Program Assignments?
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115.342 (b) Placement of residents
Are residents isolated from others only as a last resort when less yes
restrictive measures are inadequate to keep them and other residents
safe, and then only until an alternative means of keeping all residents
safe can be arranged?
During any period of isolation, does the agency always refrain from yes
denying residents daily large-muscle exercise?
During any period of isolation, does the agency always refrain from yes
denying residents any legally required educational programming or
special education services?
Do residents in isolation receive daily visits from a medical or mental yes
health care clinician?
Do residents also have access to other programs and work opportunities yes
to the extent possible?
115.342 (c) Placement of residents
Does the agency always refrain from placing: Lesbian, gay, and bisexual yes
residents in particular housing, bed, or other assignments solely on the
basis of such identification or status?
Does the agency always refrain from placing: Transgender residents in yes
particular housing, bed, or other assignments solely on the basis of such
identification or status?
Does the agency always refrain from placing: Intersex residents in yes
particular housing, bed, or other assignments solely on the basis of such
identification or status?
Does the agency always refrain from considering lesbian, gay, bisexual, yes
transgender, or intersex identification or status as an indicator or
likelihood of being sexually abusive?
110
115.342 (d) Placement of residents
When deciding whether to assign a transgender or intersex resident to a yes
facility for male or female residents, does the agency consider on a
case-by-case basis whether a placement would ensure the resident’s
health and safety, and whether a placement would present management
or security problems (NOTE: if an agency by policy or practice assigns
residents to a male or female facility on the basis of anatomy alone, that
agency is not in compliance with this standard)?
When making housing or other program assignments for transgender or yes
intersex residents, does the agency consider on a case-by-case basis
whether a placement would ensure the resident’s health and safety, and
whether a placement would present management or security problems?
115.342 (e) Placement of residents
Are placement and programming assignments for each transgender or yes
intersex resident reassessed at least twice each year to review any
threats to safety experienced by the resident?
115.342 (f) Placement of residents
Are each transgender or intersex resident’s own views with respect to his yes
or her own safety given serious consideration when making facility and
housing placement decisions and programming assignments?
115.342 (g) Placement of residents
Are transgender and intersex residents given the opportunity to shower yes
separately from other residents?
115.342 (h) Placement of residents
If a resident is isolated pursuant to paragraph (b) of this section, does yes
the facility clearly document: The basis for the facility’s concern for the
resident’s safety? (N/A for h and i if facility doesn’t use isolation?)
If a resident is isolated pursuant to paragraph (b) of this section, does yes
the facility clearly document: The reason why no alternative means of
separation can be arranged? (N/A for h and i if facility doesn’t use
isolation?)
115.342 (i) Placement of residents
In the case of each resident who is isolated as a last resort when less yes
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?
111
115.351 (a) Resident reporting
Does the agency provide multiple internal ways for residents to privately yes
report: Sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to privately yes
report: 2. Retaliation by other residents or staff for reporting sexual
abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to privately yes
report: Staff neglect or violation of responsibilities that may have
contributed to such incidents?
115.351 (b) Resident reporting
Does the agency also provide at least one way for residents to report yes
sexual abuse or sexual harassment to a public or private entity or office
that is not part of the agency?
Is that private entity or office able to receive and immediately forward yes
resident reports of sexual abuse and sexual harassment to agency
officials?
Does that private entity or office allow the resident to remain anonymous yes
upon request?
Are residents detained solely for civil immigration purposes provided yes
information on how to contact relevant consular officials and relevant
officials at the Department of Homeland Security to report sexual abuse
or harassment?
115.351 (c) Resident reporting
Do staff members accept reports of sexual abuse and sexual yes
harassment made verbally, in writing, anonymously, and from third
parties?
Do staff members promptly document any verbal reports of sexual yes
abuse and sexual harassment?
115.351 (d) Resident reporting
Does the facility provide residents with access to tools necessary to yes
make a written report?
115.351 (e) Resident reporting
Does the agency provide a method for staff to privately report sexual yes
abuse and sexual harassment of residents?
112
115.352 (a) Exhaustion of administrative remedies
Is the agency exempt from this standard? NOTE: The agency is exempt yes
ONLY if it does not have administrative procedures to address resident
grievances regarding sexual abuse. This does not mean the agency is
exempt simply because a resident does not have to or is not ordinarily
expected to submit a grievance to report sexual abuse. This means that
as a matter of explicit policy, the agency does not have an administrative
remedies process to address sexual abuse.
115.352 (b) Exhaustion of administrative remedies
Does the agency permit residents to submit a grievance regarding an na
allegation of sexual abuse without any type of time limits? (The agency
may apply otherwise-applicable time limits to any portion of a grievance
that does not allege an incident of sexual abuse.) (N/A if agency is
exempt from this standard.)
Does the agency always refrain from requiring an resident to use any na
informal grievance process, or to otherwise attempt to resolve with staff,
an alleged incident of sexual abuse? (N/A if agency is exempt from this
standard.)
115.352 (c) Exhaustion of administrative remedies
Does the agency ensure that: A resident who alleges sexual abuse may na
submit a grievance without submitting it to a staff member who is the
subject of the complaint? (N/A if agency is exempt from this standard.)
Does the agency ensure that: Such grievance is not referred to a staff na
member who is the subject of the complaint? (N/A if agency is exempt
from this standard.)
113
115.352 (d) Exhaustion of administrative remedies
Does the agency issue a final agency decision on the merits of any na
portion of a grievance alleging sexual abuse within 90 days of the initial
filing of the grievance? (Computation of the 90-day time period does not
include time consumed by residents in preparing any administrative
appeal.) (N/A if agency is exempt from this standard.)
If the agency determines that the 90 day timeframe is insufficient to na
make an appropriate decision and claims an extension of time (the
maximum allowable extension of time to respond is 70 days per
115.352(d)(3)) , does the agency notify the resident in writing of any
such extension and provide a date by which a decision will be made?
(N/A if agency is exempt from this standard.)
At any level of the administrative process, including the final level, if the na
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.)
114
115.352 (e) Exhaustion of administrative remedies
Are third parties, including fellow residents, staff members, family na
members, attorneys, and outside advocates, permitted to assist
residents in filing requests for administrative remedies relating to
allegations of sexual abuse? (N/A if agency is exempt from this
standard.)
Are those third parties also permitted to file such requests on behalf of na
residents? (If a third party, other than a parent or legal guardian, files
such a request on behalf of a resident, the facility may require as a
condition of processing the request that the alleged victim agree to have
the request filed on his or her behalf, and may also require the alleged
victim to personally pursue any subsequent steps in the administrative
remedy process.) (N/A if agency is exempt from this standard.)
If the resident declines to have the request processed on his or her na
behalf, does the agency document the resident’s decision? (N/A if
agency is exempt from this standard.)
Is a parent or legal guardian of a juvenile allowed to file a grievance na
regarding allegations of sexual abuse, including appeals, on behalf of
such juvenile? (N/A if agency is exempt from this standard.)
If a parent or legal guardian of a juvenile files a grievance (or an appeal) na
on behalf of a juvenile regarding allegations of sexual abuse, is it the
case that those grievances are not conditioned upon the juvenile
agreeing to have the request filed on his or her behalf? (N/A if agency is
exempt from this standard.)
115
115.352 (f) Exhaustion of administrative remedies
Has the agency established procedures for the filing of an emergency na
grievance alleging that a resident is subject to a substantial risk of
imminent sexual abuse? (N/A if agency is exempt from this standard.)
After receiving an emergency grievance alleging a resident is subject to na
a substantial risk of imminent sexual abuse, does the agency
immediately forward the grievance (or any portion thereof that alleges
the substantial risk of imminent sexual abuse) to a level of review at
which immediate corrective action may be taken? (N/A if agency is
exempt from this standard.)
After receiving an emergency grievance described above, does the na
agency provide an initial response within 48 hours? (N/A if agency is
exempt from this standard.)
After receiving an emergency grievance described above, does the na
agency issue a final agency decision within 5 calendar days? (N/A if
agency is exempt from this standard.)
Does the initial response and final agency decision document the na
agency’s determination whether the resident is in substantial risk of
imminent sexual abuse? (N/A if agency is exempt from this standard.)
Does the initial response document the agency’s action(s) taken in na
response to the emergency grievance? (N/A if agency is exempt from
this standard.)
Does the agency’s final decision document the agency’s action(s) taken na
in response to the emergency grievance? (N/A if agency is exempt from
this standard.)
115.352 (g) Exhaustion of administrative remedies
If the agency disciplines a resident for filing a grievance related to na
alleged sexual abuse, does it do so ONLY where the agency
demonstrates that the resident filed the grievance in bad faith? (N/A if
agency is exempt from this standard.)
116
Resident access to outside confidential support services and legal
115.353 (a)
representation
Does the facility provide residents with access to outside victim yes
advocates for emotional support services related to sexual abuse by
providing, posting, or otherwise making accessible mailing addresses
and telephone numbers, including toll-free hotline numbers where
available, of local, State, or national victim advocacy or rape crisis
organizations?
Does the facility provide persons detained solely for civil immigration yes
purposes mailing addresses and telephone numbers, including toll-free
hotline numbers where available of local, State, or national immigrant
services agencies?
Does the facility enable reasonable communication between residents yes
and these organizations and agencies, in as confidential a manner as
possible?
Resident access to outside confidential support services and legal
115.353 (b)
representation
Does the facility inform residents, prior to giving them access, of the yes
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?
Resident access to outside confidential support services and legal
115.353 (c)
representation
Does the agency maintain or attempt to enter into memoranda of yes
understanding or other agreements with community service providers
that are able to provide residents with confidential emotional support
services related to sexual abuse?
Does the agency maintain copies of agreements or documentation yes
showing attempts to enter into such agreements?
Resident access to outside confidential support services and legal
115.353 (d)
representation
Does the facility provide residents with reasonable and confidential yes
access to their attorneys or other legal representation?
Does the facility provide residents with reasonable access to parents or yes
legal guardians?
117
115.354 (a) Third-party reporting
Has the agency established a method to receive third-party reports of yes
sexual abuse and sexual harassment?
Has the agency distributed publicly information on how to report sexual yes
abuse and sexual harassment on behalf of a resident?
115.361 (a) Staff and agency reporting duties
Does the agency require all staff to report immediately and according to yes
agency policy any knowledge, suspicion, or information they receive
regarding an incident of sexual abuse or sexual harassment that
occurred in a facility, whether or not it is part of the agency?
Does the agency require all staff to report immediately and according to yes
agency policy any knowledge, suspicion, or information they receive
regarding retaliation against residents or staff who reported an incident
of sexual abuse or sexual harassment?
Does the agency require all staff to report immediately and according to yes
agency policy any knowledge, suspicion, or information they receive
regarding any staff neglect or violation of responsibilities that may have
contributed to an incident of sexual abuse or sexual harassment or
retaliation?
115.361 (b) Staff and agency reporting duties
Does the agency require all staff to comply with any applicable yes
mandatory child abuse reporting laws?
115.361 (c) Staff and agency reporting duties
Apart from reporting to designated supervisors or officials and yes
designated State or local services agencies, are staff prohibited from
revealing any information related to a sexual abuse report to anyone
other than to the extent necessary, as specified in agency policy, to
make treatment, investigation, and other security and management
decisions?
115.361 (d) Staff and agency reporting duties
Are medical and mental health practitioners required to report sexual yes
abuse to designated supervisors and officials pursuant to paragraph (a)
of this section as well as to the designated State or local services agency
where required by mandatory reporting laws?
Are medical and mental health practitioners required to inform residents yes
of their duty to report, and the limitations of confidentiality, at the
initiation of services?
118
115.361 (e) Staff and agency reporting duties
Upon receiving any allegation of sexual abuse, does the facility head or yes
his or her designee promptly report the allegation to the appropriate
office?
Upon receiving any allegation of sexual abuse, does the facility head or yes
his or her designee promptly report the allegation to the alleged victim’s
parents or legal guardians unless the facility has official documentation
showing the parents or legal guardians should not be notified?
If the alleged victim is under the guardianship of the child welfare yes
system, does the facility head or his or her designee promptly report the
allegation to the alleged victim’s caseworker instead of the parents or
legal guardians? (N/A if the alleged victim is not under the guardianship
of the child welfare system.)
If a juvenile court retains jurisdiction over the alleged victim, does the yes
facility head or designee also report the allegation to the juvenile’s
attorney or other legal representative of record within 14 days of
receiving the allegation?
115.361 (f) Staff and agency reporting duties
Does the facility report all allegations of sexual abuse and sexual yes
harassment, including third-party and anonymous reports, to the facility’s
designated investigators?
115.362 (a) Agency protection duties
When the agency learns that a resident is subject to a substantial risk of yes
imminent sexual abuse, does it take immediate action to protect the
resident?
115.363 (a) Reporting to other confinement facilities
Upon receiving an allegation that a resident was sexually abused while yes
confined at another facility, does the head of the facility that received the
allegation notify the head of the facility or appropriate office of the
agency where the alleged abuse occurred?
Does the head of the facility that received the allegation also notify the yes
appropriate investigative agency?
115.363 (b) Reporting to other confinement facilities
Is such notification provided as soon as possible, but no later than 72 yes
hours after receiving the allegation?
119
115.363 (c) Reporting to other confinement facilities
Does the agency document that it has provided such notification? yes
115.363 (d) Reporting to other confinement facilities
Does the facility head or agency office that receives such notification yes
ensure that the allegation is investigated in accordance with these
standards?
115.364 (a) Staff first responder duties
Upon learning of an allegation that a resident was sexually abused, is yes
the first security staff member to respond to the report required to:
Separate the alleged victim and abuser?
Upon learning of an allegation that a resident was sexually abused, is yes
the first security staff member to respond to the report required to:
Preserve and protect any crime scene until appropriate steps can be
taken to collect any evidence?
Upon learning of an allegation that a resident was sexually abused, is yes
the first security staff member to respond to the report required to:
Request that the alleged victim not take any actions that could destroy
physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if
the abuse occurred within a time period that still allows for the collection
of physical evidence?
Upon learning of an allegation that a resident was sexually abused, is yes
the first security staff member to respond to the report required to:
Ensure that the alleged abuser does not take any actions that could
destroy physical evidence, including, as appropriate, washing, brushing
teeth, changing clothes, urinating, defecating, smoking, drinking, or
eating, if the abuse occurred within a time period that still allows for the
collection of physical evidence?
115.364 (b) Staff first responder duties
If the first staff responder is not a security staff member, is the responder yes
required to request that the alleged victim not take any actions that could
destroy physical evidence, and then notify security staff?
115.365 (a) Coordinated response
Has the facility developed a written institutional plan to coordinate yes
actions among staff first responders, medical and mental health
practitioners, investigators, and facility leadership taken in response to
an incident of sexual abuse?
120
115.366 (a) Preservation of ability to protect residents from contact with abusers
Are both the agency and any other governmental entities responsible for no
collective bargaining on the agency’s behalf prohibited from entering into
or renewing any collective bargaining agreement or other agreement
that limits the agency’s ability to remove alleged staff sexual abusers
from contact with any residents pending the outcome of an investigation
or of a determination of whether and to what extent discipline is
warranted?
115.367 (a) Agency protection against retaliation
Has the agency established a policy to protect all residents and staff who yes
report sexual abuse or sexual harassment or cooperate with sexual
abuse or sexual harassment investigations from retaliation by other
residents or staff?
Has the agency designated which staff members or departments are yes
charged with monitoring retaliation?
115.367 (b) Agency protection against retaliation
Does the agency employ multiple protection measures for residents or yes
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?
121
115.367 (c) Agency protection against retaliation
Except in instances where the agency determines that a report of sexual yes
abuse is unfounded, for at least 90 days following a report of sexual
abuse, does the agency: Monitor the conduct and treatment of residents
or staff who reported the sexual abuse to see if there are changes that
may suggest possible retaliation by residents or staff?
Except in instances where the agency determines that a report of sexual yes
abuse is unfounded, for at least 90 days following a report of sexual
abuse, does the agency: Monitor the conduct and treatment of residents
who were reported to have suffered sexual abuse to see if there are
changes that may suggest possible retaliation by residents or staff?
Except in instances where the agency determines that a report of sexual yes
abuse is unfounded, for at least 90 days following a report of sexual
abuse, does the agency: Act promptly to remedy any such retaliation?
Except in instances where the agency determines that a report of sexual yes
abuse is unfounded, for at least 90 days following a report of sexual
abuse, does the agency: Monitor: Any resident disciplinary reports?
Except in instances where the agency determines that a report of sexual yes
abuse is unfounded, for at least 90 days following a report of sexual
abuse, does the agency: Monitor: Resident housing changes?
Except in instances where the agency determines that a report of sexual yes
abuse is unfounded, for at least 90 days following a report of sexual
abuse, does the agency: Monitor: Resident program changes?
Except in instances where the agency determines that a report of sexual yes
abuse is unfounded, for at least 90 days following a report of sexual
abuse, does the agency: Monitor: Negative performance reviews of
staff?
Except in instances where the agency determines that a report of sexual yes
abuse is unfounded, for at least 90 days following a report of sexual
abuse, does the agency: Monitor: Reassignments of staff?
Does the agency continue such monitoring beyond 90 days if the initial yes
monitoring indicates a continuing need?
115.367 (d) Agency protection against retaliation
In the case of residents, does such monitoring also include periodic yes
status checks?
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115.367 (e) Agency protection against retaliation
If any other individual who cooperates with an investigation expresses a yes
fear of retaliation, does the agency take appropriate measures to protect
that individual against retaliation?
115.368 (a) Post-allegation protective custody
Is any and all use of segregated housing to protect a resident who is yes
alleged to have suffered sexual abuse subject to the requirements of §
115.342?
115.371 (a) Criminal and administrative agency investigations
When the agency conducts its own investigations into allegations of yes
sexual abuse and sexual harassment, does it do so promptly,
thoroughly, and objectively? (N/A if the agency does not conduct any
form of administrative or criminal investigations of sexual abuse or
harassment. See 115.321(a).)
Does the agency conduct such investigations for all allegations, including yes
third party and anonymous reports? (N/A if the agency does not conduct
any form of administrative or criminal investigations of sexual abuse or
harassment. See 115.321(a).)
115.371 (b) Criminal and administrative agency investigations
Where sexual abuse is alleged, does the agency use investigators who yes
have received specialized training in sexual abuse investigations
involving juvenile victims as required by 115.334?
115.371 (c) Criminal and administrative agency investigations
Do investigators gather and preserve direct and circumstantial evidence, yes
including any available physical and DNA evidence and any available
electronic monitoring data?
Do investigators interview alleged victims, suspected perpetrators, and yes
witnesses?
Do investigators review prior reports and complaints of sexual abuse yes
involving the suspected perpetrator?
115.371 (d) Criminal and administrative agency investigations
Does the agency always refrain from terminating an investigation solely yes
because the source of the allegation recants the allegation?
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115.371 (e) Criminal and administrative agency investigations
When the quality of evidence appears to support criminal prosecution, yes
does the agency conduct compelled interviews only after consulting with
prosecutors as to whether compelled interviews may be an obstacle for
subsequent criminal prosecution?
115.371 (f) Criminal and administrative agency investigations
Do agency investigators assess the credibility of an alleged victim, yes
suspect, or witness on an individual basis and not on the basis of that
individual’s status as resident or staff?
Does the agency investigate allegations of sexual abuse without yes
requiring a resident who alleges sexual abuse to submit to a polygraph
examination or other truth-telling device as a condition for proceeding?
115.371 (g) Criminal and administrative agency investigations
Do administrative investigations include an effort to determine whether yes
staff actions or failures to act contributed to the abuse?
Are administrative investigations documented in written reports that yes
include a description of the physical evidence and testimonial evidence,
the reasoning behind credibility assessments, and investigative facts and
findings?
115.371 (h) Criminal and administrative agency investigations
Are criminal investigations documented in a written report that contains a yes
thorough description of the physical, testimonial, and documentary
evidence and attaches copies of all documentary evidence where
feasible?
115.371 (i) Criminal and administrative agency investigations
Are all substantiated allegations of conduct that appears to be criminal yes
referred for prosecution?
115.371 (j) Criminal and administrative agency investigations
Does the agency retain all written reports referenced in 115.371(g) and yes
(h) for as long as the alleged abuser is incarcerated or employed by the
agency, plus five years unless the abuse was committed by a juvenile
resident and applicable law requires a shorter period of retention?
115.371 (k) Criminal and administrative agency investigations
Does the agency ensure that the departure of an alleged abuser or yes
victim from the employment or control of the facility or agency does not
provide a basis for terminating an investigation?
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115.371 (m) Criminal and administrative agency investigations
When an outside entity investigates sexual abuse, does the facility yes
cooperate with outside investigators and endeavor to remain informed
about the progress of the investigation? (N/A if an outside agency does
not conduct administrative or criminal sexual abuse investigations. See
115.321(a).)
115.372 (a) Evidentiary standard for administrative investigations
Is it true that the agency does not impose a standard higher than a yes
preponderance of the evidence in determining whether allegations of
sexual abuse or sexual harassment are substantiated?
115.373 (a) Reporting to residents
Following an investigation into a resident’s allegation of sexual abuse yes
suffered in the facility, does the agency inform the resident as to whether
the allegation has been determined to be substantiated,
unsubstantiated, or unfounded?
115.373 (b) Reporting to residents
If the agency did not conduct the investigation into a resident’s allegation yes
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.)
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115.373 (c) Reporting to residents
Following a resident’s allegation that a staff member has committed yes
sexual abuse against the resident, unless the agency has determined
that the allegation is unfounded or unless the resident has been
released from custody, does the agency subsequently inform the
resident whenever: The staff member is no longer posted within the
resident’s unit?
Following a resident’s allegation that a staff member has committed yes
sexual abuse against the resident, unless the agency has determined
that the allegation is unfounded or unless the resident has been
released from custody, does the agency subsequently inform the
resident whenever: The staff member is no longer employed at the
facility?
Following a resident’s allegation that a staff member has committed yes
sexual abuse against the resident, unless the agency has determined
that the allegation is unfounded or unless the resident has been
released from custody, does the agency subsequently inform the
resident whenever: The agency learns that the staff member has been
indicted on a charge related to sexual abuse in the facility?
Following a resident’s allegation that a staff member has committed yes
sexual abuse against the resident, unless the agency has determined
that the allegation is unfounded or unless the resident has been
released from custody, does the agency subsequently inform the
resident whenever: The agency learns that the staff member has been
convicted on a charge related to sexual abuse within the facility?
115.373 (d) Reporting to residents
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform the
alleged victim whenever: The agency learns that the alleged abuser has
been indicted on a charge related to sexual abuse within the facility?
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform the
alleged victim whenever: The agency learns that the alleged abuser has
been convicted on a charge related to sexual abuse within the facility?
115.373 (e) Reporting to residents
Does the agency document all such notifications or attempted yes
notifications?
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115.376 (a) Disciplinary sanctions for staff
Are staff subject to disciplinary sanctions up to and including termination yes
for violating agency sexual abuse or sexual harassment policies?
115.376 (b) Disciplinary sanctions for staff
Is termination the presumptive disciplinary sanction for staff who have yes
engaged in sexual abuse?
115.376 (c) Disciplinary sanctions for staff
Are disciplinary sanctions for violations of agency policies relating to yes
sexual abuse or sexual harassment (other than actually engaging in
sexual abuse) commensurate with the nature and circumstances of the
acts committed, the staff member’s disciplinary history, and the
sanctions imposed for comparable offenses by other staff with similar
histories?
115.376 (d) Disciplinary sanctions for staff
Are all terminations for violations of agency sexual abuse or sexual yes
harassment policies, or resignations by staff who would have been
terminated if not for their resignation, reported to: Law enforcement
agencies, unless the activity was clearly not criminal?
Are all terminations for violations of agency sexual abuse or sexual yes
harassment policies, or resignations by staff who would have been
terminated if not for their resignation, reported to: Relevant licensing
bodies?
115.377 (a) Corrective action for contractors and volunteers
Is any contractor or volunteer who engages in sexual abuse prohibited yes
from contact with residents?
Is any contractor or volunteer who engages in sexual abuse reported to: yes
Law enforcement agencies (unless the activity was clearly not criminal)?
Is any contractor or volunteer who engages in sexual abuse reported to: yes
Relevant licensing bodies?
115.377 (b) Corrective action for contractors and volunteers
In the case of any other violation of agency sexual abuse or sexual yes
harassment policies by a contractor or volunteer, does the facility take
appropriate remedial measures, and consider whether to prohibit further
contact with residents?
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115.378 (a) Interventions and disciplinary sanctions for residents
Following an administrative finding that a resident engaged in resident- yes
on-resident sexual abuse, or following a criminal finding of guilt for
resident-on-resident sexual abuse, may residents be subject to
disciplinary sanctions only pursuant to a formal disciplinary process?
115.378 (b) Interventions and disciplinary sanctions for residents
Are disciplinary sanctions commensurate with the nature and yes
circumstances of the abuse committed, the resident’s disciplinary history,
and the sanctions imposed for comparable offenses by other residents
with similar histories?
In the event a disciplinary sanction results in the isolation of a resident, yes
does the agency ensure the resident is not denied daily large-muscle
exercise?
In the event a disciplinary sanction results in the isolation of a resident, yes
does the agency ensure the resident is not denied access to any legally
required educational programming or special education services?
In the event a disciplinary sanction results in the isolation of a resident, yes
does the agency ensure the resident receives daily visits from a medical
or mental health care clinician?
In the event a disciplinary sanction results in the isolation of a resident, yes
does the resident also have access to other programs and work
opportunities to the extent possible?
115.378 (c) Interventions and disciplinary sanctions for residents
When determining what types of sanction, if any, should be imposed, yes
does the disciplinary process consider whether a resident’s mental
disabilities or mental illness contributed to his or her behavior?
115.378 (d) Interventions and disciplinary sanctions for residents
If the facility offers therapy, counseling, or other interventions designed yes
to address and correct underlying reasons or motivations for the abuse,
does the facility consider whether to offer the offending resident
participation in such interventions?
If the agency requires participation in such interventions as a condition of yes
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?
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115.378 (e) Interventions and disciplinary sanctions for residents
Does the agency discipline a resident for sexual contact with staff only yes
upon a finding that the staff member did not consent to such contact?
115.378 (f) Interventions and disciplinary sanctions for residents
For the purpose of disciplinary action, does a report of sexual abuse yes
made in good faith based upon a reasonable belief that the alleged
conduct occurred NOT constitute falsely reporting an incident or lying,
even if an investigation does not establish evidence sufficient to
substantiate the allegation?
115.378 (g) Interventions and disciplinary sanctions for residents
Does the agency always refrain from considering non-coercive sexual yes
activity between residents to be sexual abuse? (N/A if the agency does
not prohibit all sexual activity between residents.)
115.381 (a) Medical and mental health screenings; history of sexual abuse
If the screening pursuant to § 115.341 indicates that a resident has yes
experienced prior sexual victimization, whether it occurred in an
institutional setting or in the community, do staff ensure that the resident
is offered a follow-up meeting with a medical or mental health
practitioner within 14 days of the intake screening?
115.381 (b) Medical and mental health screenings; history of sexual abuse
If the screening pursuant to § 115.341 indicates that a resident has yes
previously perpetrated sexual abuse, whether it occurred in an
institutional setting or in the community, do staff ensure that the resident
is offered a follow-up meeting with a mental health practitioner within 14
days of the intake screening?
115.381 (c) Medical and mental health screenings; history of sexual abuse
Is any information related to sexual victimization or abusiveness that yes
occurred in an institutional setting strictly limited to medical and mental
health practitioners and other staff as necessary to inform treatment
plans and security management decisions, including housing, bed, work,
education, and program assignments, or as otherwise required by
Federal, State, or local law?
115.381 (d) Medical and mental health screenings; history of sexual abuse
Do medical and mental health practitioners obtain informed consent from yes
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?
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115.382 (a) Access to emergency medical and mental health services
Do resident victims of sexual abuse receive timely, unimpeded access to yes
emergency medical treatment and crisis intervention services, the nature
and scope of which are determined by medical and mental health
practitioners according to their professional judgment?
115.382 (b) Access to emergency medical and mental health services
If no qualified medical or mental health practitioners are on duty at the yes
time a report of recent sexual abuse is made, do staff first responders
take preliminary steps to protect the victim pursuant to § 115.362?
Do staff first responders immediately notify the appropriate medical and yes
mental health practitioners?
115.382 (c) Access to emergency medical and mental health services
Are resident victims of sexual abuse offered timely information about and yes
timely access to emergency contraception and sexually transmitted
infections prophylaxis, in accordance with professionally accepted
standards of care, where medically appropriate?
115.382 (d) Access to emergency medical and mental health services
Are treatment services provided to the victim without financial cost and yes
regardless of whether the victim names the abuser or cooperates with
any investigation arising out of the incident?
Ongoing medical and mental health care for sexual abuse victims and
115.383 (a)
abusers
Does the facility offer medical and mental health evaluation and, as yes
appropriate, treatment to all residents who have been victimized by
sexual abuse in any prison, jail, lockup, or juvenile facility?
Ongoing medical and mental health care for sexual abuse victims and
115.383 (b)
abusers
Does the evaluation and treatment of such victims include, as yes
appropriate, follow-up services, treatment plans, and, when necessary,
referrals for continued care following their transfer to, or placement in,
other facilities, or their release from custody?
Ongoing medical and mental health care for sexual abuse victims and
115.383 (c)
abusers
Does the facility provide such victims with medical and mental health yes
services consistent with the community level of care?
130
Ongoing medical and mental health care for sexual abuse victims and
115.383 (d)
abusers
Are resident victims of sexually abusive vaginal penetration while yes
incarcerated offered pregnancy tests? (N/A if all-male facility.)
Ongoing medical and mental health care for sexual abuse victims and
115.383 (e)
abusers
If pregnancy results from the conduct described in paragraph § yes
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.)
Ongoing medical and mental health care for sexual abuse victims and
115.383 (f)
abusers
Are resident victims of sexual abuse while incarcerated offered tests for yes
sexually transmitted infections as medically appropriate?
Ongoing medical and mental health care for sexual abuse victims and
115.383 (g)
abusers
Are treatment services provided to the victim without financial cost and yes
regardless of whether the victim names the abuser or cooperates with
any investigation arising out of the incident?
Ongoing medical and mental health care for sexual abuse victims and
115.383 (h)
abusers
Does the facility attempt to conduct a mental health evaluation of all yes
known resident-on-resident abusers within 60 days of learning of such
abuse history and offer treatment when deemed appropriate by mental
health practitioners?
115.386 (a) Sexual abuse incident reviews
Does the facility conduct a sexual abuse incident review at the yes
conclusion of every sexual abuse investigation, including where the
allegation has not been substantiated, unless the allegation has been
determined to be unfounded?
115.386 (b) Sexual abuse incident reviews
Does such review ordinarily occur within 30 days of the conclusion of the yes
investigation?
131
115.386 (c) Sexual abuse incident reviews
Does the review team include upper-level management officials, with yes
input from line supervisors, investigators, and medical or mental health
practitioners?
115.386 (d) Sexual abuse incident reviews
Does the review team: Consider whether the allegation or investigation yes
indicates a need to change policy or practice to better prevent, detect, or
respond to sexual abuse?
Does the review team: Consider whether the incident or allegation was yes
motivated by race; ethnicity; gender identity; lesbian, gay, bisexual,
transgender, or intersex identification, status, or perceived status; gang
affiliation; or other group dynamics at the facility?
Does the review team: Examine the area in the facility where the incident yes
allegedly occurred to assess whether physical barriers in the area may
enable abuse?
Does the review team: Assess the adequacy of staffing levels in that yes
area during different shifts?
Does the review team: Assess whether monitoring technology should be yes
deployed or augmented to supplement supervision by staff?
Does the review team: Prepare a report of its findings, including but not yes
necessarily limited to determinations made pursuant to §§ 115.386(d)
(1)-(d)(5), and any recommendations for improvement and submit such
report to the facility head and PREA compliance manager?
115.386 (e) Sexual abuse incident reviews
Does the facility implement the recommendations for improvement, or yes
document its reasons for not doing so?
115.387 (a) Data collection
Does the agency collect accurate, uniform data for every allegation of yes
sexual abuse at facilities under its direct control using a standardized
instrument and set of definitions?
115.387 (b) Data collection
Does the agency aggregate the incident-based sexual abuse data at yes
least annually?
132
115.387 (c) Data collection
Does the incident-based data include, at a minimum, the data necessary yes
to answer all questions from the most recent version of the Survey of
Sexual Violence conducted by the Department of Justice?
115.387 (d) Data collection
Does the agency maintain, review, and collect data as needed from all yes
available incident-based documents, including reports, investigation files,
and sexual abuse incident reviews?
115.387 (e) Data collection
Does the agency also obtain incident-based and aggregated data from yes
every private facility with which it contracts for the confinement of its
residents? (N/A if agency does not contract for the confinement of its
residents.)
115.387 (f) Data collection
Does the agency, upon request, provide all such data from the previous yes
calendar year to the Department of Justice no later than June 30? (N/A if
DOJ has not requested agency data.)
115.388 (a) Data review for corrective action
Does the agency review data collected and aggregated pursuant to § yes
115.387 in order to assess and improve the effectiveness of its sexual
abuse prevention, detection, and response policies, practices, and
training, including by: Identifying problem areas?
Does the agency review data collected and aggregated pursuant to § yes
115.387 in order to assess and improve the effectiveness of its sexual
abuse prevention, detection, and response policies, practices, and
training, including by: Taking corrective action on an ongoing basis?
Does the agency review data collected and aggregated pursuant to § yes
115.387 in order to assess and improve the effectiveness of its sexual
abuse prevention, detection, and response policies, practices, and
training, including by: Preparing an annual report of its findings and
corrective actions for each facility, as well as the agency as a whole?
115.388 (b) Data review for corrective action
Does the agency’s annual report include a comparison of the current yes
year’s data and corrective actions with those from prior years and
provide an assessment of the agency’s progress in addressing sexual
abuse?
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115.388 (c) Data review for corrective action
Is the agency’s annual report approved by the agency head and made yes
readily available to the public through its website or, if it does not have
one, through other means?
115.388 (d) Data review for corrective action
Does the agency indicate the nature of the material redacted where it yes
redacts specific material from the reports when publication would
present a clear and specific threat to the safety and security of a facility?
115.389 (a) Data storage, publication, and destruction
Does the agency ensure that data collected pursuant to § 115.387 are yes
securely retained?
115.389 (b) Data storage, publication, and destruction
Does the agency make all aggregated sexual abuse data, from facilities yes
under its direct control and private facilities with which it contracts,
readily available to the public at least annually through its website or, if it
does not have one, through other means?
115.389 (c) Data storage, publication, and destruction
Does the agency remove all personal identifiers before making yes
aggregated sexual abuse data publicly available?
115.389 (d) Data storage, publication, and destruction
Does the agency maintain sexual abuse data collected pursuant to § yes
115.387 for at least 10 years after the date of the initial collection, unless
Federal, State, or local law requires otherwise?
115.401 (a) Frequency and scope of audits
During the prior three-year audit period, did the agency ensure that each yes
facility operated by the agency, or by a private organization on behalf of
the agency, was audited at least once? (Note: The response here is
purely informational. A "no" response does not impact overall
compliance with this standard.)
134
115.401 (b) Frequency and scope of audits
Is this the first year of the current audit cycle? (Note: a “no” response no
does not impact overall compliance with this standard.)
If this is the second year of the current audit cycle, did the agency na
ensure that at least one-third of each facility type operated by the
agency, or by a private organization on behalf of the agency, was
audited during the first year of the current audit cycle? (N/A if this is not
the second year of the current audit cycle.)
If this is the third year of the current audit cycle, did the agency ensure yes
that at least two-thirds of each facility type operated by the agency, or by
a private organization on behalf of the agency, were audited during the
first two years of the current audit cycle? (N/A if this is not the third year
of the current audit cycle.)
115.401 (h) Frequency and scope of audits
Did the auditor have access to, and the ability to observe, all areas of the yes
audited facility?
115.401 (i) Frequency and scope of audits
Was the auditor permitted to request and receive copies of any relevant yes
documents (including electronically stored information)?
115.401 (m) Frequency and scope of audits
Was the auditor permitted to conduct private interviews with inmates, yes
residents, and detainees?
115.401 (n) Frequency and scope of audits
Were inmates, residents, and detainees permitted to send confidential yes
information or correspondence to the auditor in the same manner as if
they were communicating with legal counsel?
115.403 (f) Audit contents and findings
The agency has published on its agency website, if it has one, or has yes
otherwise made publicly available, all Final Audit Reports. The review
period is for prior audits completed during the past three years
PRECEDING THIS AUDIT. The pendency of any agency appeal
pursuant to 28 C.F.R. § 115.405 does not excuse noncompliance with
this provision. (N/A if there have been no Final Audit Reports issued in
the past three years, or, in the case of single facility agencies, there has
never been a Final Audit Report issued.)
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program_name_raw: marion regional juvenile deterntion center

cycle: Year 2 Cycle 3