state: FL

facility_name: Oak Grove Academy

summary: PREA - Year 2 Cycle 4

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Oak Grove Academy
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 12/22/2023
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: Shirley Turner Date of
Signature:
12/22/
2023
AUDITOR INFORMATION
Auditor name: Turner, Shirley
Email: shirleyturner3199@comcast.net
Start Date of On- 11/08/2023
Site Audit:
End Date of On-Site 11/09/2023
Audit:
FACILITY INFORMATION
Facility name: Oak Grove Academy
Facility physical 11180 Northeast 38th Street, Jasper, Florida - 32052
address:
Facility mailing
address:
Primary Contact
Name: Tony Watts
Email Address: Tony. Watts@rop.com
Telephone Number: 386-223-6500
Superintendent/Director/Administrator
Name: Tony Watts
Email Address: tony.watts@rop.com
Telephone Number: 786-818-7089
Facility PREA Compliance Manager
Name: Tony Watts
Email Address: tony.watts@rop.com
Telephone Number: O: 786-818-7089
Facility Health Service Administrator On-Site
Name: Cloretta Sinletary
Email Address: Cloretta.Sinletary@rop.com
Telephone Number: 3862236500
Facility Characteristics
Designed facility capacity: 40
Current population of facility: 32
Average daily population for the past 12 32
months:
Has the facility been over capacity at any No
point in the past 12 months?
Which population(s) does the facility hold? Males
Age range of population: 14-19
Facility security levels/resident custody non-secure
levels:
Number of staff currently employed at the 61
facility who may have contact with
residents:
Number of individual contractors who have 3
contact with residents, currently
authorized to enter the facility:
Number of volunteers who have contact 0
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: 7752679411
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:
0
Number of standards met:
43
Number of standards not met:
0
POST-AUDIT REPORTING INFORMATION
GENERAL AUDIT INFORMATION
On-site Audit Dates
1. Start date of the onsite portion of the 2023-11-08
audit:
2. End date of the onsite portion of the 2023-11-09
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 Another Way Incorporated
organization(s) or victim advocates with
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 40
15. Average daily population for the past 32
12 months:
16. Number of inmate/resident/detainee 2
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
36. Enter the total number of inmates/ 34
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
38. 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:
39. 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:
40. 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:
41. 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:
42. 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:
43. Enter the total number of inmates/ 0
residents/detainees who identify as
lesbian, gay, or bisexual in the facility as
of the first day of the onsite portion of
the audit:
44. 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:
45. Enter the total number of inmates/ 1
residents/detainees who reported sexual
abuse in the facility as of the first day of
the onsite portion of the audit:
46. Enter the total number of inmates/ 0
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:
47. 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:
48. 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
49. Enter the total number of STAFF, 61
including both full- and part-time staff,
employed by the facility as of the first
day of the onsite portion of the audit:
50. Enter the total number of 0
VOLUNTEERS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
51. Enter the total number of 3
CONTRACTORS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
52. 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
53. Enter the total number of RANDOM 10
INMATES/RESIDENTS/DETAINEES who
were interviewed:
54. 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
55. How did you ensure your sample of Reviewed population sheet and conferred with
RANDOM INMATE/RESIDENT/DETAINEE staff. Consideration for age, race, ethnicity,
interviewees was geographically length of stay, and housing assignment.
diverse?
56. Were you able to conduct the Yes
minimum number of random inmate/
resident/detainee interviews?
No
57. 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
58. Enter the total number of TARGETED 1
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".
60. 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 Observed population; conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
61. Enter the total number of interviews 0
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:
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.
62. 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 Observed population; conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
63. 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 Observed population; conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
64. 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 Conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
65. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as lesbian, gay,
or bisexual 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 Conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
66. 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 Conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
67. Enter the total number of interviews 1
conducted with inmates/residents/
detainees who reported sexual abuse in
this facility using the "Inmates who
Reported a Sexual Abuse" protocol:
68. 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 Conferred with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
69. 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 Interviews, facility policy, and observations
to determine if this population exists in revealed that segregated housing/isolation is
the audited facility (e.g., based on not used in this facility.
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
70. 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
71. Enter the total number of RANDOM 12
STAFF who were interviewed:
72. 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
If "Other," describe: Consideration was also given for gender, race,
and ethnicity.
73. Were you able to conduct the Yes
minimum number of RANDOM STAFF
interviews?
No
74. 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.
75. Enter the total number of staff in a 6
SPECIALIZED STAFF role who were
interviewed (excluding volunteers and
contractors):
76. Were you able to interview the Yes
Agency Head?
No
77. Were you able to interview the Yes
Warden/Facility Director/Superintendent
or their designee?
No
78. Were you able to interview the PREA Yes
Coordinator?
No
79. 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)
80. 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
81. Did you interview VOLUNTEERS who Yes
may have contact with inmates/
residents/detainees in this facility?
No
82. Did you interview CONTRACTORS Yes
who may have contact with inmates/
residents/detainees in this facility?
No
a. Enter the total number of 2
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
83. Provide any additional comments The facility reports no volunteers at this time.
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.
84. Did you have access to all areas of Yes
the facility?
No
Was the site review an active, inquiring process that included the following:
85. 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)?
86. 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)?
87. Informal conversations with inmates/ Yes
residents/detainees during the site
review (encouraged, not required)?
No
88. Informal conversations with staff Yes
during the site review (encouraged, not
required)?
No
89. Provide any additional comments No text provided.
regarding the site review (e.g., access to
areas in the facility, observations, tests
of critical functions, or informal
conversations).
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.
90. 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?
91. Provide any additional comments No text provided.
regarding selecting additional
documentation (e.g., any documentation
you oversampled, barriers to selecting
additional documentation, etc.).
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.
92. 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 0 2 0
on-
inmate
sexual
abuse
Staff- 1 0 0 1
on-
inmate
sexual
abuse
Total 3 0 2 1
93. 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- 0 0 0 0
inmate
sexual
harassment
Staff-on- 0 0 0 0
inmate
sexual
harassment
Total 0 0 0 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.
94. 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- 0 0 0 0 0
inmate sexual
abuse
Staff-on- 0 1 0 0 0
inmate sexual
abuse
Total 0 1 0 0 0
95. Administrative SEXUAL ABUSE investigation outcomes during the 12 months
preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 2 0
sexual abuse
Staff-on-inmate 0 0 0 1
sexual abuse
Total 0 0 2 1
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.
96. 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- 0 0 0 0 0
inmate sexual
harassment
Staff-on- 0 0 0 0 0
inmate sexual
harassment
Total 0 0 0 0 0
97. Administrative SEXUAL HARASSMENT investigation outcomes during the 12
months preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 0 0
sexual
harassment
Staff-on-inmate 0 0 0 0
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Files Selected for
Review
Sexual Abuse Investigation Files Selected for Review
98. Enter the total number of SEXUAL 3
ABUSE investigation files reviewed/
sampled:
99. 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
100. Enter the total number of INMATE- 2
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
101. 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)
102. 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
103. Enter the total number of STAFF- 1
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
104. Did your sample of STAFF-ON- Yes
INMATE SEXUAL ABUSE investigation
files include criminal investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
105. Did your sample of STAFF-ON- Yes
INMATE SEXUAL ABUSE investigation
files include administrative
No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
Sexual Harassment Investigation Files Selected for Review
106. Enter the total number of SEXUAL 0
HARASSMENT investigation files
reviewed/sampled:
a. Explain why you were unable to There were no allegations of sexual abuse
review any sexual harassment during this audit period.
investigation files:
107. 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
108. Enter the total number of INMATE- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
109. 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)
110. 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
111. Enter the total number of STAFF- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
112. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include criminal No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
113. 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)
114. Provide any additional comments There were no allegations of sexual
regarding selecting and reviewing harassment during this audit period.
sexual abuse and sexual harassment
investigation files.
SUPPORT STAFF INFORMATION
DOJ-certified PREA Auditors Support Staff
115. 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
116. 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
121. 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 Communications Group, LLC
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: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ Policy 1919), Prison Rape Elimination Act (PREA)
Facility PREA Policy Statement 600.600, PREA
Organization Chart
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinator
Random Staff
Residents
Provision (a):
An agency shall have a written policy mandating zero tolerance toward all forms of
sexual abuse and sexual harassment and outlining the agency’s approach to
preventing, detecting, and responding to such conduct.
Policy mandates zero-tolerance of sexual abuse and sexual harassment and outlines
how the facility carries out its approach to preventing, detecting and responding to
sexual abuse and sexual harassment. Policy includes definitions of prohibited
behaviors and sanctions for those found to have participated in prohibited
behaviors. Policy provides strategies and responses for reducing and preventing
sexual abuse and harassment. The facility is a part of a contract between its parent
agency, Rite of Passage, Incorporated and the Florida Department of Juvenile Justice
(FDJJ). The FDJJ agency PREA Policy, FDJJ 1919, serves as the overarching policy for
the contract facilities.
The facility’s PREA Policy Statement, 600.600, provides the zero-tolerance
statement regarding all forms of sexual abuse and sexual harassment and also
contains the PREA related definitions. The facility has a collection of general PREA
policies that replicate the PREA Standards and are identified by the corresponding
standard number, under the heading of Safe Environment Standards (SES) and
other PREA related policies. Primarily, the FDJJ policies are used as the guidance for
facility practice regarding adherence to the PREA Standards. The FDJJ and facility
policies outline the strategies for addressing the components of the PREA standards.
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA Coordinator
with sufficient time and authority to develop, implement, and oversee agency
efforts to comply with the PREA standards in all of its facilities.
Oak Grove Academy is a juvenile residential treatment facility within Rite of Passage
which employs upper-level staff that serve as the PREA Coordinator. The FDJJ also
has an upper-level staff member serving as the statewide PREA Coordinator. The
PREA Coordinators have indicated there is sufficient time and authority to attend to
PREA duties. Support is provided to the facility by both PREA Coordinators and
regional contract support staff.
Provision (c):
Where an agency operates more than one facility, each facility shall designate a
PREA compliance manager with sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards.
The facility Superintendent has been designated as the PREA Compliance Manager
who stated that PREA/safety of residents is at the forefront of what he does. The
Superintendent expressed there is the time to fulfill the PREA duties and it was
observed that the Superintendent has the authority required to fulfill those duties.
The Superintendent is supported by facility staff and the contract agency's Regional
Compliance Director. Interviews conducted with all staff revealed their awareness of
the role of the PREA Compliance Manager. The agency policy and practice provide
for the designation of a PREA Compliance Manager at the facility level.
Conclusion:
Based upon the review and analysis of the available documentation, the Auditor
determined the facility is compliant with this standard.
115.312 Contracting with other entities for the confinement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy FDJJ 1919, Prison Rape Elimination Act (PREA)
Contract
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinator
Provisions (a) and (b):
Provision (a): A public agency that contracts for the confinement of its residents
with private agencies or other entities, including other government agencies, shall
include in any new contract or contract renewal the entity’s obligation to adopt and
comply with the PREA standards. Provision (b): Any new contract or contract
renewal shall provide for agency contract monitoring to ensure that the contractor is
complying with the PREA standards.
The public agency, FDJJ, contracts for the confinement of its residents. Contracts
exist that inform providers of the requirements by the Florida Department of
Juvenile Justice to comply with the PREA Standards and that they are subject to
PREA audits. The practice is also confirmed by completed PREA audit reports, signed
contract, and interviews.
Conclusion:
Based upon the review and analysis of the available documentation and interviews,
the Auditor determined compliance.
115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Safe Environment Standards
Staffing Plan
Staffing Plan Assessment
Unannounced Rounds Forms
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinator
Random Staff
Higher-Level Staff
Provision (a):
The agency shall ensure that each facility it operates shall develop, implement, and
document a staffing plan that provides for adequate levels of staffing, and, where
applicable, video monitoring, to protect residents against sexual abuse. In
calculating adequate staffing levels and determining the need for video monitoring,
facilities shall take into consideration:
(1) Generally accepted juvenile detention and correctional/secure residential
practices;
(2) Any judicial findings of inadequacy;
(3) Any findings of inadequacy from Federal investigative agencies;
(4) Any findings of inadequacy from internal or external oversight bodies;
(5) All components of the facility’s physical plant (including “blind spots” or areas
where staff or residents may be isolated);
(6) The composition of the resident population;
(7) The number and placement of supervisory staff;
(8) Institution programs occurring on a particular shift;
(9) Any applicable State or local laws, regulations, or standards;
(10) The prevalence of substantiated and unsubstantiated incidents of sexual
abuse; and
(11) Any other relevant factors.
Policy requires the facility to develop, implement and document an approved
staffing plan. The Superintendent and review of documentation verified the
development of the facility’s staffing plan and the continual assessment of
adequate staffing levels and the need for video monitoring. The staffing plan
provides details for maintaining the staffing ratios and the staffing plan outlines the
staffing requirements. The facility’s staffing plan, internal controls and management
ensures that the PREA ratios of 1:8 during the waking hours and 1:16 during the
sleeping hours are maintained due to the internal ratios of 1:8 and 1:12 during the
sleeping hours. Direct supervision is provided to residents during the daily activities
and program services. There are no reports of deviation from the ratios in the past
12 months.
Provision (b):
The agency shall comply with the staffing plan except during limited and discrete
exigent circumstances and shall fully document deviations from the plan during
such circumstances.
The staffing plan is based upon the facility’s average daily population of 30
residents. Policy requires the facility to document deviations from the staffing plan;
however, there were no deviations from the plan to review. A coordinated effort was
described in maintaining the staffing ratios which are stated in the agency contract.
The operations of the facility provide for assigning staff to cover situations as
needed. The facility is prepared to document any deviations from the staffing
requirements. The Superintendent and upper-level staff regularly monitor the work
schedules based on the staffing plan and situations within the facility. The staffing
plan ensures the PREA staffing ratios are met.
Provision (c):
Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8 during
resident waking hours and 1:16 during resident sleeping hours, except during
limited and discrete exigent circumstances, which shall be fully documented. Only
security staff shall be included in these ratios. Any facility that, as of the date of
publication of this final rule, is not already obligated by law, regulation, or judicial
consent decree to maintain the staffing ratios set forth in this paragraph shall have
until October 1, 2017, to achieve compliance.
The Superintendent's interview, staff schedules, and observations confirmed the
rations are being met. Direct care staff members provide direct observation of
residents. Since the last PREA audit the average daily number of residents is 30.
Since the last PREA audit, the average daily number of residents on which the
staffing plan was predicated is 30. The facility is not involved in any lawsuits or
consent decrees.
Provision (d):
Whenever necessary, but no less frequently than once each year, for each facility
the agency operates, in consultation with the PREA coordinator required by §
115.311, the agency shall assess, determine, and document whether adjustments
are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this section;
(2) Prevailing staffing patterns;
(3) The facility’s deployment of video monitoring systems and other monitoring
technologies; and
(4) The resources the facility has available to commit to ensure adherence to the
staffing plan.
Documentation of the annual assessment of the staffing plan dated 5/23/2023 was
reviewed and found to be in compliance with the elements contained in this
provision of the standard. The FDJJ PREA Coordinator and Superintendent
corroborated on the staffing plan assessment. It was determined that no
adjustments were made during the review. Oak Grove Academy utilizes video
monitoring combined with direct staff supervision to monitor residents. The facility
has a total of 53 cameras throughout the facility and grounds. The annual
assessment of the staffing plan indicated no recommendations.
Provision (e):
Each secure facility shall implement a policy and practice of having intermediate-
level or higher-level supervisors conduct and document unannounced rounds to
identify and deter staff sexual abuse and sexual harassment. Such policy and
practice shall be implemented for night shifts as well as day shifts. Each secure
facility shall have a policy to prohibit staff from alerting other staff members that
these supervisory rounds are occurring, unless such announcement is related to the
legitimate operational functions of the facility.
Policy requires intermediate or higher-level staff to conduct unannounced rounds to
deter and identify staff sexual abuse and sexual harassment. An interview with a
higher-level staff member and a review of unannounced rounds documentation
revealed over time unannounced rounds are conducted on the shifts and in all areas
of the facility. A dedicated form is used to document the rounds as well as notations
in the logbook. Staff members are informed not to alert other staff during the
rounds which are not conducted at set times.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with this standard regarding supervision and
monitoring.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Policy (5.06), Contraband and Search Practices
Rite of Passage Safe Environment Standards
Training Curricula
Student Personal Search Log
Posted Signs
Interviews:
Superintendent/PREA Coordinator
Random Staff
Residents
Provision (a):
The facility shall not conduct cross-gender strip searches or cross-gender visual
body cavity searches (meaning a search of the anal or genital opening) except in
exigent circumstances or when performed by medical practitioners.
Policy prohibits cross-gender strip searches and cross-gender visual cavity searches.
Cross-gender pat-sown searches are also prohibited. Policy provides guidance to
staff on how the searches are to be conducted. The interviews support that cross-
gender searches are not conducted at the facility. There is no evidence of cross-
gender searches of any type occurring at the facility in the last 12 months.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent
circumstances.
Policy does not provide for staff to conduct cross-gender pat-down searches. All
searches and the reason for the search must be documented. The training records
and materials show staff receive training on how to conduct searches; staff
participation in the training is documented. Staff interviews confirmed awareness of
the policy regarding searches. No residents or staff interviewed reported the
occurrence of any cross-gender pat-down searches. The training records and
materials show staff receive training on how to conduct searches; staff participation
in the training is documented. Staff interviews confirmed awareness of the policy
regarding searches.
Provision (c):
The facility shall document and justify all cross-gender strip searches, cross-gender
visual body cavity searches, and cross-gender pat-down searches.
Policy prohibits cross-gender strip searches and cross-gender visual body cavity
searches; all searches are documented. All interviews confirmed that cross-gender
searches have not occurred at the facility during this audit period. There was no
evidence documenting any cross-gender searches within the past 12 months.
Provision (d):
The facility shall implement policies and procedures that enable residents to
shower, perform bodily functions, and change clothing without nonmedical staff of
the opposite gender viewing their breasts, buttocks, or genitalia, except in exigent
circumstances or when such viewing is incidental to routine cell checks. Such
policies and procedures shall require staff of the opposite gender to announce their
presence when entering a resident housing 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, in accordance with policy, enables residents to shower, perform bodily
functions, and change clothes without staff of the opposite gender viewing them.
This practice was confirmed through interviews with residents and staff. None of the
residents interviewed reported ever having been naked in full view of the opposite
gender staff while showering, changing clothes, or performing bodily functions.
During the comprehensive site review, it was explained how hygiene practices are
conducted. It was observed that residents have a reasonable amount of privacy
during use of the bathroom.
Staff members of the opposite gender must announce their presence when entering
the residents’ housing units and signs are posted. Residents and direct care staff
stated female staff members announce their presence upon entering the living
units. The interviews confirm residents shower, perform bodily functions, and
change clothing without nonmedical staff of the opposite gender viewing their
buttocks or genitalia.
The staff interviews and viewing of cameras support that viewing of the monitors
does not show residents when they are showering, using the toilet or changing
clothes. The shower and toilet stalls do not allow staff to get a view of the resident’s
body and provide a reasonable amount of privacy. There are no cameras in the
bathroom.
Provision (e):
The facility shall not search or physically examine a transgender or intersex resident
for the sole purpose of determining the resident’s genital status. If the resident’s
genital status is unknown, it may be determined during conversations with the
resident, by reviewing medical records, or, if necessary, by learning that information
as part of a broader medical examination conducted in private by a medical
practitioner.
Policy prohibits the search of transgender or intersex residents solely for the
purpose of determining the residents’ genital status and staff interviews verified no
such searches have occurred in the past 12 months. Policy provides that if the
resident’s genital status is unknown, it may be determined during conversations
with the resident, by reviewing medical records, or by learning that information as
part of a broader medical examination conducted in private by a medical
practitioner. One hundred percent of direct care staff received the training on
conducting cross-gender pat-down searches and searches of transgender and
intersex residents. Staff interviews confirmed they are aware facility policy prohibits
them from conducting a physical examination of transgender or intersex resident
solely for the purpose of determining the resident’s genital status.
Provision (f):
The agency shall train security staff in how to conduct cross-gender pat-down
searches, and searches of transgender and intersex residents, in a professional and
respectful manner, and in the least intrusive manner possible, consistent with
security needs.
Policy provides that staff shall be trained in how to conduct cross-gender pat-down
searches, and searches of transgender and intersex residents, in a professional and
respectful manner, and in the least intrusive manner possible, consistent with
security needs. The documentation and staff interviews support the training is
conducted. The evidence shows staff are trained in how to conduct cross-gender
pat-down searches, and searches of transgender and intersex residents, in a
professional and respectful manner, and in the least intrusive manner possible,
consistent with security needs.
Conclusion:
Based on the reviewed documentation and interviews, the facility is in compliance
with this standard.
Residents with disabilities and residents who are limited English
115.316
proficient
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Rite of Passage Safe Environment Standards
Interviews:
Superintendent
Random Staff
Provision (a):
The agency shall take appropriate steps to ensure that residents with disabilities
(including, for example, residents who are deaf or hard of hearing, those who are
blind or have low vision, or those who have intellectual, psychiatric, or speech
disabilities), have an equal opportunity to participate in or benefit from all aspects
of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment. Such steps shall include, when necessary to ensure effective
communication with residents who are deaf or hard of hearing, providing access to
interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary. In
addition, the agency shall ensure that written materials are provided in formats or
through methods that ensure effective communication with residents with
disabilities, including residents who have intellectual disabilities, limited reading
skills, or who are blind or have low vision. An agency is not required to take actions
that it can demonstrate would result in a fundamental alteration in the nature of a
service, program, or activity, or in undue financial and administrative burdens, as
those terms are used in regulations promulgated under title II of the Americans With
Disabilities Act, 28 CFR 35.164.
Policy and addresses the provision of support services for disabled residents by
providing these residents an equal opportunity to participate in or benefit from all
aspects of the facility’s efforts to prevent, detect, and respond to sexual abuse and
sexual harassment. Policy prohibits use of resident interpreters, resident readers, or
other types of assistance from residents. The exception is during limited
circumstances where an extended delay in obtaining an effective interpreter could
compromise the resident’s safety, performance of first responder duties, or the
investigation of the allegations.
Support services are provided by the Hamilton County school system to residents
with disabilities or who may be limited English proficient. There are certified
teachers with the educational background to modify/adapt information for all
residents to understand. Assistance may also be provided by the treatment staff to
ensure all residents’ understanding of the PREA information. Posted and other PREA
information is in English, French Creole, and Spanish. The contract agency has an
arrangement with a professional interpreting service for each facility to access for
services as needed.
Provision (b):
The agency shall take reasonable steps to ensure meaningful access to all aspects
of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment to residents who are limited English proficient, including steps to
provide interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary.
An Interpreting and Translation Agreement exists with a professional agency for
services as needed. The evidence shows residents with disabilities and who may be
limited English proficient are provided 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. All staff interviewed confirmed residents are
not used as interpreters and understand prior arrangements have been made
regarding language interpreters. There are staff who can speak and translate in
other languages in an emergency situation.
Provision (c):
The agency shall not rely on resident interpreters, resident readers, or other types
of resident s except in limited circumstances where an extended delay in obtaining
an effective interpreter could compromise the resident’s safety, the performance of
first-response duties under § 115.364, or the investigation of the resident’s
allegations.
Policy prohibits the use of resident interpreters, resident readers or any kind of
resident s except when a delay in obtaining interpreter services could jeopardize a
resident’s safety, performance of the first responder duties, or the investigation of
the allegation. Staff interviews confirmed residents have not been used to relate
PREA information to or from other residents in the past 12 months. There were no
residents in need of an interpreter during the onsite audit phase.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the
facility is compliant with this standard.
115.317 Hiring and promotion decisions
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Agency Policy (FDJJ 1800), Background Screening and Hiring Practice
Facility Policy (100.209), Background Notification and Authorized Form/Background
Record Clearance
Personnel Files
Interview:
Administrative (Human Resources) Staff
Provisions (a) & (f):
Provision (a): The agency shall not hire or promote anyone who may have contact
with residents, and shall not enlist the services of any contractor who may have
contact with residents, who—(1) Has engaged in sexual abuse in a prison, jail,
lockup, community confinement facility, juvenile facility, or other institution (as
defined in 42 U.S.C. 1997); (2) Has been convicted of engaging or attempting to
engage in sexual activity in the community facilitated by force, overt or implied
threats of force, or coercion, or if the victim did not consent or was unable to
consent or refuse; or (3) Has been civilly or administratively adjudicated to have
engaged in the activity described in paragraph (a)(2) of this section. Provision (f):
The agency shall also ask all applicants and employees who may have contact with
residents directly about previous misconduct described in paragraph (a) of this
section in written applications or interviews for hiring or promotions and in any
interviews or written self-evaluations conducted as part of reviews of current
employees. The agency shall also impose upon employees a continuing affirmative
duty to disclose any such misconduct.
The policies address hiring and promotion processes and decisions and background
checks. The background checks occur initially and every five years thereafter,
aligned with policy and the Standard. The personnel files include the completed
background checks and hiring documents. Background checks are obtained through
the Florida Department of Juvenile Justice, Background Screening Unit.
Through the employment application process, prior to hire and promotion,
employees are asked to verify, in writing, the following information which is a part of
the background screening packet:
· Have 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);
· Have 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,
· Have been civilly or administratively adjudicated to have engaged in the
activity described above.
The interview and review of policies provide details about the hiring process,
completion of background checks, and grounds for termination. The forms
completed and included in the personnel files are responsive to the provisions of
this standard. All applicants are asked about any prior misconduct involving any
sexual activity. The documentation, interview and policies support the facility does
not hire anyone who has engaged in sexual abuse or anyone who has used or
attempted to use force in the community to engage in sexual abuse.
Provision (b):
The agency shall consider any incidents of sexual harassment in determining
whether to hire or promote anyone, or to enlist the services of any contractor, who
may have contact with residents.
The facility considers any incidents of sexual abuse or sexual harassment in
determining whether to hire a person, enlist the services of a contractor or
volunteer, or whether to promote an employee. No applicant will be considered for
employment if a background check reveals any history of inappropriate sexual
behavior or arrest for inappropriate sexual behavior.
Provisions (c) & (d):
Provision (c): Before hiring new employees who may have contact with residents,
the agency shall: (1) Perform a criminal background records check; (2) Consult any
child abuse registry maintained by the State or locality in which the employee would
work; and (3) Consistent with Federal, State, and local law, make its best efforts to
contact all prior institutional employers for information on substantiated allegations
of sexual abuse or any resignation during a pending investigation of an allegation of
sexual abuse. Provision (d): The agency shall also 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.
The background check process is conducted through the Florida Department of
Juvenile Justice, Background Screening Unit. Background checks are conducted on
potential employees, contractors, volunteers and interns. Best efforts are made to
contact all prior institutional employers for information of incidents or allegations of
sexual abuse. The interview, policy and background check documents confirm that
predator checks are made.
Provision (e):
The agency shall either conduct criminal background records checks at least every
five years of current employees and contractors who may have contact with
residents or have in place a system for otherwise capturing such information for
current employees.
The interview and policy are aligned with the requirements of the provisions of the
standard and provide that background checks occur prior to employment and every
five years thereafter. Initial background checks and five-year checks were reviewed
during the onsite audit phase. Based on the review of documentation and the
interview, the evidence shows the facility practices are aligned with this provision of
the Standard.
Provision (g):
Material omissions regarding such misconduct, or the provision of materially false
information, shall be grounds for termination.
Policy provides that material omissions regarding such misconduct, or the provision
of materially false information, shall be grounds for termination. Information is
shared with the facility from the Background Screening Unit regarding the arrest of
any facility staff.
Provision (h):
Unless prohibited by law, the agency shall provide information on substantiated
allegations of sexual abuse or sexual harassment involving a former employee upon
receiving a request from an institutional employer for whom such employee has
applied to work.
The information is provided as the institution makes the request and the regional
office may be involved. Policy provides that the information will be provided when
requested unless it is prohibited by law to provide the information.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document Reviewed:
Agency Policy (FDJJ 1919), PREA
Interviews:
Superintendent
Contract Agency Head
Provision (a):
If the agency designed or acquired any new facility or planned any substantial
expansion or modification of existing facilities, did the agency consider the effect of
the design, acquisition, expansion, or modification upon the agency’s ability to
protect residents from sexual abuse?
There have not been major renovations completed since the last PREA audit
conducted in 2020.
Provision (b):
If the agency installed or updated a video monitoring system, electronic surveillance
system, or other monitoring technology, the agency considered how such
technology may enhance the agency’s ability to protect residents from sexual
abuse.
The camera system remains the same since the last PREA audit conducted in 2020.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
PREA Compliance Form
Memorandum of Understanding (MOU), Another Way Inc.
Interviews:
Random Staff
Superintendent/PREA Compliance Manager
Medical Staff
Advocacy Agency Representative
Provisions (a) & (b):
Provision (a): To the extent the agency is responsible for investigating allegations
of sexual abuse, the agency shall follow a uniform evidence protocol that maximizes
the potential for obtaining usable physical evidence for administrative proceedings
and criminal prosecutions. Provision (b): The protocol shall be developmentally
appropriate for youth and, as appropriate, shall be adapted from or otherwise based
on the most recent edition of the U.S. Department of Justice’s Office on Violence
Against Women publication, “A National Protocol for Sexual Assault Medical Forensic
Examinations, Adults/Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011.
Policy provides for the uniform protocols to be followed and the Florida Department
of Juvenile Justice (FDJJ)/Office of Inspector General (OIG). The Form provide the
guidelines for investigators conducting investigations regarding allegations of
sexual abuse which is appropriate for youth and adults. The PREA Form includes
interviewing; evidence collection; victim services; notifications; and prosecution.
The agency-based investigators conduct administrative investigations and the
Hamilton Sheriff’s Office investigate sexual abuse allegations that are criminal in
nature. Staff interviews confirmed an understanding of the facility’s protocol for
obtaining usable physical evidence if a resident alleges sexual abuse and
knowledge of the entities responsible for conducting investigations.
Provision (c):
The agency shall offer all residents who experience sexual abuse access to forensic
medical examinations whether on-site or at an outside facility, without financial
cost, where evidentiary or medically appropriate. Such examinations shall be
performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse
Examiners (SANEs) where possible. If SAFEs or SANEs cannot be made available, the
examination can be performed by other qualified medical practitioners. The agency
shall document its efforts to provide SAFEs or SANEs.
Policy requires that forensic medical examinations be conducted and that all
treatment is provided at no cost to the victim. According to the medical staff,
forensic medical examinations will be conducted at the local hospital by a qualified
medical practitioner. There have been no forensic medical examinations during this
audit period.
Provisions (d) & (e):
Provision (d): The agency shall attempt to make available to the victim a victim
advocate from a rape crisis center. If a rape crisis center is not available to provide
victim advocate services, the agency shall make available to provide these services
a qualified staff member from a community-based organization or a qualified
agency staff member. Agencies shall document efforts to secure services from rape
crisis centers. For the purpose of this standard, a rape crisis center refers to an
entity that provides intervention and related assistance, such as the services
specified in 42 U.S.C. 14043g(b)(2)(C), to victims of sexual assault of all ages. The
agency may utilize a rape crisis center that is part of a governmental unit as long as
the center is not part of the criminal justice system (such as a law enforcement
agency) and offers a comparable level of confidentiality as a nongovernmental
entity that provides similar victim services. Provision (e): As requested by the
victim, the victim advocate, qualified agency staff member, or qualified community-
based organization staff member shall accompany and support the victim through
the forensic medical examination process and investigatory interviews and shall
provide emotional support, crisis intervention, information, and referrals.
The facility has a MOU with Another Way Incorporated for victim advocacy services.
According to the interview with the representative, the supportive services to
victims include access to 24-hour hotline; counseling; accompaniment; and referrals
and information. The Superintendent also confirmed residents' access to advocacy
services. It was confirmed that the resident and/or facility staff members are able to
utilize the victim service hotline to request a victim advocate. Advocacy services
have not been requested during the previous 12 months.
Provisions (f), (g) & (h):
Provision (f): To the extent the agency itself is not responsible for investigating
allegations of sexual abuse, the agency shall request that the investigating agency
follow the requirements of paragraphs (a) through (f) of this section. Provision (g):
The requirements of paragraphs (a) through (f) of this section shall also apply to: (1)
Any State entity outside of the agency that is responsible for investigating
allegations of sexual abuse in juvenile facilities; and (2) Any Department of Justice
component that is responsible for investigating allegations of sexual abuse in
juvenile facilities. Provision (h): For the purposes of this standard, a qualified
agency staff member or a qualified community-based staff member shall be an
individual who has been screened for appropriateness to serve in this role and has
received education concerning sexual assault and forensic examination issues in
general.
Florida FDJJ OIG investigators conduct administrative investigations in accordance
with agency policy and the Standard. Investigations of allegations of sexual abuse
or sexual harassment that are criminal in nature will be referred to the Hamilton
County Sheriff’s Office in accordance with policy and the provisions of the Standard.
Allegations of sexual abuse are also reported to the Florida Department of Children
and Families. Investigators from the Hamilton County Sheriff’s Office are provided
the Compliance Form provided by the OIG regarding conducting investigations in
inclusive of the PREA Standards. The interviews with the Superintendent and
advocacy agency representative confirm advocacy services that are available to
residents who are the victims of sexual abuse. There have been no request for
advocacy services during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the provisions of this standard.
115.322 Policies to ensure referrals of allegations for investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Policy and Procedures (1.06), Incident Reporting (CCC)
Interviews:
Random Staff
Superintendent
PREA Coordinator
Provision (a):
The agency shall ensure that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment.
Policy directs staff to report all allegations of sexual abuse and sexual harassment
and to document the reports. Staff members are aware of policy requirements as
verified through their interviews. Allegations are reported to the Florida Department
of Juvenile Justice (FDJJ)/Central Communications Center, Florida Department of
Children and Families child abuse hotline, and/or the Hamilton County Sheriff's
Office.
Provisions (b) & (c):
The agency shall have in place a policy to ensure that allegations of sexual abuse or
sexual harassment are referred for investigation to an agency with the legal
authority to conduct criminal investigations, unless the allegation does not involve
potentially criminal behavior. The agency shall publish such policy on its website or,
if it does not have one, make the policy available through other means. The agency
shall document all such referrals. Provision (c): If a separate entity is responsible
for conducting criminal investigations, such publication shall describe the
responsibilities of both the agency and the investigating entity.
Zero-tolerance and reporting information, including third-party, are located on the
agency’s website, within the facility and accessible to the public. The facility’s
parent agency also provides PREA information. Policy and interviews confirm
allegations of sexual abuse and sexual harassment are investigated. Administrative
investigations are conducted by FDJJ/Office of Inspector General trained
investigators. Allegations that are criminal in nature are referred to the Hamilton
County Sheriff’s Office. Reporting information is also posted in various areas of the
facility including living units and common areas. The posted information is
accessible to residents, staff, contractors and visitors.
Provision (d):
Any State entity responsible for conducting administrative or criminal investigations
of sexual abuse or sexual harassment in juvenile facilities shall have in place a
policy governing the conduct of such investigations.
The FDJJ and the other investigative entities have policies governing investigations
and trained investigators are utilized. A previous interview with the investigative
staff confirmed that administrative investigations are conducted by a trained
investigator and allegations that are criminal in nature are referred to the Hamilton
County Sheriff’s Office. The FDJJ Office of Inspector provides a PREA Compliance
Form to be provided to outside agency investigators regarding investigations in
accordance with the PREA Standards.
Provision (e):
Any Department of Justice component responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in juvenile facilities
shall have in place a policy governing the conduct of such investigations.
The Department of Justice is not responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in this facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.331 Employee training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Training Curriculum
Sign-in Sheets
Training Rosters
Interviews:
Random Staff
Superintendent/PREA Compliance Manager
Provisions (a) and (c):
Provision (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.
Provision (c): All current employees who have not received such training shall be
trained within one year of the effective date of the PREA standards, and the agency
shall provide each employee with refresher training every two years to ensure that
all employees know the agency’s current sexual abuse and sexual harassment
policies and procedures. In years in which an employee does not receive refresher
training, the agency shall provide refresher information on current sexual abuse and
sexual harassment policies.
Policy addresses PREA related training for staff. All interviewed staff members were
familiar with the PREA information regarding primary components of preventing,
detecting and responding to sexual abuse or sexual harassment. PREA training is
provided to staff, as indicated by a review of policy and training documents, and the
staff interviews. The documents and staff interviews support refresher training is
also conducted and is documented.
The direct care staff interviewed and the Superintendent/PREA Compliance Manager
reported the training is provided as required. All direct care staff members
interviewed, and document review verified the general topics below are included in
the training:
1. Zero-tolerance PREA related policies.
2. Staff responsibilities and how to fulfill them regarding allegations or incidents of
sexual abuse or sexual harassment.
3. Residents’ right to be free from sexual abuse and sexual harassment.
4. The right for staff and residents to be free from retaliation for reporting
allegations or cooperating in an investigation.
5. Dynamics of sexual abuse and sexual harassment in juvenile facilities.
6. Residents and employees rights to be free from retaliation for reporting sexual
abuse and sexual harassment.
7. How to avoid inappropriate relationships with residents.
8. Common reactions of sexual abuse and sexual harassment by juvenile victims.
9. Communicating effectively and professionally with residents, including lesbian,
gay, bisexual, transgender, intersex, or gender non-conforming residents.
10. Mandatory reporting.
11. Relevant laws regarding the applicable age of consent.
General PREA training is conducted annually, and refresher training is provided as
needed. Staff interviews confirmed they have received training on the 11 required
topics. Staff members are knowledgeable of PREA standards and of their PREA-
related duties.
Provision (b):
Such training shall be tailored to the unique needs and attributes of residents of
juvenile facilities and to the gender of the residents at the employee’s facility. The
employee shall receive additional training if the employee is reassigned from a
facility that houses only male residents to a facility that houses only female
residents, or vice versa.
The facility houses males and the training considers the needs of the population
served. Policy provides that training is tailored to the needs and attributes to the
population served.
Provision (d):
The agency shall document, through employee signature or electronic verification
that employees understand the training they have received.
Policy provides that all training is documented. Staff members sign training rosters
and electric training records are generated. New employee orientation training for
all new employees also contains primary elements of the PREA Standards. The
facility provided the Auditor with several examples for verification of the training
occurring and the training was verified through staff interviews.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with this Standard.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Rite of Passage Safe Environment Standards
Training Curriculum
Acknowledgement Statement
Interviews:
Volunteers (2)
Superintendent/PREA Compliance Manager
Provision (a):
The agency shall ensure that all volunteers and contractors who have contact with
residents have been trained on their responsibilities under the agency’s sexual
abuse and sexual harassment prevention, detection, and response policies and
procedures.
Policy requires volunteers and contractors who have contact with residents, to be
trained regarding PREA and their related responsibilities in sexual abuse prevention,
detection, and response to allegations of sexual abuse and sexual harassment. The
interviews with the contractors confirm the training occurs. There are no volunteer
services provided in the facility at this time.
Provision (b):
The level and type of training provided to volunteers and contractors shall be based
on the services they provide and level of contact they have with residents, but all
volunteers and contractors who have contact with residents shall be notified of the
agency’s zero-tolerance policy regarding sexual abuse and sexual harassment and
informed how to report such incidents.
The interviews and review of documentation revealed the PREA training informs the
participants of their role in reporting allegations of sexual abuse and sexual
harassment. The participants are informed of their responsibilities regarding sexual
abuse prevention, detection, and response to an allegation of sexual abuse or
sexual harassment. The training is based on the services provided and that is
appropriate to the secure juvenile residential setting. The interviews with the
contractors confirm they have been made aware of the facility's zero-tolerance
policy regarding sexual abuse and sexual harassment of residents, including how to
report. The interviews confirm the review of the zero-tolerance policy is included in
the PREA training. The contractors provide medical and barbering services to the
residents.
Provision (c):
The agency shall maintain documentation confirming that volunteers and
contractors understand the training they have received.
The training documentation and interviews confirm the receipt and awareness of
training by the contractors. The interviews indicated the contractors understand the
training received.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with the provisions of this Standard.
115.333 Resident education
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Rite of Passage Safety Environment Standards
PREA Information Sheet
Brochures
Acknowledgement Statements
Posted PREA Information
Training Roster/Sign-in Sheet
Interviews:
Residents; targeted interview
Intake Staff
Superintendent/PREA Compliance Manager
Regional Compliance Director
Provisions (a) & (b):
Provision (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. Provision (b): Within 10 days of
intake, the agency shall provide comprehensive age-appropriate education to
residents either in person or through video regarding their rights to be free from
sexual abuse and sexual harassment and to be free from retaliation for reporting
such incidents, and regarding agency policies and procedures for responding to
such incidents.
According to policy and interviews, all youth admitted receive information about the
facility, including PREA education. Residents receive directions on how to report
allegations of sexual abuse and sexual harassment; and the right to be free from
retaliation for reporting. The interviews confirm an orientation is provided to
residents during the intake process. Within 10 days, an agency prepared PREA video
is shown and is shown periodically thereafter during the resident's stay in the
facility. Policy provides that residents receive a comprehensive age-appropriate
PREA education session within 10 days of admission to the facility.
The results of the staff and resident interviews indicated the information provided to
the residents is cage-appropriate. The intake staff’s interview revealed she ensures
residents are educated regarding their rights to be free from sexual abuse and
sexual harassment, and to be free from retaliation for reporting such incidents. The
PREA education sessions include a review of the PREA brochure and PREA
information sheet. The residents sign acknowledgement statements confirming
receipt of the PREA education sessions.
Seven out of the 10 residents interviewed did not have a clear understanding of the
advocacy services that may be helpful in dealing with sexual abuse. A corrective
action was implemented by the Superintendent/Compliance Manager and the
Regional Compliance Director for the provision of a refresher education session
during the post onsite audit phase. The regional and facility staff provided the
education session to all residents regarding the advocacy agency which included
the identity and purpose of the advocacy agency, available services, and contact
information. Verbal confirmation and documentation of the refresher education
session were provided to the Auditor by the Regional Compliance Director. The
documentation contained the dates of training, topics reviewed, duration of the
training, names of instructors, and the names and signatures of the residents.
Provision (c):
Current residents who have not received such education shall be educated within
one year of the effective date of the PREA standards and shall receive education
upon transfer to a different facility to the extent that the policies and procedures of
the resident’s new facility differ from those of the previous facility.
Based on the evidence shown documenting the PREA education sessions in
Provisions (a) and (b), interviews and acknowledgement statements, residents
received PREA education. The facility reports that 30 youth were admitted to the
facility during the past 12 months and all participated in PREA education sessions.
Provision (d):
The agency shall provide resident education in formats accessible to all residents,
including those who are limited English proficient, deaf, visually impaired, or
otherwise disabled, as well as to residents who have limited reading skills.
The facility has the capability to provide the PREA education in formats accessible to
all residents including those who may be hearing impaired; Deaf; have intellectual,
psychiatric and speech disabilities; low vision; blind; limited reading, limited English
proficient, and based on the individual need of the resident. The local school system
and teachers have provided support to the facility regarding support services for the
provision of accommodations for residents. Treatment staff may also assist in
ensuring all residents have unimpeded access to PREA education. Posted PREA
information is in English, French Creole, and Spanish accessible to residents, staff,
contractors, and visitors.
The facility has arrangements with a national reputable agency for professional
interpreting and translating services, including services for the Deaf. The intake staff
walked the Auditor through the process of and how she will access an interpreter if
needed. There were no residents in the facility during the comprehensive site review
that required the use of an interpreter. The targeted interview provided that
assistance is provided by various staff members as needed. The interviews
confirmed residents are not used as translators or readers for other residents.
Provision (e):
The agency shall maintain documentation of resident participation in these
education sessions.
Signed acknowledgement statements are maintained which support the residents’
involvement in PREA education sessions. The residents were aware of PREA
information, including their rights regarding PREA, how to report allegations and
that they would not be punished for reporting allegations of sexual abuse or sexual
harassment. Over half of the residents interviewed were not as familiar with the
advocacy services. A corrective action was implemented which was the provision of
a refresher education session with all residents. The refresher session was
documented. The advocacy services must be stressed in subsequent PREA
education sessions.
Provision (f):
In addition to providing such education, the agency shall ensure that key
information is continuously and readily available or visible to residents through
posters, resident handbooks, or other written formats.
The PREA education materials provide residents information on how to report
allegations of sexual harassment and sexual abuse. Brochures and the PREA
education sheet are provided to each resident to eliminate incidents of sexual
abuse and sexual harassment. The brochure provides educational information
regarding sexual abuse and victims. The residents revealed they can report
allegations of sexual abuse or sexual harassment by telling a staff member; telling a
family member who may report the allegation for them; access to the hotline to
report allegations of sexual abuse or sexual harassment; or put a complaint in
writing. The posted PREA information is placed at varying eye levels and the
messages are consistent.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with the provision of this standard.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Interviews:
Superintendent
Provision (a) & (b):
In addition to the general training provided to all employees pursuant to §115.331,
the agency shall ensure that, to the extent the agency itself conducts sexual abuse
investigations, its investigators have received training in conducting such
investigations in confinement settings. Provision (b): Specialized training shall
include techniques for interviewing juvenile sexual abuse victims, proper use of
Miranda and Garrity warnings, sexual abuse evidence collection in confinement
settings, and the criteria and evidence required to substantiate a case for
administrative action or prosecution referral.
Administrative investigations are conducted by the Florida Department of Juvenile
Justice, Office of Inspector General. Allegations that are criminal in nature are
investigated by the Hamilton County Sheriff's Office.
Provision (c):
The agency shall maintain documentation that agency investigators have
completed the required specialized training in conducting sexual abuse
investigations.
Investigative training is maintained by the investigative entities; the Florida
Department of Children and Families, Hamilton County Sheriff's Office, and the
Florida Department of Juvenile Justice/Office of Inspector General.
Provision (d):
Any State entity or Department of Justice component that investigates sexual abuse
in juvenile confinement settings shall provide such training to its agents and
investigators who conduct such investigations.
Facility staff does not conduct administrative nor criminal investigations into
allegations of sexual abuse or sexual harassment.
Conclusion:
Based upon the review and analysis of the available evidence, the auditor
determined the facility is compliant with this standard.
115.335 Specialized training: Medical and mental health care
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Training Curriculum
Training Reports
Interviews:
Medical Staff
Mental Health Staff
Provision (a):
The agency shall ensure that all full- and part-time medical and mental health care
practitioners who work regularly in its facilities have been trained in:
(1) How to detect and assess signs of sexual abuse and sexual harassment;
(2) How to preserve physical evidence of sexual abuse;
(3) How to respond effectively and professionally to juvenile victims of sexual abuse
and sexual harassment; and
(4) How and to whom to report allegations or suspicions of sexual abuse and sexual
harassment.
Policy provides medical and mental health staff members receive the regular PREA
training as well as the specialized training. Training records document specialized
training for medical and mental health staff members. Specialized medical and
mental health training is provided through the Department's electronic training
system. Documentation of specialized training was reviewed for medical and mental
health staff and confirmed during the interviews. The interviews with clinical staff
and a review of training documentation confirm completion of training which
includes the provision of the standard.
Provision (b):
If medical staff employed by the agency conduct forensic examinations, such
medical staff shall receive the appropriate training to conduct such examinations.
Forensic examinations are not conducted by the facility’s medical staff as verified
during the medical staff interview. Forensic examinations are conducted at the local
hospital.
Provision (c):
The agency shall maintain documentation that medical and mental health
practitioners have received the training referenced in this standard either from the
agency or elsewhere.
The training documents and the interviews with medical and mental health staff
confirm receipt of the required training.
Provision (d):
Medical and mental health care practitioners shall also receive the training
mandated for employees under Standard 115.331 or for contractors and volunteers
under Standard 115.332, depending upon the practitioner’s status at the agency.
Medical and mental health staff completed the general training that is provided for
all staff members as documented by training records.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.341 Obtaining information from residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Policy and Procedures (2.04), Assessment and Treatment Team
Facility Policy and Procedures (3.03), Mental Health and Substance Abuse
Assessment and Evaluation
Screening for Vulnerability to Victimization and Sexually Aggressive Behavior
(VSAB)
Interviews:
Staff Responsible for Risk Screening
PREA Compliance Manager
Residents
Contract Agency PREA Coordinator
Provision (a):
Within 72 hours of the resident’s arrival at the facility and periodically throughout a
resident’s confinement, the agency shall obtain and use information about each
resident’s personal history and behavior to reduce the risk of sexual abuse by or
upon a resident. The Policy provides a risk screening occurs within 72 hours upon
arrival to the facility. The Intake Coordinator will interview the resident at intake to
obtain information about the residents personal history and behavior in order to
reduce the risk of sexual abuse by or upon a resident. The resident’s risk level is
reassessed periodically.
Policy provides for each youth to be screened for risk of victimization, prior to room
assignment, for sexual vulnerabilities or acting-out with sexually aggressive
behavior. According to the interviews and documentation, the practice is that the
risk assessment is completed on the day of admission. According to the staff
responsible for risk screening, the questions are asked from the instrument and
probing is done as needed. The youth is interviewed to obtain information about his
personal history and behavior to gain information that will assist staff in reducing
the risk of sexual abuse by or upon others. The intake screening instrument, VSAB,
is used to document such information. The risk screening is being conducted as
required and in accordance with policy. A review of documentation and the interview
with the risk screener confirm the information obtained includes but is not limited
to:
· Prior sexual victimization or abusiveness;
· Resident’s own perception of vulnerability;
· Current charges and offense history;
· Self-identification of resident;
· Intellectual or developmental disabilities;
· Physical disabilities;
· Mental illness or mental disabilities
· Information regarding relationships with other youth
· Confirmation of size and stature
· Confirmation of Age
According to the interview with the risk screener, reassessments are conducted
every six months; after a crisis situation; new information learned; or a housing
change.
Provision (b):
Such assessments shall be conducted using an objective screening instrument.
The objective screening instrument, VSAB, is used to obtain the information
required by the standard, including but not limited to prior sexual victimization or
abusiveness; self-identification; current charges and offense history; intellectual or
developmental disabilities; and a resident’s concern regarding their own safety. The
instrument is scored based on the information received where a score can identify
individual needs and assist in measuring risk. The responses on the instrument
accumulate a score and the risk level is determined by definition and the
corresponding number to that definition. The VSAB provides a presumptive
determination of risk. The interview with the risk screener and review of policy
reveal how the objective instrument is administered to obtain information to assist
staff in keeping residents safe.
Provision (c):
At a minimum, the agency shall attempt to ascertain information about:
(1) Prior sexual victimization or abusiveness;
(2) Any gender nonconforming appearance or manner or identification as lesbian,
gay, bisexual, transgender, or intersex, and whether the resident may therefore be
vulnerable to sexual abuse;
(3) Current charges and offense history;
(4) Age;
(5) Level of emotional and cognitive development;
(6) Physical size and stature;
(7) Mental illness or mental disabilities;
(8) Intellectual or developmental disabilities;
(9) Physical disabilities;
(10) The residents own perception of vulnerability; and
(11) Any other specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or separation from
certain other residents.
The Auditor reviewed the VSAB screening instrument and determined all factors
required by this provision of the Standard are included. The interview with the risk
screener confirm awareness of the elements of the risk screening instrument. The
resident interviews also confirm the administration of the VSAB risk screening
instrument.
Provision (d):
This information shall be ascertained through conversations with the resident during
the intake process and medical and mental health screenings; during classification
assessments; and by reviewing court records, case files, facility behavioral records,
and other relevant documentation from the resident’s files.
Information in determining the risk for victimization or abusiveness is obtained
through interviewing the youth based on the information contained on the
instrument. Additional information to complete the screening instrument includes
but not limited to review of court records, review of previous evaluations, and talk to
parents. The interview with the risk screener reveal the information to complete the
risk screening instrument is gleaned from the various sources. Additional
assessments are completed when the youth is admitted to the facility to obtain
supportive information for treatment planning and keeping the youth and others
safe. Resident interviews also revealed the instrument is used.
Provision (e):
The agency shall implement appropriate controls on the dissemination within the
facility of responses to questions asked pursuant to this standard in order to ensure
that sensitive information is not exploited to the resident’s detriment by staff or
other residents.
Appropriate controls are taken to ensure that sensitive information is protected and
not exploited by maintaining the files securely and the online information on
computers is password protected with limited access. The expectation of
confidentiality by staff is underscored through training. The treatment and
leadership staff have access to the risk screening instruments. Other staff may be
informed of the information based on their need to know. The evidence, including
interviews and observations, document the facility’s adherence to the provision of
the standard.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.342 Placement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Policy and Procedures (2.04), Assessment and Treatment Team
Facility Policy and Procedures (3.03), Mental Health and Substance Abuse
Assessment and Evaluation
Interviews:
Superintendent/PREA Compliance Manager
Staff Responsible for Risk Screening
Random Staff
Contract Agency PREA Coordinator
Provision (a):
The agency shall use all information obtained pursuant to § 115.341 and
subsequently to make housing, bed, program, education, and work assignments for
residents with the goal of keeping all residents safe and free from sexual abuse.
Policy provides guidance to staff regarding the use of the information obtained from
the screening instrument. The staff interviews indicate the screening information is
used to inform staff of information used to determine housing assignments and the
information may also affect program assignments.
Provision (b):
Residents may be isolated from others only as a last resort when less restrictive
measures are inadequate to keep them and other residents safe, and then only until
an alternative means of keeping all residents safe can be arranged. During any
period of isolation, agencies shall not deny residents daily large-muscle exercise and
any legally required educational programming or special education services.
Residents in isolation shall receive daily visits from a medical or mental health care
clinician. Residents shall also have access to other programs and work opportunities
to the extent possible.
Agency policy provides that a resident would only be placed in isolation as a last
resort for protection and it would only be until other arrangements could be made to
keep the resident safe. If in protective custody, the agency policy also provides
residents will receive services which include education, medical and mental health
services. However, the program practice is that isolation is not used. The interviews
support that isolation is not used in this facility. Random staff and the
Superintendent's interviews indicate that protective measures will be taken
immediately when needed, such as separating residents and notifying a supervisor
or management staff.
Provision (c):
Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in
particular housing, bed, or other assignments solely on the basis of such
identification or status, nor shall agencies consider lesbian, gay, bisexual,
transgender, or intersex identification or status as an indicator of likelihood of being
sexually abusive.
Policy prohibits gay, bi-sexual, transgender and intersex residents from being placed
in a particular living area and that LGBTI identification or status is not an indicator of
likelihood of being sexually abusive. The PREA Compliance Manager’s interview and
observations verify compliance with this standard. During the comprehensive site
review, there were no rooms observed to be reserved for transgender or intersex
residents.
Provision (d):
In deciding whether to assign a transgender or intersex resident to a facility for
male or female residents, and in making other housing and programming
assignments, the agency shall consider on a case-by-case basis whether a
placement would ensure the resident’s health and safety, and whether the
placement would present management or security problems.
Policy provides that housing and program assignments for transgender or intersex
residents will be made on a case-by-case basis and these residents will not be
placed in particular or special housing which was evident from staff interviews.
There were no transgender or intersex residents in the facility during onsite audit
phase. The facility will consider on a case-by-case basis whether a placement will
ensure the resident’s health and safety, and whether the placement will present
management or security problems.
Provision (e):
Placement and programming assignments for each transgender or intersex resident
shall be reassessed at least twice each year to review any threats to safety
experienced by the resident.
Policy provides placement and programming assignments for each transgender or
intersex resident shall be reassessed at least twice each year. This function would
be done to review any threats to safety experienced by the resident. Transgender or
intersex resident will be reassessed at least twice each year to review any threats to
their safety experienced by the resident.
Provision (f):
A transgender or intersex resident’s own views with respect to his or her own safety
shall be given serious consideration.
The resident’s concern for his own safety is taken into account through the
administration of the risk assessment instrument. The residents confirm in the
interviews that they are asked about their safety concerns. The staff interviews
revealed staff members are aware of the policy which requires the provision of this
standard to be followed.
Provision (g):
Transgender and intersex residents shall be given the opportunity to shower
separately from other residents.
Transgender and intersex residents will be given the opportunity to shower
separately from other residents, in accordance with policy.
Provision (h):
If a resident is isolated pursuant to paragraph (b) of this section, the facility shall
clearly document:
(1) The basis for the facility’s concern for the resident’s safety; and
(2) The reason why no alternative means of separation can be arranged.
Policy states if a resident is isolated pursuant to part (B.2.) of this section, the
facility shall document:
a. The basis for the facility’s concern for the resident’s safety; and
b. The reason why no alternative means of separation can be arranged.
No residents at risk of sexual victimization were placed in isolation in the 12 months
preceding the audit. Interviews with the PREA Compliance Manager confirms this
facility does not use isolation. The policy is inclusive of this provision if there were to
be an emergency situation. The isolation/separation would be documented
according to the provisions of the policy and Standard.
Provision (i):
Every 30 days, the facility shall afford each resident described in paragraph (h) of
this section a review to determine whether there is a continuing need for separation
from the general population.
Isolation is not used in this facility. No residents at risk of sexual victimization were
placed in isolation in the 12 months preceding the audit.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.351 Resident reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Agency Policy (63F-11), Central Communications Center
Facility Policy and Procedures (1.06), Incident Reporting (CCC)
PREA/Grievance Form
Sick Call Form
Speak To Form
Brochures
Incident Reports
Investigative Reports
Multilingual Posters
Interviews:
Random Staff
Residents
Superintendent/PREA Compliance Manager
Provision (a):
The agency shall provide multiple internal ways for residents to privately report
sexual abuse and sexual harassment, retaliation by other residents or staff for
reporting sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents.
Internal ways for residents to privately report sexual abuse and sexual harassment,
retaliation and staff neglect include telling a trusted staff member; filling out and
completing one of the help request forms and placing it in a secure drop box; tell
someone that does not work at the facility; and/or utilize the abuse hotline. Resident
interviews confirm their knowledge of the various ways to report allegations of
sexual abuse and sexual harassment. Policy addresses this standard and provides
for multiple internal ways a resident may report allegations of sexual abuse and
sexual harassment, including how they can privately report sexual abuse and sexual
harassment; retaliation for reporting; and staff neglect or violations of
responsibilities that may have contributed to such. Each resident receives a
brochure which provides PREA related information, including how to report
allegations of sexual abuse. Posters are located in the living units and other areas
visible to residents, staff, contractors and visitors. Staff members receive
information on how to report allegations of sexual abuse or sexual harassment
through policies and procedures, training, and staff meetings
Provision (b):
The agency shall also provide at least one way for residents to report abuse or
harassment to a public or private entity or office that is not part of the agency and
that is able to receive and immediately forward resident reports of sexual abuse and
sexual harassment to agency officials, allowing the resident to remain anonymous
upon request. Residents detained solely for civil immigration purposes shall be
provided information on how to contact relevant consular officials and relevant
officials at the Department of Homeland Security.
Policy requires residents to have one way of reporting sexual abuse and sexual
harassment to a public or private entity or office not a part of the agency. Residents
may call the Florida Abuse Hotline to report allegations of sexual abuse or sexual
harassment. Residents may request to use a telephone with some degree of privacy
to call the hotline without having to obtain staff permission and policy and practice
mandates that staff not question residents about the reason for the call or deny the
call. The residents interviewed are aware of the abuse hotline and were able to
articulate how they may gain access. The Auditor conducted a test of the hotline;
the telephone was in working order. The prompts on the hotline provides the caller
with the option to report in English or Spanish. Residents are not detained solely for
civil immigration purposes.
Provision (c):
Staff shall accept reports made verbally, in writing, anonymously, and from third
parties and shall promptly document any verbal reports.
Staff interviews confirm methods available to residents for reporting allegations of
sexual abuse and sexual harassment. Staff members are required to accept reports
made anonymously, third-party reports and to document verbal reports. The
resident interviews collectively indicated awareness of reporting either in person, in
writing, by telephone, or through a third-party. Interviewed staff members are aware
of their duty to receive and document the receipt of verbal reports and that the
documentation must be done as soon as possible. The staff interviews confirmed
the methods available to residents for reporting allegations of sexual abuse and
sexual harassment. The resident interviews demonstrated their familiarity with the
various ways they may report either in person, in writing, by telephone, completing
a form, or through a third-party. The residents were aware third-party reports may
be made and that reports can be made anonymously.
Provision (d):
The facility shall provide residents with access to tools necessary to make a written
report.
Writing materials are readily available for residents to complete reports in writing.
The Auditor observed the accessibility of writing materials during the
comprehensive site review.
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and
sexual harassment of residents.
The staff interviews revealed staff can privately report allegations of sexual abuse.
The interviews collectively identify ways a report may be made privately such as
use of the hotline number; talk to supervisor in private; or call 911.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.352 Exhaustion of administrative remedies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Brochure
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinator
If an emergency grievance is received that contains an allegation of sexual abuse or
sexual harassment or implication of such, the policy and procedures for reporting
allegations of sexual abuse or sexual harassment are initiated and a report is made
as required by policy. The grievance system does not include a process for the
facility staff to investigate or resolve allegations of sexual abuse or sexual
harassment. The content of the grievance is reported and an investigation will be
conducted by the appropriate investigative entity.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Memorandum of Understanding (MOU), Another Way Inc.
PREA Education Sheet
Posted PREA Information
Interviews:
Residents
Superintendent/PREA Compliance Manager
Advocacy Agency Representative
Provision (a):
The facility shall provide residents with access to outside victim advocates for
emotional support services related to sexual abuse, by providing, posting, or
otherwise making accessible mailing addresses and telephone numbers, including
toll free hotline numbers where available, of local, State, or national victim
advocacy or rape crisis organizations, and, for persons detained solely for civil
immigration purposes, immigrant services agencies. The facility shall enable
reasonable communication between residents and these organizations and
agencies, in as confidential a manner as possible.
Oak Grove Academy ensures residents are provided access to outside confidential
support services. The facility has a MOU for advocacy services with Another Way
Inc. The facility provides residents with the access to the hotline number at any time
needed. The interview with the advocacy agency representative confirmed the
services available to residents that include accompaniment; counseling; referrals
and information; and items needed for school upon release. Certified victim
advocates will respond to requests for telephonic advocacy services. and
accompaniment during forensic examination; counselling; follow-up support; and
referral for treatment after release or transfer to another facility. Contact
information for advocacy services is a part of the PREA education sessions and is
provided to the residents on the PREA education sheet.
Provision (b):
The facility shall inform residents, prior to giving them access, of the extent to
which such communications will be monitored and the extent to which reports of
abuse will be forwarded to authorities in accordance with mandatory reporting laws.
The MOU addresses 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 for residents. A refresher training session was provided to all
residents regarding the advocacy agency and the services available.
Provision (c):
The agency shall maintain or attempt to enter into memoranda of understanding or
other agreements with community service providers that are able to provide
residents with confidential emotional support services related to sexual abuse. The
agency shall maintain copies of agreements or documentation showing attempts to
enter into such agreements.
The policy, MOU, staff interviews, and interview with the advocacy agency
representative document the availability of advocacy services including but not
limited to emotional support; accompaniment through the forensic medical
examination and investigation interview; access to counseling services; and
referrals. There were no requests for advocacy services during this audit period.
Provision (d):
The facility shall also provide residents with reasonable and confidential access to
their attorneys or other legal representation and reasonable access to parents or
legal guardians.
The interviews confirm residents have confidential access to attorneys and court
workers and reasonable access to their parents/legal guardians. The comprehensive
site review revealed areas where residents could meet privately with a legal
representative and the visitation area for visits with family members and other
approved visitors. All residents interviewed stated family may visit and they
provided the days and times of visitation and for telephone calls. The
Superintendent confirmed the facility provides residents with reasonable and
confidential access to their attorneys or court representatives and reasonable
access to parents or legal guardians.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Agency Website Information
Multilingual Posters
Interviews:
Random Staff
Residents
§115.354
The agency shall establish a method to receive third-party reports of sexual abuse
and sexual harassment and shall distribute publicly information on how to report
sexual abuse and sexual harassment on behalf of a resident.
Staff members are to receive, document and report allegations of sexual abuse and
sexual harassment made by a third-party. The staff members are aware third-party
reporting of sexual abuse or sexual harassment may be done and indicated the
information will be accepted and reported. Staff members are to document all
verbal reports received. The interviews collectively revealed staff may report
allegations privately through the use of the abuse reporting hotline, call 911, and
tell a supervisor. The Department's website contains the information needed for
third-parties to report allegations of sexual abuse and sexual harassment.
Information regarding reporting is posted within the facility and accessible to
residents, staff and visitors. All residents interviewed indicated knowing someone
who did not work at the facility they have contact with and could report allegations
of sexual abuse and sexual harassment. It was determined that a person outside of
the facility may report allegations of sexual abuse and may make a report for a
resident without giving the resident’s name. There were no third-party reports of
sexual abuse or sexual harassment received during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance regarding third-party reporting.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Florida Statute 39.201
Posted Information
Investigative Reports
Interviews:
Random Staff
Medical Staff
Mental Health Staff
Superintendent/PREA Compliance Manager
Provisions (a) & (b):
Provision (a): The agency shall require all staff to report immediately and
according to agency policy any knowledge, suspicion, or information they receive
regarding an incident of sexual abuse or sexual harassment that occurred in a
facility, whether or not it is part of the agency; retaliation against residents or staff
who reported such an incident; and any staff neglect or violation of responsibilities
that may have contributed to an incident or retaliation. Provision (b): The agency
shall also require all staff to comply with any applicable mandatory child abuse
reporting laws.
Policy supports that all staff report any knowledge, suspicion, information, or receipt
of information regarding an incident or allegation of sexual abuse, sexual
harassment or incidents of retaliation and according to mandatory reporting laws.
The trained agency investigators conduct administrative investigations and
allegations that are criminal in nature are referred to local law enforcement. Staff
members are deemed as mandated reporters by State law. Policy provides guidance
to staff on reporting allegations of sexual abuse and sexual harassment. Policy
supports that staff members are to immediately report any knowledge, suspicion or
information they receive regarding sexual abuse and sexual harassment; retaliation
against residents or staff who report any incidents; or any staff neglect or violation
of responsibilities that may have contributed to an incident or retaliation. Policy and
practice provide that all allegations This information should be reported to the
Florida Department of Juvenile Justice (FDJJ)/Central Communications Center,
Department of Children and Families (DCF), and local law enforcement. The trained
FDJJ investigators conduct administrative investigations and allegations that are
criminal in nature are referred to local law enforcement who works cooperatively
with DCF.
Provision (c):
Apart from reporting to designated supervisors or officials and designated State or
local services agencies, staff shall be prohibited from revealing any information
related to a sexual abuse report to anyone other than to the extent necessary, as
specified in agency policy, to make treatment, investigation, and other security and
management decisions.
Policy addresses confidentiality of information and the conditions for providing
information. Policy supports and the facility practice is that after allegations have
been appropriately reported, staff will keep the information confidential regarding
what was reported except when necessary regarding the investigation and
treatment and management decisions. Staff is expected to continue to abide by the
confidentiality requirements of the facility as informed in training.
Provision (d):
(1) Medical and mental health practitioners shall be required to report sexual abuse
to designated supervisors and officials pursuant to paragraph (a) of this section, as
well as to the designated State or local services agency where required by
mandatory reporting laws.
(2) Such practitioners shall be required to inform residents at the initiation of
services of their duty to report and the limitations of confidentiality.
The medical and mental health staff interviewed stated residents are informed at
the initiation of services of the limitations of confidentiality and the duty of the staff
members to report. The clinical staff interviewed revealed they are mandated
reporters. They also indicated informed consent would be documented for a
resident 18 years old and over regarding reporting allegations of sexual abuse that
did not occur in an institutional setting.
Provision (e):
(1) Upon receiving any allegation of sexual abuse, the facility head or his or her
designee shall promptly report the allegation to the appropriate agency office and
to the alleged victim’s parents or legal guardians, unless the facility has official
documentation showing the parents or legal guardians should not be notified.
(2) If the alleged victim is under the guardianship of the child welfare system, the
report shall be made to the alleged victim’s caseworker instead of the parents or
legal guardians.
(3) If a juvenile court retains jurisdiction over the alleged victim, the facility head or
designee shall also report the allegation to the juvenile’s attorney or other legal
representative of record within 14 days of receiving the allegation.
Reports of allegations are made as soon as possible and no later than two hours to
the investigative entities, including but not limited to the FDJJ Central
Communications Center, other investigative entities, and parents/legal guardians.
The policy and interview with the Superintendent confirm that a resident’s case
worker rather than a parent will be notified where indicated by the resident being
under the guardianship of the Florida Department of Children and Families. The
resident’s attorney will be notified within 14 days. Reports of allegations of sexual
abuse will be made by the Superintendent or designee.
Provision (f):
The facility shall report all allegations of sexual abuse and sexual harassment,
including third-party and anonymous reports, to the facility’s designated
investigators.
Policy and interviews provide for all allegations to be reported and include the FDJJ
Office of the Inspector General (OIG) through the Central Communications Center.
Administrative investigations are conducted by a FDJJ/OIG investigator. Allegations
that are criminal in nature are referred for investigation to local law enforcement.
Third-party and anonymous reports received must be reported and documented by
staff as confirmed through interviews. There was no evidence of receipt of third-
party or anonymous reports.
Conclusion:
Based on the triangulation of the evidence, the Auditor determined compliance with
the Standard.
115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Superintendent/PREA Compliance Manager
Random Staff
Random Residents
Contract Agency Head Designee
§115.362
When an agency learns that a resident is subject to a substantial risk of imminent
sexual abuse, it shall take immediate action to protect the resident.
The staff is required to protect the residents through implementing protective
measures. Administration of the risk screening instrument, VSAB, provides
information that assists and guide staff in keeping residents safe through housing
and program assignments. Additional assessment instruments provide information
which offer supporting information in determining the risk level of each resident.
The interviews revealed protective measures include but are not limited to
separating youth, contacting supervisors and/or management staff, implementing
one-to-one supervision. The interviews indicated the expectation is that any action
to protect a resident will be taken immediately. During the intake process, residents
are asked about how they feel about their safety as part of the inquiries by staff
completing the risk instrument. No resident was identified to be at substantial risk
of imminent sexual abuse in the past 12 months. Policy guides the response to this
provision if it becomes necessary.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.363 Reporting to other confinement facilities
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Interviews:
Superintendent
Contract Agency Head Designee
Provisions (a)-(d):
Provision (a): 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. Provision (b): Such notification shall be provided as soon as possible, but
no later than 72 hours after receiving the allegation. Provision (c): The agency
shall document that it has provided such notification. Provision (d): The facility
head or agency office that receives such notification shall ensure that the allegation
is investigated in accordance with these standards.
Policy provide that upon receiving an allegation that a resident was sexually abused
while confined at another facility, the Superintendent will notify the head of the
facility where the alleged abuse occurred. The notification will be made as soon as
possible and within 72 hours in accordance with agency policy. The allegation must
be reported to the FDJJ Central Communications Center. The policy and interview
support that allegations of sexual abuse or sexual harassment from a resident
regarding his stay in another facility must be reported and investigated as required.
In the past 12 months, there were no allegations of sexual abuse occurring at
another facility received by this facility. Policy requires the Superintendent to notify
the head of another facility within 72 hours upon receiving an allegation a resident
was sexually abused while confined at that facility. If any allegation is made, the
notifications and documentation of the notifications will be made in accordance with
agency policy.
Conclusion:
Based upon the information received and interviews, the Auditor determined the
facility is compliant with this standard.
115.364 Staff first responder duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Oak Grove Academy Coordinated Response
Interviews:
Random Staff
Targeted Interview
Provision (a):
Upon learning of an allegation that a resident was sexually abused, the first staff
member to respond to the report shall be required to:
(1) Separate the alleged victim and abuser;
(2) Preserve and protect any crime scene until appropriate steps can be taken to
collect any evidence;
(3) If the abuse occurred within a time period that still allows for the collection of
physical evidence, request that the alleged victim not take any actions that could
destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating; and
(4) If the abuse occurred within a time period that still allows for the collection of
physical evidence, ensure that the alleged abuser does not take any actions that
could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating.
Agency Policy and Oak Grove Academy FOP PREA provides that upon learning of an
allegation that a resident was sexually abused, the first security-level staff member
to respond to the report shall be required to:
a. Separate the alleged victim and abuser;
b. Preserve and protect any crime scene until appropriate steps can be taken to
collect any evidence;
c. If the abuse occurred within a time period that still allows for the collection of
physical evidence, request that the alleged victim not take any actions that could
destroy physical evidence.
The interviews with staff confirmed awareness of first responder duties and the
training they had been provided.
Provision (b):
If the first staff responder is not a security staff member, the responder shall be
required to request that the alleged victim not take any actions that could destroy
physical evidence, and then notify security staff.
The non-security staff who may act as a first responder will request that physical
evidence be preserved and will contact direct care staff for assistance. There were
no allegations or incidents where a non-security staff member had to act as a first
responder in the last 12 months.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Rite of Passage Safety Environment Standards
Oak Grove Academy Coordinated Response Plan
Interviews:
Superintendent
Random Staff
§115.365
The facility shall develop a written institutional plan to coordinate actions taken in
response to an incident of sexual abuse among staff first responders, medical and
mental health practitioners, investigators, and facility leadership.
Policy requires the development of a written plan to coordinate actions taken in
response to an incident of sexual abuse among staff first responders, medical, and
facility leadership. The plan is in a checklist format which includes the tasks to be
performed and it may be noted who performed the task and when. The facility’s
coordinated response plan was reviewed and found in compliance with the
standard. The staff interviews revealed they are knowledgeable of their duties in
response to an allegation of sexual abuse. The random staff interviewed were
familiar with their roles regarding the response to an allegation of sexual abuse. The
Superintendent discussed the coordinated actions in response to an incident of
sexual abuse which was aligned with policy and the written plan. Forensic medical
examinations will be provided free of charge to the victim at the local hospital
where a qualified medical professional shall perform a forensic medical examination
when needed. The victim will be provided unimpeded access to crisis intervention
and medical services.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility complies with the provisions of the standard.
Preservation of ability to protect residents from contact with
115.366
abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
The Florida Department of Juvenile Justice and the facility are not collective
bargaining agencies.
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Retaliation Monitoring Forms
Interviews:
Superintendent/Retaliation Monitor
Contract Agency Head Designee
Targeted Interview
Provision (a):
The agency shall establish a policy to protect all residents and staff who report
sexual abuse or sexual harassment or cooperate with sexual abuse or sexual
harassment investigations from retaliation by other residents or staff and shall
designate which staff members or departments are charged with monitoring
retaliation.
Policy supports protecting 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. The Superintendent is responsible for
ensuring retaliation monitoring occurs. The Superintendent is familiar with the role
of the retaliation monitor and the importance of such and ensures the monitoring
occurs.
Provision (b):
The agency shall employ multiple protection measures, such as housing changes or
transfers for resident victims or abusers, removal of alleged staff or resident
abusers from contact with victims, and emotional support services for residents or
staff who fear retaliation for reporting sexual abuse or sexual harassment or for
cooperating with investigations.
The Policy identifies measures to protect staff and residents including the following:
a. Initiating housing changes or transfers for resident victims or abusers;
b. Removing alleged staff or resident abusers from contact with victims; and
c. Providing emotional support services.
The interviews confirm the facility will protect residents and staff from retaliation for
sexual abuse and sexual harassment allegations. Protective measures will include
housing changes, transfers, and removing alleged abusers. The Superintendent
identified protective measures that are aligned with the policy and Standard,
including separating the alleged abuser from the alleged victim.
Provision (c):
For at least 90 days following a report of sexual abuse, the agency shall monitor the
conduct or treatment of residents or staff who reported the sexual abuse and of
residents who were reported to have suffered sexual abuse to see if there are
changes that may suggest possible retaliation by residents or staff and shall act
promptly to remedy any such retaliation. Items the agency should monitor include
any resident disciplinary reports, housing, or program changes, or negative
performance reviews or reassignments of staff. The agency shall continue such
monitoring beyond 90 days if the initial monitoring indicates a continuing need.
Policy provides that the monitoring will occur for at least 90 days to see if there are
any changes that may suggest possible retaliation is occurring. According to the
staff interviews, the monitoring period may last longer if needed. Items that are
monitored to assess retaliation include but are not limited to reports to supervisors;
disciplinary reports; point cards; shift reports; housing changes and observations of
conversations between staff and residents. The documentation verifies that the
monitoring occurs and will last at least for 90 days. Staff will act promptly to remedy
any such retaliation, according to policy and interviews. The monitoring will
continue beyond ninety (90) days, if the initial monitoring indicates a continuing
need. There have been no incidents of retaliation occurring during the 12 months
preceding the audit.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
The Retaliation Monitor indicates status checks are initiated with staff and residents.
The Retaliation Monitoring Form is used to document the status checks and reflect
the ongoing motoring. The status checks/monitoring includes but is not limited to
inquiring and observing for: threats; unfair treatment through assignments or
disciplinary reports; and unexplained reassigned housing.
Provision (e):
If any other individual who cooperates with an investigation expresses a fear of
retaliation, the facility shall take appropriate measures to protect that individual
against retaliation.
Policy encompasses those who cooperate with an investigation if there is a concern
regarding retaliation. The staff interviews indicated that the appropriate measures
will be taken to protect any related individuals against retaliation.
Provision (f):
An agency’s obligation to monitor shall terminate if the agency determines that the
allegation is unfounded.
Policy provides that the facility’s obligation to monitor terminates if it is determined
that the allegation is unfounded.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.368 Post-allegation protective custody
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Interviews:
Superintendent
Mental Health Staff
Medical Staff
§115.368
Any use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse shall be subject to the requirements of §115.342.
Segregated housing or protective custody is not used in this facility.
Conclusion:
Based upon the review and analysis of policy, interviews and observations, the
Auditor determined the facility is compliant with this standard.
115.371 Criminal and administrative agency investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
PREA Compliance Form
Investigative Reports
Interviews:
Superintendent/PREA Compliance Manager
Random Staff
PREA Coordinators
Provision (a):
When the agency conducts its own investigations into allegations of sexual abuse
and sexual harassment, it shall do so promptly, thoroughly, and objectively for all
allegations, including third-party and anonymous reports.
Based on the written coordinated response plan, policy, interviews, and practice,
the Florida Department of Juvenile Justice (FDJJ)/Office of Inspector General (OIG)
trained investigators conduct administrative investigations and cases are assigned
promptly. Allegations that are criminal in nature are also assigned promptly and
handled by the Hamilton County Sheriff's Office in coordination with the Florida
Department of Children and Families. All allegations of sexual abuse and sexual
harassment, no matter how received, are referred for investigation to the
appropriate investigative entity.
Provisions (b) & (c):
Provision (b): Where sexual abuse is alleged, the agency shall use investigators
who have received special training in sexual abuse investigations involving juvenile
victims pursuant to § 115.334. Provision (c): Investigators shall gather and
preserve direct and circumstantial evidence, including any available physical and
DNA evidence and any available electronic monitoring data; shall interview alleged
victims, suspected perpetrators, and witnesses; and shall review prior complaints
and reports of sexual abuse involving the suspected perpetrator.
The OIG investigative staff is trained and officers with special training within law
enforcement lead the criminal investigations of sexual abuse cases. The
administrative and criminal investigators gather direct and circumstantial evidence
within their responsibility that include but is not limited to video; clothing; witness
statements; related telephone calls; and logs. Law enforcement investigators and
specialized nurse practitioners are responsible for collecting direct physical and DNA
evidence. The OIG has provided a Compliance Form outlining the conduct of a
criminal investigation inclusive of the related PREA Standards; the form is provided
to law enforcement investigators.
Provision (d): The agency shall not terminate an investigation solely because the
source of the allegation recants the allegation.
Policy provides that an investigation will not be terminated solely because the
source of the allegation recants the allegation. A previous interview with
investigative staff confirms this premise.
Provision (e): When the quality of evidence appears to support criminal
prosecution, the agency shall conduct compelled interviews only after consulting
with prosecutors as to whether compelled interviews may be an obstacle for
subsequent criminal prosecution.
The agency investigators do not conduct compelled interviews as a part of
administrative investigations.
Provision (f): The credibility of an alleged victim, suspect, or witness shall be
assessed on an individual basis and shall not be determined by the person’s status
as resident or staff. No agency shall require a resident who alleges sexual abuse to
submit to a polygraph examination or other truth-telling device as a condition for
proceeding with the investigation of such an allegation.
The credibility of an alleged victim, suspect, or witness is assessed on an individual
basis and is not determined by the person’s status as a resident or staff as
supported by a previous review of training and interview with investigative staff and
in accordance with policy. No resident who alleges sexual abuse will be subjected to
a polygraph examination or other truth telling device as a condition for proceeding
with the investigation of the allegation.
Provision (g):
Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act
contributed to the abuse; and (2) Shall be documented in written reports that
include a description of the physical and testimonial evidence, the reasoning behind
credibility assessments, and investigative facts and findings.
The FDJJ/Office of Inspector General (OIG) conducts administrative investigations.
The OIG Investigator reviews allegations to identify any misconduct by staff related
to FDJJ policy. The interviews, including previous ones with investigative staff, reveal
that administrative investigations include an effort to determine whether staff
actions or failures to act contributed to the abuse.
Provision (h):
Criminal investigations shall be documented in a written report that contains a
thorough description of physical, testimonial, and documentary evidence and
attaches copies of all documentary evidence where feasible.
A previously conducted investigator interview and review of policy and
documentation confirm that all investigations are completed with written reports
that include a description of the evidence and investigative facts and findings.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be referred for
prosecution.
The agency investigators do not conduct criminal investigations. It is the
responsibility of local law enforcement personnel to refer cases for prosecution.
Provision (j):
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 agency retains all written reports of investigations pertaining to administrative
investigations and referrals for criminal investigations are noted in those reports.
The written investigative reports are maintained for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years.
Provision (k):
The departure of the alleged abuser or victim from the employment or control of the
facility or agency shall not provide a basis for terminating an investigation.
An investigation will not end until the investigation has been completed. The
departure of the alleged abuser or victim from the employment or control of the
facility will not terminate the investigation.
Provision (l):
Any State entity or Department of Justice component that conducts such
investigations shall do so pursuant to the above requirements.
The PREA Compliance Form is provided to law enforcement investigators as a
request by the OIG that all PREA related allegations be investigated in accordance
with the PREA Standards.
Provision (m):
When outside agencies investigate sexual abuse, the facility shall cooperate with
outside investigators and shall endeavor to remain informed about the progress of
the investigation.
Agency policy and interviews collectively support that staff cooperates with
investigators and that the agency/facility is kept informed of the progress of an
investigation through local law enforcement and agency investigators. The review of
investigative reports demonstrates staff's cooperation with investigative entities
and the communication between the investigative entities and agencies.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Investigative Reports
Interviews:
Superintendent/PREA Compliance Manager
§115.372
The agency shall impose no standard higher than a preponderance of the evidence
in determining whether allegations of sexual abuse or sexual harassment are
substantiated.
The policy and practice of the Office of Inspector General, responsible for
administrative investigations, impose a standard of a preponderance of the
evidence for determining whether allegations are substantiated. The interview with
the Superintendent, previous interview with investigative staff, and review of
documentation verify the practice.
Conclusion:
Based upon the review and analysis of the available evidence and the interviews,
the Auditor determined the facility is compliant with this standard.
115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Investigative Reports
Notification Letters
Interviews:
Superintendent
PREA Coordinators
Targeted
Provision (a):
Following an investigation into a resident’s allegation of sexual abuse suffered in an
agency facility, the agency shall inform the resident as to whether the allegation
has been determined to be substantiated, unsubstantiated, or unfounded.
Policy addresses the resident being informed when the investigation is completed
and the outcome of the investigation provided in writing. The results of such
investigations are documented in a notification letter, signed by the
Superintendent.
Provision (b):
If the agency did not conduct the investigation, it shall request the relevant
information from the investigative agency in order to inform the resident.
The Superintendent and the statewide PREA Coordinator remain abreast of an
investigation conducted by law enforcement, the Department of Children and
Families, or the central office. The facility receives a copy of the administrative
investigations and where needed, may request investigative reports from the other
investigative entities. and are provided a copy of completed investigations.
Provision (c):
Following a resident’s allegation that a staff member has committed sexual abuse
against the resident, the agency shall subsequently inform the resident (unless the
agency has determined that the allegation is unfounded) whenever:
(1) The staff member is no longer posted within the resident’s unit;
(2) The staff member is no longer employed at the facility;
(3) The agency learns that the staff member has been indicted on a charge related
to sexual abuse within the facility; or
(4) The agency learns that the staff member has been convicted on a charge related
to sexual abuse within the facility.
Policy requires that following a resident’s allegation that a staff member committed
sexual abuse against the resident, the resident will be informed of the following,
unless it has been determined that the allegation is unfounded, whenever:
a. The staff member is no longer assigned within the resident’s housing unit;
b. The staff member is no longer employed at the facility;
c. The staff member has been indicted on a charge related to sexual abuse within
Oak Grove Academy; or
d. The staff member has been convicted on a charge related to sexual abuse within
the facility.
Provision (d):
Following a resident’s allegation that he or she has been sexually abused by another
resident, the agency shall subsequently inform the alleged victim whenever:
(1) The agency learns that the alleged abuser has been indicted on a charge related
to sexual abuse within the facility; or
(2) The agency learns that the alleged abuser has been convicted on a charge
related to sexual abuse within the facility.
Policy provides that following a resident’s allegation that he has been sexually
abused by another resident, the alleged victim shall be subsequently informed
whenever:
a. The alleged abuser is criminally charged related to the sexual abuse; or
b. The alleged abuser is adjudicated on a charge related to sexual abuse.
Provision (e):
All such notifications or attempted notifications shall be documented.
Policy provides that the notifications to the resident be documented and the
Superintendent is familiar with the policy due to the review of documentation and
the targeted interview verifies the practice.
Provision (f):
An agency’s obligation to report under this standard shall terminate if the resident is
released from the agency’s custody.
The agency’s obligation to report under this standard terminates if the resident is
released from the agency’s custody, in accordance with policy.
Conclusion:
Based on the review and analysis of the available documentation and interviews,
the Auditor determined the facility is compliant with this standard.
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Investigative Reports
Personnel Records
Interview:
Superintendent
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for
violating agency sexual abuse or sexual harassment policies.
Policy provides that staff is subject to disciplinary sanctions up to and including
termination for violating facility sexual abuse or sexual harassment policies. It has
been reported that one staff member violated policy regarding sexual abuse. The
disciplinary sanction was verified by the investigative reports and documented
personnel actions.
Provision (b):
Termination shall be the presumptive disciplinary sanction for staff who has
engaged in sexual abuse.
Termination is the presumptive disciplinary sanction for staff who has engaged in
sexual abuse of a resident, in accordance with policy. A staff member was
suspended pending the results of the investigation. The allegation was
substantiated and the employee was terminated as verified by documentation.
Provision (c):
Disciplinary sanctions for violations of agency policies relating to sexual abuse or
sexual harassment (other than actually engaging in sexual abuse) shall be
commensurate with the nature and circumstances of the acts committed, the staff
member’s disciplinary history, and the sanctions imposed for comparable offenses
by other staff with similar histories.
Policy provides that disciplinary sanctions for violations of 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.
Provision (d):
All terminations for violations of agency sexual abuse or sexual harassment policies,
or resignations by staff who would have been terminated if not for their resignation,
shall be reported to law enforcement agencies, unless the activity was clearly not
criminal, and to any relevant licensing bodies.
Policy provides that all terminations for violations of the facility’s sexual abuse or
sexual harassment policies, or staff resignations related to violations of this policy,
shall be reported to law enforcement, unless the activity is clearly not criminal. In
addition, it shall be reported to relevant licensing bodies. The practice was
documented through the investigative reports. The allegations were reported to the
Department of Juvenile Justice/Office of Inspector General, Department of Children
and Families, Hamilton County Sheriff's Office. The staff's position did not
necessitate reporting to a licensing body however the Superintendent is aware of
the requirement.
Conclusion:
Based upon the review of policy, supporting documentation and the interview, the
Auditor determined the facility is compliant with this standard.
115.377 Corrective action for contractors and volunteers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Rite of Passage Safe Environment Standards
Interview:
Superintendent
Provision (a):
Any contractor or volunteer who engages in sexual abuse shall be prohibited from
contact with residents and shall be reported to law enforcement agencies, unless
the activity was clearly not criminal, and to relevant licensing bodies.
Policy requires that any contractor or volunteer who engages in sexual abuse be
prohibited from contact with residents. Policy also requires contractors and
volunteers who engage in sexual abuse be reported to law enforcement and to
relevant licensing bodies. During the past 12 months, there were no allegations of
sexual abuse or sexual harassment involving contractors or volunteers. A clear
understanding is provided that sexual misconduct with a resident is strictly
prohibited and is a serious breach of conduct. Volunteers and contractors participate
in PREA training and are familiar with the zero-tolerance policy and how to report
allegations of sexual abuse or sexual harassment of residents.
Provision (b):
The facility shall take appropriate remedial measures and shall consider whether to
prohibit further contact with residents, in the case of any other violation of agency
sexual abuse or sexual harassment policies by a contractor or volunteer.
Policy requires the Superintendent to take appropriate remedial measures and
consider whether to prohibit further contact with residents in the case of any
violation of the sexual abuse and sexual harassment policies by a contractor or
volunteer.
Conclusion:
Based upon the review and analysis of the available documentation, the Auditor
determined the facility is compliant with this standard.
115.378 Interventions and disciplinary sanctions for residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Investigative Reports
Resident Handbook
Posted PREA Information
Interviews:
Superintendent/PREA Compliance Manager
Medical Staff
Mental Health Staff
Provision (a):
A resident may be subject to disciplinary sanctions only pursuant to a formal
disciplinary process following an administrative finding that the resident engaged in
resident-on-resident sexual abuse or following a criminal finding of guilt for resident-
on-resident sexual abuse.
Residents may be subject to disciplinary sanctions only after formal proceedings
regarding resident-on-resident sexual abuse. Residents found in violation of facility
rules are subject to sanctions pursuant to the administrative process. The
consequences will be administered through the administrative system,
encompassing the behavior management system. Allegations of sexual abuse are
referred for an investigation to the appropriate investigative entities. Legal actions
will be taken as indicated by the results of an investigation. The Superintendent’s
interview confirms the formal disciplinary process however residents may also face
legal charges regarding resident-on-resident sexual abuse. Sexual activity between
residents is prohibited and court or administrative processes and sanctions occur
after determination the sexual activity was coerced. Residents will be disciplined for
sexual contact with staff only when it has been determined the staff member did
not consent to the sexual contact.
Provision (b):
Any disciplinary sanctions shall be commensurate with the nature and
circumstances of the abuse committed, the resident’s disciplinary history, and the
sanctions imposed for comparable offenses by other residents with similar histories.
In the event a disciplinary sanction results in the isolation of a resident, agencies
shall not deny the resident daily large-muscle exercise or access to any legally
required educational programming or special education services. Residents in
isolation shall receive daily visits from a medical or mental health care clinician.
Residents shall also have access to other programs and work opportunities to the
extent possible.
Policy considers that disciplinary sanctions are commensurate with the nature and
circumstances of the offense committed; considers resident’s disciplinary history;
and considers similar disciplinary history of other residents. The interview with the
Superintendent supported there is consideration of mental disabilities or mental
illness contributing to the behavior. PREA related violations may result in charges
filed and residents transported to a juvenile detention center based on the
circumstances of the incident. Allegations of sexual abuse are referred for an
investigation to the appropriate investigative entities. Isolation is not used at this
facility as confirmed by medical and mental health staffs.
Provision (c):
The disciplinary process shall consider whether a resident’s mental disabilities or
mental illness contributed to his or her behavior when determining what type of
sanction, if any, should be imposed.
Policy and the Superintendent's interview provide 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.
Provision (d):
If the facility offers therapy, counseling, or other interventions designed to address
and correct underlying reasons or motivations for the abuse, the facility shall
consider whether to offer the offending resident participation in such interventions.
The agency may require participation in such interventions as a condition of access
to any rewards-based behavior management system or other behavior-based
incentives, but not as a condition to access to general programming or education.
The facility will consider whether to offer the offending resident intervention
services designed to address and correct underlying reasons or motivations for the
abuse participation, based on the interview with the mental health staff. The facility
will not require participation in such interventions as a condition for participation in
the behavior management system or to access general programming or education
as determined from the interview.
Provision (e):
The agency may discipline a resident for sexual contact with staff only upon a
finding that the staff member did not consent to such contact.
Policy provides the facility may discipline a resident for sexual contact with staff
only upon finding that the staff member did not consent to such contact.
Provision (f):
For the purpose of disciplinary action, a report of sexual abuse made in good faith
based upon a reasonable belief that the alleged conduct occurred shall not
constitute falsely reporting an incident or lying, even if an investigation does not
establish evidence sufficient to substantiate the allegation.
A report of sexual abuse made in good faith based on the belief that the alleged
incident occurred does not constitute falsely reporting an incident or lying, even if
an investigation does not establish evidence sufficient to substantiate the
allegation. Anyone reporting in good faith will be immune from any civil or criminal
liability.
Provision (g):
An agency may, in its discretion, prohibit all sexual activity between residents and
may discipline residents for such activity. An agency may not, however, deem such
activity to constitute sexual abuse if it determines that the activity is not coerced.
Policy prohibits any sexual conduct between residents. All such conduct is subject to
disciplinary action. Referrals are made to the investigative entities and court
processes occur after determination the sexual activity was coerced.
Conclusion:
Based upon the review and analysis of the available documentation, the Auditor
determined the facility is compliant with this standard.
115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Policy and Procedures (2.04), Assessment and Treatment Team
Facility Policy and Procedures (3.03), Mental Health and Substance Abuse
Assessment and Evaluation
Screenings for Vulnerability to Victimization and Sexually Aggressive Behavior
(VSABs)
Student Services Offered Acknowledgement Form
Interviews:
Staff Responsible for Risk Screening
Medical Staff
Mental Health Staff
Provisions (a) & (b):
If the screening pursuant to § 115.341 indicates that a resident has experienced
prior sexual victimization, whether it occurred in an institutional setting or in the
community, staff shall ensure that the resident is offered a follow-up meeting with a
medical or mental health practitioner within 14 days of the intake screening.
Provision (b): If the screening pursuant to § 115.341 indicates that a resident has
previously perpetrated sexual abuse, whether it occurred in an institutional setting
or in the community, staff shall ensure that the resident is offered a follow-up
meeting with a mental health practitioner within 14 days of the intake screening.
Policy provides that residents meet with mental health or medical staff within 14
days if he is identified as having been a victim or perpetrator of sexual abuse. The
practice is residents are generally seen by medical and mental health staff on the
same day of admission as part of the intake process. Interviews with the medical
and mental health staff and a review of documentation revealed residents are
generally seen by medical and mental health staff on the same day of admission as
part of the intake process. Interviews with the medical and mental health staff and
observations revealed documentation of the services provided to each resident is
maintained in the respective clinical file.
Provision (c):
Any information related to sexual victimization or abusiveness that occurred in an
institutional setting shall be strictly limited to medical and mental health
practitioners and other staff, as necessary, to inform treatment plans and security
and management decisions, including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local law.
Policy supports that no information is to be shared with other staff unless it is
required for security and management decisions regarding sexual abuse history.
Policy provides that information related to sexual victimization or abusiveness that
occurred in an institutional setting is limited to clinical staff and other staff based on
their need to know, to inform security and make effective management decisions.
The files are maintained in a secure manner and information maintained
electronically is password protected with limited access. The Auditor observed the
resident files maintained in a secure manner.
Provision (d):
Medical and mental health practitioners shall obtain informed consent from
residents before reporting information about prior sexual victimization that did not
occur in an institutional setting, unless the resident is under the age of 18.
Policy addresses informed consent being obtained for residents 18 years or over
prior to clinical personnel reporting information disclosed about prior sexual
victimization that did not occur in an institutional setting. Clinical staff members
understand the use of informed consent. The FOP provides that medical and mental
health practitioners shall obtain informed consent from residents before reporting
information about prior sexual victimization that did not occur in an institutional
setting, unless the resident is under the age of 18. Informed consent may be
documented on a dedicated form or in clinical notes.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.382 Access to emergency medical and mental health services
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 13HS:01.01), Prison Rape Elimination Act (PREA)
Memorandum of Understanding
Interviews:
Medical Staff
Mental Health Staff
Superintendent
Provision (a):
Resident victims of sexual abuse shall receive timely, unimpeded access to
emergency medical treatment and crisis intervention services, the nature and scope
of which are determined by medical and mental health practitioners according to
their professional judgment.
The interviews and policies support the alleged victim will receive timely and
unimpeded access to emergency medical treatment and crisis intervention services.
The interviews were aligned with the policy including that the nature and scope of
their services are determined according to their professional judgment. Residents
are informed of clinical services during the individual meetings through the intake
process. An alleged victim of sexual abuse will be transported to the local hospital
for a forensic medical examination by a specialized nurse practitioner or other
qualified medical practitioner, at no cost to the victim and in accordance with policy
in response to an allegation of sexual abuse. Medical and mental health staff
members maintain secondary materials and documentation of medical encounters
with residents. The allegations of sexual abuse during the last 12 months did not
require clinical interventions.
Provision (b):
If no qualified medical or mental health practitioners are on duty at the time a
report of recent abuse is made, staff first responders shall take preliminary steps to
protect the victim pursuant to § 115.362 and shall immediately notify the
appropriate medical and mental health practitioners.
The interviews revealed residents have access to unimpeded access to emergency
services. Policies and the coordinated response plan provide guidance to staff in
protecting residents and for contacting the appropriate staff and agencies regarding
allegations or incidents of sexual abuse, including contacting treatment staff and
investigative entities. A review of the coordinated response plan and related
documentation and policies; observations of the interactions among residents and
staff; and the interviews indicated unimpeded medical and crisis intervention
services will be available to an alleged victim of sexual abuse. Medical and mental
health staff provide on-call services to the facility.
Provision (c):
Resident victims of sexual abuse while incarcerated shall be offered timely
information about and timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with professionally accepted
standards of care, where medically appropriate.
Policy, review of documentation and interviews confirm processes and services are
in place for an alleged victim to receive timely access to sexually transmitted
infection prophylaxis where medically appropriate. Follow-up services as needed will
be provided by the facility’s treatment staff and/or transportation will be provided to
support services coordinated and/or contracted by staff as needed.
Provision (d):
Treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any
investigation arising out of the incident.
Treatment services will be provided to the victim without financial cost to the victim
and regardless of whether the victim names the abuser, or cooperates with any
investigation arising out of the incident. This premise is also supported by
interviews, Memorandum of Understanding, and policy.
Conclusion:
Based on the review of policy and other documents, interviews, and observations
the Auditor determined the facility is in compliance with this standard.
Ongoing medical and mental health care for sexual abuse victims
115.383
and abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Interviews:
Medical Staff
Mental Health Staff
Superintendent
Provision (a):
The facility shall offer medical and mental health evaluation and, as appropriate,
treatment to all residents who have been victimized by sexual abuse in any prison,
jail, lockup, or juvenile facility.
Medical and mental health evaluation and treatment will be offered to resident
victims of sexual abuse. The interviews revealed that follow-up services will be
provided that include but are not limited to a crisis assessment; medical assessment
by medical doctor; and general care as needed by mental health and medical staff.
Provision (b):
The evaluation and treatment of such victims shall include, as appropriate, follow-up
services, treatment plans, and, when necessary, referrals for continued care
following their transfer to, or placement in, other facilities, or their release from
custody.
Interviews and documentation of encounters confirm on-going medical and mental
health care will be provided as appropriate and will include but not be limited to
treatment planning; evaluations, and clinical follow-up and referrals as needed.
Specialized treatment may also be provided by clinicians on site and through
contracted services. Directions contained in the discharge information will also be
followed.
Provision (c):
The facility shall provide such victims with medical and mental health services
consistent with the community level of care.
Medical and mental health services are consistent with the community level of care.
Treatment services may be provided by facility staff and contract services if needed.
The interviews, review of policy, and observations during the onsite audit phase
confirm the treatment services at the facility are consistent with the community
level of care.
Provision (d):
Resident victims of sexually abusive vaginal penetration while incarcerated shall be
offered pregnancy tests.
This is a male facility only.
Provision (e):
If pregnancy results from conduct specified in paragraph (d) of this section, such
victims shall receive timely and comprehensive information about and timely access
to all lawful pregnancy-related medical services.
This is a male facility only.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for
sexually transmitted infections as medically appropriate.
The policy and interviews ensure that victims of sexual abuse will be provided tests
for sexually transmitted infections as medically appropriate. Testing will be done at
the hospital, according to the medical staff. It was also reported that tests for
sexually transmitted infections are routinely offered at the facility.
Provision (g):
Treatment services shall be provided to the victim without financial cost and
regardless of whether the victim names the abuser or cooperates with any
investigation arising out of the incident.
All treatment services will be provided at no cost to the victim, according to policy
and the staff interviews.
Provision (h):
The facility shall attempt to conduct a mental health evaluation of all known
resident-on-resident abusers within 60 days of learning of such abuse history and
offer treatment when deemed appropriate by mental health practitioners.
Policy provides for attempts to be made for a mental health practitioner to conduct
a mental health evaluation within 60 days on all known resident-on-resident abusers
and offer appropriate treatment by mental health staff. The investigations for this
audit period did not identify any resident-on-resident abusers.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the facility is compliant with this standard.
115.386 Sexual abuse incident reviews
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Incident Review Team Meeting Minutes
Interviews:
Superintendent/PREA Compliance Manager
Incident Review Team Member
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion of every
sexual abuse investigation, including where the allegation has not been
substantiated, unless the allegation has been determined to be unfounded.
The facility is required to conduct a sexual abuse incident review at the conclusion
of an investigation, unless the allegation was unfounded. The staff understands the
role of the incident review team. A review of policy and documented incident
reviews, and interviews confirm incident reviews will occur regarding the
investigation of an allegation of sexual abuse, unless unfounded. Policy requires an
incident review team meeting within 30 days of the conclusion of each
investigation. The policy mandates review team participation to include the State-
wide PREA Coordinator, the facility’s PREA Compliance Manager, regional office
staff, facility supervisor, medical and mental health staff. The PREA Coordinator will
prepare and distribute the report of the review team’s findings.
The interview with the Superintendent/PREA Compliance Manager and a review of
the incident reviews, the incident review team’s findings indicate the team:
considers 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. The team may also 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; and assess whether monitoring technology
should be deployed or augmented to supplement supervision by staff.
Provision (b):
Such review shall ordinarily occur within 30 days of the conclusion of the
investigation.
Policy requires that the reviews occur within 30 days of the conclusion of the
investigation. The documentation of the incident review team meetings and the
interviews confirm the incident review occurred within 30 days of the conclusion of
the investigation in accordance with policy and the standard.
Provision (c):
The review team shall include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners.
Policy and interviews collectively identify members of the incident review team. The
statewide PREA Coordinator facilitates the incident review team meeting. Members
of the team include the Superintendent/PREA Compliance Manager, Assistant
Superintendent, mental health staff, and medical staff. There will also be input from
line supervisors and other staff as needed. The Department's Office of Inspector
General investigator may also participate in the incident review. The additional staff
members will attend the meeting as needed, related to the alleged incident.
Provision (d):
The review team shall:
(1) Consider whether the allegation or investigation indicates a need to change
policy or practice to better prevent, detect, or respond to sexual abuse;(2) Consider
whether the incident or allegation was motivated by race; ethnicity; gender identity;
lesbian, gay, bisexual, transgender, or intersex identification, status, or perceived
status; or, gang affiliation; or was motivated or otherwise caused by other group
dynamics at the facility; (3) Examine the area in the facility where the incident
allegedly occurred to assess whether physical barriers in the area may enable
abuse; (4) Assess the adequacy of staffing levels in that area during different shifts;
(5) Assess whether monitoring technology should be deployed or augmented to
supplement supervision by staff; and (6) Prepare a report of its findings, including
but not necessarily limited to determinations made pursuant to paragraphs (d)(1)-
(d)(5) of this section, and any recommendations for improvement and submit such
report to the facility head and PREA Compliance Manager.
Policy outlines the requirements of the standard for the areas to be assessed by the
incident review team. The interviews and review of policy confirm the incident
review team is charged with considering the factors identified in this standard
provision regarding the results of the investigation. The incident review team
process is documented by the statewide PREA Coordinator. The written report also
includes any recommendations for improvement, if any. The incident review team’s
findings indicate the team uses the outline of the policy and Standard to examine
the elements for causation, review and improvement opportunities. The acceptable
practice regarding the incident review team meeting in documented through the
meeting minutes.
Provision (e):
The facility shall implement the recommendations for improvement or shall
document its reasons for not doing so.
Policy indicates the reasons for not following recommendations are documented.
The interviews revealed familiarity with the policy requirement. The incident review
process allows for the assessment of the circumstances surrounding the incident. A
format for documenting the incident review process has been developed by and is
utilized by the statewide PREA Coordinator. The interviews and review of policy and
documentation confirm the incident review team is charged with considering the
factors identified in this standard provision regarding the results of the investigation
and make recommendations as indicated. The reports provide for recommended
actions by the committee.
Conclusion:
Based upon the review and analysis of the available documentation, the Auditor
determined the facility is compliant with this standard.
115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Policy (FDJJ 2020), Incident Operations Center and Incident Reviews
PREA Incident Reports
Interviews:
Statewide PREA Coordinator
Contract Agency PREA Coordinator
Superintendent/PREA Compliance Manager
Provisions (a) & (c):
The agency shall collect accurate, uniform data for every allegation of sexual abuse
at facilities under its direct control using a standardized instrument and set of
definitions. The incident-based data collected shall include, at a minimum, the data
necessary to answer all questions from the most recent version of the Survey of
Sexual Violence conducted by the Department of Justice.
Policy provides for the collection of accurate and uniform data for every allegation
of sexual abuse from incident-based documents. The State and contract agencies
collect the data and the primary annual PREA report is completed by the statewide
PREA Coordinator. Agency Policy FDJJ 2020 contains a standardized set of definitions
and provides support for the collection of accurate and uniform data. The agency
maintains incident-based data complete enough to complete the most recent
version of the instrument formerly identified as the Survey of Sexual Violence and
now identified as the Survey of Sexual Victimization.
Provision (b):
The agency shall aggregate the incident-based sexual abuse data at least annually.
The agency aggregates the incident-based, uniform data regarding allegations of
sexual abuse and sexual harassment. The aggregated data contributes to the
development of the annual report which is supported by the reviewed data and
policy. The policy and review of the annual report, PREA incident reports, and other
documentation confirm the facility collects incident-based, uniform data regarding
allegations of sexual abuse and sexual harassment.
Provision (d):
The agency shall maintain, review, and collect data as needed from all available
incident-based documents, including reports, investigation files, and sexual abuse
incident reviews.
The facility maintains and collects various types of identified data and related
documents regarding PREA. The facility collects and maintains data in accordance
with policy directives and the Department aggregates the data which culminates
into an annual report and other management information.
Provision (e):
The agency also shall obtain incident-based and aggregated data from every private
facility with which it contracts for the confinement of its residents.
The data is collected from the contracted facilities and is maintained in a statewide
database and is included in the agency’s annual reports.
Provision (f):
Upon request, the agency shall provide all such data from the previous calendar
year to the Department of Justice no later than June 30.
Upon request, the facility completes all such data from the previous calendar year
and submits it to the Department of Justice in a timely manner based on the year of
the most recent version of the Survey of Sexual Victimization.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the facility is compliant with this standard.
115.388 Data review for corrective action
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Annual Report
Interviews:
PREA Coordinators
Superintendent/PREA Compliance Manager
Provision (a): The agency shall 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:
(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.
The interviews support the review of data and that it is used to improve the PREA
efforts, in accordance with the intent of policy. The interviews and review of
documentation revealed the collection of various types of data by the agency. The
data is reviewed to assess and improve the effectiveness of prevention, detection
and response within the agency as well as individual facilities. Pertinent and related
data is also collected by the contract agency for the same efforts. The collected
data is also primary to preparing annual reports for both agencies.
Provisions (b)-(d):
Provision (b): Such 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. Provision (c): The agency’s
report shall be approved by the agency head and made readily available to the
public through its website or, if it does not have one, through other means.
Provision (d): The agency may 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.
The annual report is prepared by the Florida Department of Juvenile Justice (FDJJ)
statewide PREA Coordinator for the contract and State-run facilities. The annual
reports are approved by the agency head/designee. The data used for the annual
report is also gleaned from State-run and contract facilities. There are no personal
identifiers in the reports. The annual report contains PREA related data that
represents previous calendar years allowing for the comparison of data. An annual
report is posted on the FDJJ website. The report contains the overarching annual
report for the agency.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor has
determined the facility is compliant with this standard.
115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Agency Policy (FDJJ 1316), Records and Information Management Procedures
PREA Data/Incident Reports
Interviews:
Superintendent/PREA Compliance Manager
Agency PREA Coordinator
Provisions (a)-(d):
Provision (a): The agency shall ensure that data collected pursuant to §115.387
are securely retained. Provision (b): 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. Provision (c): Before making aggregated
sexual abuse data publicly available, the agency shall remove all personal
identifiers. Provision (d): The agency shall maintain sexual abuse data collected
pursuant to §115.387 for at least 10 years after the date of its initial collection
unless Federal, State, or local law requires otherwise.
All data collected is securely stored and maintained for at least 10 years after the
date of collection unless a law requires otherwise. Personal identifiers are removed
from aggregated data before making the data publicly available. The annual report
is available to the public through the agency website. A review of the annual report
verified there are no personal identifiers. All facility and agency records are
securely stored and and electronic data is password protected with approved and
limited access.
Conclusion:
Based upon the review and analysis of the documentation, interviews and
observations, the Auditor determined the facility is compliant with this standard.
115.401 Frequency and scope of audits
Auditor Overall Determination: Meets Standard
Auditor Discussion
Oak Grove Academy meets the requirements of this standard based upon the
following evidence:
The Florida Department of Juvenile Justice has ensured one-third of all operated
detention centers and contracted residential facilities have been audited as
evidenced by the final audit reports provided on the agency’s website. The
comprehensive site review was provided to the Auditor by three residents and the
Assistant Facility Administrator. The Superintendent and other facility staff, regional
staff, and the statewide PREA Coordinator were cooperative in providing information
and participating in or assisting in coordinating the interviews.
The Auditor was provided complete access to the facility and observed all areas of
the facility’s buildings and grounds. Additionally, all relevant documents were
provided as required and requested. The facility made space available for private
staff and resident interviews. Residents were provided information on the “Notice of
the Auditor’s Onsite Visit” regarding how to send confidential information to the
Auditor. No correspondence was received by the Auditor and the facility has a
process for handling confidential correspondence. The posted audit notices were
observed to be in the places identified with corresponding pictures provided to the
Auditor during the pre-onsite audit phase.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
Oak Grove Academy meets the requirements of this standard based upon the
following evidence:
A review of the agency's website revealed PREA audit reports are posted for state-
run juvenile detention centers and contract residential facilities and may be
downloaded. The posted PREA reports do not contain any personal identifying
information other than selected staff names and job titles. The facility and agency
policies and additional documentation, practices and interviews with the
Superintendent/PREA Compliance Manager and other staff were reviewed regarding
compliance with the standards and have been identified in the reports. There were
no conflicts of interest regarding the completion of this audit.
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 yes
residents with private agencies or other entities including other
government agencies, has the agency included the entity’s
obligation to adopt and comply with the PREA standards in any
new contract or contract renewal signed on or after August 20,
2012? (N/A if the agency does not contract with private agencies
or other entities for the confinement of residents.)
115.312
Contracting with other entities for the confinement of residents
(b)
Does any new contract or contract renewal signed on or after yes
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 yes
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 yes
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)
Does the facility always refrain from searching or physically yes
examining transgender or intersex residents for the sole purpose
of determining the resident’s genital status?
If a resident’s genital status is unknown, does the facility yes
determine genital status during conversations with the resident,
by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted
in private by a medical practitioner?
115.315
Limits to cross-gender viewing and searches
(f)
Does the facility/agency train security staff in how to conduct yes
cross-gender pat down searches in a professional and respectful
manner, and in the least intrusive manner possible, consistent
with security needs?
Does the facility/agency train security staff in how to conduct yes
searches of transgender and intersex residents in a professional
and respectful manner, and in the least intrusive manner possible,
consistent with security needs?
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 na
community-based staff member for the purposes of this section,
has the individual been screened for appropriateness to serve in
this role and received education concerning sexual assault and
forensic examination issues in general? (Check N/A if agency
attempts to make a victim advocate from a rape crisis center
available to victims per 115.321(d) above.)
115.322
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?
Does the agency train all employees who may have contact with yes
residents on: How to communicate effectively and professionally
with residents, including lesbian, gay, bisexual, transgender,
intersex, or gender nonconforming residents?
Does the agency train all employees who may have contact with yes
residents on: How to comply with relevant laws related to
mandatory reporting of sexual abuse to outside authorities?
Does the agency train all employees who may have contact with yes
residents on: Relevant laws regarding the applicable age of
consent?
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?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any gender
nonconforming appearance or manner or identification as lesbian,
gay, bisexual, transgender, or intersex, and whether the resident
may therefore be vulnerable to sexual abuse?
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)
Does the agency always refrain from placing: Lesbian, gay, and yes
bisexual residents in particular housing, bed, or other assignments
solely on the basis of such identification or status?
Does the agency always refrain from placing: Transgender yes
residents in particular housing, bed, or other assignments solely
on the basis of such identification or status?
Does the agency always refrain from placing: Intersex residents in yes
particular housing, bed, or other assignments solely on the basis
of such identification or status?
Does the agency always refrain from considering lesbian, gay, yes
bisexual, transgender, or intersex identification or status as an
indicator or likelihood of being sexually abusive?
115.342
Placement of residents
(d)
When deciding whether to assign a transgender or intersex yes
resident to a facility for male or female residents, does the agency
consider on a case-by-case basis whether a placement would
ensure the resident’s health and safety, and whether a placement
would present management or security problems (NOTE: if an
agency by policy or practice assigns residents to a male or female
facility on the basis of anatomy alone, that agency is not in
compliance with this standard)?
When making housing or other program assignments for yes
transgender or intersex residents, does the agency consider on a
case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would
present management or security problems?
115.342
Placement of residents
(e)
Are placement and programming assignments for each yes
transgender or intersex resident reassessed at least twice each
year to review any threats to safety experienced by the resident?
115.342
Placement of residents
(f)
Are each transgender or intersex resident’s own views with yes
respect to his or her own safety given serious consideration when
making facility and housing placement decisions and
programming assignments?
115.342
Placement of residents
(g)
Are transgender and intersex residents given the opportunity to yes
shower separately from other residents?
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 na
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 na
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 na
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 na
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 na
agency’s determination whether the resident is in substantial risk
of imminent sexual abuse? (N/A if agency is exempt from this
standard.)
Does the initial response document the agency’s action(s) taken in na
response to the emergency grievance? (N/A if agency is exempt
from this standard.)
Does the agency’s final decision document the agency’s action(s) na
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 na
alleged sexual abuse, does it do so ONLY where the agency
demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.)
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 na
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 yes
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, yes
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?
Does the review team: Consider whether the incident or allegation yes
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?
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” yes
response does not impact overall compliance with this standard.)
If this is the second year of the current audit cycle, did the agency na
ensure that at least one-third of each facility type operated by the
agency, or by a private organization on behalf of the agency, was
audited during the first year of the current audit cycle? (N/A if this
is not the second year of the current audit cycle.)
If this is the third year of the current audit cycle, did the agency 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.)

source: DJJ

report_type: PREA

program_name_raw: Oak Grove Academy

cycle: Year 2 Cycle 4