facility_name: Walton Academy for Growth and Change

summary: PREA - Year 1 Cycle 5

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Walton Academy for Growth and Change
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 03/20/2026
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: Robert Manville Date of Signature: 03/20/2026
AUDITOR INFORMATION
Auditor name: Manville, Robert
Email: robertmanville9@gmail.com
Start Date of On- 02/04/2026
Site Audit:
End Date of On-Site 03/05/2026
Audit:
FACILITY INFORMATION
Facility name: Walton Academy for Growth and Change
Facility physical 286 Gene Hurley Road , DeFuniak Springs , Florida - 32433
address:
Facility mailing
address:
Primary Contact
Name: Ryan Oatts
Email Address: ryan.oatts@rop.com
Telephone Number: 8509246369
Superintendent/Director/Administrator
Name: Ryan Oatts
Email Address: ryan.oatts@rop.com
Telephone Number: 8509246369
Facility PREA Compliance Manager
Name: Ryan Oatts
Email Address: ryan.oatts@rop.com
Telephone Number: 850-924-6369
Facility Health Service Administrator On-Site
Name: Jessica Austin
Email Address: Jessica.Austin@rop.com
Telephone Number: 850-333-3675
Facility Characteristics
Designed facility capacity: 42
Current population of facility: 42
Average daily population for the past 12 25
months:
Has the facility been over capacity at any No
point in the past 12 months?
What is the facility’s population Men/boys
designation?
Age range of population: 13-18
Facility security levels/resident custody High Risk
levels:
Number of staff currently employed at the 35
facility who may have contact with
residents:
Number of individual contractors who have 6
contact with residents, currently
authorized to enter the facility:
Number of volunteers who have contact 6
with residents, currently authorized to
enter the facility:
AGENCY INFORMATION
Name of agency: Rite of Passage, Inc.
Governing authority
or parent agency (if
applicable):
Physical Address: 2560 Business Parkway, Suite A, Minden, Nevada - 89423
Mailing Address:
Telephone number: 775-267-9411
Agency Chief Executive Officer Information:
Name: S. James Broman
Email Address: sbroman@rop.com
Telephone Number: 775-267-9411
Agency-Wide PREA Coordinator Information
Name: Angela Lowe Email Address: angela.lowe@rop.com
Facility AUDIT FINDINGS
Summary of Audit Findings
The OAS automatically populates the number and list of Standards exceeded, the number of
Standards met, and the number and list of Standards not met.
Auditor Note: In general, no standards should be found to be "Not Applicable" or "NA." A
compliance determination must be made for each standard. In rare instances where an auditor
determines that a standard is not applicable, the auditor should select "Meets Standard” and
include a comprehensive discussion as to why the standard is not applicable to the facility being
audited.
Number of standards exceeded:
5
• 115.311 - Zero tolerance of sexual
abuse and sexual harassment; PREA
coordinator
• 115.317 - Hiring and promotion
decisions
• 115.335 - Specialized training: Medical
and mental health care
• 115.341 - Obtaining information from
residents
• 115.381 - Medical and mental health
screenings; history of sexual abuse
Number of standards met:
38
Number of standards not met:
0
POST-AUDIT REPORTING INFORMATION
Please note: Question numbers may not appear sequentially as some
questions are omitted from the report and used solely for internal
reporting purposes.
GENERAL AUDIT INFORMATION
On-site Audit Dates
1. Start date of the onsite portion of the 2026-02-04
audit:
2. End date of the onsite portion of the 2026-03-05
audit:
Outreach
10. Did you attempt to communicate Yes
with community-based organization(s)
or victim advocates who provide
No
services to this facility and/or who may
have insight into relevant conditions in
the facility?
a. Identify the community-based Emerald Coast Victim Children's Advocacy
organization(s) or victim advocates with Center
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 42
15. Average daily population for the past 25
12 months:
16. Number of inmate/resident/detainee 1
housing units:
17. Does the facility ever hold youthful Yes
inmates or youthful/juvenile detainees?
No
Not Applicable for the facility type audited
(i.e., Community Confinement Facility or
Juvenile Facility)
Audited Facility Population Characteristics on Day One of the Onsite
Portion of the Audit
Inmates/Residents/Detainees Population Characteristics on Day One of the Onsite Portion
of the Audit
23. Enter the total number of inmates/ 25
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
25. Enter the total number of inmates/ 0
residents/detainees with a physical
disability in the facility as of the first
day of the onsite portion of the audit:
26. Enter the total number of inmates/ 1
residents/detainees with a cognitive or
functional disability (including
intellectual disability, psychiatric
disability, or speech disability) in the
facility as of the first day of the onsite
portion of the audit:
27. Enter the total number of inmates/ 0
residents/detainees who are Blind or
have low vision (visually impaired) in the
facility as of the first day of the onsite
portion of the audit:
28. Enter the total number of inmates/ 0
residents/detainees who are Deaf or
hard-of-hearing in the facility as of the
first day of the onsite portion of the
audit:
29. Enter the total number of inmates/ 0
residents/detainees who are Limited
English Proficient (LEP) in the facility as
of the first day of the onsite portion of
the audit:
30. Enter the total number of inmates/ 1
residents/detainees who identify as
lesbian, gay, or bisexual in the facility as
of the first day of the onsite portion of
the audit:
31. Enter the total number of inmates/ 0
residents/detainees who identify as
transgender or intersex in the facility as
of the first day of the onsite portion of
the audit:
32. Enter the total number of inmates/ 0
residents/detainees who reported sexual
abuse in the facility as of the first day of
the onsite portion of the audit:
33. Enter the total number of inmates/ 1
residents/detainees who disclosed prior
sexual victimization during risk
screening in the facility as of the first
day of the onsite portion of the audit:
34. Enter the total number of inmates/ 0
residents/detainees who were ever
placed in segregated housing/isolation
for risk of sexual victimization in the
facility as of the first day of the onsite
portion of the audit:
35. Provide any additional comments No text provided.
regarding the population characteristics
of inmates/residents/detainees in the
facility as of the first day of the onsite
portion of the audit (e.g., groups not
tracked, issues with identifying certain
populations):
Staff, Volunteers, and Contractors Population Characteristics on Day One of the Onsite
Portion of the Audit
36. Enter the total number of STAFF, 35
including both full- and part-time staff,
employed by the facility as of the first
day of the onsite portion of the audit:
37. Enter the total number of 1
VOLUNTEERS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
38. Enter the total number of 6
CONTRACTORS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
39. Provide any additional comments No text provided.
regarding the population characteristics
of staff, volunteers, and contractors who
were in the facility as of the first day of
the onsite portion of the audit:
INTERVIEWS
Inmate/Resident/Detainee Interviews
Random Inmate/Resident/Detainee Interviews
40. Enter the total number of RANDOM 10
INMATES/RESIDENTS/DETAINEES who
were interviewed:
41. Select which characteristics you Age
considered when you selected RANDOM
INMATE/RESIDENT/DETAINEE Race
interviewees: (select all that apply)
Ethnicity (e.g., Hispanic, Non-Hispanic)
Length of time in the facility
Housing assignment
Gender
Other
None
42. How did you ensure your sample of I interviewed residents from each of the
RANDOM INMATE/RESIDENT/DETAINEE housing units.
interviewees was geographically
diverse?
43. Were you able to conduct the Yes
minimum number of random inmate/
resident/detainee interviews?
No
44. Provide any additional comments No text provided.
regarding selecting or interviewing
random inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews,
barriers to ensuring representation):
Targeted Inmate/Resident/Detainee Interviews
45. Enter the total number of TARGETED 2
INMATES/RESIDENTS/DETAINEES who
were interviewed:
As stated in the PREA Auditor Handbook, the breakdown of targeted interviews is intended to
guide auditors in interviewing the appropriate cross-section of inmates/residents/detainees who
are the most vulnerable to sexual abuse and sexual harassment. When completing questions
regarding targeted inmate/resident/detainee interviews below, remember that an interview with
one inmate/resident/detainee may satisfy multiple targeted interview requirements. These
questions are asking about the number of interviews conducted using the targeted inmate/
resident/detainee protocols. For example, if an auditor interviews an inmate who has a physical
disability, is being held in segregated housing due to risk of sexual victimization, and disclosed
prior sexual victimization, that interview would be included in the totals for each of those
questions. Therefore, in most cases, the sum of all the following responses to the targeted
inmate/resident/detainee interview categories will exceed the total number of targeted inmates/
residents/detainees who were interviewed. If a particular targeted population is not applicable in
the audited facility, enter "0".
47. Enter the total number of interviews 0
conducted with inmates/residents/
detainees with a physical disability using
the "Disabled and Limited English
Proficient Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies I interacted with each resident at the facility
to determine if this population exists in during the tour of the facility. I reviewed all of
the audited facility (e.g., based on the VSAB reports and the alert status report. I
information obtained from the PAQ; interviewed all staff including education,
documentation reviewed onsite; and medical and mental health staff and asked
discussions with staff and other inmates/ these staff if they knew of any of the resident
residents/detainees). that would be part of the targeted
population.
48. Enter the total number of interviews 1
conducted with inmates/residents/
detainees with a cognitive or functional
disability (including intellectual
disability, psychiatric disability, or
speech disability) using the "Disabled
and Limited English Proficient Inmates"
protocol:
49. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Blind or have low
vision (i.e., visually impaired) using the
"Disabled and Limited English Proficient
Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies I interacted with each resident during the
to determine if this population exists in tour. I reviewed all of the VSAB reports and
the audited facility (e.g., based on the alert status report. I interviewed all staff,
information obtained from the PAQ; including education, medical, and mental
documentation reviewed onsite; and health staff, and asked them whether they
discussions with staff and other inmates/ knew of any residents who would be part of
residents/detainees). the targeted population.
50. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Deaf or hard-of-
hearing using the "Disabled and Limited
English Proficient Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies I interacted with each resident during the
to determine if this population exists in tour. I reviewed all of the VSAB reports and
the audited facility (e.g., based on the alert status report. I interviewed all staff,
information obtained from the PAQ; including education, medical, and mental
documentation reviewed onsite; and health staff, and asked them whether they
discussions with staff and other inmates/ knew of any residents who would be part of
residents/detainees). the targeted population.
51. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Limited English
Proficient (LEP) using the "Disabled and
Limited English Proficient Inmates"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies I interacted with each resident during the
to determine if this population exists in tour. I reviewed all of the VSAB reports and
the audited facility (e.g., based on the alert status report. I interviewed all staff,
information obtained from the PAQ; including education, medical, and mental
documentation reviewed onsite; and health staff, and asked them whether they
discussions with staff and other inmates/ knew of any residents who would be part of
residents/detainees). the targeted population. All the youth spoke
English.
52. Enter the total number of interviews 1
conducted with inmates/residents/
detainees who identify as lesbian, gay,
or bisexual using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
53. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as transgender
or intersex using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies I interacted with each resident during the
to determine if this population exists in tour. I reviewed all of the VSAB reports and
the audited facility (e.g., based on the alert status report. I interviewed all staff,
information obtained from the PAQ; including education, medical, and mental
documentation reviewed onsite; and health staff, and asked them whether they
discussions with staff and other inmates/ knew of any residents who would be part of
residents/detainees). the targeted population.
54. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who reported sexual abuse in
this facility using the "Inmates who
Reported a Sexual Abuse" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies I interacted with each resident during the
to determine if this population exists in tour. I reviewed all of the VSAB reports and
the audited facility (e.g., based on the alert status report. I interviewed all staff,
information obtained from the PAQ; including education, medical, and mental
documentation reviewed onsite; and health staff, and asked them whether they
discussions with staff and other inmates/ knew of any residents who would be part of
residents/detainees). the targeted population. I reviewed all
investigative files to determine if any of those
youth were still at the center.
55. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who disclosed prior sexual
victimization during risk screening using
the "Inmates who Disclosed Sexual
Victimization during Risk Screening"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies I interacted with each resident during the
to determine if this population exists in tour. I reviewed all of the VSAB reports and
the audited facility (e.g., based on the alert status report. I interviewed all staff,
information obtained from the PAQ; including education, medical, and mental
documentation reviewed onsite; and health staff, and asked them whether they
discussions with staff and other inmates/ knew of any residents who would be part of
residents/detainees). the targeted population.
56. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are or were ever placed
in segregated housing/isolation for risk
of sexual victimization using the
"Inmates Placed in Segregated Housing
(for Risk of Sexual Victimization/Who
Allege to have Suffered Sexual Abuse)"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies I interacted with each resident during the
to determine if this population exists in tour. I reviewed all of the VSAB reports and
the audited facility (e.g., based on the alert status report. I interviewed all staff,
information obtained from the PAQ; including education, medical, and mental
documentation reviewed onsite; and health staff, and asked them whether they
discussions with staff and other inmates/ knew of any residents who would be part of
residents/detainees). the targeted population.
The center had two isolation rooms that were
being utilized for storage. ROP does not allow
centers to utilize isolation.
57. Provide any additional comments No text provided.
regarding selecting or interviewing
targeted inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews):
Staff, Volunteer, and Contractor Interviews
Random Staff Interviews
58. Enter the total number of RANDOM 12
STAFF who were interviewed:
59. Select which characteristics you Length of tenure in the facility
considered when you selected RANDOM
STAFF interviewees: (select all that Shift assignment
apply)
Work assignment
Rank (or equivalent)
Other (e.g., gender, race, ethnicity,
languages spoken)
None
60. Were you able to conduct the Yes
minimum number of RANDOM STAFF
interviews?
No
61. Provide any additional comments No text provided.
regarding selecting or interviewing
random staff (e.g., any populations you
oversampled, barriers to completing
interviews, barriers to ensuring
representation):
Specialized Staff, Volunteers, and Contractor Interviews
Staff in some facilities may be responsible for more than one of the specialized staff duties.
Therefore, more than one interview protocol may apply to an interview with a single staff
member and that information would satisfy multiple specialized staff interview requirements.
62. Enter the total number of staff in a 16
SPECIALIZED STAFF role who were
interviewed (excluding volunteers and
contractors):
63. Were you able to interview the Yes
Agency Head?
No
64. Were you able to interview the Yes
Warden/Facility Director/Superintendent
or their designee?
No
65. Were you able to interview the PREA Yes
Coordinator?
No
66. Were you able to interview the PREA Yes
Compliance Manager?
No
NA (NA if the agency is a single facility
agency or is otherwise not required to have a
PREA Compliance Manager per the Standards)
67. Select which SPECIALIZED STAFF Agency contract administrator
roles were interviewed as part of this
audit from the list below: (select all that Intermediate or higher-level facility staff
apply) responsible for conducting and documenting
unannounced rounds to identify and deter
staff sexual abuse and sexual harassment
Line staff who supervise youthful inmates
(if applicable)
Education and program staff who work with
youthful inmates (if applicable)
Medical staff
Mental health staff
Non-medical staff involved in cross-gender
strip or visual searches
Administrative (human resources) staff
Sexual Assault Forensic Examiner (SAFE)
or Sexual Assault Nurse Examiner (SANE) staff
Investigative staff responsible for
conducting administrative investigations
Investigative staff responsible for
conducting criminal investigations
Staff who perform screening for risk of
victimization and abusiveness
Staff who supervise inmates in segregated
housing/residents in isolation
Staff on the sexual abuse incident review
team
Designated staff member charged with
monitoring retaliation
First responders, both security and non-
security staff
Intake staff
Other
If "Other," provide additional specialized Interviewed the agency head and PREA
staff roles interviewed: coordinator for the Florida Department of
Juvenile Justice. I interviewed the ROP
compliance staff for the State of Florida.
68. Did you interview VOLUNTEERS who Yes
may have contact with inmates/
residents/detainees in this facility?
No
a. Enter the total number of 1
VOLUNTEERS who were interviewed:
b. Select which specialized VOLUNTEER Education/programming
role(s) were interviewed as part of this
audit from the list below: (select all that Medical/dental
apply)
Mental health/counseling
Religious
Other
69. Did you interview CONTRACTORS Yes
who may have contact with inmates/
residents/detainees in this facility?
No
a. Enter the total number of 1
CONTRACTORS who were interviewed:
b. Select which specialized CONTRACTOR Security/detention
role(s) were interviewed as part of this
audit from the list below: (select all that Education/programming
apply)
Medical/dental
Food service
Maintenance/construction
Other
70. Provide any additional comments No text provided.
regarding selecting or interviewing
specialized staff.
SITE REVIEW AND DOCUMENTATION SAMPLING
Site Review
PREA Standard 115.401 (h) states, "The auditor shall have access to, and shall observe, all areas
of the audited facilities." In order to meet the requirements in this Standard, the site review
portion of the onsite audit must include a thorough examination of the entire facility. The site
review is not a casual tour of the facility. It is an active, inquiring process that includes talking
with staff and inmates to determine whether, and the extent to which, the audited facility's
practices demonstrate compliance with the Standards. Note: As you are conducting the site
review, you must document your tests of critical functions, important information gathered
through observations, and any issues identified with facility practices. The information you
collect through the site review is a crucial part of the evidence you will analyze as part of your
compliance determinations and will be needed to complete your audit report, including the Post-
Audit Reporting Information.
71. Did you have access to all areas of Yes
the facility?
No
Was the site review an active, inquiring process that included the following:
72. Observations of all facility practices Yes
in accordance with the site review
component of the audit instrument (e.g.,
No
signage, supervision practices, cross-
gender viewing and searches)?
73. Tests of all critical functions in the Yes
facility in accordance with the site
review component of the audit
No
instrument (e.g., risk screening process,
access to outside emotional support
services, interpretation services)?
74. Informal conversations with inmates/ Yes
residents/detainees during the site
review (encouraged, not required)?
No
75. Informal conversations with staff Yes
during the site review (encouraged, not
required)?
No
76. Provide any additional comments Walton Academy for Growth and Change is
regarding the site review (e.g., access to located at 9680 Weisman Way. The academy
areas in the facility, observations, tests is a private center operated through a
of critical functions, or informal contract with Rite of Passage, Inc. The center
conversations). is a specialized residential program that
operates mental health and substance abuse
programming for level one youth. The center
is a staff-secure program and the second
program for most residents.
During the comprehensive tour of the facility,
posted signs were also observed regarding
general PREA information and contact
numbers for reporting sexual abuse or sexual
harassment. Also presented were the address
and ways for youth to access the emotional
support staff. and address for the Emerald
Coast Children's Advocacy Center, Child
Abuse hotline telephone number operated by
the Department of Youth and Family Services,
and the telephone number for the Central
Communication Centers (CCC). All of the
above numbers were called. The call to CCC
indicated that they would send a message to
the OIG, the facility director, the Florida PREA
coordinator, and the regional director.
However, since this is a test of the system,
they would not send this information. As an
auditor, I have contacted the CCC on more
than ten occasions and previously spoke with
the operator on duty when I called during the
tour of the center. The Child Abuse Hotline
staff indicated they would notify the local
Department of Children and Families and local
law enforcement upon receiving a call. Both
parties indicated that residents and family
members can call the hotline anonymously. A
live person answered telephone calls to the
Pierce County Child Advocacy Center. The
staff indicated that she is part of the Emerald
Coast Child Advocacy program and is located
near the center. There is an office in each
housing unit or supervisor's office that is used
by the resident to make these phone calls.
The residents’ attorneys and parents can use
this same phone for emergencies or for legal
information.
During the comprehensive tour of the facility,
one of the posters was located in several
areas, including the visitation areas of third-
party reporting. The poster indicated that a
third party could make a report to CCC and
the Child Abuse hotline.
During the tour, the youth were observed to
be under the constant supervision of staff
while engaged in various activities. PREA
signage (in bold, colorful print) was displayed
in all areas frequented by residents. They
include how to make an allegation, end the
silence, the PREA audit notice, telephone
numbers, and general information about PREA
posters. The tour covered all areas of the
facility, including Intake, all housing units,
medical, food services, programming, and
education. Signs are located at the entrance
of each housing unit that state: staff,
contractors, and volunteers must announce
themselves prior to entering the housing area
of the opposite gender. During the tour, there
were always 1 to 6 residents. During the
early-morning visit to the facility, there was a
1:6 ratio in the housing units during the day.
During the overnight tour, the center had a
1-to-10 ratio.
Staff answered questions during informal
interviews about resident activities and
program services as the tour progressed
through the facility. The site visit also included
the outside grounds. During the tour, the
intake process was reviewed by the auditor
and later discussed by the intake staff. The
person was a therapist who had been advised
that the resident was coming to the center,
and the clinical director selected her to
provide services for this youth. She indicated
she had read his file, including court
documents, the Juvenile assessment center
VSAB, and related documents from the
community providers. She indicated the
resident was being placed in the center for
substance abuse therapy. The therapist
indicated that the resident had completed a
RAY evaluation, MAYSI-2 screening, and the
VSAB screening before I arrived at the intake
area. The auditor reviewed the folder that
contained this information. The resident had
been told his rights not to be sexually abused,
the center's zero-tolerance policy, and the
way to report. After completion of the
screening, the resident was escorted to his
assigned case manager, who began the
orientation process, which included a video
and a review of a brochure. The case
manager confirmed, through
acknowledgement sheets and an interview,
that she would meet with the resident again
within 10 days, go back over the PREA
information, and show the Florida Department
of Justice PREA video. Resident informal
interviews confirmed that residents have
multiple ways to make an allegation,
including by telephone. I asked a resident to
show me how he would make a report or call
his attorney. The resident showed me the
office where you can talk to your lawyer or
parent, make a call to local law enforcement
or the victim advocate, or make a call to the
victim advocate. The auditor visited each
classroom and spoke with the residents in
each one. Later, the auditor was able to speak
in a semi-private manner with residents
during the lunch break. All residents
interviewed reported feeling safe at the
center, knew the director's name, and noted
that the administrative staff is always in the
back of the center.
Staff of the opposite gender must announce
their presence when entering the housing unit
or any area where a resident showers,
changes clothes, or performs those bodily
functions. Fifteen of the sixteen residents
interviewed stated the staff members
announce their presence before entering the
housing unit. This practice was experienced
and observed during the tour. The shower
area has shower curtains for privacy. The
facility has individual rooms, each with a
toilet. Residents indicated that staff knock on
their doors before looking into the room
during the count. The medical room has a
shower near the examination area, and staff
indicated that they close the door and use the
shower when examining residents. Medical
Request Forms, PREA/grievance forms, and
the locked boxes for each are posted in the
common area and are accessible to all
residents, staff, and visitors. All residents
have access to the writing utensils needed for
completing the forms. 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, supports direct staff supervision.
Internet research on the facility revealed no
indication of litigation, U.S. Department of
Justice involvement, or federal consent
decrees. General and specific information
about the facility, its programs, and the
services provided is detailed on the facility’s
website. You can find information, including
photos of the facility and contact details, on
the informative page. The facility’s website
also contains PREA information, including but
not limited to the zero-tolerance and
coordinated response policies.
Documentation Sampling
Where there is a collection of records to review-such as staff, contractor, and volunteer training
records; background check records; supervisory rounds logs; risk screening and intake
processing records; inmate education records; medical files; and investigative files-auditors must
self-select for review a representative sample of each type of record.
77. In addition to the proof Yes
documentation selected by the agency
or facility and provided to you, did you
No
also conduct an auditor-selected
sampling of documentation?
78. Provide any additional comments The auditor requested some specific and
regarding selecting additional some random training files for employees.
documentation (e.g., any documentation The Florida Juvenile Justice agency has
you oversampled, barriers to selecting developed a Skill Pro program with modules
additional documentation, etc.). for general and specialized training.
The auditor requested random personnel
background checks and received:
· 3 Background Checks with PREA
questionnaire for five-year tenure staff.
· 3 . Background Checks with the PREA
questionnaire for new hires
· 10 Background Checks with PREA
questionnaire for general staff and
promotions
· 1 Background Checks with PREA
questionnaire for Contracting Staff
· Ten staff Training Files
The auditor requested and received the
following information from resident files”
· 10 resident acknowledgements of
training
· 10 retaliation monitoring forms
· 10 Screening and reassessment (VSAB)
· 2 Mental Health Referrals
· 1 Notification of outcome of
investigation
Five Investigative reports (uploaded by the
FDJJ OIG)
31 unannounced rounds
SEXUAL ABUSE AND SEXUAL HARASSMENT ALLEGATIONS AND
INVESTIGATIONS IN THIS FACILITY
Sexual Abuse and Sexual Harassment Allegations and Investigations
Overview
Remember the number of allegations should be based on a review of all sources of allegations
(e.g., hotline, third-party, grievances) and should not be based solely on the number of
investigations conducted. Note: For question brevity, we use the term “inmate” in the following
questions. Auditors should provide information on inmate, resident, or detainee sexual abuse
allegations and investigations, as applicable to the facility type being audited.
79. Total number of SEXUAL ABUSE allegations and investigations overview during
the 12 months preceding the audit, by incident type:
# of allegations
# of
# of that had both
sexual # of criminal
administrative criminal and
abuse investigations
investigations administrative
allegations
investigations
Inmate- 2 1 2 1
on-
inmate
sexual
abuse
Staff- 1 1 1 1
on-
inmate
sexual
abuse
Total 3 2 3 3
80. Total number of SEXUAL HARASSMENT allegations and investigations overview
during the 12 months preceding the audit, by incident type:
# of allegations
# of sexual # of that had both
# of criminal
harassment administrative criminal and
investigations
allegations investigations administrative
investigations
Inmate-on- 1 0 1 0
inmate
sexual
harassment
Staff-on- 1 0 1 0
inmate
sexual
harassment
Total 2 0 2 0
Sexual Abuse and Sexual Harassment Investigation Outcomes
Sexual Abuse Investigation Outcomes
Note: these counts should reflect where the investigation is currently (i.e., if a criminal
investigation was referred for prosecution and resulted in a conviction, that investigation
outcome should only appear in the count for “convicted.”) Do not double count. Additionally, for
question brevity, we use the term “inmate” in the following questions. Auditors should provide
information on inmate, resident, and detainee sexual abuse investigation files, as applicable to
the facility type being audited.
81. Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding
the audit:
Referred Indicted/
Convicted/
Ongoing for Court Case Acquitted
Adjudicated
Prosecution Filed
Inmate-on- 1 0 0 0 0
inmate sexual
abuse
Staff-on- 0 0 0 0 0
inmate sexual
abuse
Total 0 0 0 0 0
82. Administrative SEXUAL ABUSE investigation outcomes during the 12 months
preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 1 1 0 0
sexual abuse
Staff-on-inmate 0 0 1 0
sexual abuse
Total 1 1 1 0
Sexual Harassment Investigation Outcomes
Note: these counts should reflect where the investigation is currently. Do not double count.
Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors
should provide information on inmate, resident, and detainee sexual harassment investigation
files, as applicable to the facility type being audited.
83. Criminal SEXUAL HARASSMENT investigation outcomes during the 12 months
preceding the audit:
Indicted/
Referred
Court Convicted/
Ongoing for Acquitted
Case Adjudicated
Prosecution
Filed
Inmate-on- 1 0 0 0 0
inmate sexual
harassment
Staff-on- 0 0 0 0 0
inmate sexual
harassment
Total 0 0 0 0 0
84. Administrative SEXUAL HARASSMENT investigation outcomes during the 12
months preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 1 0 0 0
sexual
harassment
Staff-on-inmate 0 1 0 0
sexual
harassment
Total 1 1 0 0
Sexual Abuse and Sexual Harassment Investigation Files Selected for
Review
Sexual Abuse Investigation Files Selected for Review
85. Enter the total number of SEXUAL 3
ABUSE investigation files reviewed/
sampled:
86. Did your selection of SEXUAL ABUSE Yes
investigation files include a cross-
section of criminal and/or administrative
No
investigations by findings/outcomes?
NA (NA if you were unable to review any
sexual abuse investigation files)
Inmate-on-inmate sexual abuse investigation files
87. Enter the total number of INMATE- 2
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
88. Did your sample of INMATE-ON- Yes
INMATE SEXUAL ABUSE investigation
files include criminal investigations?
No
NA (NA if you were unable to review any
inmate-on-inmate sexual abuse investigation
files)
89. Did your sample of INMATE-ON- Yes
INMATE SEXUAL ABUSE investigation
files include administrative
No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual abuse investigation
files)
Staff-on-inmate sexual abuse investigation files
90. Enter the total number of STAFF-ON- 1
INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
91. Did your sample of STAFF-ON-INMATE Yes
SEXUAL ABUSE investigation files
include criminal investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
92. Did your sample of STAFF-ON-INMATE Yes
SEXUAL ABUSE investigation files
include administrative investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
Sexual Harassment Investigation Files Selected for Review
93. Enter the total number of SEXUAL 2
HARASSMENT investigation files
reviewed/sampled:
94. Did your selection of SEXUAL Yes
HARASSMENT investigation files include
a cross-section of criminal and/or
No
administrative investigations by
findings/outcomes?
NA (NA if you were unable to review any
sexual harassment investigation files)
Inmate-on-inmate sexual harassment investigation files
95. Enter the total number of INMATE- 1
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
96. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT files
include criminal investigations?
No
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
97. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative
No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
Staff-on-inmate sexual harassment investigation files
98. Enter the total number of STAFF-ON- 1
INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
99. Did your sample of STAFF-ON-INMATE Yes
SEXUAL HARASSMENT investigation files
include criminal investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
100. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative
No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
101. Provide any additional comments No text provided.
regarding selecting and reviewing
sexual abuse and sexual harassment
investigation files.
SUPPORT STAFF INFORMATION
DOJ-certified PREA Auditors Support Staff
102. Did you receive assistance from any Yes
DOJ-CERTIFIED PREA AUDITORS at any
point during this audit? REMEMBER: the
No
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
Non-certified Support Staff
103. Did you receive assistance from any Yes
NON-CERTIFIED SUPPORT STAFF at any
point during this audit? REMEMBER: the
No
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
AUDITING ARRANGEMENTS AND COMPENSATION
108. Who paid you to conduct this audit? The audited facility or its parent agency
My state/territory or county government
employer (if you audit as part of a consortium
or circular auditing arrangement, select this
option)
A third-party auditing entity (e.g.,
accreditation body, consulting firm)
Other
Identify the name of the third-party Correctional Management and
auditing entity Communication Group
Standards
Auditor Overall Determination Definitions
• Exceeds Standard
(Substantially exceeds requirement of standard)
• Meets Standard
(substantial compliance; complies in all material ways with the stand for the relevant
review period)
• Does Not Meet Standard
(requires corrective actions)
Auditor Discussion Instructions
Auditor discussion, including the evidence relied upon in making the compliance or non-
compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions.
This discussion must also include corrective action recommendations where the facility does not
meet standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Zero tolerance of sexual abuse and sexual harassment; PREA
115.311
coordinator
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
Evidence relied upon in making
Department of Juvenile Justice Policy 1919 Prison Rape Elimination Act revised 5/25/
2025
Rite of Passage 600.600 PREA policy
Agency Organization Chart
Facility Organization Chart
Rite of Passage Operating Procedure 1.03 Provision of Abuse-Free Environment
Interviews with
PREA coordinators
PREA compliance manager
115.311 (a):
The PAQ requires that an agency have a written policy mandating zero tolerance
toward all forms of sexual abuse and sexual harassment and outlining the agency's
approach to preventing, detecting, and responding to such conduct.
The facility provided the FDJJ Policy 1919 Prison Rape Elimination, ROP 600.600,
and ROP procedure 1.03.
115.311 (a): FDJJ Policy 1919 Prison Rape Elimination mandates that the Florida
Department of Juvenile Justice is committed to a zero-tolerance standard for
incidents of sexual abuse and sexual harassment. The agency has developed and
implemented policies to comply with PREA standards for Juvenile Facilities. Walton
Academy for Growth and Change (WAGC) and other stakeholders associated with
WAGC are committed to preventing, detecting, and responding to sexual abuse and
sexual harassment. Everyone has the right to be free from sexual abuse, sexual
harassment, neglect, and exploitation. This includes not being subjected to sexually
assaultive, abusive, and/or harassing behavior from staff and other residents.
Department of Juvenile Justice Policy 1919 PREA establishes that all facilities, staff,
residents, volunteers, contractors, or visitors are committed to a zero-tolerance
standard for incidents of sexual abuse and sexual harassment. Residents with
disabilities are afforded the same rights. They will be provided access to
interpreters, presented material to effectively communicate with those residents
who have intellectual disabilities, limited reading skills, who are blind, or have low
vision. Residents will have access to interpreters who can interpret effectively,
accurately, and impartially, both receptively and expressively, using any necessary
specialized vocabulary. Interpreters will be provided through local community
resources. Residents with disabilities have equal opportunity to participate in and
benefit from all aspects of Walton Academy for Growth and Change’s efforts to
prevent, detect, and respond to sexual abuse and sexual harassment. The agency
has spent a large sum of money to upgrade the surveillance system at the center to
enhance the ability to protect residents.
Rites of Passage policy 1.03 indicates that The Walton Academy for Growth and
Change shall promote an environment of physical, psychological, and emotional
safety. Child abuse will not be tolerated. Staff shall immediately report all
allegations of abuse, neglect, or sexual harassment. Any incident or suspected
incident of retaliation against youth or staff who reported an allegation of abuse
must also be reported immediately. Staff are required to report any alleged neglect
or violation of responsibilities that may have contributed to an incident or
retaliation.
ROP 600.600 provides that all students in Rite of Passage programs will be
maintained in healthy and safe environments. Rite of Passage (ROP) programs will
actively implement this policy to prohibit and prevent any staff sexual misconduct,
juvenile sexual misconduct, abusive sexual contact, or any sexual act, regardless of
age, sexual orientation, or sexual identification.
The purpose of this policy is to provide procedures to assist in identifying,
monitoring, counseling, and tracking juveniles that have a propensity for
committing sexual acts, abusive sexual acts, or possible vulnerability to being a
victim of sexual acts, abusive sexual activity; to ensure that ROP employees,
contract workers, volunteers, or any persons providing services in the program are
trained to recognize such behaviors and take appropriate action; and to ensure
students receive orientation and have mechanisms for reporting and pursuing
criminal prosecution as deemed appropriate.
Rite of Passage has zero tolerance for employee, contractor, and/or volunteer-on-
student and student-on-student sexual misconduct and/or abuse. All acts of sexually
abusive behavior or intimacy between a student and employee, contractor, or
volunteer, or between a student and another student, are prohibited, and the
perpetrator shall be subject to administrative and disciplinary actions. Any of the
above incidents will be referred to the appropriate law enforcement agency and
social service agency for further investigation and prosecution.
Rite of Passage adopts the Juvenile Facility Standards as described in the Prison
Rape Elimination Act (PREA) under the United States Department of Justice Final
Rule (May 17, 2012)
115.311 (b):
The PAQ requires that an agency 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.
The facility provided the FDJJ policy 1919, ROP policy 1.03, ROP 600.600, and
the Rites of Passage organization chart.
The Florida Department of Juvenile Justice employs a PREA Coordinator who
oversees efforts to comply with the PREA standards across all Juvenile Facilities
under the Division of Juvenile Justice. The PREA coordinator reports to the Division
Director and indicates he has sufficient time and authority to develop, implement,
and oversee agency efforts to comply with the PREA standards in all of its facilities.
He is responsible for conducting an assessment of all private facilities and, in
consultation with the private facilities, implementing any Corrective Action Plans
based on his assessment and PREA audits conducted by PREA-certified auditors. The
PREA coordinator for the Florida Department of Juvenile Justice is a certified PREA
auditor.
Rite of Passage 600.600 PREA policy requires the agency to assign and train an
upper-level staff member to assume the duties of a Regional Improvement
Embedded PREA monitor. The responsibilities of this assignment include (but are not
limited to) assisting in the development, implementation, and oversight of the PREA
standards within the organization. The Regional PREA Coordinator will be afforded
sufficient time and authority to develop, implement, and oversee the organization’s
efforts to comply with PREA standards.
The ROP organizational chart identified the PREA coordinator position and reported
directly to the company’s chief operating officer.
The interview with the Right of Passage PREA coordinator indicated that she has
sufficient time to fulfill my PREA responsibilities. Every site in the company has a
PREA Compliance Manager. I have an opportunity to interact on the monthly
director's call. If a deficit is discovered through the process or otherwise, the site
management team and I will meet to discuss a plan to address the deficit, then
provide additional training and monitor the issue until it is addressed and/or
corrected to meet the standard compliance requirements.
115.311 (c):
The PAQ requires that, 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 provided the ROP manual and organization chart for Walton Academy for
Growth and Change.
The ROP manual ensures that PREA Site Compliance Managers have the necessary
time and authority to coordinate the facility’s efforts to comply with PREA standards.
The facility director is designated as the PREA compliance manager at Walton
Academy for Growth and Change. The Compliance Manager works with the PREA
coordinator to comply with the PREA standards.
The PREA compliance manager (PCM) indicated he has the necessary time and
resources to implement all PREA standards fully. The PCM indicated he has
resources from the ROP PREA coordinator.
115.312 Contracting with other entities for the confinement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Rite of Passage is a private vendor and does not contract with other agencies or
vendors to provide housing for juveniles. This was confirmed by interviews with the
Agency Head Designee and the ROP PREA Coordinator.
115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memoranda, and agency or facility supplements
were reviewed for compliance with this standard.
Staff-to-youth ratio docs
Unannounced Tours
Department of Juvenile Justice, FDJJ Policy 1919 Supervision and Monitoring
Rites of Passage Safe Environmental Standards PREA Standard 115.313- Supervision
and Monitoring
Prison Rape Elimination Act (PREA) Facility Operating Procedures
Monthly Schedule Resident
Daily Rosters PREA
Pre-Audit Questionnaire
Annual Assessment 2024
Annual Assessment 2023
Management Events - -PREA UAV (SharePoint Form)
ROP PREA manual
FDJJ Policy 1919
Staffing Deviation Reports
313.313 (a): The PAQ requires the agency to ensure that each facility it operates
shall develop, implement, and document a staffing plan that provides for adequate
levels of staffing, and, where applicable, video monitoring, to protect residents
against sexual abuse. In calculating adequate staffing levels and determining the
need for video monitoring, facilities shall take into consideration: (1) Generally
accepted juvenile detention and correctional/secure residential practices; (2) Any
judicial findings of inadequacy; (3) Any findings of inadequacy from Federal
investigative agencies; (4) Any findings of inadequacy from internal or external
oversight bodies; (5) All components of the facility's physical plant (including "blind
spots" or areas where staff or residents may be isolated); (6) The composition of the
resident population; (7) The number and placement of supervisory staff; (8)
Institution programs occurring on a particular shift; (9) Any applicable State or local
laws, regulations, or standards; (10) The prevalence of substantiated and
unsubstantiated incidents of sexual abuse; and (11) Any other relevant factors.
The center staff plan is based on 42 youth.
The center provided policy 1919, the ROP manual, staffing assessments for the last
three years, and documentation of unannounced rounds.
Policy 1919 requires that staffing plans be established for each residential and
detention center facility. These plans provide for adequate levels of staffing and,
where applicable, video monitoring to protect young people against sexual
misconduct. In developing appropriate staffing plans and determining the need for
video monitoring for the facility, the following must be taken into consideration:
Generally accepted juvenile detention and residential practices.
Any judicial findings of inadequacy; findings of inadequacy from Federal
investigative agencies or internal or external oversight bodies.
All components of the facility's physical plant (including "blind spots" or areas where
staff or youth may be isolated);
The composition of the youth population.
The number and placement of supervisory staff; vi. Institution programs occurring
on a particular shift; Any applicable State or local laws, regulations, or standards.
The prevalence of substantiated and unsubstantiated incidents of sexual
misconduct; and ix. Any other relevant factors.
a. Staffing ratios are to be adhered to except during limited and discrete exigent
circumstances, and any deviations from the staffing plan shall be fully documented.
b. At a minimum of once a year, each facility operated or contracted by the
Department, and in consultation with the Department's PREA Statewide
Coordinator, shall assess, determine, and document whether adjustments are
needed to:
i. The staffing plan; ii. Prevailing staffing patterns.
The deployment of video monitoring systems and other monitoring technologies,
and
The resources available to the facilities are intended to ensure adherence to the
staffing plan.
The annual assessments at the center were completed in 2023, 2024, and 2025.
Each year, the facility reviews staffing needs, the need for cameras, and the need
to rearrange the staffing plan to meet the required staffing levels to maintain a safe
and secure operation. Their staffing plan’s annual reviews conducted in June 2024
were found to comply with this standard. The staffing plan included: 1) Generally
accepted detention and correctional/secure residential practices. (2) Any judicial
findings of inadequacy. (3) Any findings of inadequacy from Federal investigative
agencies. (4) Any findings of inadequacy from internal or external oversight bodies.
(5) All components of the facility’s physical plant (including “blind spots” or areas
where staff or residents may be isolated). (6) The composition of the resident
population. (7) The number and placement of supervisory staff. (8) Institution
programs occurring on a particular shift. (9) Any applicable State or local laws,
regulations, or standards. (10) The prevalence of substantiated and unsubstantiated
incidents of sexual abuse; and (11) Any other relevant factors. The facility did report
deviation from the staffing plan during the past 12 months. According to the PAQ,
the staffing plan is based on 78 residents.
The ROP manual requires the Regional Supervisor to ensure that PREA Site
Compliance Managers, along with Program Directors, conduct an annual assessment
to determine whether staffing patterns, video monitoring systems, other
technologies, and resources are adequate to protect students against sexual abuse.
In an interview with the ROP PREA coordinator, ROP accepts the Florida PREA
coordinator's annual assessment and develops a plan of action as required by the
assessment. The State of Florida owns the facility, and annual staff would be
adjusted through the PREA coordinator's office.
Based on conversations with the FDJJ PREA coordinator and facility administrator, it
was clear that the facility reviews all areas of the center for additional staffing or
cameras based on resident movement to meet this standard's requirements. The
direct care staff was observed throughout the center during the tour or camera
monitoring review.
At least once every year, the agency or facility, in collaboration with the PREA
Coordinator, reviews the staffing plan to see whether adjustments are needed to the
staffing plan; prevailing staffing patterns; the deployment of monitoring technology;
or the allocation of agency or facility resources to commit to the staffing plan, to
ensure compliance with the staffing plan.
313.313(b):
The PAQ requires the agency to comply with the staffing plan, except in limited and
discrete exigent circumstances, and shall fully document deviations from the plan
during such circumstances.
The facility has not had any deviation from the plan in the last 12 months.
The facility administrator provided a daily roster indicating the staffing used during
the prior 24 hours.
The center had to pay overtime and use some non-essential staff to ensure
appropriate staffing was available to meet the mandatory posts. The Florida
Department of Juvenile Justice has instituted a daily staffing form for documenting
deviations from the mandatory ratios, which is available on the agency’s Share
Drive. In the last 12 months, the center had no time when it did not meet the
mandatory staffing requirements.
Randomly interviewed direct care staff confirmed that they are assigned based on
activities at each unit, which will impact the staffing plan. The random staff stated
that the center does not count control operators toward meeting this requirement.
The facility administrator provided a daily roster indicating the staffing used during
the prior 24 hours. The facility's plan strives to maintain staffing ratios of a
minimum of 1 staff to 8 residents during resident waking hours and 1 to 12 during
resident sleeping hours. The facility has had deviations in the ratios mandated by
FDJJ Policy 1919. These deviations are documented on the DJJ Share Drive. The
facility has a holdover and overtime pay program to provide coverage as required.
Staff interviewed indicated they are not allowed to abandon their post until properly
relieved.
Throughout the audit, the auditor made rounds throughout the facility. The daytime
ratio was 1:6 on each visit. For the overnight shift, the ratio was 1 to 10, except for
one living unit, which was 1 to 5.
115.313 (c):
The PAQ requires that each secure juvenile facility 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 outlined in this
paragraph shall have until October 1, 2017, to achieve compliance.
The facility provided policy 1919 and three annual staffing assessments. Daily
rosters and interviews with random staff.
FDJJ Policy 1919 - Juvenile Prison Rape Elimination Act mandates that the staffing
plan be reviewed and approved by the PREA coordinator at least once a year. The
facility staffing plan for 2024 was submitted in June 2024. WAGC conducts an
extensive review of all areas of the facility and assesses the need for additional
cameras, staff programming, and overall facility operations. During the tour of the
facility, the auditor found no blind spots or areas with residents present without
supervision.
The facility administrator indicated in the interview that the facility uploads the
number of staff on duty, the number that is required to be on duty, the number of
residents assigned, and any special programs or residents out to outside services.
The computerized staffing database is reviewed by the administrator every day. He
indicated that the PREA coordinator completes an annual assessment of the
staffing, incident reports, and blind spots. The annual assessment is signed by the
PREA coordinator and the facility administrator and forwarded to the Agency Head
through the regional office. The administrator indicated the center has not had a
deviation in the last 12 months. However, if there is a deviation he is required to
document, and it is part of the staffing share drive.
At WAGC, the facility administrator also serves as the PREA compliance manager.
115.313 (d):
The PAQ requires 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 (3) The resources
the facility has available to commit to ensure adherence to the staffing plan.
The facility-provided ROP manual requires that the PREA Site Compliance Managers,
along with the Program Directors, conduct an annual assessment to determine
whether staffing patterns, video monitoring systems, other technologies, and
resources are adequate to ensure the protection of students against sexual abuse.
The facility also provided the annual assessment for the three preceding years.
The ROP PREA Coordinator interviewed indicated that the assessment occurs
annually, and that a meeting is held to discuss the staffing plan, necessary
revisions, technological adjustments (and how to consider PREA), and other areas.
115.313 (e):
The PAQ requires that each secure facility 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 both night and day shifts. Each secure facility
shall have a policy prohibiting staff from alerting other staff members that
supervisory rounds are occurring, unless such an announcement is related to the
facility's legitimate operational functions.
The center provided Policy 1919, ROP manual, unannounced rounds, and interviews
with intermediate staff members.
Policy 1919 requires the facility administrator and PREA compliance manager to
conduct and document unannounced rounds on all shifts and all areas of the facility
to monitor and deter staff sexual abuse and harassment. Each shift supervisor
makes rounds several times during each shift. It is the policy of WAGC that staff do
not inform other staff when the shift supervisor, facility manager, or regional
administrators are making rounds. During the tour, the auditor reviewed the
logbooks in all housing units and noted that the shift supervisor and facility
administrator had signed the logbooks at least once a day for the past three weeks,
excluding weekends. The shift supervisor signed the logbooks on each day,
including weekends. FDJJ has developed a PREA form that is used to conduct daily,
weekly, and monthly unannounced rounds by administrative staff, which are then
uploaded to the DJJ share drive.
Rite of Passage will conduct unannounced rounds on all shifts, including overnight
shifts, to ensure adequate supervision and to identify and deter staff from sexual
misconduct and sexual abuse. All staff are prohibited from alerting other staff
members that these rounds are being conducted. Rite of Passage will maintain a
staffing plan that provides for adequate levels of staffing to ensure the protection of
each student against sexual abuse.
ROP Procedure:
(a) Unannounced rounds will be conducted by a Shift Supervisor (or designee) at
least once per shift.
(b) Site Vulnerability Assessments using the “Site Visit Reporting Form” will be
conducted by a Shift Supervisor (or designee) at least once per quarter.
(c) All rounds shall be random and unannounced.
(d) Documentation of these rounds will be maintained in a log in the Shift
Supervisor or designee’s office.
(e) Documentation/ findings of these rounds and the “Site Visit Reporting Forms”
will be sent quarterly to the Regional Supervisor.
The shift supervisors were interviewed as intermediate staff who conduct
unannounced rounds. They indicated they conduct rounds during different shifts,
each day, including weekends and holidays. These rounds are documented. They
indicated they don't tell staff when they arrive at the center or when they make
rounds. They indicated they vary the days and times.
Compliance was determined by reviewing policies, documentation, and
interviewing staff. During the audit, the auditor visited all areas of the facility.
During the visit, the auditor counted the number of residents and staff in each area.
The facility meets these standards' requirements during each visit.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
The following policies, directives, memoranda, and agency or facility supplements
were reviewed for compliance with this standard.
FDJJ Policy 1919 PREA (Searches)
Cross-Gender viewing and searches.
PREA Statement of Preference
WAGC Policy 5.06 Searches and Monitoring
WAGC Policy 1.05 Abuse Free Environment
WAGC Policy Admissions and Orientation
Female and Male Announcements
Interviews
Random Staff
Random Residents
Training Video on Guidance on Cross Gender and LGBTQ Searches
ROP Training acknowledgement
115.315 (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.
In the past 12 months, the number of cross-gender strip or cross-gender visual body
cavity searches of residents: 0
The center provided FDJJ Policy 1919 PREA - Searches, Cross Gender viewing and
searches, Training Video on Guidance on Cross Gender and LGBTQ searches, and
ROP policy 5.06 Contraband and Searches.
DJJ Policy 1919 PREA - Searches Cross Gender mandates Staff shall not search or
physically examine a transgender or intersex youth for the sole purpose of
determining the youth's genital status. If the youth's genital status is unknown, it
may be determined during conversation with the youth, 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.
Staff shall not conduct cross-gender (opposite-sex) strip searches or cross-gender
frisk searches.
ROP policy 5.06 Contraband and Searches mandates that all searches shall conform
to PREA guidelines/policy. Staff shall not conduct cross-gender (opposite-gender)
full-body visual searches or other searches except in exigent circumstances, which
are any set of temporary and unforeseen circumstances that require immediate
action to combat a threat to the security or institutional orders of the facility.
Based on interviews with staff and residents, there have been no cross-gender
pat-down searches in the last 12 months. An intake staff member indicated that,
upon admission to WAGC, the resident is taken to a private area by two staff
members of the same gender as the resident. The residents are asked to remove
their outer garments but not their undergarments. The staff member then visually
confirms there is no contraband and identifies any tattoos, scars, bruises, or other
marks.
Twelve residents were interviewed. All indicated that a person of the other gender
had not searched them.
Twelve staff were interviewed. Every member of staff attended the cross-gender
training and signed the training roster. All interviewed indicated they had not
searched a resident of the other gender since working at the center.
During the tour of the center, the auditor had conversations with staff and residents.
All staff indicated they don’t conduct pat searches or strip searches of residents of
the other gender. At the time of the audit, 25 residents were housed at the center.
Ten residents were engaged in a conversation during the on-site audit, and the
auditor formally interviewed 12 residents. All of the residents indicated they have
never been searched by staff of the other gender.
115.315 (b):
The PAQ requires that the agency not conduct cross-gender pat-down searches
except in exigent circumstances.
The center provided the Cross-Gender and transgender pat searches facilitator
guide and video of guidance on cross gender and transgender Pat Searches and
policy 5.06
Search procedures mandate that the facility always refrain from conducting any
cross-gender pat-down except in exigent circumstances. All staff interviewed
indicated they have never conducted a cross-gender search. All residents
interviewed stated that a staff member of the opposite gender had never searched
them. Staff were able to articulate the exigent circumstances under which they
might be required to search.
ROP policy 5.06 Contraband and Searches indicates Staff shall not conduct cross
gender (opposite gender) full-body visual searches or other searches except in
exigent circumstances, which are any set of temporary and unforeseen
circumstances that require immediate action to combat a threat to the security or
institutional orders of the facility.
115.315 (c):
The PAQ requires the facility to document and justify all cross-gender strip searches,
cross-gender visual body cavity searches, and cross-gender pat-down searches.
According to the PAQ, there were no cross-gender searches during the last 12
months.
The facility provided policy 1919, which clearly mandates that Staff shall not search
or physically examine a transgender or intersex youth for the sole purpose of
determining the youth's genital status. If the youth's genital status is unknown, it
may be determined during conversation with the youth, 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.
Staff shall not conduct cross-gender (opposite-sex) strip searches or cross-gender
frisk searches.
The facility will not do body cavity searches.
During the tour of the center, the auditor spoke with 10 staff members and
residents. All staff indicated they don’t conduct pat searches or strip searches of
residents of the other gender. Sixteen residents were engaged in a conversation
during the on-site audit. All of the residents indicated they have never been
searched by staff of the other gender.
115.315 (d):
The PAQ requires the facility to 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 require staff of the opposite gender to
announce their presence when entering a resident housing unit. In facilities (such as
group homes) that do not contain discrete housing units, staff of the opposite
gender shall be required to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions, or changing
clothing.
The facility provided the FDJJ Policy 1919 PREA - Searches, Cross-Gender viewing
and searches Training Video, Guidance on Cross-Gender and LGBTQ searches, and
ROP posters located throughout the facility.
Policy 1919 Youth must be allowed 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.
The center has posters throughout the facility. These posters are in large print with
yellow and blue borders that clearly state this is a male living unit, and female staff
must announce their presence!
A tour of the center found that all areas used to house residents have necessary
barriers to allow residents to shower without being seen by a person of the opposite
gender and to provide privacy from other residents during the showering process.
The WAGC showering procedure requires that staff of the same gender supervise all
showers and position themselves so they can’t see residents completely naked.
A review of the camera system noted there were no cameras located in the
restroom area of the facility.
All residents stated they are allowed to change clothes and shower in private. A
review of the cameras noted that none provided views of the shower or toilet areas
in any of the units. All staff of the other gender always announce their presence
when entering a housing unit. There are reminders placed at the entrance of each
housing unit.
Staff and residents confirm that staff announce their presence and will knock on the
door before looking in during counts.
All residents interviewed, both formally and informally during the onsite interview,
indicated that staff announce their presence whenever they go to the housing unit.
A review of the staff training plan includes intervention techniques and standards
required to be utilized before conducting any searches. An interview with a random
staff member confirmed they had received training in intervention techniques. This
training included conducting cross gender searches professionally and respectfully.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
Residents with disabilities and residents who are limited English
115.316
proficient
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
Zero Tolerance Poster English– Spanish
English and Spanish Third-Party Posters
PREA Posters
Bilingual Staff List
Department of Juvenile Justice Policy- 1919 PREA revised 4-16-19.
WAGC Policy 2.16 Career Education and Education Access
WAGC Policy 2.17 Education Transition Plan
ROP PREA Manual
Global Language Telephone Contract
Recognizing Signs and Symptoms
WAGC Policy 2.01 Admission and Orientation
Rites of Passage Safe Environmental Standards PREA Standard 115.316
Quick Reference Card
Random Staff Interviews
Agency Head Interview
115.316 (a)(c):
The PAQ requires that 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 enable effective communication with residents
with disabilities, including residents with 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, such as 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 agency shall not rely on resident interpreters, resident readers, or other
resident assistants except in limited circumstances in which an extended delay in
obtaining an effective interpreter could compromise the resident's safety, the
performance of first-response duties under § 115.364, or the investigation of the
resident's allegations.
The facility provided the PREA manual standard 316 and policy 1919
PREA manual standard 316 indicates that The program shall take appropriate steps
to ensure that students with disabilities (including, for example, students 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 program’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment.
When necessary to ensure effective communication with students who are deaf or
hard of hearing, the program will provide access to interpreters who can interpret
accurately, impartially, and in both receptive and expressive modes, using any
necessary specialized vocabulary. In addition, the program shall ensure that written
materials are provided in formats or through methods that enable effective
communication with students with disabilities, including students with intellectual
disabilities, limited reading skills, or who are blind or have low vision.
The program shall take reasonable steps to ensure meaningful access to all aspects
of the program’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment to students who are limited English proficient, including steps to
provide interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary.
The program shall not rely on student interpreters, student readers, or other types
of student assistants except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the student’s safety, the
performance of first-response duties under § 115.364, or the investigation of the
student’s allegations.
Policy 1919 mandates that facilities will ensure that residents with disabilities (e.g.,
those who are deaf, hard of hearing, blind, have low vision, intellectual, psychiatric,
or speech disabilities) have an equal opportunity to participate in or benefit from
the facility’s efforts to prevent, detect, and respond to Sexual Abuse and Sexual
Harassment. Such steps will include, when necessary, ensuring effective
communication with residents who are deaf or hard of hearing by providing access
to interpreters who can interpret accurately, impartially, and in both receptive and
expressive modes, using any necessary specialized vocabulary. WAGC will ensure
that all written materials to every resident are in a format or delivered through
methods that ensure effective communication with residents with disabilities,
including those with intellectual disabilities, limited reading skills, or who are blind
or have low vision. Facilities will not rely on residents, 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, or the investigation of the resident’s
allegations. Any use of these interpreters under these types of circumstances will be
justified and fully documented in the written investigative report. Residents receive
information explaining the agency’s zero-tolerance policy in an age-appropriate
fashion, including how to report incidents or suspicions of sexual abuse or sexual
harassment appropriately, taking into consideration age, disabilities, sexual
orientation, and language. Comprehensive education is accessible to all residents,
including those who are limited-English proficient, deaf, visually impaired, or
otherwise disabled, as well as those with limited reading skills. If the youth reports a
deficiency or the staff are aware of a deficiency in any of these areas, they will
report to the supervisor the need for an additional resource.
The facility is under contract with Language Line Solutions. The contract provides
interpretive telephone services, one-on-one sign language services, and in-person
services for investigative services. A review of the LLS website indicates that all of
their staff are required to have at least 2 years of experience providing verbal or
language line interpretive services.
The FDJJ agency head interview indicated that the center relies on videos in English
and Spanish, with closed captions for each video. The agency mandates that all
centers that provide services for FDJJ comply with PREA standards, which include
educating and protecting disabled residents.
The ROP agency head interview indicated that we have all of our Posters,
handbooks, videos, and memorandums in Spanish and English, and in some
facilities, other languages based on the geographic population we serve. We
maintain a list of staff who are bilingual and have a Language Line contract. We rely
on our educator to work with special education students, and, together with the
education staff and therapist, we determine any additional needed resources and
find them in the community.
All staff interviewed indicated they would not utilize and have not utilized resident
interpreters. The staff indicated they were aware of the Language Line contract and
would use it.
115.316 (b)
The PAQ requires the agency to take reasonable steps to ensure meaningful access
to all aspects of the agency's efforts to prevent, detect, and respond to sexual
abuse and sexual harassment to residents who are limited English proficient,
including steps to provide interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any necessary specialized
vocabulary.
The facility provided PREA manual standard 316 and policy 1919.
FDJJ Policy mandates that information about services, consent forms, rights, and
program rules, etc., be communicated to youth using interpreters or other auxiliary
aids. Also, these procedures will enable an effective exchange of information among
staff/employees, youth, and/or families while services are being provided. The
facility shall provide all aid and/or assistance without cost to the person being
served.
WAGC will take such steps to provide reasonable accommodations as are
necessary to ensure that disabled persons, including those with impaired sensory,
hearing, or speaking skills, receive effective notice concerning benefits, services, or
written material concerning waivers of rights or consent to treatment. All aids
needed to provide this notice, e.g., sign-language interpreters, readers, or through
other auxiliary aids, shall be provided within the service limits and availability of
qualified/ certified interpreters provided under contractual service without cost to
the person being served. The education department teachers are actively involved
in providing these services to residents. Residents who are special education
students receive an Individualized Education Program meeting that includes
parents, legal guardians, or child advocates. At the time of the audit, the center
housed one resident with cognitive challenges. The youth was interviewed and
indicated that staff showed him the video and discussed PREA with him on an
individual basis.
Family members or friends of the youth may not serve as the sign language
interpreter unless specifically requested by that individual. Other youth may not be
used for translating. The facility has a contract for language services, including sign
language services. Staff would read all the information required for facility
orientation and the comprehensive PREA training for residents who can’t read. All of
the residents interviewed were able to articulate the training programs, recall the
intake process, and feel safe at the facility.
Whenever communication accommodation is needed, the facility director or ROP
State compliance/quality assurance manager is responsible for arranging an
interpreter or another auxiliary aid to ensure reasonably prompt and effective
communication with the youth. It is the ultimate responsibility of the ROP State
supervisor to ensure all ADA needs are provided. In interviews with the mental
health staff, this is accomplished with the assistance of the education staff.
The facility maintains an at-risk log that includes any medical or developmental
concerns that require assistance in providing services to the residents.
The auditor noted posters on the Language Line access with the appropriate sign-in
code. The auditor called the number and, using the code, reached a coordinator who
was willing to connect the auditor with an interpreter. The center had no residents
with Limited English Proficiency.
Compliance was determined by reviewing the policy, the language line contract, and
interviewing the clinical supervisor, director, education staff, and facility
administrator.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.317 Hiring and promotion decisions
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
ROP PREA Manual
Department of Juvenile Justice Policy 1919 – PREA Background Checks
Department of Juvenile Justice Policy 1800 Background Screening
Five-year rescreening
DJJ Employee Handbook
BSU PREA Questionnaire Form IG/BSU form .003 revised 2024
Human resources staff interviews
115.317 (a):
The PAQ requires 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.
The PAQ indicated that 35 employee background checks and 6 contracting or
volunteer background checks have been completed in the last 12 months.
According to the human resources staff, 119 background checks were conducted;
however, only 35 were hired by the center.
The facility provided the FDJJ Policy 1919, Department of Juvenile Justice Policy 1800
Background Screening, BSU PREA Questionnaire Form IG/BSU form .003 and ROP
PREA Manual
FDJJ Policy 1919, Department of Juvenile Justice shall not hire or promote anyone
who may have contact with youth and shall not enlist the services of any contractor
who may have contact with youth, 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 or attempted 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. 4. WAGC shall consider any incidents of
sexual harassment in determining whether to hire or promote anyone, or to enlist
the services of any contractor, who may have contact with youth.
Department of Juvenile Justice Policy 1800 Background Screening states this policy
promotes the integrity of the Department of Juvenile Justice and ensures the proper
care, safety, and protection of youth in the Department's care and custody by
requiring background screening for employment and volunteer service prior to the
person having access to youth or confidential youth.
Background screening and hiring practices shall be conducted to ensure that all
department employees, contract providers, and grant recipient employees
(including owners, operators, and directors), volunteers, mentors, and interns with
access to youth or confidential youth records meet the established statutory
requirements of the Level 2 Screening Standards.
The Department is cognizant of its status as a criminal justice agency and its special
responsibilities in dealing with the youth population. It has determined that it is
appropriate to establish background screening and hiring requirements for all
Department employees and volunteers, as well as all contract provider owners,
operators, employees, and volunteers.
Any person required to complete an assessment for direct-care positions, or
undergo background screening as a condition of employment or volunteering
services who refuses to cooperate in such screenings or refuses to submit the
information necessary to complete the screening process shall not be employed or
utilized as a volunteer until a background screening is completed and the outcome
of the screening states the person is eligible for employment. Any person already
employed or working as a volunteer becomes disqualified.
The ROP Manual Rite of Passage will require every candidate for employment, as
well as contractors within the program, to undergo and pass state and federal
background checks before being hired. Every staff member is required to undergo
an additional background check every five years, or more frequently per state,
licensing, or contractual requirements.
Every volunteer will have background checks conducted before volunteering in the
program. The background checks will be conducted in accordance with state,
licensing, or contractual requirements.
WAGC shall ensure that a criminal background records check has been completed,
and consult applicable child abuse registries, before enlisting the services of any
contractor who may have unsupervised contact with youth. During initial interviews,
prospective employees, interns, and volunteers shall be informed of the background
check procedure. WAGC shall require the following background checks on all DJJ
staff, volunteers, interns, and contractors, and on any applicant being considered
for employment or promotion with DJJ: FDJJ utilizes Live Scan Background checks on
all staff. The program includes reviews of the Florida Crime Information Center, the
National Crime Information Center, and the Florida Child Registry.
115317 (b):
The PAQ requires the agency to consider any incidents of sexual harassment in
determining whether to hire or promote anyone, or to enlist the services of any
contractor, who may have contact with residents.
The facility provided policies 1919 and 1800. And the ROP PREA manual
The Agency Policy states that any incidents of sexual harassment by a staff
member will be taken into consideration when determining whether the staff
member is eligible for promotion. Before a promotion, the facility will conduct a
promotion board. Before meeting with the board, the applicant completes a
questionnaire that includes all areas of the standard. The employment interview
questions also address prior misconduct. The evidence shows the facility considers
any incident 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. Policy states that any incidents of sexual harassment by a staff member
will be taken into consideration when determining whether the staff member is
eligible for promotion. The employment interview questions also address prior
misconduct. The evidence shows the facility considers any incident 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.
ROP Manual mandates that all contract providers and Department employees will be
screened in accordance with Level 2 standards, as outlined in Chapter 435, Florida
Statutes, as a condition of initial employment and retention in those positions.
Additionally, all provider and Department employees will be re-screened every five
(5) years of continued employment.
Employment background screening shall be completed before hiring an employee or
utilizing the services of a volunteer, mentor, or intern. It'd be an assessment before
the hiring of direct-care positions.
Employees and volunteers will report any arrest, which includes any notice to
appear in court for a criminal charge, to their immediate supervisor within 24 hours
of the arrest or receipt of the notice to appear. If an employee or volunteer fails to
report an arrest within 24 hours, they shall submit an explanation for the delay in
reporting. Failure to timely report an arrest may result in disciplinary action up to
and including dismissal. Supervisors and/or Human Resources personnel will report
the new arrest or notice to appear to the Background Screening Unit, which will
determine if the offense disqualifies the employee or volunteer from continued
service.
A volunteer is never to be left alone with a student without at least sight
observation by staff.
The program shall not hire or promote anyone who may have contact with students,
and shall not enlist the services of any contractor who may have contact with
students, who:
(1) Has engaged in sexual abuse in a prison, jail, lockup, community
confinement program, juvenile program, 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 this policy.
The human resources staff interview indicated that, before a promotion, the staff
member completes another questionnaire. We also conduct a Live Scan for
prospective promotions. All people who apply to work at the center, whether full-
time, part-time, or as contractors, must have completed a background check
conducted by the Background Unit. We completed the PREA questionnaire on the DJJ
employment application before promotion and each year during annual training.
115.317 (c):
The PAQ requires before hiring new employees who may have contact with
residents, the agency shall: (1) Perform a criminal background records check; (2)
Consults 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 facility provided Policy 1919, Policy 1800, and the ROP PREA manual. The
facility also provided randomly selected background checks.
Policy 1919 mandates that the Department perform a background check before
hiring any new staff. The Department will make its best efforts to contact all prior
PREA-regulated employers for information on substantiated allegations of sexual
abuse or any resignation during a pending investigation of an allegation of sexual
abuse.
Background checks shall be conducted every five (5) years for staff.
Policy 1800 requires Background screening and hiring practices to be conducted to
ensure that all Department employees, contract providers, and grant recipients
(including owners, operators, and directors), volunteers, mentors, and interns with
access to youth or confidential youth records meet the established statutory
requirements of the Level 2 Screening Standards.
• The Department is cognizant of its status as a criminal justice agency
and its special responsibilities in dealing with the youth population. It has
determined that it is appropriate to establish background screening and hiring
requirements for all Department employees and volunteers, as well as all contract
provider owners, operators, employees, and volunteers.
• All contract providers and Department employees will be screened in
accordance with Level 2 standards, as outlined in Chapter 435, Florida Statutes, as
a condition of initial employment and retention in those positions. Additionally, all
provider and Department employees will be re-screened every five (5) years of
continued employment.
• Employment background screening shall be completed before hiring an
employee or utilizing the services of a volunteer, mentor, or intern.
• An assessment shall be completed before the hiring of direct-care
positions.
• Contract provider employment and volunteer background screenings will
be processed and housed in the Care Provider Background Screening Clearinghouse.
This database is owned and maintained by the Agency for Health Care
Administration (AHCA).
• The BSU will review and provide the results from the FDLE's Automated
Training Management
• System (ATMS) to the contract providers for screenings done on potential
or permanent employees.
• The Department does not hire, promote, or contract with anyone who:
i. 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);
ii. 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;
iii. Has been civilly or administratively adjudicated to have engaged in
the activity described in ii above.
• The Department shall ask all applicants and employees who may have contact
with youth about previous misconduct in written applications or interviews for hiring
or promotions, and in any interviews or written self-evaluations conducted as part of
the review of current employees.
• The Department shall consider any substantiated incidents of sexual misconduct
in determining whether to hire, promote, or contract with anyone.
• Employees being considered for promotion shall disclose any sexual misconduct
and material omission regarding such misconduct, or the provision of materially
false information shall be grounds for termination.
During initial interviews, prospective employees, interns, and volunteers shall be
informed of the background check procedure. FDJJ shall require the following
background checks on all DJJ staff, volunteers, interns, and contractors, and any
applicant that is being considered for employment or promotion with DJJ: 1. Criminal
background or records check. 2. Child abuse and neglect registry check. The human
resources staff indicated that, in interviews and by reviewing personnel files, she
conducts a reference check on all prospective employees. This check includes any
history of sexual abuse, sexual harassment, including sexual harassment toward
other staff. Over the last 12 months, the facility has conducted background checks
on 35 applicants for positions. There were 6 contractor or volunteer background
checks completed in the last 12 months.
ROP manual requires that the program shall consider any incidents of sexual
harassment in determining whether to hire or promote anyone, or to enlist the
services of any contractor, who may have contact with students.
Before hiring new staff who may have contact with students, the program shall:
(1) Perform a criminal background records check;
(2) Consult any child abuse registry maintained by the State or locality in which
the staff 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.
115.317 (d):
The PAQ requires the agency also to perform a criminal background records check
and consult applicable child abuse registries before enlisting the services of any
contractor who may have contact with residents. WAGC shall ensure that a criminal
background records check has been completed, and consult applicable child abuse
registries, before enlisting the services of any contractor who may have
unsupervised contact with youth.
The facility provided policies 1919 and 1800, as well as the ROP PREA Manual,
including the PREA questionnaire.
The policy 1919 and 1800 requires WAGC to ensure that a criminal background
records check has been completed, and consult applicable child abuse registries,
before enlisting the services of any contractor who may have unsupervised contact
with youth.
Interviews with contracting staff indicated that they have completed their
background checks before being employed by the local school district. The medical
staff receives their background checks through the central office, which then
contacts the BSU to complete them.
115.317 (e):
The PAQ requires the agency to either conduct criminal background records checks
at least every five years for current employees and contractors who may have
contact with residents, or to have in place a system to otherwise capture such
information for current employees.
The facility provided policy 1800 and the ROP PREA Manual.
Policy 1800 requires that all contract providers and department employees be
screened in accordance with Level 2 standards, as outlined in Chapter 435, Florida
Statutes, as a condition of initial employment and retention in those positions.
Additionally, all provider and Department employees will be re-screened every five
(5) years of continued employment.
The ROP PREA manual mandates that the program either conduct criminal
background records checks on current staff and contractors who may have contact
with students, or have in place a system to capture such information for current
staff. Criminal background checks will occur at least every five years, or more often
as required by licensing, regulatory, or contractual requirements.
Human Resources indicated in an interview that the agency utilizes Live Scan to
obtain updated background information or to verify current charges pending.
However, she indicated that she still sends five-year background checks each
January to keep them current. A review of the five-year background checks
confirmed compliance.
WAGC shall conduct background checks or alternative background checks on all
staff, volunteers, interns, and contractors every five (5) years. FDJJ used “Live Scan”
for continuous background checks on staff, contractors, or volunteers. This includes
a background check by the sheriff’s office. This was confirmed by reviewing Live
Scan background checks for staff with 5 or more years of tenure at the facility. At
the same time, the agency conducts five-year background checks on all staff before
they reach 5 years of tenure.
115.317 (f):
The PAQ requires the agency also to ask all applicants and employees who may
have contact with residents directly about previous misconduct described in
paragraph (a) of this section in written applications or interviews for hiring or
promotions, and in any interviews or written self-evaluations conducted as part of
reviews of current employees. The agency shall also impose upon employees a
continuing affirmative duty to disclose any such misconduct.
The facility provided policy 1800 and the ROP PREA manual
The agency asks applicants about previous misconduct described in paragraph (a)
of this section in written applications or during interviews for hiring or promotions.
The facility does a yearly staff appraisal, and sexual abuse or sexual harassment is
part of that appraisal. This includes having staff review and sign the BSU PREA (form
003) Questionnaire.
THE ROP PREA manual requires the program also to ask all applicants and staff who
may have contact with students 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 staff. The program shall also impose upon staff a continuing
affirmative duty to disclose any such misconduct.
According to the human resources staff, they are aware that they utilize Live Scan,
so they are not hesitant to advise the office of any criminal findings, including
speeding tickets.
115.317 (g):
The PAQ requires that material omissions regarding such misconduct, or the
provision of materially false information, shall be grounds for termination.
The facility provided policy 1800 and the ROP PREA manual. The center also
provided information on the live scan tracking system.
FDJJ Policy 1800 – Background Screening and Hiring mandates that employees and
volunteers report any arrest, including any notice to appear in court for a criminal
charge, to their immediate supervisor within 24 hours of the arrest or receipt of the
notice to appear. Failure to report may result in disciplinary action up to and
including termination. Material omissions regarding such misconduct, or the
provision of materially false information, shall be grounds for termination.
ROP PREA manual states that material omissions regarding such misconduct, or the
provision of materially false information, shall be grounds for termination
The Human Resources staff interviewed indicated that staff are made aware of their
duty to report and are told that the center is part of the Live Scan and that it will
be reported, which would be grounds for termination.
115.317 (h):
The PAQ requires, unless prohibited by law, that the agency provide information on
substantiated allegations of sexual abuse or sexual harassment involving a former
employee upon receiving a request from an institutional employer for whom such
employee has applied to work.
The center provided policy 1919, policy 1800, and the ROP PREA manual.
The polices mandate that, 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
human resources department confirmed that the facility would provide this
information if requested. The policy states that the information will be provided
upon request unless prohibited by law. According to interviews with the human
resources staff, the center would have the prospective candidate sign a release
form and then send the requested information.
ROP PREA manual (g) indicates that, unless prohibited by law, the program shall
provide information on substantiated allegations of sexual abuse or sexual
harassment involving a former staff member upon receiving a request from an
institutional employer for whom such staff has applied to work. All such requests will
be forwarded to the Corporate Director of Human Resources, who is the sole person
authorized to respond.
Human Resources staff interviewed indicated that she would send the request to the
Corporate Director of Human Resources along with a signed request from the hiring
agency and prospective employee.
A review of 8 randomly selected staff files contained the BSU approval-to-hire
notification and the PREA questionnaire for new hires, promotions, and annual
assessments.
Based on a review of the documentation and an interview with the Facility
Administrator and Human Resources staff, the facility complies with all provisions of
this standard. FJDC utilizes Live Scan, which provides background information while
still completing a five-year background check on all staff with over 5 years of tenure
in the agency.
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
Annual Facility Assessment
Interview with
Agency head ROP
Agency head FDJJ
Facility administrator
115.318 (a)
The PAQ requires that, when designing or acquiring any new facility and when
planning any substantial expansion or modification of existing facilities, the agency
shall consider the effect of the design, acquisition, expansion, or modification on the
agency's ability to protect residents from sexual abuse.
The facility provided that there has been no substantial expansion or modification of
existing facilities; however, the agency would consider the effect of the design,
acquisition, expansion, or modification upon the agency's ability to protect residents
from sexual abuse.
115. 318 (b)
The PAQ requires that when installing or updating a video monitoring system,
electronic surveillance system, or other monitoring technology, the agency shall
consider how such technology may enhance the agency's ability to protect residents
from sexual abuse.
The facility provided that the center has modified some cameras.
The Facility director showed the auditor several newly upgraded cameras. He also
indicated that, on an annual basis, the PREA coordinator and regional staff conduct
a review of the PREA and make recommendations for upgrades or additional
cameras. The 2025 review did not recommend any additional cameras.
The FDJJ agency head indicated that the agency conducts an annual review of
cameras and software to identify blind spots across all facilities. The agency then
allocates either more cameras or additional resources to ensure there are no blind
spots in that area without staff supervision.
The ROP agency head indicated that we work as a team. In determining contact
with an agency or partner with private vendors, we meet as a team to determine
strategies to establish a Safe environment for staff and students. We will have a
team to look at the physical structure for blind spots, camera mapping, and
available resources to determine first if we would like to operate the facility, and
second, if we have the resources to make the needed modifications to ensure there
are not blind spots, staffing plan, and monitoring and camera needs. We don’t send
one person to review, but bring in a team to look at every inch of the facility.
Technology is now affordable. We utilize technology for training and documentation.
We have staff who are extremely knowledgeable about the new technology and
utilize their expertise.
A review of the last 12 months’ assessment did not make any recommendations. A
tour of the center did not reveal any blind spots or needs for additional cameras.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
FDJJ Policy 1919 PREA - Investigative Protocols
OIG requested Law Enforcement Officers to follow uniform evidence protocols.
Investigative protocol
PREA Youth Posters
Interview with Emerald Coast
Updated interview with Emerald Coast
PREA compliance manager
SANE staff from Walton/Destin Medical Center
PREA Coordinator
PREA Compliance Manager
MOU with Emerald Coast Children's Advocacy Center
115.321 (a):
The PAQ requires that, 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.
The facility provided policy 1919 Investigative protocol and OIG training.
Policy 1919 Investigative protocol mandates that the Department not conduct
criminal investigations for youth-related sexual abuse reports. Local law
enforcement agencies and the Department of Children and Families handle such
investigations involving youth in Florida. The Department conducts administrative
investigations and management reviews, separate and apart from any criminal
investigations, to identify any misconduct by staff related to the Department's
regulatory guidance. Staff are expected to cooperate with the Office of the Inspector
General (OIG) investigations.
The OIG staff will be trained in the Department's policies and procedures for
handling sexual misconduct incidents and reports.
The Department will ensure that administrative investigations and reviews are
completed for all criminal allegations.
Twelve random 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. 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.
115.321 (b):
The PAQ requires that 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.
The facility states that the department does not conduct criminal investigations into
youth-related sexual abuse reports. Local law enforcement and the Department of
Children and Families conduct such investigations involving youth in Florida.
The Department conducts administrative investigations and management reviews,
separate from criminal investigations. 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. The Policy provides for uniform
Protocols to be followed. The Protocol is outlined with respect to appropriateness for
youth and adults. 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.
The chief of OIG investigations in interviewed indicated that his staff was trained on
conducting PREA investigations utilizing the National Protocol for Sexual Assault
Medical Forensic Examinations, Adults/Adolescents, or similarly comprehensive and
authoritative protocols. He indicated that he has sent a letter to all local law
enforcement agencies that conduct criminal investigations, asking them to consider
using the same protocol.
Random staff interview knew staff responsibilities to protect the residents, secure
the crime scene, and notify the shift supervisor and CCC. The center staff indicated
they would move the residents to a safe location and have them not change
clothes, wash, shower, use the toilet, or brush their teeth. The staff indicated, based
on training, that the Walton County Sheriff's Office or the OIG would be responsible
for collecting the evidence upon arrival at the center.
115.321 (c):
The PAQ requires that the agency shall offer all residents who experienced 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 facility provided Policy 1919 and an interview with Walton/Destin Medical
Center.
The Policy 1919 states:
Residents will receive timely, unimpeded access to on-site and off-site 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.
Be offered access to forensic medical examinations, whether on-site or at an
outside facility, at no cost, where evidence-based or medically appropriate. Such
examinations shall be performed by Sexual Assault Forensic Examiners (SAFE) or
Sexual Assault Nurse Examiners (SANE) where possible. If a SAFE or SANE cannot be
made available, the examination can be performed by other qualified medical
practitioners. The facility utilizes Walton/Destin Medical Center for emergency
treatment and SANE. In interviews with the Emergency Room, the hospital has a
SART program that includes victim advocates and SANE staff.
The center has established an MOU with the Emerald Coast Children's Advocacy
Center for victim advocacy and has staff on duty or on call twenty-four hours a day.
The facility provided credentials for the clinical staff. In interviews with the clinical
director, all clinical staff are licensed mental health counselors or social workers,
and would respond by providing victim advocacy services to the youth if requested
by the youth.
The facility policy and MOU state that the services will be provided at no cost to the
victim. The Nurse’s interview was aligned with the facility Policy.
115.321 (d)(e) (h):
The PAQ requires the agency to attempt to make available to the victim a victim
advocate from a rape crisis center. If a rape crisis center is not available to provide
victim advocate services, the agency shall make available a qualified staff member
from a community-based organization or a qualified agency staff member to provide
these services. Agencies shall document efforts to secure services from rape crisis
centers. For 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, provided the center is not part
of the criminal justice system (such as a law enforcement agency). It offers a level
of confidentiality comparable to that of a nongovernmental entity providing similar
victim services.
As requested by the victim, the victim advocate, a qualified agency staff member,
or a 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.
For the purposes of this standard, a qualified agency staff member or a qualified
community-based staff member shall be an individual who has been screened for
appropriateness to serve in this role and has received education concerning sexual
assault and forensic examination issues in general.
The facility has established an MOU with the Emerald Coast Child Advocacy Center.
In an interview with the PREA compliance manager, they indicated that the MOU
includes advocacy, emotional support, SANE examinations, and an emotional
support system.
According to the MOU, the supportive services to victims include access to 24-hour
reporting and contact for advocacy services; emotional support; accompaniment
through forensic examination and investigative interviews upon request; and the
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 that the resident and/or facility staff members can
use the victim services hotline to request a victim advocate.
In interviews with ECCAC, the program would provide victim advocacy and follow-
up services as required. This includes meeting with the family, attending court
hearings, providing a haven for the family, and follow-up treatment as needed. This
would continue when the youth left the center if they were from the geographical
area. The ECCAC indicated in the interview that they are a member of the Florida
Coalitions Against Sexual Violence and provide and receive training from the
Statewide organization.
115.321 (f)
The PAQ requires, to the extent that the agency itself is not responsible for
investigating allegations of sexual abuse, the agency requests that the investigating
agency follow the requirements of paragraphs (a) through (e) of this section.
The facility provided a memorandum, sent to all local law enforcement, from the
Chief of the OIG investigative units. Requesting that law enforcement utilize the
Sexual Assault Medical Forensic Examinations, Adults/Adolescents. The center is
required to notify the Central Communication Center, Department of Children and
Family Services, and Walton County Sheriff’s Office to report allegations of sexual
abuse.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.322 Policies to ensure referrals of allegations for investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
FDJJ Policy 1919 - Investigative Protocols
1.04 - Incident Reporting-WAGC
OIG Compliance Form-directive
OIG Directive requests that Law Enforcement Officers follow uniform evidence
protocols.
FDJJ Website
Investigator Database
Investigative Chief Interview
Agency Head Interview
115.322 (a & b)
The PAQ requires the agency shall ensure that an administrative or criminal
investigation is completed for all allegations of sexual abuse and sexual
harassment.
harassment.
Based on the PAQ, there have been 5 allegations of sexual abuse or sexual
harassment that have been or are in the process of being investigated.
This includes two allegations of sexual abuse and three allegations of sexual
harassment. The local law enforcement interviewed the youth involved in the sexual
abuse allegation and determined one was unfounded, and one was not criminal in
nature, and declined to investigate.
The facility provided the FDJJ Policy 1919 - Investigative Protocols.
The agency shall have in place a policy to ensure that allegations of sexual abuse
and/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.
The facility provided policy 1919 Investigative Protocol.
WAGC does not conduct criminal investigations for residents related to sexual abuse
reports. Local Law enforcement and the Department of Children and Families handle
such investigations involving youth in Florida. The Department conducts
administrative investigations and management reviews, separate and apart from a
criminal investigation. The DJJ PREA Policy describes how investigative
responsibilities are handled for allegations of sexual abuse and harassment and can
be found on the Florida DJJ's website. This information is available in both English
and Spanish. Further, the agency has a Policy that requires allegations of sexual
abuse or sexual harassment be referred to an agency with the legal authority to
conduct criminal investigations unless the allegation does not involve criminal
behavior. Staff, including the facility administrator and contractors, indicated that
any allegations received by residents, staff, volunteers, or contractors would be
reported to the Central Communication Center and the Child Abuse Hotline by the
person with the most information, when possible. This information is sent to Central
Control Center (CCC), Child Abuse Hotline, and local law enforcement within 2 hours
of the first staff or volunteer being made aware of an allegation. This information is
documented in the Investigative database maintained by the OIG office.
The agency head was interviewed and indicated that we have a PREA policy that
requires all allegations of sexual abuse or sexual harassment be reported to the
Central Communication Center within 2 hours.
Based on an interview with the chief of the Office of Inspector General, we have an
IG office that completes administrative investigations. We contact the local law
enforcement to conduct criminal investigations. We notify the Department of
Children and Family Services, which conducts an independent investigation. If it is a
criminal investigation, the OIG will follow with an administrative investigation that
includes a review of policy, cameras, staffing, notifications, and staff actions.
WAGC does not conduct criminal investigations for residents related to sexual
abuse reports. Local Law enforcement and the Department of Children and Families
handle such investigations involving youth in Florida. The Department conducts
administrative investigations and management reviews, separate and apart from a
criminal investigation.
The DJJ PREA Policy describes how investigative responsibilities are handled for
allegations of sexual abuse and harassment and can be found on the Florida DJJ's
website. This information is available in both English and Spanish. Further, the
agency has a Policy that requires allegations of sexual abuse or sexual harassment
be referred to an agency with the legal authority to conduct criminal investigations
unless the allegation does not involve criminal behavior. Staff, including the facility
administrator and residents, indicated that any allegations received by residents,
staff, volunteers, or contractors would be reported to the Central Communication
Center and the Child Abuse Hotline by the person with the most information, when
possible. This information is sent to Central Control Center (CCC), Child Abuse
Hotline, and local law enforcement within 2 hours of the first staff or volunteer being
made aware of an allegation. This information is documented in the Investigative
database maintained by the OIG office.
Rites of Passage ROP Policy 1.04 Incident Reporting mandates it is the policy of
Walton Academy for Growth and Change to provide accurate reporting and
dissemination of information regarding occurrences which require the immediate
and/or urgent response, action or other intervention to protect and ensure the
safety and security of the youth, the public, and significant incidents relating to the
care, safety and humane treatment of youth. All staff shall adhere to the Florida
Department of Juvenile Justice 63F-11 F.A.C. for incident reporting, as well as the
outlined procedures for internal incident reporting that may not require a call to the
Central Communications Center (CCC). The Program Director shall ensure that all
designated reportable incident types are reported to the CCC within two (2) hours of
the incident or of becoming aware of the incident.
The Program Director shall ensure that the program maintains a separate file for all
incident reports and has a system in place to track incidents.
The agency head was interviewed and confirmed that all allegations, suspicions, or
anonymous reports must be reported to the CCC, the Department of Children and
Family Services, and legal services within 2 hours of staff, volunteers, and
contractors becoming aware of a report.
The chief of investigation indicated that, upon receiving the report, we assign it to
an OIG staff member and, if it is criminal in nature, we reach out to local law
enforcement for a criminal investigation. If it is criminal in nature, OIG assists local
law enforcement upon request.
115.322 (c):
The PAQ requires 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 provided FDJJ Policy 1919 and staff training mandates that staff secure
the scene and not allow the victim or predator to change clothing, brush teeth, use
the restroom, or shower. The facility will assist the investigator in making video and
other materials available upon request. There were two allegations referred for
criminal investigation during the last 12 months.
The investigation procedures are available at djj.state.fl.us/inspector general/central
communication-center-ccc. Org. Walton Academy for Growth and Change is required
to comply with the Florida Department of Juvenile Justice investigative procedures.
Compliance was verified by reviewing policies and procedures, the Florida DJJ
website, and interviews with the agency designee, facility administrator,
investigators, staff, and the PREA Coordinator.
Based on this analysis, the facility is substantially compliant with this provision, and
a corrective action plan is not required.
115.331 Employee training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
FDJJ Policy 1919 PREA - Staff Training
ROP Safe Environment Standards - 115.331 Employee training
PREA Acknowledgement form
Victimization and Sexual Aggressive Resident Identification Developmentally
Disabled Resident identification training.
PREA Skill Pro training curriculum, Part one and Part 2
PREA training 2023
PREA training 2024
PREA training 2025
PREA VSAB Training
115.331 (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.
The facility provided ROP Safe Environment Standards - 115.331, Employee training
PREA Part 1 content, PREA Part 2 content, FDJJ Policy 1919 Staff training Part 1
content, which includes what is known as the Skill Pro includes
What is PREA
Required Training
Standard and procedure
Part 2 content includes
Reporting
Responding to Abuse Reports
Investigations
Policy 1919 requires that all Florida Department of Juvenile Justice employees
complete training as outlined in FDJJ 1520, Employee Training, and Florida
Administrative Code Rule 63-H, Staff Training. This curriculum includes training on
the agency's zero-tolerance policy for sexual misconduct.
Each employee is required to take refresher training every two (2) years. The
Department will document, through employee signature or electronic verification,
that employees understand the training they have received. Information on current
sexual misconduct policies will be available for staff on the Department's PREA
webpage.
Direct Care staff shall be trained in how to conduct cross-gender pat searches, and
searches of transgender and intersex youth, professionally and respectfully, and in
the least intrusive manner possible.
ROP provided PREA Standard 115.331- Employee training
Rite of Passage programs will provide the following appropriate training to all staff
at pre-service and then every six months from the last site training. PREA Standard
115.331- Employee training policy mandates that Rite of Passage programs will
provide the following appropriate training to all staff at pre-service and then every
six months from the last site training. (a) The PREA Site Compliance Manager, Site
Trainer, or Human Resources Manager shall train all staff (full-time, part-time, and
contracted mental health care practitioners): 1. The site's zero tolerance policy for
sexual abuse and sexual harassment; 2. How to fulfill their responsibilities under the
program's sexual abuse and sexual harassment prevention, detection, reporting,
and response policies and procedures; 3. Students’ right to be free from sexual
abuse and sexual harassment; 4. The right of students and staff 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 students; 8. How to
avoid inappropriate relationships with students; 9. How to communicate effectively
and professionally with students, including lesbian, gay, bisexual, transgender,
intersex, or gender nonconforming students; 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.
All interviewed staff members were familiar with the PREA information regarding
primary components of preventing, detecting, and responding to sexual abuse or
sexual harassment. PREA training is provided for staff, as indicated by a review of
policy and training documents. The documents and staff interviews support
refresher training, which is also conducted and documented. The direct care staff
interviewed, and the PREA Compliance Manager reported that the training is
provided as required. All staff members interviewed, and documentation reviewed
verified the general topics below were included in the training: 1. The center's Zero
Tolerance Policy for sexual abuse and sexual harassment. 2. How to fulfill their
responsibilities under the center's 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. 10. How to
comply with relevant laws related to mandatory reporting of sexual abuse to outside
authorities; and 11. Relevant laws regarding the applicable age of consent.
115.331 (b):
The PAQ requires that such training 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 provided PREA Part 1 content, PREA Part 2 content, and the FDJJ Policy
1919 Staff.
Skill Pro 1 and 2 are tailored to all genders housed in Florida Centers, including
State and privately operated centers. The agency training for all staff also includes
working with LGBTI youth in DJJ facilities. Additionally, the agency has developed
training for First Responder duties and responsibilities.
ROP policy 331 requires that training be tailored to the unique needs and attributes
of students in the programs and to their gender. The staff shall receive additional
training if reassigned from a program that houses only male students to one that
houses only female students, or vice versa.
Walton Academy for Growth and Change houses male youth.
115.331 (c):
The PAQ requires that all current employees who have not received such training be
trained within one year of the effective date of the PREA standards, and that the
agency provide each employee with refresher training every two years to ensure
that all employees know the agency's current sexual abuse and sexual harassment
policies and procedures. 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 PAQ also indicated that staff will receive refresher training each year.
The center provided Skill Pro 1 and 2, and ROP policy 331
The agency provides each employee with a refresher each year to ensure they are
familiar with the agency’s current sexual abuse and sexual harassment policies and
procedures. In recent years, the annual in-service training included a video on
conducting cross-gender or person frisks (pat-downs). All staff are required to
complete this training. Training roster and training records were reviewed and
documented for this training for staff working at WAGC. Additional training is
provided at the facility for the on-site training staff. The review included an
additional refresher on most topics in the Skill Pro Curriculum. The agency's policy
addresses PREA-related staff training.
ROP policy 331 mandates that the program shall provide each staff member with
refresher training every six months to ensure that all staff members know the
program’s current sexual abuse and sexual harassment policies and procedures.
All interviewed staff members were familiar with the PREA information regarding
primary components of preventing, detecting, and responding to sexual abuse or
sexual harassment. Interviews with non-direct care staff and contracting staff, and
the files of non-direct care and contracting staff, confirmed that all staff working at
WAGC receive the same training. All direct care staff interviewed indicated they had
received initial PREA training during Pre-Service. They then received additional
training at the Florida DJJ Training Academy. Upon returning from the academy, the
center provided training specific to the center, including information on the Rape
Crisis Center. In interviews with staff, each indicated that PREA was discussed on a
daily basis, that formal training is a four-hour training session with instructors, and
that the skill pro modules 1 and 2 were completed, which include a questionnaire.
Policy and procedure mandate that staff are trained at least every two years.
Policy 1919 staff training requires a refresher every two years. Based on a review of
the staff training files and interviews with the Facility administrator, the training is
required each year.
115.331 (d):
The PAQ requires the agency to document, through employee signature or
electronic verification, that employees understand the training they have received.
The facility provided electronic signs in sheets for all random staff interviewed by
the auditor and an additional staff roster for cross-gender pat searches.
The agency documents training through employee signature or electronic
verification to confirm that employees understand the training they have received.
The policy provides that all training be documented.
ROP policy 331 mandates that the program shall document, through an attendance
sheet and Form 13.44, which must include a staff signature or electronic verification
that staff understand the training they have received. Documentation will be kept in
employee files.
Staff members sign training rosters and training acknowledgement statements. A
checklist is used for orientation training of all new employees and includes the
elements of PREA training. The facility provided the Auditor with several examples
of training occurring, and the training was verified through staff interviews. PREA
training is provided to all staff, as indicated by a review of policy and training
documents. The documents and staff interviews support refresher training, which is
also conducted and documented. The direct care staff interviewed, and the PREA
Compliance Manager reported that the training is provided as required. All direct
care staff members interviewed and document reviewed, verified that the general
topics below were included in the training: At the facility, it was evident through
documentation, interviews, and observation of the day-to-day operations, the staff
is trained continually in the PREA standards during shift briefings, monthly staff
meetings, and the completion of various online and instructor-led trainings.
WAGC requires staff to complete informal PREA training quarterly and at each
monthly all-staff meeting. All staff are also mandated to conduct Skill Pro module
one and two. Staff interviewed indicated that one of the administrators meets with
staff during staff briefings at least once a month to discuss PREA-related topics.
There are over 10 posters on sexual safety located throughout the facility. All of the
staff interviewed were able to articulate each training topic and their understanding
of it.
Compliance was determined by reviewing the preservice and in-service training
curricula and staff training records. An interview with a random staff member also
confirmed that they had received the training and refresher training as mandated
by policy. The interview included questions about the specialized training programs.
Staff were able to articulate an understanding of working with LGBTI youth.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
Volunteers and Contractors Training
FDJJ Policy 1919 - Volunteer and Contractor Training
Contractors Training acknowledgement
Interviews
2 Contractors
1 volunteer
115.332 (a):
The PAQ requires 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 facility provided the FDJJ Policy 1919 - Volunteer and contractor Training and the
volunteer and contractor training curriculum.
Training curriculum outline includes:
Agency zero tolerance and Policy 1919
Definitions
· Sexual abuse
· Sexual harassment
· Sexual abuse
· Sexual harassment
Reporting Allegation of Sexual Misconduct
Detecting Sexual abuse and sexual harassment
Maintaining Professional Relationships with Youth
Summary
PREA Acknowledgements Form
FDJJ Policy 1919 - Volunteer and contractor Training provides Volunteer and
Contractor Training: All volunteers and contracted providers in Residential and
Detention facilities who have contact with youth must be trained on their
responsibilities under the Department's sexual misconduct prevention, detection,
and response policy and procedures (FDJJ 1919).
The level and type of training provided to volunteers and contractors are based on
the services they provide and the level of contact they have with youth. Volunteers
and contractors who perform services continuously or at regular intervals, or who
volunteer for 10 hours or more each month, must complete the PREA training
prescribed for all full-time employees. The course is available on the Department's
Learning Management System (Course FDJJ 110).
Volunteers and contractors who perform services or interact with youth for less
than 10 hours a month and/or accompanied by a staff member who is always
present and has the volunteer or contractor in their line of sight, will not be required
to take the Course FDJJ 110, but shall read the FDJJ Course for Volunteers and sign
the PREA Acknowledgement to document their understanding of the training
received this course is available on the Department's PREA web page at htt1://www
.di j .state.fl. us/partners/prison-rape-elimination-act-
Before having contact with the residents, all volunteers and contractors receive
training on their responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detention, and response policies and procedures. The level
and type of training provided shall be based on the services they provide and the
level of contact they have with residents. Still, 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 be informed how to report such
incidents.
Contracting staff who were interviewed indicated that they signed a contract for
more than 10 hours a week and must attend Skill Pro 1 and 2. The medical and
mental health providers are contracted through Vital Pro and are also required to
attend Skill Pro 3 and 4. Upon reviewing the training for contractors, it was
determined that all contracting staff have completed the required training.
115.332 (b):
The PAQ requires that the level and type of training provided to volunteers and
contractors shall be based on the services they provide and the level of contact they
have with residents. Still, 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 of how to report such incidents.
The facility policy 1919 PREA volunteer training provides that the level and type of
training provided to volunteers and contractors are based on the services they
provide and the level of contact with youth. Volunteers and contractors who perform
services continuously or at regular intervals, or who volunteer for 10 hours or more
each month, must complete the PREA training prescribed for all full-time employees.
The course is available on the Department's Learning Management System (Course
FDJJ 110).
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 of how to report such incidents.
115.332 (c):
The PAQ requires the agency to maintain documentation confirming that volunteers
and contractors understand the training they have received
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, containing the participant's
signature and date, confirming their understanding of the PREA information.
During the last year, the center trained 6 contractors or volunteers. In an interview
with the State director for Rites of Passage, he indicated that ROP has a contract
with a medical practitioner to provide clinical supervision for medical staff, but that
practitioner is not located at Walton Academy for Growth and Change.
Based on this analysis, the facility was substantially compliant with this provision,
and corrective action was not required.
115.333 Resident education
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
FDJJ Policy 1919 - Youth Training and Education
Facility Operating Procedures (FOP) 3.09 PREA (Attachment)
PREA acknowledgement form
Ten Different PREA Brochures (French Creole, Spanish, and English)
Special accommodations for disability
Youth education sign in Youth training
Education material
Advocacy Posters, including National Child Abuse
PREA Education Rosters
Resident acknowledgement forms
PREA Education Video
12 Resident Files
ROP PREA Standard 115.333- Student education
115.333 (a):
During the intake process, residents shall receive information explaining, in an age-
appropriate fashion, the agency's zero-tolerance policy regarding sexual abuse and
sexual harassment and how to report incidents or suspicions of sexual abuse or
sexual harassment.
The facility provided PREA Juvenile intake caption MP4 in English and Spanish, and
trifold PREA brochure and policy 1919 PREA and ROP PREA Standard 115.333 -
Student education.
The video utilized for the juvenile orientation program is captioned in English and
Spanish. It provides the youth with 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.
The trifold is brightly colored and has four pages of information for newly arrived
youth, with the same information they can keep on their person. The trifold
explicitly indicates the agency's Zero Tolerance against sexual abuse and sexual
harassment, youth rights, and how to report.
Policy 1919 mandates that all DJJ facilities 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 residents with limited reading
skills. The agency maintains documentation of participation in the education
program. 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 center conducts initial
training for all new residents upon arrival at the facility, usually within 72 hours,
covering all aspects of the training requirements. At present, the facility provides
comprehensive training to residents upon completion of the intake process.
PREA Standard 115.333- Student education
Students shall receive information explaining the program’s zero-tolerance policy
regarding sexual abuse and sexual harassment, and how to report incidents or
suspicions of sexual abuse or sexual harassment.
(a) During the intake process, students shall receive ROP Safe Environment
Standards: A Student Guide to Rights, Protections, and Reporting of Sexual Abuse,
explaining the program’s zero-tolerance policy regarding sexual abuse and sexual
harassment and how to report incidents or suspicions of sexual abuse or sexual
harassment.
(b) During the intake process, students shall receive and sign the " ROP Safe
Environment Standards “Student Acknowledgment of Zero Tolerance. The signed
acknowledgment form will be maintained in the Case Management file.
The intake staff reviewed the intake system and explained the education program
for new intake residents. According to the intake staff, review the first video that
explains PREA. They then get a copy of the trifold, and the staff goes over the
trifold. Then they meet with the resident and medical and mental health. After the
medical and mental health interview, the residents return to the intake area, which
is very close to the medical and mental health area. The residents and intake staff
review the VSAB, and then the resident views a more comprehensive video.
According to the intake staff, all center staff have been trained to conduct the initial
orientation upon the resident's arrival at the facility. The intake staff indicated that
the video is in Spanish and that they have a quick reference for contacting an
interpreter within five minutes. When the resident is seen by medical or mental
health staff, they will let us know if the resident needs initial training by having the
information read to them if the resident is cognitively disabled or a non-reader.
All residents interviewed indicated that they viewed several videos upon arrival at
the facility. The video included how to report, the zero tolerance, and that it was
against the rules to participate in any form of sexual activity. Nine of the residents
remember being given the trifold and the ACT pamphlet.
During the last 12 months, 42 residents have received the initial orientation.
115.333 (b):
The PAQ requires that, 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.
The facility provided a PREA juvenile-comprehensive video with English captions and
a Spanish-language version with Spanish captions, along with information on
emotional support and an acknowledgement form stating that the resident saw the
video, received the orientation trifold, and understood the PREA training.
The comprehensive video includes all aspects of the PREA 115.333 standard.
According to an interview with the intake staff, the resident watches the video after
the staff has reviewed the VSAB with the resident. The resident can watch on a
television located in the intake area or on a computer screen.
ROP PREA Standard 115.333- Student education requires that, within 10 days of
intake during the Orientation Program, the program shall provide comprehensive
age-appropriate education to students regarding their rights to be free from sexual
abuse and sexual harassment and to be free from retaliation for reporting such
incidents, and regarding program policies and procedures for responding to such
incidents.
Residents receive information explaining the agency’s zero-tolerance policy in an
age-appropriate fashion, including how to report incidents or suspicions of sexual
abuse or sexual harassment in the following manner. The comprehensive education
is accessible to all residents, including those who are limited-English proficient,
deaf, visually impaired, or otherwise disabled, as well as those with limited reading
skills. The facility can provide PREA education in formats accessible to all residents,
including those who may be limited-English proficient, deaf, visually impaired, or
otherwise disabled, as well as those with limited reading skills. According to
documentation and interviews with the Facility administrator and the Assistant
Facility Administrator, the local school system will assist in providing services for
disabled and limited-English-proficient residents. If the youth reports a deficiency or
the staff are aware of one in any of these areas, they report the need for an
additional resource to the supervisor. The supervisor notifies the facility
administrator, who will contact the appropriate community resource services,
including the local board of education. Arrangements will be made for an interpreter
who can interpret effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary. In all circumstances, this
center will not rely on resident interpreters. Special-needs youth receive age- and
maturity-based training per FOP Special Needs. Compliance was confirmed by
review of the resident acknowledgement statement and by interviews with the
resident during the facility tour and in a formal interview with 12 residents.
115.333 (c):
The PAQ requires that current residents who have not received such education 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.
The facility provided FDJJ Policy 1919 - Youth Training and education, which requires
that residents receive such education upon arrival or transfer to the facility, and
shall receive education upon transfer to a different FDJJ center to the extent that the
policies and procedures of the resident’s new facility differ from those of the
previous center.
ROP PREA Standard 115.333- Student education establishes that students shall
receive education upon transfer to a different program to the extent that the
policies and procedures of the student’s new program differ from those of the
previous program.
Upon arrival at the center, all residents receive an initial orientation and a
comprehensive education, which includes two videos and two tri-fold brochures.
In interviews with residents, each confirmed they must watch the videos and
receive the brochures every time they come to the facility.
115.333 (d):
The PAQ requires the agency to 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 those with limited reading skills.
The facility provided policy 1919 and language line contracts.
Policy 1919 mandates that the facility 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 residents with limited reading
skills.
The facility can provide PREA education in formats accessible to all residents,
including those who may be hearing impaired, Deaf, have intellectual, psychiatric,
and speech disabilities, have low vision, be blind, have limited reading, be limited
English proficient, and, based on the resident's individual needs.
ROP PREA Standard 115.333- Student education establishes that the program shall
provide student education in formats accessible to all students, including those who
are limited English proficient, deaf, visually impaired, or otherwise disabled, as well
as to students who have limited reading skills.
Documentation was reviewed for a contracting service with Language Lines. Posted
PREA information is available in English and Spanish and is accessible to residents,
staff, contractors, volunteers, and visitors.
The PREA videos are available in English and Spanish, with captions in the
appropriate language for each.
Staff interviews confirmed that residents are not used as translators or readers for
other residents. The facility staff indicated that the facility director, education
supervisor, and medical staff would work with the community resources to provide
education to residents regardless of their limitations or disabilities.
The education department assists in providing information, one-on-one, in large
print, visual aids, magnifiers, translation, and other services through the resident's
individual Education Plan.
One youth has limited reading abilities, as indicated in his IEP, which states that
staff showed him a video and that his therapist went over the brochure with him
on the day he arrived at the center. He indicated that he had received the same
information at the Regional Juvenile Detention Center.
115.333 (e):
The PAQ requires the agency to maintain documentation of resident participation in
these education sessions.
The facility provided policy 1919, acknowledgement forms, and ROP PREA Standard
115.333- Student education.
Policy 1919 mandates that the facility shall maintain documentation of resident
participation in these education sessions.
ROP PREA Standard 115.333- Student education mandates that the program shall
maintain documentation of student participation in these education sessions in the
student's file.
A sample of signed acknowledgement statements was reviewed, which supported
the residents’ involvement in PREA education sessions.
A file review of 12 residents included an acknowledgement statement for orientation
and comprehensive education.
115.333 (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 facility provides 10 posters and policy 1919, which indicates that, in addition to
providing formal 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.
ROP PREA Standard 115.333- Student education mandates, in addition to providing
such education, the program shall ensure that key information is continuously and
readily available or visible to students through posters, student handbooks, or other
written formats.
The PREA education materials provide residents with information on how to report
allegations of sexual harassment and sexual abuse. A safety guide is provided to
each resident to eliminate incidents of sexual abuse and sexual harassment. The
guide provides educational information regarding sexual abuse and victims in a
cartoon format. The residents revealed they can report allegations of sexual abuse
or sexual harassment by telling a staff member or a family member. PREA
educational documentation was observed throughout the facility, including the
lobby, visitation areas, and living units.
The Florida Department of Juvenile Justice has 10 posters located throughout the
facility.
All residents interviewed, both formally and informally, during the tour and
subsequent visits to the recreation area, confirmed that staff talk to them daily
about PREA. They indicated that the staff who conduct PREA rounds will ask them
questions about PREA.
Based on this analysis, the facility is substantially compliant with this provision, and
no corrective action is required.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
Prison Rape Elimination Act - OIG investigator training
PREA Management Policy 1919 Investigations
115.334 (a):
The PAQ requires, in addition to the general training provided to all employees
pursuant to § 115.331, that the agency ensure that, to the extent the agency
conducts sexual abuse investigations, its investigators have received training in
conducting such investigations in confinement settings.
In an interview with the facility administrator, he indicated that WAGC does not
conduct any form of administrative or criminal sexual abuse investigation. Under
contractual obligations, WAGC must notify the Central Communication Center of all
allegations of sexual abuse or sexual harassment, and OIG or the local sheriff’s
office will conduct all investigations.
All OIG investigators undergo extensive training before conducting administrative
investigations, which includes the “Basic Investigation Training” requirement.
115.334 (b):
The PAQ requires Specialized training that 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.
The facility provided policy 1919, which entails that, 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.
While WAGC does not conduct any investigation, the chief of the Office of General
Inspectors indicated that the OIG staff receive specialized training that 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 required to substantiate a case for administrative action or prosecution
referral.
115.334 (c):
The PAQ requires the agency to maintain documentation that agency investigators
have completed the required specialized training in conducting sexual abuse
investigations.
The Florida Department of Juvenile Justice provided certifications from all staff who
have received the specialized training. There are 12 trained OIG inspectors at the
time of the onsite audit. 12 staff members have received training to conduct
administrative reviews.
The chief of investigation indicated that all OIG staff received the specialized
training required by this standard and additional training through the Office of
Inspector General.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required
115.335 Specialized training: Medical and mental health care
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
Evidence relied upon in making the compliance determinations
FDJJ Policy 1919 -
Specialized Training Medical-MH Medical training
Mental health training
PREA-Mental Health and Medical Professionals Skill PRO Module 1
PREA-Mental Health and Medical Professionals Skill PRO Module 3
PREA-Mental Health and Medical Professionals Skill PRO Module 4
PREA-Mental Health and Medical Professionals Skill Pro Medical/Mental Health
Modules
115.335 (a):
PAQ requires The agency shall ensure that all full- and part-time medical and mental
health care practitioners who work regularly in its facilities have been trained in:(1)
How to detect and assess signs of sexual abuse and sexual harassment;(2) How to
preserve physical evidence of sexual abuse;(3) How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual harassment; and(4)
How and to whom to report allegations or suspicions of sexual abuse and sexual
harassment.
The facility provided the FDJJ Policy 1919 PREA - Specialized Training. Medical-MH
Medical and mental health staff receive regular PREA training, and specialized
training is provided as part of the FDJJ Sill Pro training modules. In addition to the
Zero Tolerance policy, all full- and part-time medical and mental health care
practitioners will be trained in the following: 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. 4. How and to whom to report allegations or
suspicions of sexual abuse and sexual harassment. 5. Medical and mental health
practitioners are required by mandatory reporting laws to report sexual abuse. 6.
Medical and mental health practitioners shall inform residents at the initiation of
services of their duty to report and the limitations of confidentiality regarding sexual
abuse. The medical and mental health staff are contractors and also receive
contractor training.
115.335 (b):
The PAQ requires If medical staff employed by the agency conduct forensic
examinations, such medical staff shall receive the appropriate training to conduct
such examinations.
The facility provided that the facility's medical staff or mental health staff does not
conduct forensic medical examinations.
Medical and mental health staff who were interviewed indicated they do not conduct
forensic examinations. All of the medical staff who were interviewed indicated they
had received training from the Florida Department of Juvenile Justice Skill Pro and
additional training from their contracting provider.
115.335 (c):
The PAQ requires the agency to maintain documentation that medical and mental
health practitioners have received the training referenced in this standard either
from the agency or elsewhere.
The facility provided acknowledgement forms for medical and mental health staff.
The facility acknowledges training, indicating that 5 medical and mental health staff
have attended medical specialized training. Based on PAQ, 100% of the medical and
mental health professionals employed at the center have received specialized
training.
115.335 (d):
The PAQ requires That Medical and mental health care practitioners also receive the
training mandated for employees under § 115.331 or for contractors and volunteers
under § 115.332, depending on the practitioner's status at the agency.
The facility provided staff training and a spreadsheet for specialized (Skill Pro 3) use
across all medical and mental health files.
Policy 1919 requires mental health and medical staff to complete the general and
refresher training provided to all staff members. Since this is a diverse population of
residents, the clinical staff provides additional training on de-escalation, suicide
prevention, recognizing the needs of transgender residents, and sexual orientation,
gender identity, and expression.
A review of the training curriculum, acknowledgement documentation, and an
interview with medical and mental health staff confirmed that the staff have
received specialized and general training as required by standards and have
additional training that exceeds those standards.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.341 Obtaining information from residents
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
Evidence relied upon in making the compliance determination.
Screening procedures Vulnerability for Victimization and Sexual Aggressive Behavior
(VSAB)
FDJJ Policy 1919 –
Screening (VSAB) Sample
Suicide Risk Screening Instrument
115.341 (a)(b)
The PAQ requires that, 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.
Such assessments shall be conducted using an objective screening instrument.
The facility provided Policy 1919 Screening (VSAB) and ROP policy 2.04 Assessment
and Performance.
FDJJ Policy 1919 PREA - Screening mandates that all residents will be interviewed
using an objective screening instrument for risk of victimization, potential
vulnerabilities or sexual abusiveness tendencies to act out with sexually. Such
assessments shall be conducted using an objective screening instrument.
The initial screening occurs within four hours upon arrival at the facility to
determine placement and their special needs. The medical and mental health
screenings, conversations, classification assessments, as well as reviewed court
records and case files. The Florida Department of Juvenile Justice has developed a
seamless system to provide youth in the State of Florida with the best possible
programs to help them succeed. Before being placed in the facility, FDJJ will forward
to the center a completed VSAB from the Juvenile Assessment Center.
The center will complete another VSAB during the intake process at WAGC.
Additionally, the center conducts a MAYSI-2, RAY, and suicide screening.
FDJJ Policy 1919 - Screening (VSAB) mandates that staff conduct screening. All
residents who make an allegation of sexual abuse or are named in the sexual abuse
allegation will be rescreened. Medical, mental health, and supervisory staff may
conduct an additional rescreening based on reasonable concerns regarding resident
safety.
At WAGC, before arrival, the center will review all documentation and determine
which program the resident is being sent to participate in. The clinical director will
review the community referral, VSAB, and court documents, then assign a therapist
to the resident. The therapist will meet with the resident and complete a host of
evaluations, including the VSAB. The facility uses the information gathered to make
room and develop a treatment plan, including a safety plan, to keep youth safe and
free from sexual abuse. The program is prohibited from isolating youth. The staff
members conducting the intake process will complete the screening using the PREA
screening tool and immediately report any heightened risks to the on-duty
supervisor before making housing decisions. Residents will be reassessed as
needed. A review of the resident files found that most residents have been
rescreened multiple times. Residents who were involved in an allegation of sexual
abuse or sexual harassment were rescreened during the investigative process.
115.341 (c):
The PAQ requires 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
resident's 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. During the
screening, the therapist will contact the resident’s legal guardian and discuss the
resident's history, known sexual orientation, and any concerns about his safety.
The facility provided copies of the Risk of Victimization and Sexually Aggressive
Behavior(VSAB) The screening include mental, physical, or developmental
disabilities, age, physical build, prior incarcerations, criminal history (violent and
non-violent), prior convictions for sex offenses against an adult or child, prior acts of
sexual abuse, prior convictions for violent offenses, history of prior institutional
violence or sexual abuse, prior sexual victimization, perception of vulnerability, and
if the resident is or is perceived to be (LGBTQI) or gender nonconforming.
115.341 (d):
The PAQ requires that this information 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 facility provided the FDJJ Policy1919, which mandates that all residents will be
interviewed using an objective screening instrument for risk of victimization,
potential vulnerabilities, or sexual abusiveness tendencies to act out with sexually
aggressive, predatory behavior within seventy-two (72) hours.
The screening staff interviewed indicated reviewing the residents’ court records,
suicide screening reports, family information, and any other documents that are
provided to them at the time of intake. The screening staff uses the screening
instrument during the initial intake process, which includes a conversation with the
resident in a private setting.
The screening staff indicated they introduced the screening instrument to the
residents by explaining the purpose of the questions and acknowledging that they
had the same questions, but that it was important to ensure they were safe and got
the most out of their stay at the center. After the initial screening or before it, the
medical staff interviews the residents and conducts medical screening. The nurse
indicated she talks about sexually transmitted diseases and residents’ perception of
vulnerability.
The clinical staff then interviews the resident, reviews the resident’s file, the VSAB,
and suicide screening, and has a general conversation with the resident to
determine the clinician’s opinion on the best placement for the resident.
All residents interviewed indicated they received the screening at a Juvenile
assessment center, and WAGC staff then went over the screening with them when
they arrived. The interviews were in a private office.
115.341 (e)
The PAQ requires the agency to implement appropriate controls on the
dissemination of responses to questions asked according to this standard within the
facility to ensure that sensitive information is not exploited to the resident's
detriment by staff or other residents.
In interviews with the intake staff, the PREA compliance manager, and the State
PREA coordinator, it was indicated that the VSAB is located in the resident's
computerized file, which is password-protected and available only on a need-to-
know basis. The resident files also contain copies of the VSAB. These files are
maintained in the file room, which is locked and available to the case managers,
clinical staff, medical staff, the PREA compliance manager, and the facility
administrator.
The PREA coordinator interviewed indicated that the agency’s PREA policy (FDJJ
1919) specifically states that youth responses to risk-screening questions shall be
on a need-to-know basis to ensure that sensitive information is not exploited to the
youth’s detriment by staff or other youth.
The therapist who conducted the screening indicated that all information from the
screening instrument is entered into the DJJ portal, which is password-protected and
accessible only to clinical and administrative staff, such as the facility director.
The therapist and clinical director indicated that either a therapist or a case
manager conducts the screening. If a youth were to arrive when they are not on
duty, they are placed in a single room until they arrive; however, the center is
notified when a youth is arriving at the center, and has a staff on call if it is past
normal working hours to complete the assessment and related assessments, such
as suicide screening, and Maysi 2. The screening is conducted in a private office.
Staff who conduct the screening are required to take the DJJ screener training, and,
like all of the assessments we utilize at the center, it is conducted in a manner that
fosters comfort and elicits responses.
Youth who were interviewed, either formally or informally, during the center tour
indicated that their therapist or case manager conducts the screening in a private
office. They indicated that they did not feel uncomfortable discussing their sexual
orientation or past victimization.
The PREA compliance manager indicated that the screening instrument, along with
additional evaluation, is used for resident placement and that all information
obtained from the screening instrument or maintained in the mental health files is
shared only with those who need to know. The only non-clinical staff who have
access to the VSAB are the Case Manager, the supervisor, and the facility director.
During the tour of the facility, the auditor noted that all computers were locked, the
file room door was secure, and there were no files or confidential information on
anyone’s desk.
Based on the review of the agency's policy and procedures, observations, and
information obtained through staff and resident interviews, and review of resident
files, the facility has demonstrated compliance with this standard.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.342 Placement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 - Placement of Youth
Mental Health Substance Abuse (MHSA) Intake and Screening
Statement of Fact
Mental Health and Substance Abuse Assessment and Evaluation
ROP policy 2.04 Assessment and Performance
ROP PREA policy 115.342- Placement of students in housing, bed, program,
education
115.342 (a):
The PAQ requires the agency shall use all information obtained pursuant to §
115.341 and subsequently to make housing, bed, program, education, and work
assignments for residents with the goal of keeping all residents safe and free from
sexual abuse.
The facility provided the policy, FDJJ Policy 1919 - Placement of Youth, which
establishes protocol for housing residents in a safe environment, taking into
consideration their VSAB, programming plan, and sexual orientation. The center did
not have any transgender or intersex residents at the time of the on-site audit.
The facility also provided policy 342. and Mental Health and Substance Abuse
Assessment and Evaluation.
ROP Mental Health and Substance Abuse Assessment and Evaluation provides that
at Walton Academy for Growth and Change, the mental health and substance abuse
treatment needs of a youth shall be identified through a comprehensive screening
process that ensures referrals are made when youth are identified with mental
health and/or substance abuse needs or are identified as a possible suicide risk. It is
the policy of this program to administer mental health and substance abuse
screening, including suicide risk screening, upon a youth’s admission to the
program. When indicated, referrals are made for further evaluation, assessment,
and clinical services. The initial intake and screening process ensures equitable
treatment, prioritizes urgent needs and emergencies, facilitates the identification of
youth with co-occurring conditions, supports access to an integrated assessment
process, and results in the timely initiation of services.
Policy 342 requires that Rite of Passage programs shall use all information obtained
pursuant to § 115.341 and subsequently to make housing, bed, program, education,
and work assignments for students with the goal of keeping all students safe and
free from sexual abuse.
Procedures state that screening information shall be used to determine housing,
bed, work, education, and programming assignments within the Facility to keep
potential victims away from potential abusers. The computerized management
system will assign codes to identified predators, potential predators, high-
aggression risk, moderate-aggression risk, identified prey, potential prey, high-
victimization risk, and moderate-victimization risk.
According to interviews with the PCM and the staff who conduct screening, the
mental health, medical, and PREA compliance manager (facility administrator)
reviews the screening instrument and MAYSI 2 and discusses the placement of
residents while the resident is watching the PREA video.
Prior to the youth arriving at the facility, the treatment team meets and reviews the
request to house the youth at WAGC, which includes the VSAB from the Juvenile
Assessment Center, the community review of the youth's mental health or
substance abuse treatment needs, and any present or previous court
documentation. From this information, the clinical team determines the youth’s
therapist and tentative housing plan. Upon completion of the intake screenings,
including the VSAB, the clinical director determines the appropriate housing and
program assignment.
115.342 (b)(h)(i)
The PAQ requires 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 all residents safe can be
arranged. During any period of isolation, agencies shall not deny residents access to
daily large-muscle exercise and 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.
The PAQ requires that 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.
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 facility provided the policy, FDJJ Policy 1919: Placement of Youth. Individualized
determinations are made about how to ensure the safety of each resident.
Residents who score at risk of victimization or abusiveness are referred for further
evaluation with the Mental Health provider. Residents have the option of refusing
these services. The center has not segregated or removed residents from the
program for a PREA incident in the last 12 months.
The facility provided policy 115.342- Placement of students in housing, bed,
program, education, which states students may be isolated from others only as a
last resort when less restrictive measures are inadequate to keep them and other
students safe, and then only until an alternative means of keeping all students safe
can be arranged. During any period of isolation, programs shall not deny students
daily large-muscle exercise and any legally required educational programming or
special education services. Students in isolation shall receive daily visits from a
medical or mental health care clinician. Students shall also have access to other
programs and work opportunities to the extent possible.
In an interview with the facility administrator and clinical director, the center does
not utilize isolation unless the youth is on an active suicide alert that would rise to
the level of one-on-one constant supervision. The Facility administrator indicated
that the center does have single rooms for the placement of residents to keep them
safe; however, they do not isolate residents. The facility is in proximity to another
RYDC. If the facility staff feel they cannot protect the residents, the resident would
be moved to the other RYDC rather than placed in an isolated area. He further
stated that in his years at the facility, he has never isolated or moved a resident for
fear of being a victim of sexual abuse.
When pressed, the center administrator indicated that it would exceed the review of
placement in a segregated area, as the center would reassess the youth every two
hours for the duration to determine alternative housing or moving the youth or the
abusing youth to keep the youth safe. He indicated that the Rite of Passage state
supervisor would be contacted and most likely would require the center to move as
many residents as needed to keep a youth safe from sexual victimization. He
indicated that the Rite of Passage does not allow centers to isolate residents.
The agency PREA coordinator and facility administrator interviewed indicated that
the center would comply with the standard's requirements if a detainee were placed
in isolation. However, before placement, the center would complete an assessment,
suicide screening, and notify the ROP executive director, the Florida PREA
Coordinator, the youth probation officers, and the parent.
The PREA coordinator indicated in the interview that FDJJ does not have special
housing units for LGBTI youth.
If the center has to utilize isolation as a last resort, then policy 1919 requires that if
a student is isolated pursuant to paragraph (b) of this section, the program shall
clearly document:
(1) The basis for the program’s concern for the student’s safety; and
(2) The reason why no alternative means of separation can be arranged.
During the tour of the facility, no isolated rooms were located in the center. All staff
asked about isolation indicated that they are not allowed to utilize isolation. During
the tour, the auditor asked random staff to show him the isolation area. All 5 staff
members I asked indicated they had no such room at the center.
Compliance with this standard was determined by reviewing the screening
instrument, interviewing the medical and mental health directors, and the facility
administrator.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.351 Resident reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
CCC Florida Administrative Code 63F
FDJJ Policy 1919 PREA –
Youth reporting General Counsel - PREA immigration status.
Youth/Parent Handbook
PREA Brochures
Memo from DJJ General Counsel – Civil Immigration.
Mail and phone procedures. (site review)
Youth reporting Posters
2020 Florida Statutes Title V Chapter 39 Proceedings related to Children.
Interviews
Random and Targeted Residents
PREA compliance manager
Random Staff
115.351 (a)
The PAQ requires 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. The facility
provided policy 1919, youth reporting posters, and PREA brochures.
Policy 1919 indicates resident reporting states:
1. Florida Administrative Code Rule 63F-11, Central Communications
Center (CCC), requires that any allegation of sexual misconduct or youth-on-youth
sexual activity be reported to the CCC. The person making the report shall provide
basic information, including the date and time of the incident, where the incident
occurred, the supervising staff, and who may be involved. The CCC will make
appropriate notification to senior DJJ management, who will, in turn, notify
management overseeing the facility where the alleged abuse occurred. Other than
making appropriate notifications through Department channels, staff should take no
further action other than that directed by law enforcement or first responders.
2. There is no time limit on when a youth may report an allegation of
sexual misconduct. Youth shall be provided multiple internal ways to privately report
sexual misconduct, retaliation by other youth or staff for reporting sexual
misconduct, and staff neglect or violation of responsibilities that may have
contributed to such incidents.
3. Facilities must ensure all youth with disabilities (including, for
example, youth who are deaf or hard of hearing, those who are blind or have low
vision, or those who have intellectual, developmental, psychiatric, or speech
disabilities), have an equal opportunity to participate in or benefit from all aspects
of the Department's efforts to prevent, detect, and respond to sexual misconduct.
The facility must also ensure meaningful access to its efforts to prevent, detect, and
respond to sexual misconduct to youth who are limited English proficient, including
steps to provide interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any necessary specialized
vocabulary. The facility may not use youth as interpreters, readers, or other
assistants to perform such functions except in limited circumstances in which an
extended delay in obtaining an effective interpreter/reader/assistant could
compromise the youth's safety, the performance of first responder duties, or the
investigation of the youth's allegations.
The above policies and external reporting mechanisms identify the multiple
internal ways for residents to report sexual abuse and harassment incidents,
retaliation, staff neglect, or violation of responsibilities that may have contributed to
such incidents. Included are reporting to the Department of Children and Family
hotline, or to the Central Communication Center Hotline. Both hotlines may be
confidential. Reports to these entities will be received and forwarded to the Office of
Inspector General or the local Child and Family program. Policies also identified the
resident’s accessibility to filing a grievance to make a report, communication
(telephone, visitation, and correspondence) with their attorney and/ or parent/
guardian, staff providing access to the hotline without asking the resident the
purpose of the call, the staff requirement of mandatory reporting, and completing
an incident report. The department has provided a method for staff to report sexual
abuse and sexual harassment of residents privately. Florida Law explicitly mandates
reporting of sexual abuse and sexual harassment. It also established a State Child
Abuse Hotline, which is under the supervision of the Department of Children and
Family.
Services. The reporting of child abuse, abandonment, or neglect is codified in 2020
Florida Statutes Title V Chapter 39-“39.201” Mandatory reports of child abuse,
abandonment, or neglect; mandatory reports of death; central abuse hotline.—
(1)(a) Any person who knows, or has reasonable cause to suspect, that a child is
abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other
persons responsible for the child’s welfare, as defined in this chapter, or that a child
requires supervision and care and has no parent, legal custodian, or responsible
adult relative immediately known and available to provide supervision and care
shall report such knowledge or suspicion to the department in the manner
prescribed in subsection (2). (b) Any person who knows, or who has reasonable
cause to suspect, that a child is abused by an adult other than a parent, legal
custodian, caregiver, or other person responsible for the child’s welfare, as defined
in this chapter, shall report such knowledge or suspicion to the department in the
manner prescribed in subsection
(2). (c) Any person who knows, or has reasonable cause to suspect, that a child is
the victim of childhood sexual abuse or the victim of a known or suspected juvenile
sexual offender, as defined in this chapter, shall report such knowledge or suspicion
to the department in the manner prescribed in subsection (2). (d) Reporters in the
following occupation categories are required to provide their names to the hotline
staff: 1. Physician, osteopathic physician, medical examiner, chiropractic physician,
nurse, or hospital personnel engaged in the admission, examination, care, or
treatment of persons; 2. Health or mental health professional other than one listed
in subparagraph 1.; 3. Practitioner who relies solely on spiritual means for healing;
4. School teacher or other school official or personnel; 5. Social worker, day care
center worker, or other professional childcare, foster care, residential, or
institutional worker; 6. Law enforcement officer; or 7. Judge.”
Residents are advised during orientation and on posters throughout the facility to
talk to, call, or send a letter or note to any of the following: A staff member you
trust. Program Administrator, Your attorney or advocate, Your parents or guardians,
Child Abuse Hotline, Central Communication Center Hotline. Residents have the
right to privately report sexual assault, abuse, harassment, or 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
to the Direct Care Staff,
Volunteer, Intern, Supervisor, PREA Compliance Manager, and Facility Administrator
Resident can request facility staff call CCC, Sexual abuse registry (DCF), victim
advocate center to make an allegation of sexual abuse or sexual harassment. The
center has multiple cell phones in the control room that residents can use to report
to the Child Abuse Hotline or Central Communication Center.
The facility provided a PREA brochure that provides the many ways that residents
can make a report of an allegation of sexual abuse or sexual harassment. The
brochure is provided to each resident and is located in each housing unit, the
educational wing, the multipurpose room, the visitation area, and at the front
entrance to the facility. It was visible during the onsite audit. The brochure indicated
that youth can:
Youth can call the Florida Abuse Hotline, notify staff, or complete a PREA Reporting
Form. Youth will have immediate access to call the abuse hotlines by asking the
staff. As long as the safety and security of the youth, the facility, and the staff are
not jeopardized, the youth will have unlimited access to use the telephone to call
the Florida Child Abuse Hotline or Central Communication Center. The staff cannot
refuse youth access to the Florida Child Abuse Hotline. You can report a PREA
Incident at any time. There are five PREA boxes located throughout the building:
Dining Hall, all of the housing units, and the Multipurpose room. Each box is non-
descriptive and located in a generalized area away from the control rooms or staff
stations. There are 4-compartment holders near the box with grievance forms,
medical requests, staff requests, and PREA reporting forms.
These programs were called using the telephone available to residents. In each
case, the auditor was able to make a report to the program. CCC indicated they
would respond to the report by text to the facility administrator. The Child Abuse
Hotline indicated they would report to the Department of Children and Family
Services and local law enforcement. Both indicated that a resident could make a
report anonymously and did not have to use their name.
The ROP PREA coordinator indicated in the interview that, by contract, ROP utilizes
the Florida Department of Juvenile Justice reporting system.
Twelve residents were interviewed. Each of the residents was able to articulate at
least two ways to report an allegation of sexual abuse or sexual harassment. Ten of
the residents knew that calling the Central Communication Center or the Child
Abuse Hotline would be confidential and private. All of the residents had seen the
PREA posters that had multiple ways to make a report.
The PREA brochure that is provided to all residents when they arrive at the center
indicates ways to make a report; They include
DCF sexual abuse hotline 1-800-962-2873
• DJJ Incident hotline 1-800-355-2280
• Report to any staff, volunteer, or contractor.
• Report to medical or mental health staff.
• Submit a PREA reporting form.
• Report to the PREA Compliance Manager
115.351 (b):
The PAQ requires 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 can 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 with information on how to contact relevant consular officials and
Department of Homeland Security officials.
Policy 1919 requires the facility 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 can receive and immediately forward resident reports of sexual
abuse and sexual harassment to agency officials, allowing the resident to remain
anonymous upon request. Residents may call the Child sexual abuse hotline or the
Central Control Center. Residents may request to use a telephone with some degree
of privacy to call the hotline without obtaining staff permission, and staff must not
question residents about the reason for the call. The facility also has posters for the
national child abuse hotline located throughout the center.
A resident can request writing materials to write and send a letter to one of these
resources. Random residents interviewed were aware of the abuse hotline and could
articulate how they could access the telephone. Residents indicated they use the
same phones to call their parents, legal guardians, and attorneys.
115.351 (c):
The PAQ requires staff to accept reports made verbally, in writing, anonymously,
and from third parties and shall promptly document any verbal reports.
Policy 1919 requires that any staff, contractor(s), or volunteer(s) who receive a
report of sexual misconduct or possible sexual misconduct must ensure that it is
reported to the Department of Children and Families, Florida Abuse Hotline, local
law enforcement if criminal in nature, and the CCC. Reports can be received
verbally, in writing, anonymously, and from third parties. All verbal reports shall be
documented promptly and reported accordingly. Apart from reporting directly to a
supervisor or official and designated state or local service agencies, staff are
prohibited from revealing any information related to a sexual misconduct report to
anyone other than to the extent necessary to make treatment, investigation, and
other security and management decisions. While victims and complainants may
report anonymously, staff who receive and follow up on allegations shall not be
afforded anonymous status. Staff can make an anonymous report to make an
allegation or suspicion of sexual abuse or sexual harassment.
All staff, contractors, and volunteers are required to immediately report any
knowledge, suspicion, or information received regarding 1) any incident of sexual
misconduct that has occurred in a facility; 2) retaliation against youth or staff who
report sexual misconduct; and 3) any staff neglect or violation of responsibilities
that may have contributed to an incident of sexual misconduct or retaliation to the
Florida Abuse Hotline, local law enforcement if criminal in nature, and the CCC as
required by mandatory reporting laws and Department policy.
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 document verbal reports. All staff and residents
interviewed reported familiarity with the standard's provisions.
All of the residents’ interviews demonstrated their familiarity with the various ways
they may report, including in person, in writing, by phone, by completing a PREA/
grievance or Medical Request Form, or through a third party. Fifteen of the sixteen
residents interviewed were aware that third-party reports could be made, and that
reports could be made anonymously.
The interviewed staff members were aware of their duty to receive and document
third-party reports. Staff indicated they would accept a verbal report, complete an
incident report, notify the shift supervisor, and call CCC or the Child Abuse hotline
as soon as possible, within two hours.
115.351 (d):
The PAQ requires that the facility provide residents with access to the tools
necessary to make a written report.
The facility provides residents with the tools necessary to prepare a written report.
Writing materials are readily available for residents to complete the accessible
forms. Before the site visit, pictures were sent to the auditor showing the reporting
forms, such as PREA/Grievance forms and Medical Request Forms, and the
accessibility of writing utensils. During the site visit and during the site review, the
auditor observed the accessibility of writing utensils for residents. When requested,
a staff member provided the auditor with a pencil, paper, and an envelope to send a
letter. The staff member indicated that several of the residents routinely send
letters. Mail is placed in the drop box, and the PCM, assistant director, or clinical
director checks it twice a day.
The PCM indicated that the center has no contact list for residents who are not
allowed to contact certain people through court order. If the resident is sending a
letter to anyone else, the staff member seals the letter, applies a stamp to the
envelope, and mails it. Letters addressed to attorneys, victim advocacy programs,
PREA coordinators, or any Florida DJJ staff are considered legal. They are sealed
when provided to staff for stamping and placement in the outgoing mail.
The auditor took a grievance form and a pencil from the folders located above the
drop box and wrote a mock grievance. The grievance and the next day's pass
reporting were provided to the auditor the following morning.
115.351 (e):
The PAQ requires the agency shall provide a method for staff to report sexual abuse
and sexual harassment of residents privately.
Policy and employee handbook provide ways staff may make anonymous reports
of sexual abuse and sexual harassment of residents to their local law enforcement,
state reporting agency (CCC), Department of Family and Children Hotline, PREA
Coordinator, facility administrator, or the PREA compliance manager. Reporting
posters were located in the staff break area.
All staff interviewed knew how to make a private report.
Compliance was determined by reviewing posters, policies, and interviews with staff
and residents, as well as calls to the CCC, the child abuse registry hotline, and
the PREA Coordinator.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.352 Exhaustion of administrative remedies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 Youth Grievance
Youth Grievances Forms
Florida Administrative Code Rule 63f-11
Central Communications Center (CCC
FDJJ Policy 1919 Youth Grievance
Youth Grievances Forms
Florida Administrative Code Rule 63f-11
Central Communications Center (CCC)
1.08 - Grievance Process-WAGC.docx
Third Party Reporting Form 1.27.16.pdf
Student Grievance Form.pdf
15.252 (a):
The PAQ requires that an agency shall be exempt from this standard if it does not
have administrative procedures to address resident grievances regarding sexual
abuse.
FDJJ provided Florida Administrative Code Rule 63f-11 and the Central Control
Center
Florida Administrative Code Rule 63f-11 Central Communications Center (CCC)
requires that any allegation of sexual misconduct or youth-on-youth sexual activity
be reported to the CCC. The person making the report shall provide basic
information such as the date and time of the incident, where the incident occurred,
the supervising staff, and who may be involved. The CCC will make appropriate
notification to senior DJJ management, who will, in turn, notify management
overseeing the facility where the alleged abuse occurred. Other than making
appropriate notifications through Department channels, staff should take no further
action other than that directed by law enforcement or first responders. There is no
time limit on when a youth may report an allegation of sexual misconduct. Youth
shall be provided multiple internal ways to privately report sexual misconduct,
retaliation by other youth or staff for reporting sexual misconduct, and staff neglect
or violation of responsibilities that may have contributed to such incidents.
The resident may file a grievance regarding sexual abuse or sexual harassment.
However, the director will forward the grievance to the CCC within 2 hours of
receiving the grievance. The facility will not undertake investigations of the
grievance, however if it is an emergency grievance and the resident claims or
appears to be imminent danger or if the grievance claims staff member sexual
abuse, the facility director will take immediate steps to protect the resident, to
preserve the crime scene and to remove the staff from the areas where the resident
is housed or placed staff member on administrative leave pending investigation.
Instructions on filing grievances are provided to residents in the PREA Education
Manual for Residents and on PREA posters. While the agency utilizes the grievance
system only for residents to make allegations of sexual abuse or sexual harassment,
the grievance system does meet the standards for reporting non PREA related
allegations. There has been one allegation of sexual harassment that was filed by a
resident utilizing the Grievance system.
115.252 (b): There is no time limit for a resident to submit a grievance regarding
sexual abuse. WAGC does not impose a time limit on any portion of a grievance that
does not allege an incident of sexual abuse. Residents are not required to use any
informal grievance process or attempt to resolve with staff an alleged incident of
sexual abuse.
15.252 (c): Based on facility policies, residents have a right to submit grievances
alleging sexual abuse to someone other than the staff member who is the subject of
the complaint, and the grievance will not be referred to the subject of the complaint.
Residents may submit grievances to the Facility Director or PREA Coordinator. If a
third party files a grievance on a resident’s behalf, the alleged victim must agree to
have the grievance filed on his behalf.
115.252 (d): A final decision shall be issued on the merits of any portion of the
grievance alleging sexual abuse within 90 days of the initial filing of the grievance.
The 90-day time period shall not include time spent by individuals in the facility
preparing any administrative appeal. Facilities may claim an extension of time to
respond (for good cause) of up to 70 days and shall notify the individual of the
extension in writing. At any level of the administrative process, including the final
level, if the individual does not receive a response within the time allotted for reply,
including any properly noticed extension, the individual may consider the absence
of the response to be a denial at the first level. If the agency is unable to conduct
the investigation and notify the resident within the time permitted by the policy, the
agency may notify the resident of the inability to respond, the purpose of the delay,
and a time when the investigation will be completed.
115.252 (e): Third parties such as fellow residents, family members, attorneys, or
outside advocates may assist residents in filing requests for administrative
remedies relating to allegations of sexual abuse and may file on behalf of residents.
The alleged victim must agree to have the request filed on their behalf; however,
they are not required to pursue any subsequent steps in the administrative remedy
process personally. If the resident declines to have the request processed on his or
her behalf, the agency shall document the resident’s decision. Based on an
interview with the PREA Compliance Manager and information provided in the Pre-
Audit Questionnaire, no third-party grievances were filed in the past 12 months.
115.252 (f): Residents may file an emergency grievance if they feel they are subject
to substantial risk of imminent sexual abuse. After receiving an emergency
grievance of this nature, the Facility Director designee will ensure that immediate
corrective action is taken to protect the alleged victim. The allegation will be
reported to the Central Communication Center within 2 hours of receiving the report
or being made aware of a resident who is at risk of sexual abuse.
115.252 (g): A resident can be disciplined for filing a grievance related to alleged
sexual abuse if it is determined that the inmate filed the grievance in bad faith.
There has been no disciplinary action due to filing a grievance in bad faith.
Staff and residents interviewed were aware of the grievance system, how to access
forms and pencils, and the location of the drop box.
The auditor completed a mock report and placed it in the grievance box. The report
was returned the following day, along with the center's daily report form.
Compliance was determined by reviewing the policies, interviewing PREA
compliance managers, and reviewing the presence of grievance procedures for
residents to submit grievances regarding sexual abuse. The agency has procedures
for dealing with these grievances. Instructions on filing grievances are provided to
residents in the residents’ handbook and on PREA posters.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination.
FLDJJ Policy 1919 Outside Support
Attempt to update the MOU with Emerald Coast/ Pierce County Victim Advocacy
Center
MOU with Emerald Coast Children's Advocacy Center
Undated interview with Emerald Coast Children's Advocacy Center
Interview with Emerald Coast Victim Advocacy Center
National Child Abuse Hotline Poster
Victim Advocate Posters
115.353 (a):
The PAQ requires 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, as confidentially as possible.
The facility provided the FDJJ policy 1919 Outside Support Services, an MOU with
Emerald Coast Child Advocacy Center, and a Poster for U.S. Citizenship and
Immigration Services.
DJJ Policy 1919 mandates 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, as confidentially as possible. WAGC ensures residents have access to
external confidential support services.
The center has reestablished an MOU with Emerald Coast Child Advocacy Center to
provide emotional support, counselling, follow-up support, and referral for treatment
after release or transfer to another facility. The staff indicated that, in addition to
providing victim advocacy, they would coordinate with the facility to provide a
telephone number allowing residents to speak with a trained counselor for
emotional support. The program's address is posted at the center, and youth can
write to the center. They would also arrange to visit the victim or have the victim
brought to them or another location, if allowed by the facility. The center provides
an address and will coordinate with the center to provide a phone number that
youth can call to speak with emotional support staff. The telephone call would be
made from a private office, and no one would listen to the call.
The program has a poster listing the services it provides located throughout the
center.
The Citizenship and Immigration poster is in English and Spanish and is located in
the living units, the multipurpose room, and the front entrance.
The WAGC does not house residents for civil immigration purposes. There are
posters throughout the facility regarding U.S. Citizenship and Immigration Services,
including the corresponding address and telephone number.
Twelve residents were interviewed regarding the Emerald Coast Child Advocacy
Center. Seven were well aware of the program, its services, how to contact the
program, that calls were free, and that you could call at any time.
Three were aware of the program; however, they were unsure of its purpose or how
to contact it.
Two of the residents were unaware of the program or how to contact it.
Based on five residents having little or no knowledge of the program, it was
recommended that the center provide updated training to all residents about the
Emerald Coast Child Advocacy Center. The staff at the center indicated that they
had provided information in person. It was recommended to the PREA compliance
manager that she reach out to the center to have them provide the information in
person and, if possible, record the presentation to share with residents during the
intake process.
In an interview with the Emerald Coast Children's Advocacy Center staff, the staff
indicated they had been to the center on several occasions in the past.
115.353 (b):
The PAQ requires the facility to inform residents, before 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 facility provided policy 1919 and an MOU with Emerald Coast Children's
Advocacy Center.
Policy 1919 requires the center to inform residents, before 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 policy addresses the confidentiality of the advocacy support
services. The resident receives information regarding the limitations of
confidentiality during the intake process. An acknowledgement statement specific to
the review of the reporting and advocacy services contains information regarding
the advocacy services to be provided by Emerald Coast Children's Advocacy Center.
When contacted by phone, the center’s staff explained that they always tell callers
that telephone calls are confidential.
115.353 (c):
The PAQ requires the agency to maintain or attempt to enter into memoranda of
understanding or other agreements with community service providers that can
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 agency shall maintain or attempt to enter into memoranda of understanding or
other agreements with community service providers that can 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 agency is identified on the signage along with directions for
reporting allegations or requesting advocacy services. The Facility Administrator,
Florida ROP Compliance Analyst, and the Florida PREA coordinator confirmed the
establishment of an MOU with ECCAC.
In interviews with the Emerald Coast Children's Advocacy Center staff, the MOU has
been approved and signed by the executive director. The ECCAC staff indicated they
planned to visit the center next week and provide additional posters.
115.353 (d):
The PAQ requires that the facility also provide residents with reasonable and
confidential access to their attorneys or other legal representation, and reasonable
access to parents or legal guardians.
The interview’s confirmed residents have access to attorneys and court workers and
reasonable access to their parents/legal guardians. Resident indicated they are
allowed to call their parents three times a week and may make private calls in an
office if they need to speak with their parents/legal guardian about legal or private
matters.
The site tour revealed areas where residents could meet privately with a legal
representative and where they could meet with family members.
All residents interviewed stated that families could visit, and they provided the days
and times for visitation and phone calls.
Residents interviewed confirmed that the facility would allow them to see or speak
privately with their lawyer, another lawyer, or a court representative. Residents
interviewed confirmed that the facility would allow them to see and speak with their
parents or another person, such as a legal guardian. Visitors to the facility are
informed of PREA.
The Facility Administrator confirmed the facility provides residents with reasonable
and confidential access to their attorneys or court representatives, and reasonable
access to parents or legal guardians. The resident can contact their attorney by
requesting an attorney call, and staff will expedite the call and allow the resident to
call from a private office. Attorneys are requested to provide a 30-minute notice
before coming to see a client. However, based on interviews and during the site
review, the staff indicated they would always allow attorneys access to the youth.
The PREA compliance manager indicated that attorneys or residents can schedule a
call, and residents may use a phone in one of the private offices to speak with their
attorney.
The PREA compliance manager indicated they do the same with parents in an
emergency or when the resident needs to speak with them about private matters
before going to court.
Residents interviewed, formally and informally, while touring the facility, indicated
they are allowed to visit their families and to talk privately with their parents or
legal counsel. Unless the youth has been adjudicated and is being held for an
opening in a program, the community corrections staff and attorneys continue to
meet with the residents to determine placement decisions.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required
115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
Third Party Reporting Poster
Posted Information
FDJJ Policy 1919 PREA- Third Party Reporting
115.354 (a)
The PAQ requires the agency shall establish a method to receive third-party reports
of sexual abuse and sexual harassment and shall distribute publicly information on
how to report sexual abuse and sexual harassment on behalf of a resident.
The center provided policy 1919 and posted third-party reporting procedures.
FDJJ Policy 1919- Third Party Reporting process, instructs staff to accept third party
reports from any source, provides information for anyone who sees or suspects
sexual abuse, sexual harassment, or victimization of any kind to report it promptly
through the FDJJ websites, and provides the public with information regarding third
party reporting of sexual abuse or sexual harassment on behalf of a resident.
All staff interviewed indicated they would accept a third-party report, document it,
and notify the center shift supervisor and CCC immediately.
Additionally, the staff provides the parent/guardian with a packet containing varied
forms, victim advocate services, and third-party reporting information.
Reporting Posters were posted in the visitation room during the audit and in the
facility's main lobby. The posters contain a phone number and the various ways for
families to make a notification of sexual abuse or sexual harassment to the FDJJ or
to WAGC. The poster was brightly colored and was posted in the front lobby and the
visitation room.
The Poster provided that the visitor or third party reporting could report to the
Central Communication Center or the Department of Youth and Family Service
hotline.
The center also had the reporting to the National Child Abuse Hotline located in the
visitation area.
The PREA auditor called the Youth and Family Services hotline from his personal
telephone and reached a live person.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 PREA - Reporting Allegations
FDJJ Staff PREA Education and Training
Florida Code 39 Section 201-2020
FDJJ Policy 1.12 Incident- CCC reporting Staff Training
Interview
PREA Compliance Manager
Facility Administrator
Random Staff
Medical and Mental Health Staff
115.361 (a) (b):
The PAQ requires 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. The agency shall also
require all staff to comply with any applicable mandatory child abuse reporting laws.
The facility provided Florida Code 39, Sections 201-2020; FDJJ Policy 1919, PREA:
Reporting Allegations; and FDJJ Staff PREA Education and Training.
Florida Code 39 Section 201-2020 Mandatory reports of child abuse,
abandonment, or neglect; mandatory reports of death; central abuse hotline.—
(1)(a) Any person who knows, or has reasonable cause to suspect, that a child is
abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other
person responsible for the child’s welfare, as defined in this chapter, or that a child
is in need of supervision and care and has no parent, legal custodian, or responsible
adult relative immediately known and available to provide supervision and care
shall report such knowledge or suspicion to the department in the manner
prescribed in subsection (2). (b) Any person who knows, or who has reasonable
cause to suspect, that a child is abused by an adult other than a parent, legal
custodian, caregiver, or other person responsible for the child’s welfare, as defined
in this chapter, shall report such knowledge or suspicion to the department in the
manner prescribed in subsection (2). (c) Any person who knows, or has reasonable
cause to suspect, that a child is the victim of childhood sexual abuse or the victim of
a known or suspected juvenile sexual offender, as defined in this chapter, shall
report such knowledge or suspicion to the department in the manner prescribed in
subsection (2). (d) Reporters in the following occupation categories are required to
provide their names to the hotline staff: 1. Physician, osteopathic physician, medical
examiner, chiropractic physician, nurse, or hospital personnel engaged in the
admission, examination, care, or treatment of persons; 2. Health or mental health
professional other than one listed in subparagraph 1.; 3. Practitioner who relies
solely on spiritual means for healing; 4. School teacher or other school official or
personnel; 5. Social worker, day care center worker, or other professional child care,
foster care, residential, or institutional worker; 6. Law enforcement officer; or 7.
Judge. The names of reporters shall be entered into the record of the report, but
shall be held confidential and exempt as provided in s. 39.202. (e) A professional
who is hired by or enters into a contract with the department for the purpose of
treating or counseling any person, as a result of a report of child abuse,
abandonment, or neglect, is not required to again report to the central abuse hotline
the abuse, abandonment, or neglect that was the subject of the referral for
treatment. (f) An officer or employee of the judicial branch is not required to again
provide notice of reasonable cause to suspect child abuse, abandonment, or neglect
when that child is currently being investigated by the department, there is an
existing dependency case, or the matter has previously been reported to the
department, provided there is reasonable cause to believe the information is
already known to the department. This paragraph applies only when the information
has been provided to the officer or employee in the course of carrying out their
official duties.
3. Policy 1919 requires All staff, contractors, and volunteers are required to
immediately report any knowledge, suspicion, or information received regarding 1)
any incident of sexual misconduct that has occurred in a facility; 2) retaliation
against youth or staff who report sexual misconduct; and 3) any staff neglect or
violation of responsibilities that may have contributed to an incident of sexual
misconduct or retaliation to the Florida Abuse Hotline, local law enforcement if
criminal in nature, and the CCC as required by mandatory reporting laws and
Department policy.
In interviews with the mental health staff, they indicated that during the intake
process, residents are informed of the facility’s duty to report and the limitations of
confidentiality. Medical and Mental Health Staff meet with the residents upon arrival
at the facility. Medical conducts a nurse’s appraisal, and a mental health therapist
does several diagnostic tests and the VSAB. During this intake process, residents
are informed of their duties to report and sign an acknowledgement form.
1. Employees, Contractors, and Volunteers are required to report any of the
following immediately:
a. Knowledge, suspicion, or information regarding an incident of sexual abuse,
sexual harassment, or exploitation that occurred in the facility.
b. Retaliation against residents or employees who reported such an incident.
c. Any employee, contractor, or volunteer neglect or violation of responsibilities
that may have contributed to an incident or retaliation.
3. Any employee, contractor, or volunteer suspecting abuse, neglect, or
exploitation must immediately report the incident to the DJJ CCC and the child abuse
registry hotline. Following a report, the employee, volunteer, or contractor
suspecting sexual abuse or sexual harassment will immediately notify the PREA
Compliance Manager or Administrator On-Duty.
4. If an alleged crime occurs against a child or adolescent, the PREA
Compliance Manager, Administrator On-Duty, or designee shall immediately notify
law enforcement authorities.
5. The alleged victim’s parents/legal guardians will also be notified,
unless the facility has official documentation showing the parents or legal guardians
should not be notified.
6. If a juvenile court has jurisdiction over the alleged victim, and contact
information is able to be obtained, the Administrator On-Duty or designee will also
report the allegation to the alleged victim’s attorney, juvenile probation officer, or
other legal representative of record within 14 days of receiving the allegation.
All attempts to contact the child’s attorney or receive contact information for the
child’s attorney will be documented.
FDJJ Policy 1919 - Reporting Allegations and FDJJ Staff training mandates that all
employees, volunteers, interns, and contractors shall immediately report to their
supervisor any knowledge, suspicion, or information regarding an incident of sexual
abuse or sexual harassment that occurred in the facility, 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. Upon
receiving any allegation of sexual abuse, the facility administrator promptly reports
allegations to the Agency’s Central Communication Center (CCC). Florida
Administrative Code Rule 63f-11 Central Communications Center (CCC) requires that
any allegation of sexual misconduct or youth-on-youth sexual activity be reported to
the CCC. The person making the report shall provide basic information such as the
date and time of the incident, where the incident occurred, the supervising staff,
and who may be involved. The CCC will make appropriate notifications to senior DJJ
management, who will, in turn, notify management overseeing the facility where
the alleged abuse occurred. Other than making appropriate notifications through
Department channels, staff should take no further action other than that directed by
law enforcement or first responders.
115.361 (c):
The PAQ requires 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.
The facility provided policy 1919 and staff training.
Policy 1919 indicates that only designated employees specified by policy should be
informed of the incident in order to respect the victim’s privacy, security, and
identity. All allegations of sexual abuse shall be handled confidentially throughout
the investigation. All conversations and contact with the alleged victim should be
sensitive, supportive, and non-judgmental.
Skill Pro 1 training indicates that all staff in Florida are mandated reporters.
Twelve random staff members were interviewed. Each of the people interviewed
knew they were mandated reporters and were aware that they report to their shift
supervisor and to the CCC or Child Abuse Hotline, and only to another person, such
as a medical professional, on a need-to-know basis. All staff interviewed indicated
they can make an anonymous report by calling CCC or the Child Abuse Hotline.
115.361 (d):
The PAQ requires (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 that residents are informed
at the initiation of services of the limitations of confidentiality and the staff
members' duty 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. The medical staff interviewed indicated that
they do a medical appraisal as soon as they arrive at the center. During the
appraisal, the residents are advised of their duty to report and explain the reporting
process. If the resident is 18 years or older, the medical staff indicated that if they
report sexual abuse or neglect that did not happen in a facility and did not happen
prior to them turning 18, they would have to get another consent form to make a
report.
115.361 (e):
The PAQ requires 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 case worker 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.
The facility provided interviews with the PREA Compliance Manager, the
Superintendent, and the CCC policy and procedures, and policy 1919
Policy 1919 and CCC and staff are trained in the following;
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 case worker 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.
Policy 1919 and CCC further mandate that the PREA Compliance Manager,
Administrator On-Duty, or designee shall immediately notify law enforcement
authorities. The alleged victim’s parents/legal guardians will also be notified, unless
the facility has official documentation indicating they should not be notified. If a
juvenile court has jurisdiction over the alleged victim, and contact information is
able to be obtained, the Administrator On-Duty or designee will also report the
allegation to the alleged victim’s attorney, juvenile probation officer, or other legal
representative of record within 14 days of receiving the allegation. All attempts to
contact the child’s attorney or receive contact information for the child’s attorney
will be documented.
In interview with the Facility administrator who also serves as the PREA compliance
manager, Florida Department of Justice mandate that the person with the most
information on an incident or the facility administrator will contact the Central
Communication Center within 2 hours of being made aware of any sexual abuse or
sexual harassment that occurs within the program, regardless of if it happened in
the center or while away from the center.
It is the responsibility of the Administrator to notify the parents, case manager,
attorney, and child abuse hotline, and to document the notification, including the
date, time, and person they advised.
115.361 (f):
The PAQ requires the facility to report all allegations of sexual abuse and sexual
harassment, including third-party and anonymous reports, to the facility's
designated investigators.
The facility provided policy 1919 and staff training:
Staff training and policy mandates that all employees, volunteers, interns, and
contractors shall immediately report any knowledge, suspicion, or information
regarding an incident of sexual abuse or sexual harassment that occurred in the
facility, 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 to the shift supervisor, PCM or Administrator. The Administrator or
highest-ranking staff on duty will notify CCC and the child abuse registry hotline
within 2 hours of being informed of an allegation of sexual abuse or sexual
harassment. CCC will notify OIG. The facility staff on duty will immediately notify
Local Law Enforcement of any allegation that is criminal in nature.
Policy and training also require reporting any third-party reports of sexual abuse,
sexual harassment, staff neglect, and retaliation.
The center has had 5 allegations of sexual abuse or sexual harassment during the
last 12 months. All were reported within the timeline as required by Policy 1919 and
CCC mandates of less than 2 hours to report allegations of sexual abuse or sexual
harassment.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 - Agency Protection Duties
FDJJ 1919 Imminent risk
ROP agency head
Florida DJJ agency head
Random Staff
Facility Administrator
PREA Compliance Manager
PAQ
115.362 (a)
The PAQ requires that 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 center provided Policy 1919, which requires staff to protect residents by
immediately implementing protective measures. Interviews with the residents
revealed their concerns about their own safety, which is discussed during the intake
process and during the administration of Screening assessments. Policies require
that if the residents allege that they are at substantial risk of imminent sexual
abuse, staff will take immediate steps to ensure the safety of the resident. The
direct care staff will take steps to separate the alleged victim from the alleged
perpetrator and notify the staff with the highest authority at the facility and the
assistant facility administrator, or facility administrator. These staff will then
determine the best options to protect the victim. The staff will then follow the
mandatory reporting steps. All residents meet with the mental health staff within 72
hours of arriving at the center and once a month with their case manager and
mental health provider. During these meetings, residents are asked if they feel safe
at the facility. There have been no instances where residents were in imminent
danger of sexual abuse.
During the formal interviews with residents, the auditor asked each resident about
their feelings of safety at the center. All residents indicated they felt safe, and the
center's staff were available to them if they had any concerns.
The Florida Agency Head, the PREA coordinator, and the facility administrator all
indicated that staff have a duty to immediately provide protective measures to
protect a resident from sexual abuse or perception or fear of being sexually abused.
The Rite of Passage agency head indicated that the center would immediately move
to a different unit. Provide one-on-one supervision. If we cannot protect the child,
we will ask the agency to move the child or the perpetrator. We provide specialized
treatment for youth and work extremely hard to keep them from moving, since
some have waited months for access to our programs.
Compliance was determined by reviewing policies and interviewing direct care staff,
non-direct care staff, and the facility administrator.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.363 Reporting to other confinement facilities
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1.12 Incident- CCC reporting
FDJJ Policy 1919 - Reporting to other facilities
Statement of Fact
Interviews
Facility Administrator
Agency Head
115.363(a-d)
The PAQ requires that 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 the appropriate office of the agency
where the alleged abuse occurred, and shall also notify the appropriate
investigative agency.
Such notification shall be provided as soon as possible, but no later than 72 hours
after receiving the allegation.
The agency shall document that it has provided such notification.
The facility head or agency office that receives such notification shall ensure that
the allegation is investigated in accordance with these standards.
The agency head indicated that they must notify the PREA coordinator and the
Facility Director:
a. The facility will notify the Agency PREA Coordinator, CCC, and the child abuse
registry. The director will also notify my office and our PREA Coordinator.
b. In each case, we notify the PREA Coordinator and any other staff based on the
Agency Contract.
The facility provides policy FDJJ Policy 1919 - Reporting to other facilities, which
states that 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 the agency office that receives such notification
shall ensure that the allegation is investigated in accordance with these standards.
During the past 12 months, there were no allegations received that a resident was
abused while confined to another facility.
The head of the Florida DJJ agency indicated in an interview that the receiving
center must immediately notify the sending center and the CCC. The notification
must occur within 2 hours of the center being made aware of an allegation of sexual
abuse or sexual harassment.
The Rite of Passage agency head indicated that the center must notify the PREA
coordinator and the Facility Director:
a. The facility will notify the Agency PREA Coordinator and other entities based on
the contract.
b. The director will also notify my office and our PREA Coordinator for Florida
c. In each case, we notify the Agency and Rites of Passage PREA Coordinator and
any other staff based on the Agency Contract.
d. If we get a report from a student, we will notify the sending facility, contracting
agency, and PREA Coordinator
The facility administrator indicated that they must make the notification unless they
are unavailable. In which case, the acting facility administrator will make the
notification.
In interviews with the Chief of Investigation, he indicated that the OIG has staff
located throughout the State, who would respond to the center where the
notification originated and to the sending center.
Based on the review of the agency's policy and procedures, observations, and
information obtained through staff interviews and review of documentation, the
facility has demonstrated compliance with this standard.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.364 Staff first responder duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 – Responding to Allegations
Staff training
Random Staff interviews
Non-direct staff interview
115.364 (a):
The PAQ requires Upon learning of an allegation that a resident was sexually
abused, the first staff member to respond to the report shall be required to: (1)
Separate the alleged victim and abuser; (2) Preserve and protect any crime scene
until appropriate steps can be taken to collect any evidence; (3) If the abuse
occurred within a time period that still allows for the collection of physical evidence,
request that the alleged victim not take any actions that could destroy physical
evidence, including, as appropriate, washing, brushing teeth, changing clothes,
urinating, defecating, smoking, drinking, or eating; and (4) If the abuse occurred
within a time period that still allows for the collection of physical evidence, ensure
that the alleged abuser does not take any actions that could destroy physical
evidence, including, as appropriate, washing, brushing teeth, changing clothes,
urinating, defecating, smoking, drinking, or eating
The facility provided policy 1919 and staff/contractor training
FDJJ Policy 1919 Upon discovery of an incident defined as sexual abuse, staff
members are responsible for taking immediate actions to ensure the safety of the
victim and notifying appropriate law enforcement and medical personnel. These
actions include, but are not limited to, identifying and separating victim(s),
suspect(s), and making every attempt to preserve evidence.
It is essential that the garments/clothing worn by those involved and the scenes
where alleged act(s) occurred be protected to ensure that evidence is not further
contaminated. This means simply securing any evidence until law enforcement
arrives. Securing is defined as maintaining control over the evidence or scene and
documenting any access to or deviations from access to that evidence. Staff shall
not move, touch, or alter the evidence in any way. Staff shall not discuss any facts
of the incident with anyone except those directly involved in the response or
investigation. All of this information is reportable to law enforcement and
subsequent investigators.
Upon receipt of notice that any sexual abuse has occurred in the last 72 hours,
whether informed by the victim or a third party, take the following actions:
a. If the victim reports the incident:
i. Ensure the victim is safe, has no further contact with the alleged subject (youth
or staff), and if medical staff is available, take the victim to medical staff.
ii. Do not question the youth, other than to obtain basic information such as the
date and time of the incident, where the incident occurred, the supervising staff,
and who may be involved. Do not request youth to write a statement.
iii. Immediately preserve the area where the incident allegedly
occurred, including ensuring that bedding, clothing, or related material are not
disposed of or cleaned up by staff, and keep those materials secure or free from
contamination by anyone else until instructed to do differently by law enforcement.
iv. Immediately notify the facility management.
v. Immediately notify law enforcement (911).
vi. Immediately contact the DCF Florida Abuse Hotline.
vii. Notify the CCC within two (2) hours of the incident or learning of the incident.
viii. Do not discuss the facts of the incident with anyone except those directly
involved in the response or investigation of the incident.
ix. If the suspect is in the care and custody of the facility, do not notify them of
the victim's report, but take adequate steps to ensure the safety of other youth, and
report suspect or subject information to law enforcement upon their arrival.
x. Cooperate fully with law enforcement.
xi. Within seven (7) days of the reported event, the youth's VSAB shall be
reviewed and updated by the youth's case manager or the facility's mental health
provider.
b. Upon receipt of notice that any sexual abuse occurred longer than 72 hours ago,
whether informed by the victim or a third party, take the following actions:
i. Ensure the victim is safe, has no further contact with the alleged subject (youth
or staff), and if medical staff is available, take the victim to medical staff.
ii. Do not question the youth, other than to obtain basic information such as the
date and time of the incident, where the incident occurred, the supervising staff,
and who may be involved. Do not request youth to write a statement.
Skill Pro training 1 includes a section on responding to sexual allegations of sexual
abuse and includes all of the information stated above.
Fourteen random staff members were interviewed. Each of the staff members was
able to articulate their responses if a resident made an allegation of sexual abuse.
115.364 (b):
The PAQ requires that, if the first staff responder is not a security staff member,
the responder shall request that the alleged victim refrain from taking any actions
that could destroy physical evidence, and then notify security staff.
Policy 1919 was provided and stated that if the first staff responder is not a
security staff member, the responder shall request that the alleged victim refrain
from taking any actions that could destroy physical evidence. Staff interviewed
confirmed they knew their obligations when a resident makes an allegation or they
suspect an incident of sexual abuse has occurred.
During the last 12 months, there were two allegations of sexual abuse made by a
resident at WAGC.
An interview with the education and mental health staff determined that no direct
care staff were aware of their first person who was made aware of a sexual abuse
duty.
Mental Health staff indicated they would notify the closest direct care provider. They
would advise the residents not to take a shower, change clothes, use the restroom,
or do anything that would destroy the evidence.
The education staff indicated she would notify the officer in her classroom or, if not
in the classroom, the closest staff member, explain to the youth what he had said in
the presence of the youth, and remain with the youth until staff could take over. Yes,
I would tell them not to change clothes, brush their teeth, use the restroom, or do
anything that could destroy the evidence.
The random staff interview indicated that all staff were aware of the responsibilities
to protect the resident, secure the scene, notify the supervisor, and remain with the
victim until properly relieved. Six of the staff interviewed indicated they would
immediately notify the local law enforcement.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required
115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
WAGC Coordinated Response
115.365 (a)
The PAQ requires the facility shall develop a written institutional plan to coordinate
actions taken in response to an incident of sexual abuse, among staff first
responders, medical and mental health practitioners, investigators, and facility
leadership.
The facility provided the WAGC Coordinated Response, which includes a written
plan to coordinate actions of employee first responders, medical and mental health
practitioners, investigators, and facility leadership in response to an incident of
sexual abuse. FDJJ has a system in place that provides staff with clear actions to
take, including contacting administrative staff, medical and mental health staff, OIG,
law enforcement, victim advocate services, & parent/guardian and several other
individuals. Staff members are directed to follow the steps outlined and use the
checklist to address the situation.
WAGC Coordinated Response Plan
1. Upon discovery of an incident defined as sexual abuse, the first responding staff
members are responsible for taking immediate action to ensure the safety of the
victim. These actions include, but are not limited to:
a. Identifying victim(s)
b. Identifying suspects
c. Making every attempt to preserve evidence.
d. Notify the Shift Supervisor.
e. Notify law enforcement.
2. Upon notification of a PREA related incident the Shift Supervisor will:
a. Immediately report the incident to the CCC, providing as many facts and details
as
possible about the incident(s) and victim(s), suspect(s), or witnesses. The CCC will
make appropriate notification to senior DJJ management, who will, in turn, notify
management overseeing the facility where the alleged abuse occurred.
e. Do not allow access to the area by anyone, including staff, until the arrival of,
and at the direction of, law enforcement.
f. Do not question the victim, other than to identify basic information about where
the incident occurred and who may be involved.
g. Provide as much detail as possible to the police and responding emergency
services.
h. If the subject (the person who allegedly committed the offence) is in your care,
control, or custody, do not notify them of the victim’s report, but take adequate
steps to ensure the safety of other youth and report subject information to law
enforcement when they arrive.
i. Ensure that any clothing, bedding, or related materials are not disposed of or
cleaned up by staff. Keep those materials secure or free from contamination by
anyone else until instructed otherwise by law enforcement.
j. Do not discuss any facts of the incidents with anyone except those directly
involved in response or investigation of the incident.
k. Cooperate fully with law enforcement.
7. The Superintendent or Assistant Superintendent shall notify the alleged victim’s
parents or guardians, unless there is official documentation showing the parents or
legal guardians should not be contacted.
a. If the youth is in the custody of DCF, the caseworker shall be notified.
b. If applicable, the youth’s attorney or other legal representative of record shall be
notified of the allegation within 14 days of receiving the allegation.
8. Medical personnel are to be immediately notified by the Shift Supervisor. They
will also ensure that physical evidence is preserved.
a. In the event they are not available, the Shift Supervisor will make a referral within
24 hours.
b. Medical staff will conduct a follow-up with the youth as a precautionary measure
to ensure any prescribed medical treatment is completed.
c. Evaluate youth to determine if any other follow-up medical referrals are
necessary and make appropriate referrals.
9. Mental health personnel are to be immediately notified by the Shift Supervisor.
The facility staff will seek their assistance in ensuring the youth is evaluated and
treated.
a. In the event they are not available, the Shift Supervisor will ensure that a referral
is made to the facility's mental health personnel within 24 hours.
b. Mental health staff will assess the youth and determine if further evaluation and
treatment are needed, and make the appropriate referrals.
10. Full cooperation will be rendered to responding law enforcement agencies and
responding medical emergency teams. More than likely, the victim will have to be
transported out with a supervising staff member to the hospital after the
investigation is launched to be evaluated and treated, including the use of a rape
kit. As this is a very traumatic experience for the victim, follow-up treatment to
Emerald Coast Center will be offered, as well as access to victim advocates. Once
law enforcement leaves the facility, the youth will be transported out for medical
services, and regular programming will resume.
11. The Superintendent shall:
a. Ensure all follow-ups are conducted within the specified timeframes, that every
effort is made not to re-traumatize the victim, and that the subjects are removed
from victim contact.
b. If it is a staff person who has been reported as the subject, they will be removed
from all youth contact during the investigation.
c. If allegations occurred at another facility, the Superintendent will immediately
notify the Superintendent of that facility to report allegations. Compliance was
determined by review of the Coordinated Response to an Allegation of Sexual Abuse
and interviews with random staff. The facility administrator, medical staff, mental
health staff, shift supervisors, random staff, and education staff were asked about
their roles in the coordinated response, and each named their essential roles.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
Preservation of ability to protect residents from contact with
115.366
abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
Statement of Fact
Not applicable to the Rite of Passage since no collective bargaining agreements
exist
In interviews with the Facility agency head, neither the agency nor any other
governmental entity responsible for collective bargaining on the agency's behalf
shall enter into or renew any collective bargaining agreement or other agreement
that limits the agency's ability to remove alleged staff sexual abusers from contact
with residents pending the outcome of an investigation or of a determination of
whether and to what extent discipline is warranted.
The agency provided a statement of fact in every case where the alleged abuser is
an employee, contractor or volunteer there will be no contact between the alleged
abuser and the alleged victim pending the outcome of an investigation. Separation
orders (e.g., safety plans) requiring “no contact” will be documented by facility
management.
Rites of Passage will not enter or renew any collective bargaining agreement or
other agreement that limits a facility’s ability to remove alleged Employee sexual
abusers from contact with any resident pending the outcome of an investigation or
of determination of whether and to what extent discipline is warranted.
Rites of Passage agency head indicated in interview that ROP does not have a
collective bargaining agreement and can place staff on administrative leave.
Compliance was determined by the agency head, and facility administrator.
Based on this analysis, the facility is substantially compliant with this provision and
corrective action is not required.
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 - Protection against Retaliation
Rite of Passage Retaliation Form
PAQ
Interviews with
Agency Head
Facility Administrator
Staff who conduct Retaliation Monitoring
115.367 (a):
The PAQ requires 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.
The facility provided the FDJJ policy 1919 – Agency Protection Against Retaliation,
related forms, and a staff member in a collateral duty to monitor for retaliation.
FDJJ policy 1919 Facility establishes for the protection of residents against
retaliation and staff for reports of sexual abuse or harassment or cooperation with
investigations. Allegations of retaliation shall be immediately reported to the site
supervisor or designee. In instances where the supervisor is believed to be involved
in the retaliation, the employee shall notify the supervisor or supervisors at the next
appropriate supervisory level. For 90 calendar days, or longer if continuing need
warrants, following a report of sexual abuse, the PREA retaliation monitor (captain)
shall monitor the conduct or treatment of any individual, youth, or employee
involved in a reported incident and shall act promptly to remedy any such
retaliation. Monitoring steps include reviewing group or facility assignments,
reviewing youth progress reports, conducting periodic status checks with the youth,
and conducting performance reviews or reassigning employees involved in the
initial report or investigation.
During the last 12 months, there was no retaliation for reporting allegations of
sexual abuse or sexual harassment.
FDJJ has developed an agency-wide form for all facilities managed by the
corporation to document retaliation monitoring. During the last 12 months, there
has been one allegations of sexual allegation of sexual abuse that is being
monitored for retaliation.
At Walton Academy for Growth and Change, the facility administrator and clinical
director monitor for retaliation. In an interview with the facility administrator and
clinical director, they explained their roles were to meet with the resident who made
a report, allegation, or was a witness to a sexual abuse incident. The facility
administrator indicated that he would meet with the resident as soon as the CCC
report was completed, which would be within 2 hours of the center being made
aware of the sexual abuse allegation. The center administrator indicated that he
would meet with the staff and residents to explain the retaliation-monitoring
process. The clinical director indicated she would meet with the resident to provide
crisis intervention services and offer additional services. She would continue to
meet with the resident and monitor his services, including any retaliation, through
review of clinical notes and phase-level progression, and also offer the resident the
opportunity to meet with the Victim Services staff either at the center or in the
Victim Services office.
115.367 (b):
The PAQ requires the agency to 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 facility 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 agency head interviewed indicated that the agency would move the resident
who made the allegation or the resident who was the abuser to another center, or
housing unit, or arrange for him to work with one of the many victims’ emotional
support programs we have MOUs with around Florida. If a member of staff were
involved, they would be either placed on no-contact status or on administrative
leave pending the outcome of the investigation.
The facility administrator stated that he would meet with the youth as soon as the
incident was reported, ask them about their safety concerns, and make immediate
accommodations as needed to protect the resident and staff.
The retaliation monitor indicated in the interview that she has the authority to move
the resident to another living unit and would have to coordinate with the facility
administrator to move the resident to another center.
Policy 1919 indicates that youth, staff, contractor(s), or volunteer(s) who have
reported sexual misconduct shall be protected against retaliation. Accommodation
will include housing changes and removal of alleged staff or youth from contact with
victims. Emotional support services for youth or staff who fear retaliation for
reporting or cooperating with investigations will be available.
The retaliation monitors and facility administrator indicated they would provide
resident housing changes or transfers for resident victims or abusers, removal of
alleged staff or resident abusers from contact with victims, and emotional support
services.
115.367 (c):
The PAQ requires that, for at least 90 days following a report of sexual abuse, the
agency shall monitor the conduct or treatment of residents or staff who reported the
sexual abuse and of residents who were reported to have suffered sexual abuse to
see if there are changes that may suggest possible retaliation by residents or staff.
It shall act promptly to remedy any such retaliation. Items the agency should
monitor include resident disciplinary reports, housing or program changes, and
negative performance reviews or staff reassignments. The agency shall continue
such monitoring beyond 90 days if the initial monitoring indicates a continuing
need.
The facility provided policy 1919, which requires the facility to monitor residents for
the treatment of residents or staff who reported sexual abuse and of residents who
were reported to have suffered sexual abuse to see if there are changes that may
suggest possible retaliation by residents or staff, and shall act promptly to remedy
any such retaliation. Items the agency should monitor include resident disciplinary
reports, housing or program changes, and negative performance reviews or staff
reassignments. The agency shall continue such monitoring beyond 90 days if the
initial monitoring indicates a continuing need.
FDJJ Policy 1919 requires the monitoring of items identified in this provision of the
standard. The Retaliation Monitor explained during the interview how she 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 assess whether any changes
suggest possible retaliation by residents or staff. It shall act promptly to remedy any
such retaliation in accordance with 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.
115.367 (d):
The PAQ requires In the case of residents, such monitoring shall also include
periodic status checks.
Policy 1919 indicates that in the case of residents, such monitoring shall also
include periodic status checks. The Retaliation Monitor indicated status checks
would be initiated with staff and residents.
In interviews with the facility administrator and retaliation monitors, both indicated
that they see the youth at the center almost every day and usually five to ten times
a day, and they conduct status checks with all youth on a daily basis. They indicated
they are required to document monitoring. The Retaliation Status Checklist would be
used to document status checks, as would the Retaliation Monitoring Checklist, to
document the ongoing monitoring and use of the Retaliation Status Checklist.
115.367 (e):
The PAQ requires If any other individual who cooperates with an investigation
expresses a fear of retaliation, the agency shall take appropriate measures to
protect that individual against retaliation.
Policy 1919 and interviews with the agency head and facility administrator were
provided by the facility.
Policy 1919 indicated that 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. Policy states that if any other
individual who cooperates with an investigation reports retaliation by another
resident or staff member.
The Florida DJJ agency head indicated the agency would take appropriate measures
to protect that individual against retaliation.
The Rites of Passage agency head indicated that retaliation monitoring is part of
the training we conduct with staff, both locally and as an organization. We monitor
housing changes, transfers, the residents’ points, and the reflection of his/her status
in the program. We always have staff meet with students and will refer them to the
emotional support staff. Most of our programs have a clinical director who would
be involved in retaliation monitoring. We have an appointed staff in each program to
conduct Monitoring.
First and foremost, we have zero tolerance for retaliation; we will place staff on
administrative leave and move the resident who is engaging in retaliation from the
program. Place residents who fear retaliation under one-on-one supervision if
needed. We would make whatever accommodation was needed to avoid retaliation.
The retaliation monitor indicated she would visit the resident whenever residents or
third parties lodge an allegation, immediately, and discuss her role in monitoring for
retaliation.
The facility administrator indicated he would monitor staff who report and/or
cooperate with any investigations. The retaliation monitor interviewed indicated
they would meet with the resident every week to ensure there is no retaliation for
reporting sexual abuse or sexual harassment.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required
115.368 Post-allegation protective custody
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
Facility PREA Response Plan
FDJJ Policy 1919 PREA
PAQ
Interviews
Facility Administrator
Medical and Mental Health Staff
115.368 (a):
The PAQ requires that 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.
FDJJ Policy 1919 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 residents must have access to
daily large-muscle activities, legally required educational programming or special
education services, and daily visits by mental health and medical personnel.
Residents shall also have access to other programs and work opportunities.
The facility indicated no residents have been segregated for allegations of sexual
abuse or a resident's fear of being sexually abused in the past 12 months.
The facility’s administrator interview confirmed compliance with this standard.
According to the facility administrator, isolation or segregated housing has not been
used to protect a resident who alleged sexual abuse.
In interview the director indicated in an interview with the facility administrator and
clinical director, the center does not utilize isolation unless the youth is on an active
suicide alert that would rise to the level of one-on-one constant supervision. The
Facility administrator indicated that the center has single rooms for residents'
placement to keep them safe; however, they do not isolate residents. The facility is
in proximity to another RYDC. If the facility staff feel they cannot protect the
residents, the resident would be moved to the other RYDC rather than placed in an
isolated area. He further stated that in his years at the facility, he has never isolated
or moved a resident for fear of being a victim of sexual abuse.
According to the facility administrator, there has been no time when a resident was
separated or isolated from other residents for an allegation of sexual abuse or
harassment, or for fear of being sexually abused. ROP does not allow residents to be
isolated or segregated. If we need to house a resident until he can be transferred to
an appropriate facility, he would be placed in the intake area away from other
residents under one-on-one supervision. He would still have all of the privileges,
including education, therapist sessions, showers, telephone, visitation, and
recreation. I would have to notify the ROP coordinator and agency head
immediately.
The medical and mental health staff stated they are not aware of an incident
regarding sexual abuse or sexual harassment in which a resident was segregated.
The clinical staff confirmed that the center would complete an assessment and
suicide screening, notify the ROP executive director, the Florida PREA Coordinator,
the youth probation officers, the youth's parent or legal guardian, and, in such a
case, the resident would be visited at least daily.
During the tour of the center, it was noted that there were no isolated rooms in the
facility.
Compliance was determined by reviewing policy and interviewing the facility
administrator and medical and mental health staff.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.371 Criminal and administrative agency investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 PREA – Investigations
Investigation procedures from OIG Investigative
Recent allegation of sexual abuse.
Interviews
Chief of Investigations
Facility Administrator
PREA Coordinator
115.371 (a):
The PAQ requires 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.
Based on the PAQ and interviews with the facility director, ROP does not conduct
any investigations. The facility must report all allegations of sexual abuse to the
CCC within 2 hours of being made aware of an allegation. CCC notifies OIG who
conducts administrative investigations. OIG notifies the local law enforcement if the
allegation is criminal in nature.
The facility provided the FDJJ Policy 1919, which establishes the agency policy that
all allegations of sexual abuse or sexual harassment will be investigated. The Office
of the Inspector General conducts administrative investigations, and criminal
investigations are conducted by local law enforcement. The Department of Family
and Children conducts a separate investigation involving residents under the age of
eighteen.
Investigator interview indicated Yes, we have several policies that require all
allegations of sexual abuse or sexual harassment be investigated. All reports to CCC
are reviewed and assigned within 24 hours. On the date we get the report, we
assign the report to reach out to local law enforcement. If local law enforcement is
not going to conduct a criminal investigation, we begin the investigation the day
that it is received. The facility provided the FDJJ Policy 1919, which establishes the
agency policy that all allegations of sexual abuse or sexual harassment will be
investigated. The Florida Department of Juvenile Justice does not conduct their own
investigations of sexual abuse and harassment. The Office of the Inspector General
conducts administrative investigations, and criminal investigations are conducted
by local law enforcement. The Department of Family and Children conducts a
separate investigation involving residents under the age of eighteen.
The Chief of Investigation indicated that the center has 2 hours to notify the Central
Communications Center, and he assigns staff based on the location of the center
within 1 hour of notification from the CCC. CCC notifies him by text immediately
after receiving a report.
115.371 (b):
The PAQ requires 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.
In interview with the chief of investigation and review of standard § 115.334 The
Office of Inspector General follows protocols in conducting administrative
investigations in FDJJ settings and the investigators receive training on the related
agency policies Florida Department of Juvenile Justice has requested the agencies
that conduct allegation of sexual abuse or sexual harassment follow the PREA
standards. The training includes all topics noted in standard 334.
15.371 (c):
The PAQ requires Investigators shall gather and preserve direct and circumstantial
evidence, including any available physical and DNA evidence and any available
electronic monitoring data; shall interview alleged victims, suspected perpetrators,
and witnesses; and shall review prior complaints and reports of sexual abuse
involving the suspected perpetrator.
The facility provided policy 1919 PREA Investigation, staff training and facility
respond plan.
Policy 1919, staff training and the facility respond plan requires that staff secure
the evidence and provide assistance as required by OIG or local law enforcement.
OIG or local law enforcement 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.
Twelve random staff interviewed indicated they would preserve the scene and
instruct the youth not to bathe, change clothes, use the restroom, brush their teeth
or do anything to destroy evidence.
In interview with the chief of investigation indicated the first step in an
investigation is to develop an investigative plan based on the allegation which
usually takes 20 minutes. The investigator then either asks for local law
enforcement to gather crime scene evidence or the investigator would go to the
center and gather crime scene evidence if it is going to be an administrative
investigation. If it is a criminal investigation, then the Local Law enforcement is
notified and the OIG investigator meet the Law enforcement staff at the center. Staff
have been trained to not let the victim or abuser do anything to that may lead to
the destruction of evidence. The investigator gathers all surveillance documents,
telephone calls recording if available, conduct interviews with resident victim,
witnesses, staff on duty, control room staff, and lastly the abuser.
115.371 (d):
The PAQ requires the agency not terminate an investigation solely because the
source of the allegation recants the allegation.
Policy 1919 recent allegation of sexual abuse and OIG interviews requires that the
agency will not terminate an investigation solely because the source of the
allegation recants the allegation.
OIG indicates in interview that OIG will not terminate an investigation even if the
residents recant the allegations.
One allegation of sexual abuse was reviewed in which a resident recanted his
statement that he saw a staff member having sex with another resident. The
allegation was completely investigated including view of video, interviews with
several resident working in the area of the allegation, the staff member and the
youth who resident indicated had sex with a staff member. After complete
investigation is was determined as unfounded by local law enforcement and
administratively unfounded by OIG.
115.371 (e):
The PAQ requires 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.
Any criminal investigations are conducted by local law enforcement and would be
referred to appropriate jurisdiction for prosecution. Completed reports shall be
retained in the Office of the inspector general in accordance with the state retention
schedule.
In interview with the chief of investigation, OIG does not utilize compelled
interviews.
115.371 (f):
The PAQ requires the credibility of an alleged victim, suspect, or witness shall be
assessed on an individual basis and shall not be determined by the person's status
as resident or staff. No agency shall require a resident who alleges sexual abuse to
submit to a polygraph examination or other truth-telling device as a condition for
proceeding with the investigation of such an allegation.
The facility provided interview with the chief of investigations who indicated 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.
115.371 (g):
The PAQ requires 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.
The facility provided policy 1919, which includes that administrative investigations
shall include an effort to determine whether staff actions or failures to act
contributed to the abuse; and 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.
In an interview with the chief of investigation, he indicated that OIG conducts an
administrative investigation, which includes interviews with staff, logbooks, written
statements, resident-to-staff ratios, placement of staff, and violations of policies and
procedures. All of this information as well as all investigations or documented and
uploaded to the OIG investigative portal that is limited to who has access to review.
It is also password protected and a printout is provided anytime anyone views the
portal.
A review of two allegations of sexual abuse and one completed allegation of sexual
harassment contained an administrative review that included staff compliance with
policy, staff action or failure to act. All investigations reviewed included a
description of physical and testimonial evidence, reasoning behind the credibility
assessment and facts and findings.
115.371 (h):
The PAQ requires that criminal investigations shall be documented in a written
report that contains a thorough description of physical, testimonial, and
documentary evidence and attaches copies of all documentary evidence where
feasible.
The facility provided a memo request from the chief of investigations that law
enforcement staff who conduct criminal investigations utilize the State investigative
protocol and document all criminal investigations in a written report that contains a
thorough description of physical, testimonial, and documentary evidence and
attaches copies of all documentary evidence where feasible.
OIG maintains all investigative reports in a password-protected database accessible
only to authorized personnel. The system automatically includes verification when a
person accesses the database.
115.371 (i):
The PAQ requires that substantiated allegations of conduct that appears to be
criminal shall be referred for prosecution.
According to OIG interview, the Office of Inspector does not conduct criminal
investigations, however they request substantiated allegations of conduct that
appear to be criminal shall be referred for prosecution.
115.371 (j):
The PAQ requires the agency shall retain all written reports referenced in
paragraphs (g) and (h) of this section for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years, unless the abuse was
committed by a juvenile resident and applicable law requires a shorter period of
retention.
The facility provided policy 1919 investigation which states the agency shall retain
all written reports referenced in paragraphs (g) and (h) of this section for as long as
the alleged abuser is incarcerated or employed by the agency, plus five years,
unless the abuse was committed by a juvenile resident and applicable law requires
a shorter period of retention.
115.371 (k):
The PAQ requires 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.
In interview with the chief of investigations any investigation will continue until a
finding and appropriate action occurs based on that finding. OIG has officers located
throughout Florida and all Florida counties. The departure of the alleged abuser or
victim from employment or control of the facility or agency shall not provide a basis
for terminating an investigation. The area OIG would work with local law
enforcement to conclude the investigation.
115.371 (m):
The PAQ requires that 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.
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. As part of the coordinated response plan, staff are trained in
protecting the crime scene and cooperating with investigative units.
In an interview with the facility administrator (PCM), they indicated they have a
great working relationship with law enforcement. They would also rely on the Florida
DJJ coordinator to assist in gaining information.
The PREA coordinator interview indicated that the investigative agency provides OIG
a copy of the investigation and the findings of the investigation. The investigative
information is uploaded into the OIG CCC system.
The Chief of the Office of General indicated that his investigator establish a working
relationship with local law enforcement and assist the investigator in any way they
can to solicit cooperation in staying abreast of criminal investigations.
Compliance was determined through interviews with the OIG investigator, the PREA
coordinator, the agency website, and the facility administrator.
Based on this analysis, the facility is substantially compliant with this provision and
corrective action is not required.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 – Investigations
115.372 (a):
The PAQ requires the agency shall impose no standard higher than a preponderance
of the evidence in determining whether allegations of sexual abuse or sexual
harassment are substantiated.
The facility provided policy 1919 investigations, which require the investigator to
make a finding of Substantiated, Not Substantiated, Unfounded, or Pending Further
Investigation. The finding will be made using the standard of proof of the
preponderance of the evidence (51 % of the evidence). The Investigator must
objectively review all evidence in favor of or against the finding. The investigator
must objectively consider and balance the evidence in favor of or contrary to the
finding, and support the finding of child abuse or neglect by a Preponderance of
Evidence. Investigators must be convinced that the evidence in favor of the finding
outweighs the evidence against the finding, or are convinced that the evidence,
when taken as a whole, shows that it is more probable than not that the alleged
incident took place in this case.
Compliance with the standard was determined by reviewing the Policy, interviewing
the agency PREA coordinator, and reviewing investigations completed by the Office
of Inspector General.
The chief of investigation indicated that the administrative investigation includes
findings based on the preponderance of the evidence. It also includes administrative
findings, such as the timing of the report, notifications, and policy violations.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 – Reporting to Youth
Facility Administrator
Chief of OIG
Investigations
Notifications
115.373 (a):
The PAQ requires the following: 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.
The facility provided Policy 1919, which requires that when an investigation into a
youth's allegation of sexual misconduct occurring in a facility, the facility shall
inform the victim or victim's parent(s) or legal guardian(s) by letter as to whether
the allegation has been determined to be substantiated, unsubstantiated, or
unfounded.
Based on an interview with the facility administrator (PREA compliance manager) at
the conclusion of an investigation, the OIG or PREA Compliance Manager will inform
the victim of the allegation in writing, whether it has been substantiated,
unsubstantiated, or unfounded.
The chief of investigation indicated that OIG will forward a notification letter to the
center to be provided to the residents, and a copy will be mailed or delivered to the
parent or legal guardian.
115.373 (b):
If the agency did not conduct the investigation, it shall request the relevant
information from the investigative agency to inform the resident.
FDJJ Policy 1919 Investigating PREA Allegations requires that, if the facility did not
conduct the investigation, it will request the relevant information from the
investigating agency to inform the individual.
2 complete investigations required a notification to be provided to residents.
115.373 (c):
The PAQ requires 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 facility provided policy 1919 investigation that indicates 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.
115.373 (d):
The PAQ requires 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 facility provided policy 1919 which indicates 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.
115.373 (e):
The PAQ requires that all such notifications or attempted notifications shall be
documented.
Policy requires that all such notifications or attempted notifications shall be
documented. The PREA Coordinator has developed a form that for notification to
residents of the outcome of investigations that includes a signature from the
resident. During the last 12 months there were 2 residents that was notified of the
outcome of an investigation that was completed by the facility.
Based on review of policy and interviews with PREA compliance manager and PREA
coordinator it was determined that the agency is in compliance with this standard.
Based on this analysis, the facility is substantially compliant with this provision and
corrective action is not required.
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 – Disciplinary sanctions for Staff
Statement of Fact
Interview with Facility Administrator
115.376 (a)(b):
The PAQ requires staff is subjected to disciplinary sanctions up to and including
termination for violating agency sexual abuse or sexual harassment policies.
Termination shall be the presumptive disciplinary sanction for staff who have
engaged in sexual abuse.
The facility provided policy 1919 Disciplinary Sanction for staff, and statement of
fact. The facility also provided PREA Manual section 376 - Disciplinary sanctions for
staff
Section 376 indicates staff shall be subject to disciplinary sanctions up to and
including termination for violating program sexual abuse or sexual harassment
policies.
Termination shall be the presumptive disciplinary sanction for staff who have
engaged in sexual abuse.
Policy 1919 states failure to comply with the requirements contained in this policy
and procedures may result in disciplinary action up to and including dismissal. All
terminations for violations of agency sexual abuse policy, 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. Termination shall
be the presumptive disciplinary sanction for staff who have engaged in sexual
abuse.
Skill Pro training contains the same information that is provided in yearly refresher
training for staff.
115.376 (c):
The PAQ requires 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.
The facility provided policy 1919 which indicates that disciplinary sanctions for
violations of agency policies relating to sexual abuse and harassment other than
engaging in sexual abuse will be commensurate with the nature and circumstances
of the acts committed. However, most likely any degree of sexual abuse and
harassment will be met with termination of the staff member.
ROP Section 376 indicates disciplinary sanctions for violations of program 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.
115.376 (d):
The PAQ requires all terminations for violations of agency sexual abuse or sexual
harassment policies, or resignations by staff who would have been terminated if not
for their resignation, shall be reported to law enforcement agencies, unless the
activity was clearly not criminal, and to any relevant licensing bodies.
Policy 1919 indicates All terminations for violations of agency sexual abuse policy,
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.
ROP Section 376 indicates all terminations for violations of program 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 and
social services agencies.
According to interview with the facility administrator all staff members who are
terminated or resign in lieu of termination due to violations of the sexual abuse and
sexual harassment policy shall be reported to law enforcement. Staff who resign
because they would have been terminated are reported to the local law
enforcement unless the activities were not clearly criminal.
There has been no adverse action taken against staff for violation of the agency
policy 1919 PREA or related policies.
Compliance was determined by review of the agency policy, interview with PREA
coordinator and facility administrator.
Based on this analysis, the facility is substantially compliant with this provision and
corrective action is
115.377 Corrective action for contractors and volunteers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 – Disciplinary sanctions for Contractors or Volunteers
PREA Ind Contractor and Volunteer Knowledge Assessment.pdf
ROP PREA Manual Student Additional Education Acknowledgment Form
Contractor Training
Contractor Acknowledgement for Training
Statement of Fact
Interview with Facility Administrator
115.377 (a)
The PAQ requires that any contractor or volunteer who engages in sexual abuse 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.
The facility provided policy 1919 and the PREA Manual.
FDJJ Policy 1919 states that all employees, contractors, juveniles, and volunteers are
expected to have a clear understanding that the Department strictly prohibits any
type of sexual relationship with an individual under Department supervision and
considers such a relationship a serious breach of the standards of employee
conduct, and these relationships will not be tolerated.
Engaging in a romantic and/or sexual relationship may result in employment
termination and/or termination of the contractual or volunteer status, or imposition
of criminal charges.
115.377 (b)
The PAQ requires the facility to take appropriate remedial measures and 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.
The facility provided policy 1919 and interviews with the facility administrator.
In interview with the facility administrator he indicated that he has the authority to
take remedial measures to prohibit contractor of volunteer from entering the
centers In the case of any other violation of agency sexual abuse or sexual
harassment policies by a contractor or volunteer, the facility will take appropriate
remedial measures, and consider whether to prohibit further contact with residents,
however, would most likely prohibit them from further contact with residents.
At present, the center has one volunteer and 5 contractors at WAGC.
There have been no allegations of sexual abuse or sexual harassment involving
contractors and volunteers during the last 12 months.
Based on this analysis, the facility is substantially compliant with this provision, and
a corrective action is not required.
115.378 Interventions and disciplinary sanctions for residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 – Youth Disciplinary Action
Florida Statue section 985.701
FDJJ Intervention and Discipline
PAQ
Interview with
Facility Administrator
Random Residents
Mental Health staff
115.378 (a):
The PAQ requires that 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.
The facility provided Florida Statutes section 985.701 and FDJJ Policy 1919.
Florida Statutes section 985.701 makes certain acts of sexual misconduct between
a youth and a staff person a felony. A youth's consent to sexual acts with a staff
member is not a defense under this subsection of the law.
Youth must be allowed unimpeded access to report any allegation of misconduct or
neglect to the Florida Abuse Hotline operated by the Department of Children and
Families. Youth 18 years of age or older would call the CCC or local law enforcement
to report an allegation of abuse or neglect.
Youth shall be advised that any person who knowingly and willfully makes a false
report to the Florida Abuse Hotline or counsels another to make a false report is
guilty of a third-degree felony in accordance with Chapter 39.205, Florida Statutes.
Anyone reporting in good faith shall be immune from any civil or criminal liability.
A report of sexual misconduct made in good faith based upon a reasonable belief
that the alleged conduct occurred shall not constitute falsely reporting an incident,
even if an investigation does not establish sufficient evidence to substantiate the
allegation.
According to the PAQ, there were no administrative findings of resident sexual
abuse.
Youth must be allowed unimpeded access to report any allegation of misconduct or
neglect to the Florida Abuse Hotline operated by the Department of Children and
Families. Youth 18 years of age or older would call the CCC or local law enforcement
to report an allegation of abuse or neglect.
Youth shall be advised that any person who knowingly and willfully makes a false
report to the Florida Abuse Hotline or counsels another to make a false report is
guilty of a third-degree felony in accordance with Chapter 39.205, Florida Statutes.
Anyone reporting in a good faith shall be immune from any civil or criminal liability.
A report of sexual misconduct made in good faith based upon a reasonable belief
that the alleged conduct occurred shall not constitute falsely reporting an incident,
even if an investigation does not establish sufficient evidence to substantiate the
allegation.
Policy 1919 indicates that individuals in WAGC who are found guilty of engaging in
sexual abuse involving other individuals in the facility (either through administrative
or criminal investigations) will be subject to formal disciplinary sanctions. Sanctions
will be commensurate with the nature and circumstances of the abuse committed,
the individual’s disciplinary history, and the sanctions imposed for comparable
offenses by other individuals with similar histories.
The disciplinary process will consider whether an individual’s mental disabilities or
mental illness contributed to his or her behavior when determining what type of
sanction, if any, should be imposed. d. If the facility offers counseling or other
treatment interventions designed to address the reasons or motivations for the
abuse, the facility will consider requiring the offending individual to participate.
Disciplining an individual in an FDJJ facility for sexual contact with an employee is
prohibited unless it is found that the employee did not consent to the contact. A
report of sexual abuse made in good faith by an individual in an FDJJ facility, based
upon a reasonable belief that the alleged conduct occurred, will not constitute false
reporting or lying. g. Facilities may not deem that sexual activity between
individuals in an FDJJ facility is sexual abuse unless it is determined that the activity
was coerced.
The PREA Compliance Manager will receive copies of all disciplinary reports
regarding sexual activity, sexual harassment, and sexual abuse for monitoring
purposes. The incident will be reported to law enforcement unless the activity is
clearly not criminal.
115.378 (b):
The PAQ requires that 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.
The facility provided FDJJ Policy 1919, which indicates 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. Isolation will not be utilized for a
disciplinary sanction.
ROP Manual section 378 Intervention and Discipline of Residents mandates that any
disciplinary sanctions shall be commensurate with the nature and circumstances of
the abuse committed, the student’s disciplinary history, and the sanctions imposed
for comparable offenses by other students with similar histories. In the event a
disciplinary sanction results in the isolation of a student, programs shall not deny
the student daily large-muscle exercise or access to any legally required educational
programming or special education services. Students in isolation shall receive daily
visits from a medical or mental health care clinician. Students shall also have access
to other programs and work opportunities to the extent possible
115.378 (c):
The PAQ requires the disciplinary process to 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 facility provided FDJJ Policy 1919, which indicates 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.
WAGC 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. The interview with the Clinical
Director and facility administrator confirmed this.
ROP Manual section 378 Intervention and Discipline of Residents indicates the
disciplinary process shall consider whether a student’s mental disabilities or mental
illness contributed to his or her behavior when determining what type of sanction, if
any, should be imposed.
Medical and Mental health staff interviews indicated they are contacted and provide
intervention services for residents for all behavioral reports.
115.378 (d):
The PAQ requires that, if the facility offers therapy, counseling, or other
interventions designed to address and correct the 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 of access to
general programming or education.
In interviews with the clinical director, the center does not have a formal sexual
abuse treatment program; it does have licensed mental health professionals who
would provide counseling and other intervention services. However, the center is
part of the FDJJ continuum of care. It would provide information to community
partners, such as Juvenile Probation Officers, for consideration of whether to offer
the offending resident participation in one of the State’s Sexual Offender programs.
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 of access to general programming or education.
The WAGC does not house a sex offender resident. Its mission is to provide services
for Substance Abuse and mental health services.
115.378 (e):
The PAQ requires that 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.
The facility provided FDJJ Policy 1919, which indicates 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.
ROP Manual section 378 Intervention and Discipline of Residents indicates the
program will discipline a student for sexual contact with staff only upon a finding
that the staff member did not consent to such contact.
115.378 (f):
The PAQ requires, for 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 facility provided FDJJ Policy 1919, which states that, for disciplinary action, a
report of sexual abuse made in good faith, based on 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. Investigating PREA Allegations states that 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.
ROP Manual section 378 Intervention and Discipline of Residents indicates that 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.
115.378 (g):
The PAQ requires that 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.
The facility provided FDJJ Policy 1919, which indicates WAGC prohibits 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.
Residents interviewed indicated they were provided the orientation in which they
were told it was against the rules to participate in any sexual misconduct. They
would be disciplined for any sexual abuse, sexual harassment, or sexual
misconduct. Most indicated that they are reminded of their duty to hold each other
responsible for maintaining a safe environment for all residents. The statement of
fact indicated that during this audit period, this facility has not had any incidents
that require intervention for residents engaging in sexual conduct.
Based on t
115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Exceeds Standard
Auditor Discussion
Evidence relied upon in making a compliance determination
FDJJ Policy 1919 – MH and Medical Screening
ROP Policy 3.03 MHSA Intake and Screening
ROP Policy 2.04 Assessment and Screening
MAYSI Referral
Crisis Assessment
Screening referrals to Mental Health Staff
ROP Safe Environment Standards (PREA)
WAGC Trifold Safe Environment Standards Brochure
Interviews
Staff who conduct screenings
Medical and Mental Health Interviews
115.381 (a)
The PAQ required that 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.
The facility provided FDJJ Policy 1919, which indicates that the department's
screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
shall be completed in JJIS, an information portal for all juveniles housed in State or
privately operated facilities.
Staff shall ensure that any report of sexual abuse obtained during screening, that
has not been previously reported, is immediately reported to the Central
Communications Center (CCC), the Department of Children and Families (DCF),
Florida Abuse Hotline, and local law enforcement.
If any of the intake screening forms indicate that a resident has experienced prior
sexual victimization, whether it occurred in an institutional setting or in the
community, the facility administrator or other intake officer shall document the
information on the Follow-up Notification Form. If the resident makes the notification
during the Juvenile Assessment Center, the center will send a referral along with the
VSAB to the intake staff when the resident is transported to the center.
According to the clinical director, the Florida Department of Juvenile Justice
forwards copies of the VSAB and related documentation before the youth arrives at
the center. The clinical director assigns a therapist to conduct another VSAB along
with additional evaluations as soon as the resident arrives at the center. The clinical
director sees any youth who has a history of being victimized during the intake
process. The screening staff documents and forwards a follow-up notification form.
Mental health staff were interviewed. There were no residents who claimed a history
of sexual victimization at the center during the last 12 months.
In interviews with random residents, all indicated that they see medical and mental
health services during intake at the center.
115.381 (b)
The PAQ requires that 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.
The facility provided policy 1919, which indicates that if any of the intake screening
forms indicate a resident has previously perpetrated sexual abuse, whether it
occurred in an institutional setting or in the community, staff ensure that the
resident is offered a follow-up meeting with a mental health practitioner within 14
days of the intake screening. This same information is discussed with the clinical
staff within 72 hours of intake.
The center has brochures and postings educating residents on mental health
services for victims of sexual abuse or exploitation. Staff at the center verified that
the program reaches out to allow residents to speak with the Emerald Coast
Children's Advocacy Center for emotional support staff.
Whenever the VSAB or related documentation, such as charging offenses, history, or
information reviewed during the intake process, is used, an Alert Program is utilized
to make referrals to mental health or other services based on this alert system.
At WAGC, the center uploads the information into the Florida Department of Juvenile
Justice portal, and the clinical director is immediately notified and interviews the
residents on the same day.
115.381 (c):
The PAQ requires any information related to sexual victimization or abusiveness that
occurred in an institutional setting that 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 facility provided policy 1919, which requires any information related to sexual
victimization or abuse that occurred in an institutional setting shall be strictly
limited to medical and mental health practitioners and other staff, as necessary, to
develop treatment plans and security and management decisions, including
housing, bedding, education, and or as otherwise required by Federal, State, or
Local law.
115.381 (d):
The PAQ requires medical and mental health practitioners to 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.
Interviews with the medical and mental health staff confirmed that, when a youth
arrives at the facility, they are informed of their duty to report. If the resident is 18
or older, the medical and mental health staff have them sign an informed consent
before reporting prior sexual victimization that did not occur in an institutional
setting.
Medical and mental health staff are required to notify residents at the initiation of
services of their duty to report, limitations of confidentiality, and residents’ informed
consent from youth who are 18 years old or older before reporting information
about the resident’s prior sexual victimization that did not occur in an institutional
setting. Residents who report prior incidents of perpetrating sexual abuse, either in
an institution or in the community, are required to be offered a follow-up with a
medical or mental health practitioner within 14 days of admission/screening.
Compliance was determined by reviewing the agency policy and interviewing
medical and mental health staff.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.382 Access to emergency medical and mental health services
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making a compliance determination
FDJJ Policy 1919 – MH and Medical Screening
Crisis Assessment
Treatment Plan
Partnership Agreement with Victim Services
115.382 (a)
The PAQ requires that resident victims of sexual abuse receive timely, unimpeded
access to emergency medical treatment and crisis intervention services, the nature
and scope of which are determined by medical and mental health practitioners
according to their professional judgment.
The facility provided Policy 1919 and Emerald Coast Victim Service (ECVS)
The Policy 1919 states residents will receive timely, unimpeded access to on-site
and off-site 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. All services for residents are
provided at no cost.
In interviews with the medical and mental health staff, all services they provide are
based on their professional judgement. If a resident returns from a SANE evaluation,
the center medical staff indicated they would verify the discharge order with
the ROP clinical director and provide services as advised.
The facility has a Partnership agreement with ECVS and uses HCA Florida Fort
Walton - Destin Hospital for emergency treatment. In an interview
with the staff of Victim Services, the program has a Forensic Team that conducts
SANE and forensic Interviews. Their victim advocates are available during any
forensic examination and continue to advocate for the victim after the forensic
Examination is concluded.
PREA Response Plan Following Resident Report 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 judgment of medical and mental health professionals. Interviews
with medical and mental health staff confirmed that emergency medical care and
crisis intervention services will be provided as required. Observations revealed that
medical and mental health staff members maintain secondary materials that
document services to residents, and these staff members 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 that treatment services will
be provided at no cost to the victim, whether or not the victim cooperates with the
investigation.
Medical and mental health services shall be provided to the victims consistent
with the community level of care. Resident victims of sexual abuse shall be offered
tests for sexually transmitted infections as medically appropriate. Treatment
services shall be provided to the victim without financial cost and regardless of the
victim’s name, the abuser, or cooperation with any investigation of the incident.
115.382 (b):
The PAQ requires that 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 facility provided policy 1919 and a coordinated response plan.
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. They shall immediately notify the
appropriate medical and mental health practitioners. The interviews with clinical
staff revealed that residents have unimpeded access to emergency services. The
coordinated response plan flow chart guides staff in protecting residents and
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 numbers. A medical staff
member is on-call 24/7 as determined by the interview. Interviews with
Emerald Coast Victim Service indicated that on-call SAFE staff is available 24/7 for
forensic examinations. There is also a Victim Advocate on call 24/7 to support a
resident who has been sexually assaulted.
115.382 (c):
The PAQ requires that 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 facility provided policy 1919 and an interview with medical and mental health
staff.
Policy 1919 indicates that 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. All residents are provided
with access to infection prophylaxis upon arrival at the facility. In interviews with the
medical staff, they indicated that the SANE program would provide the services.
However, they would reinstate the services upon the resident's return to the center.
Medical staff 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. According to the medical staff, all residents are educated on sexually
transmitted infections as part of the intake process and offered medical services as
required or requested.
115.382 (d):
The PAQ requires that treatment services 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 facility provided the Policy 1919 and the PREA Response Plan, in accordance
with the Resident Report mandates that treatment services be provided to the
victim at no 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. The policy revealed emergency services will be
provided by medical and mental health staff.
The medical and mental health staff interviews revealed they are knowledgeable
about actions to take regarding an incident of sexual abuse. It is documented
through policy and understood by the medical and mental health staff that
treatment services will be provided at no cost to the victim.
Based on the review of policies, interviews with the medical and mental health staff,
and interviews with staff from Emerald Coast County Victim Service, this standard is
met.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
Ongoing medical and mental health care for sexual abuse victims
115.383
and abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
Statement of Fact
FDJJ Policy 1919 PREA – Ongoing Medical and Mental Health Services
Interview with
Medical Staff
Mental Health Staff
Emerald Coast Victim Services Partnership Agreement with Victim Services
115.383 (a):
The PAQ requires 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.
The facility provided the FDJJ Policy 1919 PREA – Ongoing Medical and Mental Health
Services and Partnership Agreement with Emerald Coast Victim Services.
Policy 1919 indicates 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.
The medical and mental health staff indicated in the interview that the facility
would provide treatment, as prior victimization can be part of the treatment needed
for recovering youth. The facility makes a referral to mental health for anyone who
provides information on prior victimization or past predator behavior to comply with
the standard. However, the clinical director indicated that all residents who go
through intake at the facility are seen by their assigned therapist as soon as they
arrive at the center.
Emerald Coast Victim Service provides ongoing mental health counseling services
for residents assigned from their geographic location and makes referrals to the
Florida Coalition against sexual victimization.
According to interviews with the mental health and medical staff, when a resident
goes out for medical care, the center receives a discharge summary from the
provider. Medical notifies the medical clinical director to continue the services, or
the physician will come to the center and review the discharge summary, examine
the resident, and create an additional care plan. The mental health staff will notify
the psychologist or psychiatrist if the resident is prescribed medication and will
develop a treatment plan in consultation with these providers. The mental health
staff indicated they would also contact the PBCVS to access additional services.
115.383 (b):
The PAQ requires that 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.
The facility provided the Facility PREA Response Plan Following Resident Report
includes a provision that 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 that ongoing medical and mental health care will be provided as
appropriate, including, but not limited to, additional testing and medical services;
medication management, if prescribed; individual counseling; a trauma group; and
referrals as needed. Emerald Coast Victim Service would provide residents with
support programs upon release from the center, or provide information and arrange
a transfer to a certified victim advocacy program within the Florida Coalition of
Victim Services in other areas of Florida for emotional support.
115.383 (c):
The PAQ requires that the facility provide such victims with medical and mental
health services consistent with the community level of care.
Based on interviews with the medical and mental health staff, the facility shall
provide victims with medical and mental health services consistent with the
community level of care. The medical staff indicated that the center has medical
staff on duty or on call twenty-four hours a day and has professional agreements
with specialist medical providers. Mental health staff are on duty 12 hours a day and
on call 24 hours a day. The center has an MOU with Emerald Coast Victim Service to
provide SANE, victim advocate, and emotional support staff 24 hours a day.
115.383 (d-e):
The PAQ requires that resident victims of sexually abusive vaginal penetration while
incarcerated shall be offered pregnancy tests.
The WAGC program is an all-male center.
115.383 (f)
The PAQ requires that resident victims of sexual abuse while incarcerated shall be
offered tests for sexually transmitted infections as medically appropriate.
The facility provided policy 1919 and interviews with medical staff ensure that
victims of sexual abuse will be provided tests for sexually transmitted infections as
medically appropriate. Testing would be done at the local hospital, and follow-up
services may be done at the facility, as needed. The center medical staff indicated
that all residents are offered testing for STD upon arrival and would continue to
provide that service as part of the aftercare following a SANE or SAFE evaluation.
115.383 (g)
The PAQ requires that treatment services 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.
Policy 1919 indicates that all treatment services will be provided at no cost to the
victim.
115.383 (h)
The PAQ requires the facility to 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.
Services will include, but not be limited to, individual, group, and family counseling.
Additionally, an evaluation or reassessment will be administered utilizing
Vulnerability Assessment.
Any resident who makes an allegation of past victimization is allowed to call the
ECVS, and staff from the program will go to the facility to meet with the resident
and offer their services when released from the center. According to the Emerald
Coast Victim Service, it will coordinate with the WAGC clinical director to arrange
subsequent follow-up meetings with WAGC youth who have used the Hotline to
request follow-up services or emotional support.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.386 Sexual abuse incident reviews
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 – Incident Reviews Incident
Statement of Fact
Review Meeting reports
Interviews with
Incident Review Team
PREA Compliance Manager,
Facility Director
115.386 (a):
The PAQ requires the facility shall conduct a sexual abuse incident review at the
conclusion of every sexual abuse investigation, including where the allegation has
not been substantiated, unless the allegation has been determined to be
unfounded.
The facility provided policy 1919 and the Facility PREA Response Plan, following the
Resident Report.
Policy 1919 and the Facility response plan require an incident review team meeting
within 30 days of the conclusion of each investigation unless the finding is
unfounded. The policy mandates team participation, including the agency-wide
PREA Coordinator, the facility’s PREA Compliance Manager, the facility
administrator, and medical and mental health staff. There were two allegations of
sexual abuse during the last 12 months. One allegation was unfounded, and one
was unsubstantiated. An Incident Review Team reviewed each allegation and
completed an incident review report.
The interview with the PREA Compliance Manager 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.
115.386 (b):
The PAQ requires that such a review shall ordinarily occur within 30 days of the
conclusion of the investigation.
The Agency policy requires that the reviews occur within 30 days of the conclusion
of the investigation. There has been no allegation of sexual abuse that required an
IRT meeting.
115.386 (c):
The PAQ requires the review team shall include upper-level management officials,
with input from line supervisors, investigators, and medical or mental health
practitioners.
The policy mandates team participation to include the agency wide PREA
Coordinator, the facility’s PREA Compliance Manager, facility administrator, and
medical and mental health staff.
115.386 (d):
The PAQ requires 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 facility provided a copy of an incident review form. The form included the
following: 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.
A member of the incident review team confirmed that all areas identified above are
reviewed in completing an incident review.
The Florida PREA Coordinator interviewed indicated that he schedules the review
team meetings and includes the regional supervisor in the notification. 115.386 (e):
The PAQ requires 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 Facility Administrator and review of documentation
confirmed that the incident review team meetings are documented, including
recommendations, and that the document was provided to the Facility
Administrator, who serves as the PREA compliance manager for the center.
The interview with the Incident Review Team Member and review of the Incident
Review form confirmed that the facility prepared a report of its findings and any
recommendations for improvement when conducting a sexual abuse incident
review.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination.
FDJJ 2020 - Incident Operations Center.
PREA FY 2024-2025 Annual Report
FDJJ 1919 Data Collection
115.387 (a)(b):-
The PAQ requires 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 PAQ requires the agency shall collect accurate, uniform data for every
allegation of sexual abuse at The agency shall aggregate the incident-based sexual
abuse data at least annually.
The facility provided policy 1919, Data Collection; policy 2020, Operations Center;
and the PREA FY 24-25 Annual Report.
Policy 1919 Data Requires
1. The Department shall collect uniform data in the CCC for every allegation of
sexual misconduct at its facilities, both state-operated and those with contracted
providers. Incident-based sexual misconduct data shall be aggregated at least
annually.
2. The PREA Statewide Coordinator will review data collected and aggregated
in115.387 (a)(b):-
The PAQ requires 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 PAQ requires the agency shall collect accurate, uniform data for every
allegation of sexual abuse at The agency shall aggregate the incident-based sexual
abuse data at least annually.
The facility provided policy 1919, Data Collection; policy 2020, Operations Center;
and the PREA FY 24-25 Annual Report.
Policy 1919 Data Requires
1. The Department shall collect uniform data in the CCC for every allegation of
sexual misconduct at its facilities, both state-operated and those with contracted
providers. Incident-based sexual misconduct data shall be aggregated at least
annually.
2. The PREA Statewide Coordinator will review data collected and aggregated
in115.387 (a):
order to assess and improve the effectiveness of the Department’s sexual
misconduct prevention, detection, and response policies, practices, and training.
3. The Department’s PREA Statewide Coordinator will prepare an annual report of
sexual misconduct incidents, findings, and corrective actions for all facilities, state
and contracted, and the Department as a whole. The report will include a
comparison of the current year’s data and corrective actions with those from prior
years and shall provide an assessment of the agency’s progress in addressing
sexual misconduct. The report will be reviewed and approved by the Secretary and
be made readily available to the public through the agency’s website. Information
that may present a clear and specific threat to the safety and security of a facility
may be redacted but must indicate the nature of the information redacted.
4. Reports will be maintained in accordance with State of Florida record retention
schedules. All data collected will be maintained for at least 10 years after the date
of the initial collection.
5. Upon request, the PREA Statewide Coordinator will provide all sexual misconduct
data collected in the CCC to the Department of Justice no later than June 30 of each
year.
During the 2024 through 2025 fiscal year, there were a total of 162 allegations of
sexual abuse or sexual harassment for the State of Florida. This makes up 2.7% of
reporting to the central communication center.
WAGC had five allegations of sexual abuse or sexual harassment. One allegation for
sexual abuse was unfounded, one allegation for sexual abuse was unsubstantiated.
One allegation of sexual harassment was unsubstantiated (for information only)
and two sexual harassment allegations investigations are ongoing.
A review of reports confirms that FDJJ collects incident-based, uniform data
regarding allegations of sexual abuse at facilities under its direct control, including
contractors, using a standardized instrument and specific guidelines. The format
used for FDJJ facilities captures the information required to complete the most
recent version of the Survey of Sexual Violence conducted by the U. S. Department
of Justice (DOJ). FDJJ maintains and collects various types of identified data and
related documents regarding sexual abuse incidents. The facility collects and
maintains data in accordance with FDJJ directives. FDJJ aggregates the sexual abuse
data, which culminates in an annual report. The agency provides the requested data
to the DOJ.
115.387 (c):
The PAQ requires that 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.
The format used for FDJJ facilities captures the information required to complete the
most recent version of the Survey of Sexual Violence conducted by the U.S.
Department of Justice (DOJ)
115.387 (d):
The PAQ requires 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 PREA data and related
documents. The facility collects and maintains data in accordance with Policy 2020
Incident Operation Center directives.
115.387 (e):
The PAQ also requires the agency to obtain incident-based and aggregated data
from every private facility with which it contracts for the confinement of its
residents.
The facility Policy 1919 requires the department to collect uniform data in the CCC
for every allegation of sexual misconduct at its facilities, both state-operated and
those with contracted providers. Incident-based sexual misconduct data shall be
aggregated at least annually. The format used for FDJJ facilities and contractors
captures the information required to complete the most recent version of the Survey
of Sexual Violence conducted by the U.S. Department of Justice (DOJ). Private
facilities are required to follow the same PREA policies and procedures and to report
information under the same basic requirements as State-operated facilities. Walton
Academy for Growth and Change is a privately operated center.
115.387 (f):
The PAQ requires, upon request, that the agency shall provide all such data from the
previous calendar year to the Department of Justice no later than June 30
FDJJ policy mandates that upon request, FDJJ 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 in the prior calendar year.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
A review of reports confirms that FDJJ collects incident-based, uniform data
regarding allegations of sexual abuse at facilities under its direct control, including
contractors, using a standardized instrument and specific guidelines. The format
used for FDJJ facilities captures the information required to complete the most
recent version of the Survey of Sexual Violence conducted by the U. S. Department
of Justice (DOJ). FDJJ maintains and collects various types of identified data and
related documents regarding sexual abuse incidents. The facility collects and
maintains data in accordance with FDJJ directives. FDJJ aggregates the sexual abuse
data, which culminates in an annual report. The agency provides DOJ with the
requested data.
115.387 (c):
The PAQ requires that 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.
The format used for FDJJ facilities captures the information required to complete the
most recent version of the Survey of Sexual Violence conducted by the U.S.
Department of Justice (DOJ)
115.387 (d):
The PAQ requires 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 2020 Incident Operation Center directives.
115.387 (e):
The PAQ also requires the agency to obtain incident-based and aggregated data
from every private facility with which it contracts for the confinement of its
residents.
The facility Policy 1919 requires the department to collect uniform data in the CCC
for every allegation of sexual misconduct at its facilities, both state-operated and
those with contracted providers. Incident-based sexual misconduct data shall be
aggregated at least annually. The format used for FDJJ facilities and contractors
captures the information required to complete the most recent version of the Survey
of Sexual Violence conducted by the U. S. Department of Justice (DOJ). Private
facilities are required to follow the same PREA policies and procedures and to report
the same information on the same basic level as State-operated facilities. WAGC is a
privately operated facility.
115.387 (f):
The PAQ requires, upon request, that the agency provide all such data from the
previous calendar year to the Department of Justice no later than June 30
FDJJ policy mandates that upon request, FDJJ 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.
Based on this analysis, the facility is substantially compliant with this provision and
corrective action is not required.
115.388 Data review for corrective action
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 – Data Collection
PREA FY 2022-23 Annual Report
PREA FY 23-=24 Annual Report
PREA Compliance Manager
115.388 (a)(b):
The PAQ requires The agency shall review data collected and aggregated pursuant
to § 115.387 to assess and improve the effectiveness of its sexual abuse prevention,
detection, and response policies, practices, and training, including: (1) Identifying
problem areas; (2) Taking corrective action on an ongoing basis; and (3) Preparing
an annual report of its findings and corrective actions for each facility, as well as the
agency as a whole.
Such a report shall include a comparison of the current year's data and corrective
actions with those from prior years and shall provide an assessment of the agency's
progress in addressing sexual abuse.
Annual PREA Report for fiscal year 23-24 and FDJJ Policy 1919 – Data Collection
recognizes the purpose of conducting annual reports and annual PREA assessments
are to review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and
response policies, practices, and training, including by: Identifying problem areas 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. Further to assess and improve the effectiveness of its sexual abuse
prevention, detection, and response policies, practices, and training, including by
preparing an annual report on its findings and corrective actions for each facility and
for the agency as a whole.
The annual report includes data collected in 23-24 and 24-25. The report included
the following narrative. “The most recent year’s data shows there were 95 PREA-
related allegations reported to the CCC in Fiscal Year 2023-2024. The previous
year’s data show that there were 70 and 80 PREA-related allegations reported to the
CCC, respectively. The FDJJ has a zero-tolerance policy for sexual abuse and sexual
harassment, which has led to a healthy reporting culture where staff and youth
know that reporting sexual abuse and sexual harassment will be taken seriously and
investigated thoroughly.
The Florida Agency Head indicated that the agency compares reports to review
policies and enhance training. The PREA coordinator is involved in all tenets of PREA
and takes the lead in policy and training initiatives.
According to an interview with the ROP agency head, we use the information to
improve operations across all our facilities. We receive the information every month
and review each center's reports. We review performance and identify problematic
areas in operations. We look at times, dates, staffing, programming, changes in
administrations, and are very proactive in conducting a review of all data we receive
from the center, the contracting agency, and the public, such as parents’ concerns.
We look at our website to see what the mass media are reporting. We have 7
regional directors who meet as a team quarterly to review all of our reports and
determine whether we need to implement a strategic plan to ensure the safety of
our staff and students.
I review and the agency at a leadership review, approve the after-action plan, and
sign off on the final report.
The Florida DJJ PREA Coordinator indicated in the interview that Data is collected
through the Central Communication Center (CCC), where information from all
incidents is reported and maintained. The PREA Statewide Coordinator prepares an
annual report, complete with current and previous PREA data from all residential
and detention facilities operated and contracted by the FDJJ. The annual reports are
made available through the FDJJ PREA webpage. Youth and staff identifying
information is not included in the annual report.
The ROP PREA coordinator maintains the information on specific “drives” that
require password access, so not everyone has access to this information. ROP
consistently analyzes its systems and practices to ensure they function as they
should. Adjustments are made based on incident data, survey feedback, and other
information sources.
These reports are available on the agency website and on individual campus
websites.
In the reports, no specific identifying information is made available to the public
regarding who was involved in any matter. It is specified that this information is not
included in the report for HIPAA and other privacy considerations.
The WAGC PREA Compliance Manager interviewed said he is involved in reviewing
the annual report and making recommendations in developing a corrective action
plan when indicated.
115.388 (c):
The PAQ requires that the agency's report be approved by the agency head and
made readily available to the public on the agency's website or, if it does not have
one, through other means.
The annual report is reviewed by the PREA coordinator, his supervisor, and agency
leadership staff and signed by the Agency Head. It is then uploaded to the Florida
Department of Juvenile Justice at https://www.djj.state.fl.us/partners-providers-staff/
prison-rape-elimination-act-prea.
115.388 (d):
The PAQ requires the agency to redact specific material from the reports when
publication would present a clear and specific threat to the safety and security of a
facility but must indicate the nature of the material redacted.
FDJJ Policy 1919 states that all information placed on the website will not include
personal identities. The annual report has been reviewed and is accessible to the
public on the facility’s website. There are no personal identifiers in the annual
report.
Based on an interview with the PREA coordinator, the youth and staff identifying
information is not included in the annual report.
Compliance was determined by reviewing data collections for the preceding three
years and reviewing the FDJJ website.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination: DJJ Policy 1316 –
Records and Information Management Procedures
115.389 (a)(b):
The PAQ requires the agency shall ensure that data collected pursuant to § 115.387
are securely retained.
The agency shall make all aggregated sexual abuse data from facilities under its
direct control and private facilities with which it contracts readily available to the
public at least annually through its website or, if it does not have one, through other
means.
The agency provided the Florida Department of Juvenile Justice Policy 1316 Records
and Information Management Procedures.
The Florida Department of Juvenile Justice- Records and Information Management
Procedures requires the collection of data through the CCC for every allegation of
sexual misconduct that occurs in its state-operated detention centers and its
contracted residential facilities. All collected data is maintained for ten years 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 to post the report there. A review of
the annual report verified that there are no personal identifiers, and it was observed
to be posted on the website, as required. Related documentation in the facility was
securely stored.
The PREA Coordinator indicated in the interview that Data is collected through the
Central Communication Center (CCC), where information from all incidents is
reported and maintained. The PREA Statewide Coordinator prepares an annual
report, complete with current and previous PREA data from all residential and
detention facilities operated and contracted by the FDJJ. The annual reports are
made available through the FDJJ PREA webpage. Youth and staff identify that
information is not included in the annual report.
THE ROP PREA coordinator indicated the center must report all incidents to the
Central Communication Center, the ROP PREA coordinator, and the ROP regional
director. ROP uses the Florida DJJ to prepare the annual report under the contract
with the Florida Department of Juvenile Justice.
Compliance was determined by reviewing the website and interviewing with the
agency's PREA coordinator.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.401 Frequency and scope of audits
Auditor Overall Determination: Meets Standard
Auditor Discussion
Evidence relied upon in making the compliance determination
FDJJ Policy 1919 PREA
PREA Audit 2014
PREA Audit 2017
PREA Audit 2020
PREA Audit 2023
115.401 (a)(b):
The PAQ requires that during the three-year period starting on August 20, 2013, and
during every three years thereafter, the agency shall ensure that each facility
operated by the agency, or by a private organization on behalf of the agency, is
audited at least once.
The agency shall ensure that at least one-third of each facility type operated by the
agency, or by a private organization on behalf of the agency, is audited.
The facility provided the FDJJ Policy 1919, which requires all DJJ facilities be audited
every three years for compliance with the Prison Rape Elimination Act.
The initial PREA audit of Walton Academy for Growth and Change was conducted in
December 2014 by a DOJ-certified PREA auditor. The second audit was conducted in
December 2027 by a certified PREA auditor. The third audit of the facility was
conducted in November 2020. The fourth audit was conducted in February 2023.
The on-site audit for the present audit was conducted in February 2026.
115.401 (h):
The PAQ requires the auditor shall have access to, and shall observe, all areas of the
audited facilities.
During the audit, I was allowed access to all areas of the Facility. I was allowed to
visit areas throughout the facility during the official tour and during additional visits
to different areas to interview and observe camera locations. There were no
limitations on interviewing staff or residents, and no obstacles in conducting tours
during waking and sleeping hours.
115.401 (i):
The PAQ requires that the auditor be permitted to request and receive copies of any
relevant documents (including electronically stored information).
I requested personnel files, resident files, training records, investigation files,
logbooks, and pertinent forms used to fulfill the audit requirements. Each document
was provided on a timely basis.
115.401 (m):
The PAQ requires that the auditor be permitted to conduct private interviews with
residents.
I interviewed random staff on duty for the first 24 hours of the audit and a random
sample of residents during the on-site audit. Interviews were conducted in a private
area (a conference room) at the facility. No residents declined to be interviewed.
115.401 (n):
The PAQ requires residents shall be permitted to send confidential information or
correspondence to the auditor in the same manner as if they were communicating
with legal counsel.
Postings were displayed throughout the facility with the name and address of the
PREA auditor. The auditor did not receive any correspondence from residents. The
information was posted on December 22, 2025. The auditor interviewed the PREA
Compliance Manager and asked whether residents were allowed to send mail to the
auditor through the same legal mail system. He indicated they were and provided
that, as a resident, you just place mail in the information box, and the staff will
stamp it and mail it. He indicated that unless requested by the court or community
case manager, the center does not read mail. They just put a stamp on it and send
it. The PREA Compliance manager indicated that he or the clinical director checks
the drop boxes at least twice a day during the week and at least once on weekends.
Compliance was determined by reviewing four past audits, email providing dates of
audit postings, and interviews with the Facility Administrator, PREA Coordinator, and
Agency Head designee.
Based on this analysis, the facility is substantially compliant with this provision, and
corrective action is not required.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
This is fifth PREA audit for this facility. The initial PREA audit of Walton Academy for
Growth and Change was conducted in December 2014 by a DOJ certified PREA
auditor. The second audit was conducted in December 2027 by a certified PREA
auditor. The third audit of the facility was conducted in November 2020. The fourth
audit was conducted in February 2023. The on-site audit occurred for the present
audit was conducted in February 2026.
Each audit was conducted by a certified PREA auditor and were located on the
agency website at https://www.djj.state.fl.us/partnersproviders-staff/prison-rape-e-
limination-act-prea.
Appendix: Provision Findings
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(a) coordinator
Does the agency have a written policy mandating zero tolerance yes
toward all forms of sexual abuse and sexual harassment?
Does the written policy outline the agency’s approach to yes
preventing, detecting, and responding to sexual abuse and sexual
harassment?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(b) coordinator
Has the agency employed or designated an agency-wide PREA yes
Coordinator?
Is the PREA Coordinator position in the upper-level of the agency yes
hierarchy?
Does the PREA Coordinator have sufficient time and authority to yes
develop, implement, and oversee agency efforts to comply with
the PREA standards in all of its facilities?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(c) coordinator
If this agency operates more than one facility, has each facility yes
designated a PREA compliance manager? (N/A if agency operates
only one facility.)
Does the PREA compliance manager have sufficient time and yes
authority to coordinate the facility’s efforts to comply with the
PREA standards? (N/A if agency operates only one facility.)
115.312
Contracting with other entities for the confinement of residents
(a)
If this agency is public and it contracts for the confinement of its na
residents with private agencies or other entities including other
government agencies, has the agency included the entity’s
obligation to adopt and comply with the PREA standards in any
new contract or contract renewal signed on or after August 20,
2012? (N/A if the agency does not contract with private agencies
or other entities for the confinement of residents.)
115.312
Contracting with other entities for the confinement of residents
(b)
Does any new contract or contract renewal signed on or after na
August 20, 2012 provide for agency contract monitoring to ensure
that the contractor is complying with the PREA standards? (N/A if
the agency does not contract with private agencies or other
entities for the confinement of residents OR the response to
115.312(a)-1 is "NO".)
115.313
Supervision and monitoring
(a)
Does the agency ensure that each facility has developed a staffing yes
plan that provides for adequate levels of staffing and, where
applicable, video monitoring, to protect residents against sexual
abuse?
Does the agency ensure that each facility has implemented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility has documented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
prevalence of substantiated and unsubstantiated incidents of
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Generally accepted juvenile detention and correctional/secure
residential practices?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
judicial findings of inadequacy?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from Federal investigative agencies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from internal or external oversight bodies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: All
components of the facility’s physical plant (including “blind-spots”
or areas where staff or residents may be isolated)?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
composition of the resident population?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
number and placement of supervisory staff?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Institution programs occurring on a particular shift?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
applicable State or local laws, regulations, or standards?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
other relevant factors?
115.313
Supervision and monitoring
(b)
Does the agency comply with the staffing plan except during yes
limited and discrete exigent circumstances?
In circumstances where the staffing plan is not complied with, na
does the facility fully document all deviations from the plan? (N/A
if no deviations from staffing plan.)
115.313
Supervision and monitoring
(c)
Does the facility maintain staff ratios of a minimum of 1:8 during yes
resident waking hours, except during limited and discrete exigent
circumstances? (N/A only until October 1, 2017.)
Does the facility maintain staff ratios of a minimum of 1:16 during yes
resident sleeping hours, except during limited and discrete
exigent circumstances? (N/A only until October 1, 2017.)
Does the facility fully document any limited and discrete exigent yes
circumstances during which the facility did not maintain staff
ratios? (N/A only until October 1, 2017.)
Does the facility ensure only security staff are included when yes
calculating these ratios? (N/A only until October 1, 2017.)
Is the facility obligated by law, regulation, or judicial consent no
decree to maintain the staffing ratios set forth in this paragraph?
115.313
Supervision and monitoring
(d)
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The staffing plan established
pursuant to paragraph (a) of this section?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: Prevailing staffing patterns?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The facility’s deployment of
video monitoring systems and other monitoring technologies?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The resources the facility has
available to commit to ensure adherence to the staffing plan?
115.313
Supervision and monitoring
(e)
Has the facility implemented a policy and practice of having yes
intermediate-level or higher-level supervisors conduct and
document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? (N/A for non-secure facilities )
Is this policy and practice implemented for night shifts as well as yes
day shifts? (N/A for non-secure facilities )
Does the facility have a policy prohibiting staff from alerting other yes
staff members that these supervisory rounds are occurring, unless
such announcement is related to the legitimate operational
functions of the facility? (N/A for non-secure facilities )
115.315
Limits to cross-gender viewing and searches
(a)
Does the facility always refrain from conducting any cross-gender yes
strip or cross-gender visual body cavity searches, except in
exigent circumstances or by medical practitioners?
115.315
Limits to cross-gender viewing and searches
(b)
Does the facility always refrain from conducting cross-gender pat- yes
down searches in non-exigent circumstances?
115.315
Limits to cross-gender viewing and searches
(c)
Does the facility document and justify all cross-gender strip yes
searches and cross-gender visual body cavity searches?
Does the facility document all cross-gender pat-down searches? yes
115.315
Limits to cross-gender viewing and searches
(d)
Does the facility implement policies and procedures that enable yes
residents to shower, perform bodily functions, and change clothing
without nonmedical staff of the opposite gender viewing their
breasts, buttocks, or genitalia, except in exigent circumstances or
when such viewing is incidental to routine cell checks?
Does the facility require staff of the opposite gender to announce yes
their presence when entering a resident housing unit?
In facilities (such as group homes) that do not contain discrete na
housing units, does the facility require staff of the opposite gender
to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions,
or changing clothing? (N/A for facilities with discrete housing
units)
115.315
Limits to cross-gender viewing and searches
(e)
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.315
Limits to cross-gender viewing and searches
(f)
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.316 Residents with disabilities and residents who are limited
(a) English proficient
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are deaf or hard of hearing?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are blind or have low vision?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have intellectual disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have psychiatric disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have speech disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Other? (if "other," please explain in overall determination notes.)
Do such steps include, when necessary, ensuring effective yes
communication with residents who are deaf or hard of hearing?
Do such steps include, when necessary, providing access to yes
interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any
necessary specialized vocabulary?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
intellectual disabilities?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
limited reading skills?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Who are
blind or have low vision?
115.316 Residents with disabilities and residents who are limited
(b) English proficient
Does the agency take reasonable steps to ensure meaningful yes
access to all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment to residents
who are limited English proficient?
Do these steps include providing interpreters who can interpret yes
effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary?
115.316 Residents with disabilities and residents who are limited
(c) English proficient
Does the agency always refrain from relying on resident yes
interpreters, resident readers, or other types of resident assistants
except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s
safety, the performance of first-response duties under §115.364,
or the investigation of the resident’s allegations?
115.317
Hiring and promotion decisions
(a)
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has engaged in sexual
abuse in a prison, jail, lockup, community confinement facility,
juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been convicted of
engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or
coercion, or if the victim did not consent or was unable to consent
or refuse?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been civilly or
administratively adjudicated to have engaged in the activity
described in the bullet immediately above?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has
engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as
defined in 42 U.S.C. 1997)?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
convicted of engaging or attempting to engage in sexual activity
in the community facilitated by force, overt or implied threats of
force, or coercion, or if the victim did not consent or was unable to
consent or refuse?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
civilly or administratively adjudicated to have engaged in the
activity described in the two bullets immediately above?
115.317
Hiring and promotion decisions
(b)
Does the agency consider any incidents of sexual harassment in yes
determining whether to hire or promote anyone, or to enlist the
services of any contractor, who may have contact with residents?
115.317
Hiring and promotion decisions
(c)
Before hiring new employees who may have contact with yes
residents, does the agency: Perform a criminal background records
check?
Before hiring new employees who may have contact with yes
residents, does the agency: Consult any child abuse registry
maintained by the State or locality in which the employee would
work?
Before hiring new employees who may have contact with yes
residents, does the agency: Consistent with Federal, State, and
local law, make its best efforts to contact all prior institutional
employers for information on substantiated allegations of sexual
abuse or any resignation during a pending investigation of an
allegation of sexual abuse?
115.317
Hiring and promotion decisions
(d)
Does the agency perform a criminal background records check yes
before enlisting the services of any contractor who may have
contact with residents?
Does the agency consult applicable child abuse registries before yes
enlisting the services of any contractor who may have contact
with residents?
115.317
Hiring and promotion decisions
(e)
Does the agency either conduct criminal background records yes
checks at least every five years of current employees and
contractors who may have contact with residents or have in place
a system for otherwise capturing such information for current
employees?
115.317
Hiring and promotion decisions
(f)
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in written applications or
interviews for hiring or promotions?
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in any interviews or
written self-evaluations conducted as part of reviews of current
employees?
Does the agency impose upon employees a continuing affirmative yes
duty to disclose any such misconduct?
115.317
Hiring and promotion decisions
(g)
Does the agency consider material omissions regarding such yes
misconduct, or the provision of materially false information,
grounds for termination?
115.317
Hiring and promotion decisions
(h)
Unless prohibited by law, does the agency provide information on yes
substantiated allegations of sexual abuse or sexual harassment
involving a former employee upon receiving a request from an
institutional employer for whom such employee has applied to
work? (N/A if providing information on substantiated allegations of
sexual abuse or sexual harassment involving a former employee is
prohibited by law.)
115.318
Upgrades to facilities and technologies
(a)
If the agency designed or acquired any new facility or planned any 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
Upgrades to facilities and technologies
(b)
If the agency installed or updated a video monitoring system, na
electronic surveillance system, or other monitoring technology,
did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if
agency/facility has not installed or updated a video monitoring
system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit,
whichever is later.)
115.321
Evidence protocol and forensic medical examinations
(a)
If the agency is responsible for investigating allegations of sexual yes
abuse, does the agency follow a uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for
administrative proceedings and criminal prosecutions? (N/A if the
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
115.321 Evidence protocol and forensic medical examinations
(b)
Is this protocol developmentally appropriate for youth? (N/A if the yes
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
Is this protocol, as appropriate, adapted from or otherwise based yes
on the most recent edition of the U.S. Department of Justice’s
Office on Violence Against Women publication, “A National Protocol
for Sexual Assault Medical Forensic Examinations, Adults/
Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative
sexual abuse investigations. )
115.321
Evidence protocol and forensic medical examinations
(c)
Does the agency offer all residents who experience sexual abuse yes
access to forensic medical examinations, whether on-site or at an
outside facility, without financial cost, where evidentiarily or
medically appropriate?
Are such examinations performed by Sexual Assault Forensic yes
Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs)
where possible?
If SAFEs or SANEs cannot be made available, is the examination yes
performed by other qualified medical practitioners (they must
have been specifically trained to conduct sexual assault forensic
exams)?
Has the agency documented its efforts to provide SAFEs or yes
SANEs?
115.321
Evidence protocol and forensic medical examinations
(d)
Does the agency attempt to make available to the victim a victim yes
advocate from a rape crisis center?
If a rape crisis center is not available to provide victim advocate yes
services, does the agency make available to provide these
services a qualified staff member from a community-based
organization, or a qualified agency staff member?
Has the agency documented its efforts to secure services from yes
rape crisis centers?
115.321 Evidence protocol and forensic medical examinations
(e)
As requested by the victim, does the victim advocate, qualified yes
agency staff member, or qualified community-based organization
staff member accompany and support the victim through the
forensic medical examination process and investigatory
interviews?
As requested by the victim, does this person provide emotional yes
support, crisis intervention, information, and referrals?
115.321
Evidence protocol and forensic medical examinations
(f)
If the agency itself is not responsible for investigating allegations yes
of sexual abuse, has the agency requested that the investigating
entity follow the requirements of paragraphs (a) through (e) of this
section? (N/A if the agency is responsible for investigating
allegations of sexual abuse.)
115.321
Evidence protocol and forensic medical examinations
(h)
If the agency uses a qualified agency staff member or a qualified yes
community-based staff member for the purposes of this section,
has the individual been screened for appropriateness to serve in
this role and received education concerning sexual assault and
forensic examination issues in general? (Check N/A if agency
attempts to make a victim advocate from a rape crisis center
available to victims per 115.321(d) above.)
115.322
Policies to ensure referrals of allegations for investigations
(a)
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual abuse?
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual
harassment?
115.322
Policies to ensure referrals of allegations for investigations
(b)
Does the agency have a policy in place to ensure that allegations yes
of sexual abuse or sexual harassment are referred for
investigation to an agency with the legal authority to conduct
criminal investigations, unless the allegation does not involve
potentially criminal behavior?
Has the agency published such policy on its website or, if it does yes
not have one, made the policy available through other means?
Does the agency document all such referrals? yes
115.322
Policies to ensure referrals of allegations for investigations
(c)
If a separate entity is responsible for conducting criminal yes
investigations, does such publication describe the responsibilities
of both the agency and the investigating entity? (N/A if the
agency/facility is responsible for criminal investigations. See
115.321(a))
115.331
Employee training
(a)
Does the agency train all employees who may have contact with yes
residents on: Its zero-tolerance policy for sexual abuse and sexual
harassment?
Does the agency train all employees who may have contact with yes
residents on: How to fulfill their responsibilities under agency
sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures?
Does the agency train all employees who may have contact with yes
residents on: Residents’ right to be free from sexual abuse and
sexual harassment
Does the agency train all employees who may have contact with yes
residents on: The right of residents and employees to be free from
retaliation for reporting sexual abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: The dynamics of sexual abuse and sexual
harassment in juvenile facilities?
Does the agency train all employees who may have contact with yes
residents on: The common reactions of juvenile victims of sexual
abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: How to detect and respond to signs of threatened
and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents?
Does the agency train all employees who may have contact with yes
residents on: How to avoid inappropriate relationships with
residents?
The subsection of this provision is no longer applicable to your na
compliance finding, please select N/A.
Does the agency train all employees who may have contact with yes
residents on: How to comply with relevant laws related to
mandatory reporting of sexual abuse to outside authorities?
Does the agency train all employees who may have contact with yes
residents on: Relevant laws regarding the applicable age of
consent?
115.331
Employee training
(b)
Is such training tailored to the unique needs and attributes of yes
residents of juvenile facilities?
Is such training tailored to the gender of the residents at the yes
employee’s facility?
Have employees received additional training if reassigned from a yes
facility that houses only male residents to a facility that houses
only female residents, or vice versa?
115.331
Employee training
(c)
Have all current employees who may have contact with residents yes
received such training?
Does the agency provide each employee with refresher training yes
every two years to ensure that all employees know the agency’s
current sexual abuse and sexual harassment policies and
procedures?
In years in which an employee does not receive refresher training, yes
does the agency provide refresher information on current sexual
abuse and sexual harassment policies?
115.331
Employee training
(d)
Does the agency document, through employee signature or yes
electronic verification, that employees understand the training
they have received?
115.332
Volunteer and contractor training
(a)
Has the agency ensured that all volunteers and contractors who yes
have contact with residents have been trained on their
responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and
procedures?
115.332
Volunteer and contractor training
(b)
Have all volunteers and contractors who have contact with yes
residents been notified of the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment and informed how
to report such incidents (the level and type of training provided to
volunteers and contractors shall be based on the services they
provide and level of contact they have with residents)?
115.332
Volunteer and contractor training
(c)
Does the agency maintain documentation confirming that yes
volunteers and contractors understand the training they have
received?
115.333
Resident education
(a)
During intake, do residents receive information explaining the yes
agency’s zero-tolerance policy regarding sexual abuse and sexual
harassment?
During intake, do residents receive information explaining how to yes
report incidents or suspicions of sexual abuse or sexual
harassment?
Is this information presented in an age-appropriate fashion? yes
115.333
Resident education
(b)
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from sexual abuse and
sexual harassment?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from retaliation for
reporting such incidents?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Agency policies and procedures for responding to
such incidents?
115.333
Resident education
(c)
Have all residents received such education? yes
Do residents receive education upon transfer to a different facility yes
to the extent that the policies and procedures of the resident’s
new facility differ from those of the previous facility?
115.333
Resident education
(d)
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are limited English proficient?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are deaf?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are visually impaired?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are otherwise disabled?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Have limited reading skills?
115.333
Resident education
(e)
Does the agency maintain documentation of resident participation yes
in these education sessions?
115.333
Resident education
(f)
In addition to providing such education, does the agency ensure yes
that key information is continuously and readily available or visible
to residents through posters, resident handbooks, or other written
formats?
115.334
Specialized training: Investigations
(a)
In addition to the general training provided to all employees na
pursuant to §115.331, does the agency ensure that, to the extent
the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such
investigations in confinement settings? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.334
Specialized training: Investigations
(b)
Does this specialized training include: Techniques for interviewing na
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 na
Garrity warnings? (N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See
115.321(a).)
Does this specialized training include: Sexual abuse evidence na
collection in confinement settings? (N/A if the agency does not
conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
Does this specialized training include: The criteria and evidence na
required to substantiate a case for administrative action or
prosecution referral? (N/A if the agency does not conduct any form
of administrative or criminal sexual abuse investigations. See
115.321(a).)
115.334
Specialized training: Investigations
(c)
Does the agency maintain documentation that agency na
investigators have completed the required specialized training in
conducting sexual abuse investigations? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.335
Specialized training: Medical and mental health care
(a)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to detect and assess signs of sexual
abuse and sexual harassment? (N/A if the agency does not have
any full- or part-time medical or mental health care practitioners
who work regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to preserve physical evidence of sexual
abuse? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual
harassment? (N/A if the agency does not have any full- or part-
time medical or mental health care practitioners who work
regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How and to whom to report allegations or
suspicions of sexual abuse and sexual harassment? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(b)
If medical staff employed by the agency conduct forensic na
examinations, do such medical staff receive appropriate training
to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams or the agency does not
employ medical staff.)
115.335
Specialized training: Medical and mental health care
(c)
Does the agency maintain documentation that medical and yes
mental health practitioners have received the training referenced
in this standard either from the agency or elsewhere? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(d)
Do medical and mental health care practitioners employed by the yes
agency also receive training mandated for employees by
§115.331? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Do medical and mental health care practitioners contracted by yes
and volunteering for the agency also receive training mandated
for contractors and volunteers by §115.332? (N/A if the agency
does not have any full- or part-time medical or mental health care
practitioners contracted by or volunteering for the agency.)
115.341
Obtaining information from residents
(a)
Within 72 hours of the resident’s arrival at the facility, does the yes
agency obtain and use information about each resident’s personal
history and behavior to reduce risk of sexual abuse by or upon a
resident?
Does the agency also obtain this information periodically yes
throughout a resident’s confinement?
115.341
Obtaining information from residents
(b)
Are all PREA screening assessments conducted using an objective yes
screening instrument?
115.341
Obtaining information from residents
(c)
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Prior sexual
victimization or abusiveness?
The subsection of this provision is no longer applicable to your na
compliance finding, please select N/A.
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Current
charges and offense history?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Age?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Level of
emotional and cognitive development?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical size
and stature?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Mental illness
or mental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Intellectual or
developmental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical
disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: The resident’s
own perception of vulnerability?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any other
specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or
separation from certain other residents?
115.341
Obtaining information from residents
(d)
Is this information ascertained: Through conversations with the yes
resident during the intake process and medical mental health
screenings?
Is this information ascertained: During classification assessments? yes
Is this information ascertained: By reviewing court records, case yes
files, facility behavioral records, and other relevant documentation
from the resident’s files?
115.341
Obtaining information from residents
(e)
Has the agency implemented appropriate controls on the yes
dissemination within the facility of responses to questions asked
pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or
other residents?
115.342
Placement of residents
(a)
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Housing Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Bed assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Work Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Education
Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Program Assignments?
115.342
Placement of residents
(b)
Are residents isolated from others only as a last resort when less yes
restrictive measures are inadequate to keep them and other
residents safe, and then only until an alternative means of
keeping all residents safe can be arranged?
During any period of isolation, does the agency always refrain yes
from denying residents daily large-muscle exercise?
During any period of isolation, does the agency always refrain yes
from denying residents any legally required educational
programming or special education services?
Do residents in isolation receive daily visits from a medical or yes
mental health care clinician?
Do residents also have access to other programs and work yes
opportunities to the extent possible?
115.342
Placement of residents
(c)
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(d)
This provision is no longer applicable to your compliance finding, na
please select N/A.
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(e)
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(f)
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(g)
This provision is no longer applicable to your compliance finding, na
please select N/A.
115.342
Placement of residents
(h)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The basis for the facility’s
concern for the resident’s safety? (N/A for h and i if facility doesn’t
use isolation?)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The reason why no alternative
means of separation can be arranged? (N/A for h and i if facility
doesn’t use isolation?)
115.342
Placement of residents
(i)
In the case of each resident who is isolated as a last resort when yes
less restrictive measures are inadequate to keep them and other
residents safe, does the facility afford a review to determine
whether there is a continuing need for separation from the general
population EVERY 30 DAYS?
115.351 Resident reporting
(a)
Does the agency provide multiple internal ways for residents to yes
privately report: Sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: 2. Retaliation by other residents or staff for
reporting sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: Staff neglect or violation of responsibilities that
may have contributed to such incidents?
115.351
Resident reporting
(b)
Does the agency also provide at least one way for residents to yes
report sexual abuse or sexual harassment to a public or private
entity or office that is not part of the agency?
Is that private entity or office able to receive and immediately yes
forward resident reports of sexual abuse and sexual harassment to
agency officials?
Does that private entity or office allow the resident to remain yes
anonymous upon request?
Are residents detained solely for civil immigration purposes yes
provided information on how to contact relevant consular officials
and relevant officials at the Department of Homeland Security to
report sexual abuse or harassment?
115.351
Resident reporting
(c)
Do staff members accept reports of sexual abuse and sexual yes
harassment made verbally, in writing, anonymously, and from
third parties?
Do staff members promptly document any verbal reports of sexual yes
abuse and sexual harassment?
115.351
Resident reporting
(d)
Does the facility provide residents with access to tools necessary yes
to make a written report?
115.351
Resident reporting
(e)
Does the agency provide a method for staff to privately report yes
sexual abuse and sexual harassment of residents?
115.352
Exhaustion of administrative remedies
(a)
Is the agency exempt from this standard? yes
NOTE: The agency is exempt ONLY if it does not have
administrative procedures to address resident grievances
regarding sexual abuse. This does not mean the agency is exempt
simply because a resident does not have to or is not ordinarily
expected to submit a grievance to report sexual abuse. This
means that as a matter of explicit policy, the agency does not
have an administrative remedies process to address sexual abuse.
115.352
Exhaustion of administrative remedies
(b)
Does the agency permit residents to submit a grievance regarding na
an allegation of sexual abuse without any type of time limits? (The
agency may apply otherwise-applicable time limits to any portion
of a grievance that does not allege an incident of sexual abuse.)
(N/A if agency is exempt from this standard.)
Does the agency always refrain from requiring an resident to use na
any informal grievance process, or to otherwise attempt to resolve
with staff, an alleged incident of sexual abuse? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(c)
Does the agency ensure that: A resident who alleges sexual abuse na
may submit a grievance without submitting it to a staff member
who is the subject of the complaint? (N/A if agency is exempt from
this standard.)
Does the agency ensure that: Such grievance is not referred to a na
staff member who is the subject of the complaint? (N/A if agency
is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(d)
Does the agency issue a final agency decision on the merits of any na
portion of a grievance alleging sexual abuse within 90 days of the
initial filing of the grievance? (Computation of the 90-day time
period does not include time consumed by residents in preparing
any administrative appeal.) (N/A if agency is exempt from this
standard.)
If the agency determines that the 90 day timeframe is insufficient na
to make an appropriate decision and claims an extension of time
(the maximum allowable extension of time to respond is 70 days
per 115.352(d)(3)) , does the agency notify the resident in writing
of any such extension and provide a date by which a decision will
be made? (N/A if agency is exempt from this standard.)
At any level of the administrative process, including the final level, na
if the resident does not receive a response within the time allotted
for reply, including any properly noticed extension, may a resident
consider the absence of a response to be a denial at that level?
(N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(e)
Are third parties, including fellow residents, staff members, family na
members, attorneys, and outside advocates, permitted to assist
residents in filing requests for administrative remedies relating to
allegations of sexual abuse? (N/A if agency is exempt from this
standard.)
Are those third parties also permitted to file such requests on na
behalf of residents? (If a third party, other than a parent or legal
guardian, files such a request on behalf of a resident, the facility
may require as a condition of processing the request that the
alleged victim agree to have the request filed on his or her behalf,
and may also require the alleged victim to personally pursue any
subsequent steps in the administrative remedy process.) (N/A if
agency is exempt from this standard.)
If the resident declines to have the request processed on his or na
her behalf, does the agency document the resident’s decision?
(N/A if agency is exempt from this standard.)
Is a parent or legal guardian of a juvenile allowed to file a na
grievance regarding allegations of sexual abuse, including
appeals, on behalf of such juvenile? (N/A if agency is exempt from
this standard.)
If a parent or legal guardian of a juvenile files a grievance (or an na
appeal) on behalf of a juvenile regarding allegations of sexual
abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her
behalf? (N/A if agency is exempt from this standard.)
115.352 Exhaustion of administrative remedies
(f)
Has the agency established procedures for the filing of an yes
emergency grievance alleging that a resident is subject to a
substantial risk of imminent sexual abuse? (N/A if agency is
exempt from this standard.)
After receiving an emergency grievance alleging a resident is yes
subject to a substantial risk of imminent sexual abuse, does the
agency immediately forward the grievance (or any portion thereof
that alleges the substantial risk of imminent sexual abuse) to a
level of review at which immediate corrective action may be
taken? (N/A if agency is exempt from this standard.)
After receiving an emergency grievance described above, does yes
the agency provide an initial response within 48 hours? (N/A if
agency is exempt from this standard.)
After receiving an emergency grievance described above, does yes
the agency issue a final agency decision within 5 calendar days?
(N/A if agency is exempt from this standard.)
Does the initial response and final agency decision document the yes
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 yes
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) yes
taken in response to the emergency grievance? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(g)
If the agency disciplines a resident for filing a grievance related to yes
alleged sexual abuse, does it do so ONLY where the agency
demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.)
115.353 Resident access to outside confidential support services and
(a) legal representation
Does the facility provide residents with access to outside victim yes
advocates for emotional support services related to sexual abuse
by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll-free hotline
numbers where available, of local, State, or national victim
advocacy or rape crisis organizations?
Does the facility provide persons detained solely for civil yes
immigration purposes mailing addresses and telephone numbers,
including toll-free hotline numbers where available of local, State,
or national immigrant services agencies?
Does the facility enable reasonable communication between yes
residents and these organizations and agencies, in as confidential
a manner as possible?
115.353 Resident access to outside confidential support services and
(b) legal representation
Does the facility inform residents, prior to giving them access, of yes
the extent to which such communications will be monitored and
the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws?
115.353 Resident access to outside confidential support services and
(c) legal representation
Does the agency maintain or attempt to enter into memoranda of yes
understanding or other agreements with community service
providers that are able to provide residents with confidential
emotional support services related to sexual abuse?
Does the agency maintain copies of agreements or documentation yes
showing attempts to enter into such agreements?
115.353 Resident access to outside confidential support services and
(d) legal representation
Does the facility provide residents with reasonable and yes
confidential access to their attorneys or other legal
representation?
Does the facility provide residents with reasonable access to yes
parents or legal guardians?
115.354
Third-party reporting
(a)
Has the agency established a method to receive third-party yes
reports of sexual abuse and sexual harassment?
Has the agency distributed publicly information on how to report yes
sexual abuse and sexual harassment on behalf of a resident?
115.361
Staff and agency reporting duties
(a)
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding an incident of sexual abuse or
sexual harassment that occurred in a facility, whether or not it is
part of the agency?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding retaliation against residents or
staff who reported an incident of sexual abuse or sexual
harassment?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding any staff neglect or violation of
responsibilities that may have contributed to an incident of sexual
abuse or sexual harassment or retaliation?
115.361
Staff and agency reporting duties
(b)
Does the agency require all staff to comply with any applicable yes
mandatory child abuse reporting laws?
115.361
Staff and agency reporting duties
(c)
Apart from reporting to designated supervisors or officials and yes
designated State or local services agencies, are staff prohibited
from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency
policy, to make treatment, investigation, and other security and
management decisions?
115.361
Staff and agency reporting duties
(d)
Are medical and mental health practitioners required to report yes
sexual abuse to designated supervisors and officials pursuant to
paragraph (a) of this section as well as to the designated State or
local services agency where required by mandatory reporting
laws?
Are medical and mental health practitioners required to inform yes
residents of their duty to report, and the limitations of
confidentiality, at the initiation of services?
115.361
Staff and agency reporting duties
(e)
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
appropriate office?
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
alleged victim’s parents or legal guardians unless the facility has
official documentation showing the parents or legal guardians
should not be notified?
If the alleged victim is under the guardianship of the child welfare yes
system, does the facility head or his or her designee promptly
report the allegation to the alleged victim’s caseworker instead of
the parents or legal guardians? (N/A if the alleged victim is not
under the guardianship of the child welfare system.)
If a juvenile court retains jurisdiction over the alleged victim, does yes
the facility head or designee also report the allegation to the
juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation?
115.361
Staff and agency reporting duties
(f)
Does the facility report all allegations of sexual abuse and sexual yes
harassment, including third-party and anonymous reports, to the
facility’s designated investigators?
115.362
Agency protection duties
(a)
When the agency learns that a resident is subject to a substantial yes
risk of imminent sexual abuse, does it take immediate action to
protect the resident?
115.363
Reporting to other confinement facilities
(a)
Upon receiving an allegation that a resident was sexually abused yes
while confined at another facility, does the head of the facility that
received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse
occurred?
Does the head of the facility that received the allegation also yes
notify the appropriate investigative agency?
115.363
Reporting to other confinement facilities
(b)
Is such notification provided as soon as possible, but no later than yes
72 hours after receiving the allegation?
115.363
Reporting to other confinement facilities
(c)
Does the agency document that it has provided such notification? yes
115.363
Reporting to other confinement facilities
(d)
Does the facility head or agency office that receives such yes
notification ensure that the allegation is investigated in
accordance with these standards?
115.364
Staff first responder duties
(a)
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Separate the alleged victim and abuser?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Request that the alleged victim not take any actions
that could destroy physical evidence, including, as appropriate,
washing, brushing teeth, changing clothes, urinating, defecating,
smoking, drinking, or eating, if the abuse occurred within a time
period that still allows for the collection of physical evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating,
defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical
evidence?
115.364
Staff first responder duties
(b)
If the first staff responder is not a security staff member, is the yes
responder required to request that the alleged victim not take any
actions that could destroy physical evidence, and then notify
security staff?
115.365
Coordinated response
(a)
Has the facility developed a written institutional plan to coordinate yes
actions among staff first responders, medical and mental health
practitioners, investigators, and facility leadership taken in
response to an incident of sexual abuse?
115.366 Preservation of ability to protect residents from contact with
(a) abusers
Are both the agency and any other governmental entities yes
responsible for collective bargaining on the agency’s behalf
prohibited from entering into or renewing any collective
bargaining agreement or other agreement that limits the agency’s
ability to remove alleged staff sexual abusers from contact with
any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is
warranted?
115.367
Agency protection against retaliation
(a)
Has the agency established a policy to protect all residents and yes
staff who report sexual abuse or sexual harassment or cooperate
with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff?
Has the agency designated which staff members or departments yes
are charged with monitoring retaliation?
115.367
Agency protection against retaliation
(b)
Does the agency employ multiple protection measures for yes
residents or staff who fear retaliation for reporting sexual abuse or
sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers,
removal of alleged staff or resident abusers from contact with
victims, and emotional support services?
115.367
Agency protection against retaliation
(c)
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents or staff who reported the sexual abuse to
see if there are changes that may suggest possible retaliation by
residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents who were reported to have suffered sexual
abuse to see if there are changes that may suggest possible
retaliation by residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Act promptly to remedy any
such retaliation?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident housing
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident program
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Negative performance
reviews of staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Reassignments of
staff?
Does the agency continue such monitoring beyond 90 days if the yes
initial monitoring indicates a continuing need?
115.367
Agency protection against retaliation
(d)
In the case of residents, does such monitoring also include yes
periodic status checks?
115.367
Agency protection against retaliation
(e)
If any other individual who cooperates with an investigation yes
expresses a fear of retaliation, does the agency take appropriate
measures to protect that individual against retaliation?
115.368
Post-allegation protective custody
(a)
Is any and all use of segregated housing to protect a resident who yes
is alleged to have suffered sexual abuse subject to the
requirements of § 115.342?
115.371
Criminal and administrative agency investigations
(a)
When the agency conducts its own investigations into allegations na
of sexual abuse and sexual harassment, does it do so promptly,
thoroughly, and objectively? (N/A if the agency does not conduct
any form of administrative or criminal investigations of sexual
abuse or harassment. See 115.321(a).)
Does the agency conduct such investigations for all allegations, na
including third party and anonymous reports? (N/A if the agency
does not conduct any form of administrative or criminal
investigations of sexual abuse or harassment. See 115.321(a).)
115.371
Criminal and administrative agency investigations
(b)
Where sexual abuse is alleged, does the agency use investigators yes
who have received specialized training in sexual abuse
investigations involving juvenile victims as required by 115.334?
115.371
Criminal and administrative agency investigations
(c)
Do investigators gather and preserve direct and circumstantial yes
evidence, including any available physical and DNA evidence and
any available electronic monitoring data?
Do investigators interview alleged victims, suspected yes
perpetrators, and witnesses?
Do investigators review prior reports and complaints of sexual yes
abuse involving the suspected perpetrator?
115.371
Criminal and administrative agency investigations
(d)
Does the agency always refrain from terminating an investigation yes
solely because the source of the allegation recants the allegation?
115.371
Criminal and administrative agency investigations
(e)
When the quality of evidence appears to support criminal yes
prosecution, does the agency conduct compelled interviews only
after consulting with prosecutors as to whether compelled
interviews may be an obstacle for subsequent criminal
prosecution?
115.371
Criminal and administrative agency investigations
(f)
Do agency investigators assess the credibility of an alleged victim, yes
suspect, or witness on an individual basis and not on the basis of
that individual’s status as resident or staff?
Does the agency investigate allegations of sexual abuse without yes
requiring a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition
for proceeding?
115.371
Criminal and administrative agency investigations
(g)
Do administrative investigations include an effort to determine yes
whether staff actions or failures to act contributed to the abuse?
Are administrative investigations documented in written reports yes
that include a description of the physical evidence and testimonial
evidence, the reasoning behind credibility assessments, and
investigative facts and findings?
115.371
Criminal and administrative agency investigations
(h)
Are criminal investigations documented in a written report that yes
contains a thorough description of the physical, testimonial, and
documentary evidence and attaches copies of all documentary
evidence where feasible?
115.371
Criminal and administrative agency investigations
(i)
Are all substantiated allegations of conduct that appears to be yes
criminal referred for prosecution?
115.371
Criminal and administrative agency investigations
(j)
Does the agency retain all written reports referenced in yes
115.371(g) and (h) for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years unless
the abuse was committed by a juvenile resident and applicable
law requires a shorter period of retention?
115.371
Criminal and administrative agency investigations
(k)
Does the agency ensure that the departure of an alleged abuser yes
or victim from the employment or control of the facility or agency
does not provide a basis for terminating an investigation?
115.371
Criminal and administrative agency investigations
(m)
When an outside entity investigates sexual abuse, does the facility yes
cooperate with outside investigators and endeavor to remain
informed about the progress of the investigation? (N/A if an
outside agency does not conduct administrative or criminal sexual
abuse investigations. See 115.321(a).)
115.372
Evidentiary standard for administrative investigations
(a)
Is it true that the agency does not impose a standard higher than yes
a preponderance of the evidence in determining whether
allegations of sexual abuse or sexual harassment are
substantiated?
115.373
Reporting to residents
(a)
Following an investigation into a resident’s allegation of sexual yes
abuse suffered in the facility, does the agency inform the resident
as to whether the allegation has been determined to be
substantiated, unsubstantiated, or unfounded?
115.373
Reporting to residents
(b)
If the agency did not conduct the investigation into a resident’s yes
allegation of sexual abuse in an agency facility, does the agency
request the relevant information from the investigative agency in
order to inform the resident? (N/A if the agency/facility is
responsible for conducting administrative and criminal
investigations.)
115.373
Reporting to residents
(c)
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer posted within the resident’s unit?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer employed at the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been indicted on a charge related to
sexual abuse in the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been convicted on a charge related to
sexual abuse within the facility?
115.373
Reporting to residents
(d)
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been indicted on a charge related to sexual abuse
within the facility?
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been convicted on a charge related to sexual abuse
within the facility?
115.373
Reporting to residents
(e)
Does the agency document all such notifications or attempted yes
notifications?
115.376
Disciplinary sanctions for staff
(a)
Are staff subject to disciplinary sanctions up to and including yes
termination for violating agency sexual abuse or sexual
harassment policies?
115.376
Disciplinary sanctions for staff
(b)
Is termination the presumptive disciplinary sanction for staff who yes
have engaged in sexual abuse?
115.376
Disciplinary sanctions for staff
(c)
Are disciplinary sanctions for violations of agency policies relating yes
to sexual abuse or sexual harassment (other than actually
engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s
disciplinary history, and the sanctions imposed for comparable
offenses by other staff with similar histories?
115.376
Disciplinary sanctions for staff
(d)
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to: Law
enforcement agencies, unless the activity was clearly not
criminal?
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to:
Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(a)
Is any contractor or volunteer who engages in sexual abuse yes
prohibited from contact with residents?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Law enforcement agencies (unless the activity was
clearly not criminal)?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(b)
In the case of any other violation of agency sexual abuse or sexual yes
harassment policies by a contractor or volunteer, does the facility
take appropriate remedial measures, and consider whether to
prohibit further contact with residents?
115.378
Interventions and disciplinary sanctions for residents
(a)
Following an administrative finding that a resident engaged in yes
resident-on-resident sexual abuse, or following a criminal finding
of guilt for resident-on-resident sexual abuse, may residents be
subject to disciplinary sanctions only pursuant to a formal
disciplinary process?
115.378
Interventions and disciplinary sanctions for residents
(b)
Are disciplinary sanctions commensurate with the nature and yes
circumstances of the abuse committed, the resident’s disciplinary
history, and the sanctions imposed for comparable offenses by
other residents with similar histories?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied daily
large-muscle exercise?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied access
to any legally required educational programming or special
education services?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident receives daily visits
from a medical or mental health care clinician?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the resident also have access to other programs
and work opportunities to the extent possible?
115.378 Interventions and disciplinary sanctions for residents
(c)
When determining what types of sanction, if any, should be yes
imposed, does the disciplinary process consider whether a
resident’s mental disabilities or mental illness contributed to his or
her behavior?
115.378
Interventions and disciplinary sanctions for residents
(d)
If the facility offers therapy, counseling, or other interventions yes
designed to address and correct underlying reasons or motivations
for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions?
If the agency requires participation in such interventions as a yes
condition of access to any rewards-based behavior management
system or other behavior-based incentives, does it always refrain
from requiring such participation as a condition to accessing
general programming or education?
115.378
Interventions and disciplinary sanctions for residents
(e)
Does the agency discipline a resident for sexual contact with staff yes
only upon a finding that the staff member did not consent to such
contact?
115.378
Interventions and disciplinary sanctions for residents
(f)
For the purpose of disciplinary action, does a report of sexual yes
abuse made in good faith based upon a reasonable belief that the
alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish
evidence sufficient to substantiate the allegation?
115.378
Interventions and disciplinary sanctions for residents
(g)
Does the agency always refrain from considering non-coercive yes
sexual activity between residents to be sexual abuse? (N/A if the
agency does not prohibit all sexual activity between residents.)
115.381
Medical and mental health screenings; history of sexual abuse
(a)
If the screening pursuant to § 115.341 indicates that a resident yes
has experienced prior sexual victimization, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a medical or
mental health practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(b)
If the screening pursuant to § 115.341 indicates that a resident yes
has previously perpetrated sexual abuse, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a mental health
practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(c)
Is any information related to sexual victimization or abusiveness yes
that occurred in an institutional setting strictly limited to medical
and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions,
including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local
law?
115.381
Medical and mental health screenings; history of sexual abuse
(d)
Do medical and mental health practitioners obtain informed yes
consent from residents before reporting information about prior
sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18?
115.382
Access to emergency medical and mental health services
(a)
Do resident victims of sexual abuse receive timely, unimpeded yes
access to emergency medical treatment and crisis intervention
services, the nature and scope of which are determined by
medical and mental health practitioners according to their
professional judgment?
115.382
Access to emergency medical and mental health services
(b)
If no qualified medical or mental health practitioners are on duty yes
at the time a report of recent sexual abuse is made, do staff first
responders take preliminary steps to protect the victim pursuant
to § 115.362?
Do staff first responders immediately notify the appropriate yes
medical and mental health practitioners?
115.382
Access to emergency medical and mental health services
(c)
Are resident victims of sexual abuse offered timely information yes
about and timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically
appropriate?
115.382
Access to emergency medical and mental health services
(d)
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(a) victims and abusers
Does the facility offer medical and mental health evaluation and, yes
as appropriate, treatment to all residents who have been
victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility?
115.383 Ongoing medical and mental health care for sexual abuse
(b) victims and abusers
Does the evaluation and treatment of such victims include, as yes
appropriate, follow-up services, treatment plans, and, when
necessary, referrals for continued care following their transfer to,
or placement in, other facilities, or their release from custody?
115.383 Ongoing medical and mental health care for sexual abuse
(c) victims and abusers
Does the facility provide such victims with medical and mental yes
health services consistent with the community level of care?
115.383 Ongoing medical and mental health care for sexual abuse
(d) victims and abusers
Are resident victims of sexually abusive vaginal penetration while na
incarcerated offered pregnancy tests? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(e) victims and abusers
If pregnancy results from the conduct described in paragraph § na
115.383(d), do such victims receive timely and comprehensive
information about and timely access to all lawful pregnancy-
related medical services? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(f) victims and abusers
Are resident victims of sexual abuse while incarcerated offered yes
tests for sexually transmitted infections as medically appropriate?
115.383 Ongoing medical and mental health care for sexual abuse
(g) victims and abusers
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(h) victims and abusers
Does the facility attempt to conduct a mental health evaluation of yes
all known resident-on-resident abusers within 60 days of learning
of such abuse history and offer treatment when deemed
appropriate by mental health practitioners?
115.386
Sexual abuse incident reviews
(a)
Does the facility conduct a sexual abuse incident review at the yes
conclusion of every sexual abuse investigation, including where
the allegation has not been substantiated, unless the allegation
has been determined to be unfounded?
115.386
Sexual abuse incident reviews
(b)
Does such review ordinarily occur within 30 days of the conclusion yes
of the investigation?
115.386
Sexual abuse incident reviews
(c)
Does the review team include upper-level management officials, yes
with input from line supervisors, investigators, and medical or
mental health practitioners?
115.386
Sexual abuse incident reviews
(d)
Does the review team: Consider whether the allegation or yes
investigation indicates a need to change policy or practice to
better prevent, detect, or respond to sexual abuse?
The subsection of this provision is no longer applicable to your na
compliance finding, please select N/A.
Does the review team: Examine the area in the facility where the yes
incident allegedly occurred to assess whether physical barriers in
the area may enable abuse?
Does the review team: Assess the adequacy of staffing levels in yes
that area during different shifts?
Does the review team: Assess whether monitoring technology yes
should be deployed or augmented to supplement supervision by
staff?
Does the review team: Prepare a report of its findings, including yes
but not necessarily limited to determinations made pursuant to §§
115.386(d)(1)-(d)(5), and any recommendations for improvement
and submit such report to the facility head and PREA compliance
manager?
115.386
Sexual abuse incident reviews
(e)
Does the facility implement the recommendations for yes
improvement, or document its reasons for not doing so?
115.387
Data collection
(a)
Does the agency collect accurate, uniform data for every yes
allegation of sexual abuse at facilities under its direct control
using a standardized instrument and set of definitions?
115.387
Data collection
(b)
Does the agency aggregate the incident-based sexual abuse data yes
at least annually?
115.387
Data collection
(c)
Does the incident-based data include, at a minimum, the data yes
necessary to answer all questions from the most recent version of
the Survey of Sexual Violence conducted by the Department of
Justice?
115.387
Data collection
(d)
Does the agency maintain, review, and collect data as needed yes
from all available incident-based documents, including reports,
investigation files, and sexual abuse incident reviews?
115.387
Data collection
(e)
Does the agency also obtain incident-based and aggregated data yes
from every private facility with which it contracts for the
confinement of its residents? (N/A if agency does not contract for
the confinement of its residents.)
115.387
Data collection
(f)
Does the agency, upon request, provide all such data from the na
previous calendar year to the Department of Justice no later than
June 30? (N/A if DOJ has not requested agency data.)
115.388
Data review for corrective action
(a)
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Identifying problem areas?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Taking corrective action on an
ongoing basis?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Preparing an annual report of
its findings and corrective actions for each facility, as well as the
agency as a whole?
115.388
Data review for corrective action
(b)
Does the agency’s annual report include a comparison of the yes
current year’s data and corrective actions with those from prior
years and provide an assessment of the agency’s progress in
addressing sexual abuse?
115.388
Data review for corrective action
(c)
Is the agency’s annual report approved by the agency head and yes
made readily available to the public through its website or, if it
does not have one, through other means?
115.388
Data review for corrective action
(d)
Does the agency indicate the nature of the material redacted yes
where it redacts specific material from the reports when
publication would present a clear and specific threat to the safety
and security of a facility?
115.389
Data storage, publication, and destruction
(a)
Does the agency ensure that data collected pursuant to § 115.387 yes
are securely retained?
115.389
Data storage, publication, and destruction
(b)
Does the agency make all aggregated sexual abuse data, from yes
facilities under its direct control and private facilities with which it
contracts, readily available to the public at least annually through
its website or, if it does not have one, through other means?
115.389
Data storage, publication, and destruction
(c)
Does the agency remove all personal identifiers before making yes
aggregated sexual abuse data publicly available?
115.389
Data storage, publication, and destruction
(d)
Does the agency maintain sexual abuse data collected pursuant to yes
§ 115.387 for at least 10 years after the date of the initial
collection, unless Federal, State, or local law requires otherwise?
115.401
Frequency and scope of audits
(a)
During the prior three-year audit period, did the agency ensure yes
that each facility operated by the agency, or by a private
organization on behalf of the agency, was audited at least once?
(Note: The response here is purely informational. A "no" response
does not impact overall compliance with this standard.)
115.401
Frequency and scope of audits
(b)
Is this the first year of the current audit cycle? (Note: a “no” no
response does not impact overall compliance with this standard.)
If this is the second year of the current audit cycle, did the agency yes
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 na
ensure that at least two-thirds of each facility type operated by
the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle?
(N/A if this is not the third year of the current audit cycle.)
115.401
Frequency and scope of audits
(h)
Did the auditor have access to, and the ability to observe, all yes
areas of the audited facility?
115.401
Frequency and scope of audits
(i)
Was the auditor permitted to request and receive copies of any yes
relevant documents (including electronically stored information)?
115.401
Frequency and scope of audits
(m)
Was the auditor permitted to conduct private interviews with yes
inmates, residents, and detainees?
115.401
Frequency and scope of audits
(n)
Were inmates, residents, and detainees permitted to send yes
confidential information or correspondence to the auditor in the
same manner as if they were communicating with legal counsel?
115.403
Audit contents and findings
(f)
The agency has published on its agency website, if it has one, or yes
has otherwise made publicly available, all Final Audit Reports. The
review period is for prior audits completed during the past three
years PRECEDING THIS AUDIT. The pendency of any agency
appeal pursuant to 28 C.F.R. § 115.405 does not excuse
noncompliance with this provision. (N/A if there have been no Final
Audit Reports issued in the past three years, or, in the case of
single facility agencies, there has never been a Final Audit Report
issued.)

report_type: PREA

pdf_url: https://www.djj.state.fl.us/content/download/1952860/file/Florida_Walton Academy for Growth and Change_Year1Cycle5.pdf?version=1

program_name_raw: Walton Academy for Growth and Change

cycle: Year 1 Cycle 5