facility_name: Deep Creek Youth Academy

summary: PREA - Year 2 Cycle 4

raw_content:
PREA Facility Audit Report: Final
Name of Facility: Deep Creek Youth Academy
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 03/14/2024
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:
03/14/
2024
AUDITOR INFORMATION
Auditor name: Turner, Shirley
Email: shirleyturner3199@comcast.net
Start Date of On- 01/29/2024
Site Audit:
End Date of On-Site 01/30/2024
Audit:
FACILITY INFORMATION
Facility name: Deep Creek Youth Academy
Facility physical 765 East Saint Johns Avenue, Hastings, Florida - 32145
address:
Facility mailing
address:
Primary Contact
Name: Timothy Patterson
Email Address: timothy.patterson@youthopportunity.com
Telephone Number: 904-881-3173
Superintendent/Director/Administrator
Name: Timothy Patterson
Email Address: Timothy Patterson
Telephone Number: 904-881-3173
Facility PREA Compliance Manager
Name: Timothy Patterson
Email Address: timothy.patterson@youthopportunity.com
Telephone Number: O: 904-881-3173
Name: Jonathan Ware
Email Address: jonathan.ware@youthopportunity.com
Telephone Number: O: 904-572-9991
Name: Tiffany Mitchell
Email Address: tiffany.mitchell@youthopportunity.com
Telephone Number: O: 904-495-8880
Name: Steve Canidate
Email Address: steve.canidate@youthopportunity.com
Telephone Number: O: 386-237-7025
Facility Health Service Administrator On-Site
Name: Samantha Sullivan
Email Address: samantha.sullivan@youthopportunity.com
Telephone Number: 407-338-7044
Facility Characteristics
Designed facility capacity: 117
Current population of facility: 75
Average daily population for the past 12 52
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: 13-19
Facility security levels/resident custody non-secure
levels:
Number of staff currently employed at the 108
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 2
with residents, currently authorized to
enter the facility:
AGENCY INFORMATION
Name of agency: Youth Opportunity Investments, LLC.
Governing authority
or parent agency (if
applicable):
Physical Address: 701 94th Avenue North , Suite 100, St. Petersburg , Florida - 33702
Mailing Address:
Telephone number:
Agency Chief Executive Officer Information:
Name:
Email Address:
Telephone Number:
Agency-Wide PREA Coordinator Information
Name: Joseph Nixon Email Address: joseph.nixon@youthopportunity.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 2024-01-29
audit:
2. End date of the onsite portion of the 2024-01-30
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 Betty Griffin Center Outreach Domestic Abuse
organization(s) or victim advocates with Treatment Center - St. Augustine, FL
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 117
15. Average daily population for the past 52
12 months:
16. Number of inmate/resident/detainee 4
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/ 82
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
38. Enter the total number of inmates/ 2
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/ 8
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/ 0
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, 108
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 2
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 6
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 the resident rosters, observed
RANDOM INMATE/RESIDENT/DETAINEE population, and conferred with staff.
interviewees was geographically
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 10
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 2
conducted with inmates/residents/
detainees with a physical disability using
the "Disabled and Limited English
Proficient Inmates" protocol:
61. Enter the total number of interviews 8
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:
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 Conferred with staff, observed population, and
to determine if this population exists in observed population.
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 Conferred with staff and observed population.
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 various 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 0
conducted with inmates/residents/
detainees who reported sexual abuse in
this facility using the "Inmates who
Reported a Sexual Abuse" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Conferred with staff, reviewed population
to determine if this population exists in rosters, and reviewed investigative
the audited facility (e.g., based on documents.
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
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 various 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 Segregation/isolation is not used.
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).
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 14
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
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
a. Enter the total number of 2
VOLUNTEERS who were interviewed:
b. Select which specialized VOLUNTEER Education/programming
role(s) were interviewed as part of this
audit from the list below: (select all that Medical/dental
apply)
Mental health/counseling
Religious
Other
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 No text provided.
regarding selecting or interviewing
specialized staff.
SITE REVIEW AND DOCUMENTATION SAMPLING
Site Review
PREA Standard 115.401 (h) states, "The auditor shall have access to, and shall observe, all areas
of the audited facilities." In order to meet the requirements in this Standard, the site review
portion of the onsite audit must include a thorough examination of the entire facility. The site
review is not a casual tour of the facility. It is an active, inquiring process that includes talking
with staff and inmates to determine whether, and the extent to which, the audited facility's
practices demonstrate compliance with the Standards. Note: As you are conducting the site
review, you must document your tests of critical functions, important information gathered
through observations, and any issues identified with facility practices. The information you
collect through the site review is a crucial part of the evidence you will analyze as part of your
compliance determinations and will be needed to complete your audit report, including the Post-
Audit Reporting Information.
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 1 0
on-
inmate
sexual
abuse
Total 3 0 3 0
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 0 0 0 0
inmate sexual
abuse
Total 0 0 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 1 0 0
sexual abuse
Total 0 1 2 0
Sexual Harassment Investigation Outcomes
Note: these counts should reflect where the investigation is currently. Do not double count.
Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors
should provide information on inmate, resident, and detainee sexual harassment investigation
files, as applicable to the facility type being audited.
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
review any sexual harassment harassment.
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 No text provided.
regarding selecting and reviewing
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:
Policy FDJJ 1919, PREA
Facility Policy 5-19, PREA
Agency Organization Chart
Facility Organization Chart
Employee Handbook
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinators
Random Staff
Residents
Provision (a):
An agency shall have a written policy mandating zero tolerance toward all forms of
sexual abuse and sexual harassment and outlining the agency’s approach to
preventing, detecting, and responding to such conduct.
The policies require zero-tolerance of sexual abuse and sexual harassment of
residents and combine to provide guidance to staff regarding the facility’s approach
to preventing, detecting, and responding to allegations of sexual abuse and sexual
harassment. The policies provide and address conduct that violates the zero-
tolerance approach regarding all forms of sexual abuse and sexual harassment.
Definitions of prohibited behaviors of sexual abuse and sexual harassment are
contained in policy and include sanctions for those found to have participated in the
prohibited behaviors. The Department of Juvenile Justice (DJJ) agency Policy, FDJJ
1919, serves as the overarching PREA Policy for the state-run and contract facilities.
The facility also has additional policies which outline and support adherence to the
PREA standards.
Accessibility to PREA information by staff and residents; risk screening; and
monitoring assist in detecting sexual abuse and sexual harassment. The identified
and other supporting policies include but are not limited to responding to sexual
abuse and sexual harassment through prevention; responsive planning; training and
education; reporting; investigations; medical and mental care; assessments;
disciplinary sanctions for residents and staff; and data collection and review. The
interviews confirmed knowledge of the zero-tolerance and other related policies
regarding sexual abuse and sexual harassment.
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA Coordinator
with sufficient time and authority to develop, implement, and oversee agency
efforts to comply with the PREA standards in all of its facilities.
Policy provides for the designation of a PREA Coordinator. The DJJ PREA Coordinator
manages the PREA implementation efforts statewide. The Regional Director serves
as the facility’s parent agency’s PREA Coordinator. Both have knowledge of the
standards, implementation, and audit processes. Collaboration exists with the PREA
Coordinators and Facility Administrator/Superintendent as needed.
The interview with the Regional Director, observations and other interviews
revealed the authority to oversee the PREA initiatives and efforts at the facility. The
DJJ statewide PREA Coordinator lends support and direction to all of the contract
facilities as determined from interviews, observations, review of documentation,
previous interview and continual communication between the Auditor and the DJJ
statewide PREA Coordinator.
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 Administrator/Superintendent has been designated as the PREA
Compliance Manager and reports directly to the Regional Director who serves as the
contract agency's PREA Coordinator. The interview indicated he has the time to
fulfill the PREA duties and it was determined that he has the authority required to
fulfill those duties. Interviews conducted with staff revealed their awareness of the
role of the PREA Compliance Manager. Observations confirmed the Facility
Administrator/Superintendent has the support of the facility staff and the PREA
Coordinators.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, it was determined there is compliance 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, PREA
Provider Contract
Contract Log
Interview:
Superintendent
Provision (a) & (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 Florida Department of Juvenile Justice, contracts for the confinement of some of
its residents with Youth Opportunity Investments, LLC. Contracts with this facility
and others exist that inform all providers of the requirements by the Florida
Department of Juvenile Justice to comply with the PREA Standards and be subject to
PREA audits by third-party certified PREA Auditors. The practice was also confirmed
by the interview with the Superintendent and previous interview with the statewide
PREA Coordinator. The facility is not involved in a contract with other facilities for
the confinement if its assigned youth.
Conclusion:
Based upon the review and analysis of the available evidence and communication
maintained with the statewide PREA Coordinator, the Auditor determined
compliance with this standard.
115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Staffing Plan
Annual Staffing Plan Assessment
Unannounced Rounds Reports
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinators
Intermediate/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.
The policies and staffing plan provide 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 staffing ratios are
maintained during the waking hours and during the sleeping hours. Direct
supervision is provided to residents during the daily activities and program services.
The number of staff increases as needed due to program activities, one-on-one
supervision indicated, or other relevant factors. Observations during the site review
and interviews indicated the PREA staffing ratios are maintained. The facility
maintains a mandatory hold-over system to ensure adherence to the staffing ratio
and staffing plan.
The primary camera system is located in the control room and is consistently
monitored. Provisions of the standard are taken into consideration regarding
adequate staffing levels as confirmed through the interviews, policy, and staffing
plan which outline staffing requirements. The work schedules are based on the
facility’s staffing plan, contract requirements, and population. There is collaboration
and review of the work schedules by the administrators and supervisors to ensure
ratios are maintained. In addition to program activities and special needs of
residents, the shift schedules are made regarding the considerations that ensure
adequate shift coverage including standard security practices; composition of the
resident population; inclement weather; and emergencies; and supervisors are
assigned to each shift.
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.
There are no reported deviations from the staffing ratios in the past 12 months. A
coordinated effort was described in maintaining the staffing ratios through
communication, holdovers, in accordance with the staffing plan and consideration of
the population. The facility is prepared to document any deviations from the staffing
requirements. The administrators monitor the effectiveness of the work schedules
based on the staffing plan requirements. The staffing plan shows the required
staffing ratios and is aligned with the agency contract. The staffing plan provides for
the staffing ratios to be met and practice provides for additional staff for days and
times if increased staffing is required.
Provision (c):
Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8 during
resident waking hours and 1:10 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.
Staffing ratios for the facility are routinely provided by the direct care staff and staff
with the same required training to act in the stead due to any staff shortage. The
security practices and policies ensure the PREA ratios of 1:8 during the waking
hours and 1:16 during the sleeping hours. The facility’s contract requires less
residents to a staff member during the sleeping hours (1:10) which ensures the
PREA ratios will be met. The ratios were discussed and observed for and met during
the site review. Direct care staff members provide direct observation of residents.
Since the last PREA audit the average daily number of residents is 52. Since the last
PREA audit, the average daily number of residents on which the staffing plan was
predicated is 117. 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 Compliance Manager 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.
The annual staffing plan assessment was completed by the Department of Juvenile
Justice (DJJ) statewide PREA Coordinator on March 14, 2023. He also facilitated the
process, in collaboration with the Superintendent/PREA Compliance Manager. The
document reviews but is not limited to the following areas: prevailing staffing
patterns and review of staffing plan; electronic monitoring system; and review of
other areas related to adequate supervision. The review considers any adjustments
that need to be made by the construction and implementation of a corrective action
plan that would be indicated through findings or recommendations. The annual
assessment documents the summarization of the review including the staffing,
physical plant and the electronic monitoring system. The Staffing Plan Assessment
did not contain any recommendations for corrective actions.
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.
Unannounced rounds are conducted by the administrators and the rounds are
documented through the use of a dedicated form. The rounds are made at various
times. The interview with the staff making rounds and review of documentation and
policy confirm the unannounced rounds occur. Areas reviewed during the
unannounced rounds include but are not limited to observations of routines being
followed; appropriate interactions; all residents accounted for; and staffing
requirements met.
The staff is not informed of when the rounds will occur and an administrator will
randomly show up at the facility. The unannounced rounds are conducted
throughout the facility to identify and deter sexual abuse and sexual harassment.
Staff members are prohibited from alerting other staff when the rounds are
occurring which is in accordance with policy. The facility reports there were no
deviations from the staffing plan which was also supported by the Staffing Plan
Assessment.
Conclusion:
Based upon the review and analysis of the available evidence and the staff
interview, the Auditor determined the facility is adhering to this standard.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Facility Policy 5-06, Contraband and Search Practices
Agency Policy FDJJ 1919, PREA
Training Video
Interviews:
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.
Cross-gender strip, visual body cavity, and pat-down searches are prohibited and
searches must be documented. The policies and training provide guidance to staff
on how the searches are to be conducted. There is no evidence of cross-gender
searches of any type occurring at the facility in the last 12 months. According to the
interviews and lack of evidence, no type of cross-gender search has been conducted
at the facility during the past 12 months.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent
circumstances.
Policy does not support staff conducting cross-gender pat-down searches. All
searches must be documented. Responses from staff included that only male staff
routinely conduct searches. Staff receives training on how to conduct searches,
including cross gender searches and searches of transgender and intersex youth.
Staff interviews confirmed awareness of how to conduct searches. No residents or
staff interviewed reported the occurrence of any cross-gender searches. The
evidence shows cross-gender pat-down searches have not occurred at the facility
during the last 12 months.
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.
Cross-gender strip and cross-gender visual body cavity searches are prohibited.
Policy provides for documenting the occurrence of searches. All interviews
confirmed that no cross-gender searches have occurred at the facility during this
audit period. Staff members are aware of the requirement to documenting such
searches. There was no evidence documenting any type cross-gender search.
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.
Bathroom/Shower Protocols exist and residents are able to shower, perform bodily
functions, and change clothes without staff of the opposite gender viewing them,
supported by policy and interviews. No residents interviewed reported ever having
been naked in full view of the opposite gender staff while showering, changing
clothes, and performing bodily functions. During the site review, the Superintendent
explained how hygiene practices are conducted and the bathroom procedures. It
was observed that residents have a reasonable amount of privacy during use of the
bathroom. Residents use the bathroom one-two at a time and shower curtains are
utilized and the toilets are encased.
Staff members of the opposite gender are informed through policy and signage to
announce their presence when entering the residents’ housing or bathroom area as
demonstrated during the site review. Seven of the 16 residents interviewed and one
random staff stated that the female staff do not announce their presence when
entering the dorm. A staff meeting was held and during the meeting there was a
reminder for female staff to announce their presence when entering the dorms.
The evidence shows residents shower, perform bodily functions, and change
clothing without non-medical staff of the opposite gender viewing their buttocks or
genitalia. The staff interviews and observations support that viewing of the camera
monitors does not show residents when they are showering, using the toilet or
changing clothes. The bathroom area does not allow staff to get a view of the
resident while performing bodily functions. Hygiene practices are performed with
the expectations of reasonable privacy for each resident.
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.
The policies and staff training prohibit the search of transgender or intersex
residents solely for the purpose of determining the residents’ genital status. Staff
interviews verified no such searches have occurred or would occur at the facility.
The facility reports that staff received the training on conducting searches and
searches of transgender and intersex youth. Staff interviews confirmed they are
aware that policy prohibits staff from conducting a physical examination of
transgender or intersex youth solely for the purpose of determining the resident’s
genital status. When the genital status of a resident is unknown, learning this
information would be part of a broader medical examination conducted by a medical
practitioner in private. The facility will utilize the Statement of Preference Form
when indicated by a youth regarding the gender of the staff preferred to conduct
the search as directed by agency policy. A transgender or intersex youth was not
present in the facility during the site review.
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.
The training materials for staff provide information on conducting cross-gender pat-
down searches and searches of transgender and intersex youth. Training materials
indicate the provision of search techniques consistent with the security needs. A
dedicated form, Statement of Preference, is to be used for a transgender or intersex
youth to identify their sexual preference of the staff to conduct the searches. No
such searches have been conducted during the past 12 months.
Conclusion:
Based on the reviewed documentation and interviews, the Auditor determined
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:
Facility Policy 5-19, PREA
Facility Policy 1-22, Americans With Disabilities Act
Agency Policy FDJJ 1919, PREA
Interpreting Agreement
Posted PREA Information
PREA Brochures
Interviews:
Residents
Random Staff
Superintendent
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.
Policies address the provision of support services for Limited English Proficient and
disabled residents by providing residents the equal opportunity to participate in or
benefit from all aspects of the facility’s efforts to prevent, detect, and respond to
sexual abuse and sexual harassment. Residents are not used as readers or
interpreters, confirmed by staff interviews and the information is noted on the
posted list of bilingual staff members who may be used as interpreters. PREA
information, including posted information, is accessible to residents in English,
Spanish, French Creole, and other languages are obtainable if needed.
Policy provides for interpreter and translation services, including the services for the
Deaf by requiring PREA education to be in formats accessible to all residents. The
education staff provide support services through accommodating resources,
including a certified teacher with the educational background to modify/adapt
information for all residents to understand. Assistance may also be provided by the
treatment staff and bilingual staff to ensure all residents’ understanding of the PREA
information.
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 Service Agreement exists between the parent agency and the
American Sign Language Services Corporation for professional interpreting services
as needed to ensure the residents’ understanding of PREA and other information.
Each resident has 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. The facility is capable of providing access to support services for
preventing, detecting, and responding to sexual abuse and sexual harassment to
residents who are Limited English Proficient, including taking steps to provide
interpreters who can interpret effectively, accurately, and impartially, through
LanguageLine Solutions.
Provision (c):
The agency shall not rely on resident interpreters, resident readers, or other types
of resident assistants except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s safety, the
performance of first-response duties under §115.364, or the investigation of the
resident’s allegations.
The use of resident readers and interpreters is prohibited except in limited
circumstances where an extended delay in obtaining an interpreter could
compromise a resident’s safety; performance of first responder duties; or
investigation of allegations of sexual abuse or sexual harassment. The random staff
interviews support that resident are not used as readers or interpreters. The
education unit and mental health staff members have the capabilities to provide
support services. Information regarding reporting allegations of sexual abuse and
sexual harassment is posted and accessible in both English, French Creole, and
Spanish. The facility has the resources available to get the PREA information
translated and printed in additional languages as needed.
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:
Facility Policy 1-04, Initial Background Screening and Rescreening
Facility Policy 5-19, PREA
Agency Policy FDJJ 1800, Background Screening and Hiring Practice
Agency Policy FDJJ 1919, PREA
Orientation/New Hire Training Plan
Employee Handbook
Personnel Records
Interview:
Human Resources Staff
Provision (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 collectively address hiring and other personnel matters, including and
not limited to promotion processes and decisions, position descriptions, and
background checks. The background checks occur initially and every five years
thereafter, aligned with policy. 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, which
includes State, federal and local inquiries.
Through the employment application process, prior to hire, applicants are asked to
verify, in writing, the following information which is a part of the background
screening information 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;
• Have been civilly or administratively adjudicated to have engaged in the
activity described above.
The interview and a review of policies provided 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 or promote 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. The
documentation inquiring about prior sexual misconduct is also a part of the
background information packet, required for conducting the background check.
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.
Policies support that the facility does not hire or promote anyone who has been
civilly or administratively adjudicated or have been convicted of engaging in or
attempted to engage in sexual activity by any means. The interview was aligned
with the standard and the documentation shows that inquiries are made during the
application process regarding previous sexual misconduct.
Policy and the interview indicate the facility considers any incidents of sexual
harassment in determining whether to hire or promote anyone, or to enlist the
services of any contractor or volunteer, who may have contact with residents. 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 includes consulting a child abuse registry, including
the National Sex Offender Public Website. The prospective employee or contractor
also has to be cleared through the background check process. Best efforts are made
to identify information of incidents or allegations of sexual abuse by a prospective
employee.
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.
Initial background checks are conducted and are conducted every five years
thereafter, in accordance with policy. The interview, review of documentation and a
review of the policies provide details about the hiring process, completion of
background checks, and the grounds for termination in accordance with the PREA
standard.
Provision (g):
Material omissions regarding such misconduct, or the provision of materially false
information, shall be grounds for termination.
The omission of sexual misconduct information or providing false information is
grounds for termination in accordance with policy. This information is also covered in
the new employee orientation training. Staff members have a continuing duty to
report related misconduct. Employees are informed during participation in the
Orientation/New Hire Training that they have a continuing affirmative duty to
disclose any such misconduct. Additionally, an electronic alert is sent to the facility
from DJJ if an employee is arrested.
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.
When a former employee applies for work at another institution, upon the request
from that institution, information will be provided regarding substantiated
allegations of sexual abuse or sexual harassment involving a former employee
unless prohibited by law.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has
determined the facility meets the provisions of the standard.
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy FDJJ 1919, PREA
Annual Staffing Plan Assessment
Interviews:
Superintendent
Contract Agency Head Designee
Provision (a):
If the agency designed or acquired any new facility or planned any substantial
expansion or modification of existing facilities, the agency considered the effect of
the design, acquisition, expansion, or modification upon the agency’s ability to
protect residents from sexual abuse.
Observations and interviews confirmed the facility has not completed major
renovations since the last PREA audit conducted in 2018.
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 enhance the agency’s ability to protect residents from sexual abuse.
The camera system supplements direct supervision provided to residents by staff.
The camera system was updated since the last PREA audit conducted in 2018 to
address the identified blind spots. Additional cameras were added bringing the total
number of cameras to 177.
Conclusion:
The facility is compliant with the standard based on interviews, policy and
observations.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy FDJJ 1900, PREA
Facility Policy 5.19, PREA
Memorandum of Understanding (MOU)
Posted Advocacy Information
PREA Compliance Form
Interviews:
Random Staff
Residents
Superintendent/PREA Compliance Manager
Medical Staff
Representative, Betty Griffin Center Outreach Domestic Abuse Treatment Center
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.
Administrative investigations are investigated by the Department of Juvenile Justice
(DJJ), Office of Inspector General (OIG), agency investigators. All allegations of
sexual abuse are also reported to local law enforcement and the Florida Department
of Children and Families. Policy is followed regarding investigations of sexual abuse
in accordance with the standard. A previous interview with investigative staff and
random staff confirmed awareness of protocol for obtaining usable physical
evidence and knowledge of the entities responsible for conducting investigations.
The protocol for investigations is appropriate for youth and provided by DJJ/OIG. The
PREA Compliance Form is shared with local law enforcement investigators outlining
the PREA standards that must be adhered to regarding an investigation of an
allegation of sexual abuse. The DJJ investigators are also aware of the PREA
Compliance Form and investigation protocols. All services provided will be at no cost
to the victim and services are available in various languages as needed.
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 evidentiarily 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.
A MOU exists between the facility and the Betty Griffin Center. Forensic medical
examinations will be conducted by a Sexual Assault Nurse Examiner (SANE) at the
hospital. Upon request, accompaniment will be provided by a certified advocate
from the Betty Griffin Center, confirmed by the staff from the advocacy agency.
Continuity of care will be provided at the facility to include medical and mental
health follow-up services as confirmed by interviews. Forensic medical examinations
will be provided at no cost to the victim. No forensic medical examinations were
required during this audit period. The interview with the advocacy agent confirmed
the services available as outlined in the MOU such as but not limited to
accompaniment, hotline services, counseling and advocacy. Information is posted
outlining the services accessible through the Betty Griffin Center.
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.
Victim advocacy services include a range of services and the MOU shows both
agencies working together in response for the need of advocacy services. The
advocacy agency follows all applicable laws and regulations with respect to
confidentiality which is noted in the MOU and the posted information. The MOU and
representative interview collectively confirm victim advocacy services include but
are not limited to the following:
• 24-hour hotline services;
• Emotional Support;
• Accompaniment;
• Referrals; and
• Counseling
Information regarding victim advocacy services is provided to the residents during
the intake process, according to staff, and is provided through the accessibility of
information which is posted. The interviews with the residents did not reveal
consistent knowledge of the advocacy services although the information is posted
and referenced during during PREA education. A corrective action plan was
developed and implemented to provide a refresher regarding advocacy services
during House Meetings. The advocacy information was reviewed during February
House Meetings and specifically in House Meetings in March. The Assistant Facility
Administrators provided to the Auditor House Meeting Notes for both months and
sign-in sheets for residents for the initial meeting. Both Assistant Facility
Administrators confirmed completion of the PREA education refresher regarding the
advocacy agency and the available services. The focus on advocacy services will be
more pronounced during the initial PREA education and in follow-up sessions.
Provisions (f) & (g):
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.
Florida DJJ/OIG investigators from its central office will conduct administrative
investigations in accordance with agency policy, and the protocols as outlined on
the PREA Compliance Form, aligned with the Standard. Investigations of allegations
of sexual abuse or sexual harassment that is criminal in nature is investigated by
local law enforcement.
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.
The facility has made arrangements for victim advocacy services as confirmed
through the staff and advocacy agent interviews, posted information, MOU, and
refresher PREA education sessions.
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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Agency Website
PREA Compliance Form
Investigative Reports
Interviews:
Random Staff
Superintendent
Agency Head Designees
Provision (a):
The agency shall ensure that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment.
Policy provides that staff report all allegations of sexual abuse and sexual
harassment and to document reports; staff members are aware of the requirements.
Previous interviews were conducted with the agency head designee of the State and
contract agencies. Sexual abuse and sexual harassment allegations are referred to
the Department of Juvenile Justice/Office of Inspector General (DJJ/OIG), Florida
Department of Children and Families (DCF), and law enforcement where the
allegation is criminal in nature. Policies and interviews provide for investigations of
all allegations of sexual abuse and sexual harassment.
The review of investigative reports and formal interviews and informal
conversations with facility staff revealed three allegations of sexual abuse during
this audit period. There were one allegation of staff-on-youth sexual abuse and two
allegations of youth-on-youth sexual abuse. The allegations were reported to the
three investigative entities; DJJ, DCF and law enforcement. There were no criminal
findings and the administrative investigations by DJJ resulted in closure as
Unfounded for the staff-on-youth allegation and Information Only for the two youth-
on-youth allegations.
Provision (b) & (c):
Provision (b): The agency shall have in place a policy to ensure that allegations of
sexual abuse or sexual harassment are referred for investigation to an agency with
the legal authority to conduct criminal investigations, unless the allegation does not
involve potentially criminal behavior. The agency shall publish such policy on its
website or, if it does not have one, make the policy available through other means.
The agency shall document all such referrals. Provision (c): If a separate entity is
responsible for conducting criminal investigations, such publication shall describe
the responsibilities of both the agency and the investigating entity.
Policy and reporting information are located on the DJJ and facility’s parent agency
websites and posted within the facility and accessible to the public. Policies,
investigative reports and interviews confirmed allegations of sexual abuse and
sexual harassment are investigated. Administrative investigations are conducted by
trained DJJ/OIG investigators from the DJJ central office. Allegations of sexual abuse
and sexual harassment that are criminal in nature are referred to local law
enforcement. Allegations are also reported to the Florida Department of Children
and Families.
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 DJJ/OIG has policy governing administrative investigations. The agency utilizes
trained investigators. The previous interview with investigative staff confirmed that
administrative investigations are conducted by trained investigators and allegations
that are criminal in nature are referred to local law enforcement as evidenced
through interviews, investigative reports, and incident review team meeting
minutes.
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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Training Curricula
Orientation/New Hire Training Plan
Electronic Training Records
Acknowledgement Statements
Contract
Interviews:
Random Staff
Superintendent
Provisions (a) & (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.
Policies and the agency's contract with providers, including this facility, address and
require PREA related training for staff. PREA training is provided initially upon
employment and annually. Interviewed staff members were generally familiar with
the PREA information and could identify when their last training/refresher was
provided. Policy provides for refresher training to occur annually. PREA training is
provided to staff, as indicated by a review of facility and agency policies, training
documents, and interviews. The facility reports all staff members that may have
contact with residents have been trained or re-trained on the PREA Standards
requirements. The interviews and documentation support that PREA training occurs.
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 with varying levels of mental health and behavioral needs
and staff training considers the needs of the population served as indicated by the
interviews and documentation. Policies and interviews support training being
tailored to the needs and attributes of the population served. All staff within the
facility are provided PREA training.
The program provides gender-responsive services that are tailored to the special
needs of the population served and contribute to strong regular as well as
specialized staff support. Interactions with residents, observations, and observed
staff and resident interactions indicate the responsive treatment modalities within
the facility.
Provision (d):
The agency shall document, through employee signature or electronic verification
that employees understand the training they have received.
The PREA training reviewed was documented electronically and verified through
staff interviews, the agency’s training curricula, the contract agency's Orientation/
New Hire Training Plan, and acknowledgement statements.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the standard.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Training Curriculum
Acknowledgement Statements
Interviews:
Volunteers (2)
Contractors (2)
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 on PREA and their responsibilities regarding sexual assault prevention,
detection, and response to allegations of sexual abuse and sexual harassment. The
training curriculum includes but is not limited to reporting allegations of sexual
abuse and sexual harassment, related definitions and maintaining professional
relationships with residents. The contractors interviewed are part of the education
unit and the volunteers provide religious services. The interviews revealed
knowledge of the agency’s zero-tolerance policy and how to report allegations of
sexual abuse and sexual harassment.
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 by the
contractors and volunteers.
The interviews revealed familiarity with the zero-tolerance policy regarding sexual
abuse and sexual harassment of residents, including how to report. The interviews
confirmed that the review of the zero-tolerance policy for the facility and agency is
included in the PREA training. The contractors interviewed provide education
services to the residents and the volunteers interviewed provide and/or facilitate
religious services. PREA education is available through the Department of Juvenile
Justice's online course, within the facility, and child abuse training is available
through the school system for the education contractors.
Provision (c):
The agency shall maintain documentation confirming that volunteers and
contractors understand the training they have received.
The training documentation and interviews confirmed the receipt and awareness of
PREA training. The interviews indicated the understanding of the training received.
The DJJ online training course is made available to contractors and volunteers and
staff review of the PREA information is provided onsite. The education contractors
are mandated reporters and receive related training through the school system.
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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Acknowledgement Statements
PREA Brochures
Youth & Parent Program Handbook
PREA Education Video
Interviews:
Residents
Intake Staff
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.
All residents receive directions on how to report allegations of sexual abuse and
sexual harassment; and information about the right to be free from retaliation for
reporting, in accordance with policy, other documentation, and interviews. A review
of the education materials indicated the information provided to the residents is
age-appropriate. The intake staff reviewed the subject matter during the interview
that is used to provide PREA education to residents.
The residents initially sign acknowledgement statements which represent receipt of
the PREA information provided. The interviews with the residents revealed their
understanding of the information covered in the PREA education sessions. The
intake staff and the residents revealed the initial PREA education is generally
conducted on the first day of admission to the facility during the intake process.
PREA refresher education sessions are conducted during House Meetings; additional
information is provided in increments.
Information regarding victim advocacy services is provided to the residents and is
provided through the accessibility of information which is posted. The interviews
with the residents did not reveal consistent knowledge of the advocacy services
although the information is posted and referenced during PREA education. A
corrective action plan was developed and implemented to provide a refresher
regarding advocacy services during House Meetings. The advocacy information was
reviewed during February House Meetings and specifically in House Meetings in
March. The Assistant Facility Administrators provided to the Auditor House Meeting
Notes for both months and sign-in sheets for residents for the initial meeting. Both
Assistant Facility Administrators confirmed completion of the PREA education
refresher regarding the advocacy agency and the available services. It was
acknowledged that the focus on advocacy services will be more pronounced during
the initial PREA education and in follow-up sessions.
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, residents
received PREA education. The facility reports that 48 youth were admitted to the
facility during the past 12 months prior to the onsite audit phase and all participated
in PREA education sessions. Eighty-two residents were in the facility during the
onsite audit phase and all had been involved in PREA education sessions.
Acknowledgement statements reviewed onsite, observed posted information,
brochures, and the interviews indicate that general PREA education is provided to
residents and that residents sign acknowledging receipt of the Handbook.
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 education unit is a
resource for accessibility and accommodations. The education staff provides
support services through certified teachers with the educational background to
modify/adapt information for all residents to understand.
Policy addresses the provision of support services for limited English proficient and
disabled residents by the requirement of providing 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. The contract agency has an
agreement for interpreting and translation services and an agreement with the
American Sign Language Services Corporation for services for the Deaf. Assistance
may also be provided by the treatment staff and bilingual staff to ensure all
residents’ understanding of the PREA information.
PREA information is available in English, French Creole and Spanish. Reporting
information is posted within the facility, accessible to residents, staff and visitors.
The information is posted at varying eye levels and is consistent through the
brochures and other printed materials. The staff revealed a practice of residents not
used as translators or readers for other residents. The facility has knowledge of the
youth’s arrival to the facility prior to the admission date. This time period provides
for the identified staff to make plans to accommodate the special needs of
residents. The special arrangements are coordinated by treatment team staff in
collaboration with the administrators.
Residents are asked about feelings of safety during informal encounters with staff
and during formal treatment team meetings. PREA information is included in the
Youth & Parent Handbook, provided through the agency PREA video, information is
posted, and elements of PREA are discussed in House Meetings. The PREA brochure
and Handbook are accessible in languages other than English, as needed.
Provision (e):
The agency shall maintain documentation of resident participation in these
education sessions.
Signed acknowledgement statements, reviewed onsite, support the residents’
involvement in PREA education sessions and residents also sign for receipt of the
Youth & Parent Program Handbook. The interviews with the residents and intake
staff confirm PREA education sessions occur. The residents were aware of how to
report allegations of sexual abuse and sexual harassment and that they would not
be punished for reporting such. The residents are aware of their PREA related rights.
The refresher educations sessions regarding advocacy services has bolstered the
residents' awareness of the availability of specific advocacy services.
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 interviews with the residents and observations confirmed PREA information is
continuously and readily available and visible to residents during their stay in the
facility. The PREA education materials provide residents information on how to
report allegations of sexual harassment and sexual abuse. PREA information is
posted and provided to residents to assist in eliminating incidents of sexual abuse
and sexual harassment. The printed materials provide information on sexual abuse
and sexual harassment; steps victims may take; definitions of related terms; safety
tips; and reporting information. Each resident is provided a Youth and Parent
Program Handbook which contains PREA and reporting information.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and
observations, the Auditor determined the facility is compliant with this standard.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documentation Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Agency Training Curriculum
PREA Compliance Form
Interviews:
Superintendent
Provisions (a) & (b):
Provision (a): 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 Department of Juvenile Justice
(DJJ), Office of Inspector General (OIG). PREA training is required in addition to the
specialized training regarding conducting administrative investigations. Allegations
of sexual abuse are referred for investigation to be conducted by law enforcement.
A previous interview with the agency's investigative staff and review of agency
documents confirmed administrative investigations are conducted by trained
investigators within the DJJ/OIG and that allegations of sexual abuse are also
referred to the child welfare agency and law enforcement. The specialized training
for DJJ investigators includes but is not limited to interviewing techniques; proper
use of Garrity and Miranda warnings; preserving evidence; and criteria for
supporting a finding of substantiated, unsubstantiated or unfounded.
Provision (c):
The agency shall maintain documentation that agency investigators have
completed the required specialized training in conducting sexual abuse
investigations.
Training records of the administrative investigators are maintained by the agency,
DJJ. Allegations of sexual abuse are referred to law enforcement and the Florida
Department of Children and Families, in accordance with policy. All allegations of
sexual abuse and sexual harassment are reported to DJJ, 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.
The DJJ provides training to its investigators who will conduct administrative
investigations at the contract facilities and State-run facilities which was confirmed
by interviews. Local law enforcement is responsible for training their investigators
who conduct sexual abuse investigations and allegations that are criminal in nature.
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, PREA
Training Curricula
Training Records
Interviews:
Mental Health Staff
Medical 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.
The Florida Department of Juvenile Justice requires medical and mental health staff
members to receive the regular PREA training as well as the specialized training
provided through the agency. Electronic training records, training modules, and the
interviews document regular PREA training and the specialized training for medical
and mental health staff members.
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 facility staff.
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.
Electronic training records and interviews with medical and mental health staff
confirmed receipt of the regular and specialized training. The regular and
specialized PREA training is provided online by the Department of Juvenile Justice.
The specialized training is provided through different modules. Regular and
refresher PREA trainings are provided online and refresher training is provided
during staff meetings and shift briefings as needed.
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 complete the general training that is provided for all
employees as indicated by training documentation and the interviews. The standard
PREA training is provided to all employees and the specialized training is provided
online by the Department of Juvenile Justice and the records are maintained
electronically.
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:
Facility Policy 5-19
Agency Policy FDJJ 1919
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
Superintendent/PREA Compliance Manager
Contract Agency PREA Coordinator
Residents
Provision (a):
The Policy provides that upon arrival or 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.
Policy provides for each resident to be screened for risk of victimization or
abusiveness prior to room assignment in order to reduce the risk of sexual abuse by
or upon a resident. The interviews and practice indicate the primary risk
assessment, Screening for Vulnerability, Victimization and Sexually Aggressive
Behavior (VSAB), is generally completed on the day of admission. The staff
responsible for risk screening revealed that prior to administering the VSAB, she
establishes a rapport with the youth. The youth is asked questions and elaboration
may be needed regarding some of the questions. The youth is interviewed to obtain
information about personal history and behavior; information is also gleaned from
parents/guardians. The court packet for the youth is also reviewed to gather
pertinent information.
The primary PREA intake screening instrument, , is used to document such
assessment. The interviews revealed the practice of the risk screening being
conducted in accordance with the policy Review of the screening instrument and
interviews confirmed 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 Confirmation of size; and Confirmation of Age.
Policy addresses the occurrence and criteria regarding formal reassessments of
residents. The risk assessments are accessible to the clinical team. The resident
files were observed to be maintained in a confidential manner within lockable
offices.
Provision (b):
Such assessments shall be conducted using an objective screening instrument.
An objective screening instrument 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; disabilities; and a resident’s
concern regarding his/her own safety. The instrument, VSAB, is tabulated based on
the information received where identified responses can identify special needs and
safety concerns. Assessments are conducted through the use of the objective
primary instrument containing items that collectively provide a presumptive
determination of risk for victimization or abusiveness. Additional assessment tools
are used in the facility for measuring various risks, including sexual safety.
At a minimum, the agency obtains 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 and determined the items required by this provision
of the standard are included within the instrument. The interview with the risk
screener confirmed awareness of the elements of the risk screening instrument and
the use of the instrument was explained. The resident interviews also confirmed the
administration of the screening instrument and the general inquiries made. The
interviews revealed the practice is that the instrument is generally administered the
first day of the youth’s admission to the facility.
Provision (d):
This information shall be ascertained through conversations with the resident during
the intake process and medical and mental health screenings; during classification
assessments; and by reviewing court records, case files, facility behavioral records,
and other relevant documentation from the resident’s files.
The information to complete the risk screening instrument is gleaned from various
sources. Information in determining the risk for victimization or abusiveness is
obtained through interviewing the youth, review of the commitment packet through
the court, and other assessments conducted prior to and after arrival to the facility.
Additional information may be obtained from interviews with parents/guardians
where indicated. The facility is aware of the youth’s pending arrival to the facility
and treatment staff has the opportunity to review the resident’s record in an effort
to prepare for the needs prior to arrival. Additional assessments and screenings are
completed after the youth is admitted to the facility to obtain supportive
information for treatment planning and keeping the youth safe.
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.
Staff takes appropriate controls to ensure that sensitive information is protected and
not exploited by maintaining the files in a locked and secure manner, behind locked
doors. The online information is password protected and is only accessible to
identified staff. The Superintendent and staff responsible for risk screening
addressed the management of sensitive information and the limited and guarded
access by treatment staff. Pertinent information is provided to other staff based on
the need to know. Staff training includes information regarding confidentiality of
information concerning residents.
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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Admission Classification Form
Interviews:
Staff Responsible for Risk Screening
Medical Staff
Residents
Superintendent/PREA Compliance Manager
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.
Policies provide guidance to staff regarding the use of the information obtained from
the screening instrument, VSAB. The interviews indicate the screening and
assessment information and observations are used to inform staff of information
helpful in determining housing and program assignments, and assist in identifying
treatment needs and the need of any special services.
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.
Isolation is not used in this facility and interviews and observations support this
premise. The staff interviews indicated that protective measures will be taken
immediately when needed and includes separating residents; notifying other staff,
including treatment staff and administrators; and implementing closer supervision
measures. No residents were determined to be at risk for sexual victimization during
this audit period.
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.
Gay, bisexual, transgender, or intersex residents are not placed in specific housing
solely based on how the residents identify or their status, in accordance with policy.
Staff members are prohibited from considering the identification as an indicator that
these residents may be more likely to be sexually abusive. During the site review,
there were no rooms or units observed or identified to be reserved for LGBTI youth.
Housing assignments are made on a case-by-case basis as supported by policy and
procedures, interviews and observations.
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 residents’ health and safety, and whether the placement
would present management or security problems.
Policy and practice support that housing and program assignments for transgender
or intersex residents are made on a case-by-case basis which was evident from staff
interviews and observations. Policy prohibits placing such youth in specific housing
or making other assignments solely based on how the residents identify or their
status. Housing and program assignments are decided on a case-by-case basis
considering whether a placement would ensure a resident’s health and safety, and
whether the placement would present management or security problems. The
interview with the risk screener indicates awareness and the importance of
considering the youth's concern for their own safety in keeping transgender and
intersex youth safe.
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 be reassessed twice per year to determine any threats to safety
experienced by the resident. The interview with the risk screener confirmed
familiarity with reassessments. There were no transgender or intersex residents
identified in the facility during this audit period.
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 their own safety is taken into account through the
administration of the risk vulnerability screening instruments, treatment team
meetings and individual sessions and informal interactions with treatment and other
staff. The interviews with staff and review of documentation were aligned with the
policy.
Provision (g):
Transgender and intersex residents shall be given the opportunity to shower
separately from other residents.
Transgender or intersex residents will be given the opportunity to shower separately
from other residents which is supported by the interview with the risk screener and
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.
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. The provisions of this standard would be provided if such
occurs however the practice is that isolation is not used in this facility. No residents
were determined at risk of sexual victimization in the 12 months preceding the
audit. The interviews and observations during the site review confirm that isolation
is not used in this facility
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 were identified to be at risk of
sexual victimization 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:
Facility Policy 1-6, Incident Reporting
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Employee Handbook
Youth & Parent Program Handbook
Grievance Form
Speak Out Form
Sick Call Request Form
Posted Information
Legal Correspondence
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.
Policies provide for internal ways a resident may report allegations of sexual abuse
and sexual harassment, including how to privately report sexual abuse and sexual
harassment; retaliation for reporting; and staff neglect or violations of
responsibilities that may have contributed to such. Residents may report allegations
of sexual abuse or sexual harassment by telephone through the 24-hour Florida
abuse reporting hotline. There are also posters containing information regarding a
national abuse hotline. Collectively, all posted PREA information is printed in
English, Spanish and French Creole. The posted information is in varying eye levels
and easy to read.
Aligned with agency policy, telephones throughout the facility are made accessible
to residents for reporting allegations of sexual abuse and sexual harassment. Staff
members are required to make the use of a telephone accessible for residents to
report allegations of sexual abuse and sexual harassment, staff neglect or violation
of responsibilities that may have contributed to such incidents; or to request
advocacy services.
Policy, posters, brochures, and the Youth and Parent Program Handbook collectively
provide telephone numbers and instructions for reporting allegations of sexual
abuse or sexual harassment. In addition to accessing a telephone, residents are also
informed in the PREA education sessions, determined from the interviews, that they
may tell staff; submit a complaint in writing, or use the Florida abuse reporting
hotline regarding allegations of sexual abuse or sexual harassment.
The residents interviewed could identify someone who did not work at the facility
they would report to about sexual abuse or sexual harassment if needed. The
random staff and resident interviews collectively revealed residents may use the
telephone, submit a complaint in writing, or talk to staff to privately report
allegations of sexual abuse and sexual harassment. The resident is provided the
hotline number in writing in the Youth & Parent Program Handbook and through
brochures and posted information.
Residents have access to writing materials; Grievance, Speak Out, and Sick Call
Forms; and locked boxes for receipt of the forms which are accessible to all
residents for reporting allegations. Written notes or letters may also be given to
staff. If a grievance form is used to make a written allegation of sexual abuse, the
reporting procedures will be implemented in accordance with policy. The Grievance
Form informs the resident that a PREA related allegation should be reported to staff
immediately or indicate the issue and place the form in the grievance box.
Grievances alleging sexual abuse will be handled directly by the facility
administrators/designee and reported to the Department of Juvenile Justice/Central
Communications Center, law enforcement, and the Florida Department of Children
and Families. The residents interviewed understood the process for using the
Grievance Form and other forms to report allegations of sexual abuse and sexual
harassment.
The Speak Out Form provides for the resident to request the specific staff member
they would like to speak to regarding any of the following areas: security; mental
health; education; case management; medical; maintenance; food services; positive
improvements for the facility and recognition. The Speak Out, Sick Call Request, and
Grievance Forms were observed posted in the dorms along with the locked boxes for
deposit of the forms.
PREA information is posted and each resident is provided a Youth and Parent
Program Handbook which contains reporting and other PREA related information.
Residents sign an acknowledgement statement confirming receipt of PREA
information. Staff members receive information on how to report allegations of
sexual abuse or sexual harassment through policies and procedures, training, staff
meetings, and shift briefings.
Provision (b):
The agency shall also provide at least one way for residents to report abuse or
harassment to a public or private entity or office that is not part of the agency and
that is able to receive and immediately forward resident reports of sexual abuse and
sexual harassment to agency officials, allowing the resident to remain anonymous
upon request. Residents detained solely for civil immigration purposes shall be
provided information on how to contact relevant consular officials and relevant
officials at the Department of Homeland Security.
The Florida abuse reporting hotline may be used by residents and staff to report
allegations of sexual abuse and sexual harassment. The interviews revealed
familiarity with policies and posted and other printed information on how to report
allegations of sexual abuse and sexual harassment. Telephones are accessible to all
staff and are made accessible to residents by staff. The reports of sexual abuse or
sexual harassment are accepted and referred for an investigation. The facility does
not detain residents solely for civil immigration purposes according to written
communication between the statewide PREA Coordinator and the agency's legal
department. The hotline number was tested and determined to be in working order;
there are language options for English and Spanish.
Provision (c):
Staff shall accept reports made verbally, in writing, anonymously, and from third-
parties and shall promptly document any verbal reports.
The interviews confirmed 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 and random staff interviews collectively indicated awareness of reporting
either in person, in writing, by telephone, or through a third-party. 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.
Provision (d):
The facility shall provide residents with access to tools necessary to make a written
report.
Observations during the comprehensive site review and interviews revealed writing
materials are available for residents to complete Grievance, Speak Out and Sick Call
Request Forms or write notes. The forms are posted in each living unit and pencils
are accessible through staff and in education classes. Each resident is provided a
Youth & Parent Program Handbook which contains information regarding reporting
allegations and the residents are informed of the reporting methods during PREA
education sessions. The interviews, review of documents and facility practices
revealed that residents are provided the tools to make written allegations of sexual
abuse and sexual harassment.
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and
sexual harassment of residents.
The staff interviews collectively revealed staff can privately report allegations of
sexual abuse and sexual harassment through a call to the Florida abuse reporting
hotline, Department of Juvenile Justice Central Communications Center, law
enforcement, or 911. Staff also reported they could privately report to their
supervisor and/or administrator.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, 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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Grievance Form
Youth and Parent Handbook
Interviews:
Random Staff
Residents
Superintendent
Provision (a):
An agency shall be exempt from this standard if it does not have administrative
procedures to address resident grievances regarding sexual abuse.
When an emergency complaint is received on a Grievance Form making an
allegation of sexual abuse or sexual harassment, the policy and procedures for
reporting allegations of sexual abuse or sexual harassment are initiated and a
report is submitted 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 Department of Juvenile Justice (DJJ)/Office of Inspector
General (OIG), Florida Department of Children and Families, and/or law enforcement.
Provision (b):
(1) The agency shall not impose a time limit on when a resident may submit a
grievance regarding an allegation of sexual abuse.
(2) The agency may apply otherwise-applicable time limits on any portion of a
grievance that does not allege an incident of sexual abuse.
(3) The agency shall not require a resident to use any informal grievance process, or
to otherwise attempt to resolve with staff, an alleged incident of sexual abuse.
(4) Nothing in this section shall restrict the agency’s ability to defend against a
lawsuit filed by a resident on the ground that the applicable statute of limitations
has expired.
There is no time limit for completing a Grievance Form to report allegations of
sexual abuse. Residents are not required to use an informal process or give the
Grievance Form to any staff member regarding allegations of sexual abuse. Locked
boxes and forms are located in the common areas of the living units for residents to
deposit forms or notes if they choose. The Grievance Form differentiates for the
resident on how to utilize it if the complaint is PREA related. Residents are informed
to notify staff immediately or complete the top part of the Grievance Form (name,
date, time, check box for reason) and place it in the grievance box.
Provision (c):
The agency shall ensure that—
(1) A resident who alleges sexual abuse may submit a grievance without submitting
it to a staff member who is the subject of the complaint, and
(2) Such grievance is not referred to a staff member who is the subject of the
complaint.
The grievance system does not include investigating allegations of sexual abuse
and sexual harassment. Residents are not required to use an informal process or
give the Grievance Form to any staff member regarding allegations of sexual abuse.
The staff member involved in the allegation will not be involved in reporting the
allegation stated in the complaint. To assist in the prompt and proper handling of
the allegation of sexual abuse or sexual harassment, residents may put the
completed Grievance Form in the locked box.
The Florida abuse reporting hotline and the contact information is provided and the
residents are informed that they will have unhindered access to a telephone. The
locked boxes are located in the common areas for depositing Forms or notes. The
Handbook explains the regular grievance system and contains information
regarding reporting allegations of sexual abuse and sexual harassment. The
Grievance Form informs residents that they are to report the allegation to staff
immediately or complete basic information on the form and deposit it in the
grievance box.
Provision (d):
(1) The agency shall issue a final agency decision on the merits of any portion of a
grievance alleging sexual abuse within 90 days of the initial filing of the grievance.
(2) Computation of the 90-day time period shall not include time consumed by
residents in preparing any administrative appeal.
(3) The agency may claim an extension of time to respond, of up to 70 days, if the
normal time period for response is insufficient to make an appropriate decision. The
agency shall notify the resident in writing of any such extension and provide a date
by which a decision will be made.
(4) At any level of the administrative process, including the final level, if the resident
does not receive a response within the time allotted for reply, including any properly
noticed extension, the resident may consider the absence of a response to be a
denial at that level.
All Grievance Forms that contain an allegation of sexual abuse or sexual harassment
will be referred for an investigation in accordance with policy. The purpose of the
submission of a PREA related complaint on a Grievance Form provides residents and
staff another avenue for ensuring the reporting of allegations and provides staff with
an additional opportunity to protect the resident.
Provision (e):
(1) Third parties, including fellow residents, staff members, family members,
attorneys, and outside advocates, shall be permitted to assist residents in filing
requests for administrative remedies relating to allegations of sexual abuse, and
shall also be permitted to file such requests on behalf of residents.
(2) 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.
(3) If the resident declines to have the request processed on his or her behalf, the
agency shall document the resident’s decision.
(4) A parent or legal guardian of a juvenile shall be allowed to file a grievance
regarding allegations of sexual abuse, including appeals, on behalf of such juvenile.
Such a grievance shall not be conditioned upon the juvenile agreeing to have the
request filed on his or her behalf.
When third-party reports of allegations of sexual abuse or sexual harassment are
received, the policies 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 facility staff to investigate or
resolve allegations of sexual abuse or sexual harassment. The allegation on the
Grievance Form is reported and an investigation will be conducted by the
investigative entity as appropriate.
Provision (f):
(1) The agency shall establish procedures for the filing of an emergency grievance
alleging that a resident is subject to a substantial risk of imminent sexual abuse.
(2) After receiving an emergency grievance alleging a resident is subject to a
substantial risk of imminent sexual abuse, the agency shall 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, shall provide an initial response within 48 hours, and shall issue a final
agency decision within five calendar days. The initial response and final agency
decision shall document the agency’s determination whether the resident is in
substantial risk of imminent sexual abuse and the action taken in response to the
emergency grievance.
If a Grievance Form alleging sexual abuse is received, it is reported by staff to the
appropriate investigative entity. The response will also include staff implementing
measures to ensure safety of the resident. There has not been a grievance
submitted alleging sexual abuse during this audit period.
Provision (g):
The agency may discipline a resident for filing a grievance related to alleged sexual
abuse only where the agency demonstrates that the resident filed the grievance in
bad faith.
The grievance system does not include a process for facility staff to investigate or
resolve allegations of sexual abuse. Once a Grievance Form alleging sexual abuse is
received, the allegation is reported to the appropriate investigative entities and an
investigation will be conducted by the DJJ/ OIG, Florida Department of Children and
Families, or local law enforcement. There has not been a Grievance Form submitted
alleging sexual abuse during this audit period.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Memorandum of Understanding (MOU)
PREA Education Sign-In Sheets
House Meeting Notes
Posted Information
Interviews:
Residents
Superintendent/PREA Compliance Manager
Advocate 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.
The interviews with the residents did not reveal consistent knowledge of the
advocacy services although the information is posted and referenced during during
PREA education. A corrective action plan was developed and implemented to
provide a refresher regarding advocacy services during House Meetings with the
residents. The advocacy information was reviewed during February House Meetings
and specifically in House Meetings in March. The Assistant Facility Administrators
provided to the Auditor House Meeting Notes for both months and sign-in sheets for
residents for the initial meeting. Both Assistant Facility Administrators confirmed
completion of the PREA education refresher regarding the advocacy agency and the
available services. The focus on advocacy services will be more pronounced during
the initial PREA education and in follow-up sessions.
A MOU exists between the facility and the Betty Griffin Center Outreach Domestic
Abuse Treatment Center and services will be provided to the resident when
requested by a resident, facility staff, or law enforcement personnel. The availability
of services was confirmed by the interview with the advocacy agency
representative. Posted information includes the name of the advocacy agency and
contact information. The MOU provides the available services including but not
limited to emotional support, accompaniment, counseling and other advocacy
services. The advocacy information
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.
Policy, posted information, facility staff interviews, and the refresher PREA education
sessions provide that there will be adherence to confidentiality measures. The
facility has posted information that provide information about the advocacy agency
and contain information about the limitation of confidentiality; the information is
consistent. The posted information address privacy for the resident and general
confidentiality.
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 interviews with staff and the advocacy agency representative document the
provision 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. A MOU between the facility
and the advocacy agency exists. The interview with the advocacy agent also
confirmed the accessibility of advocacy services to the residents upon request.
Policy support confidentiality regarding victims of sexual abuse.
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 residents have reasonable and confidential access to attorneys and court
workers and reasonable access to their parents/legal guardians which is supported
by policy, interviews and the Youth and Parent Program Handbook. All residents
interviewed confirmed communication opportunities occur. The Superintendent
confirmed the facility provides residents with reasonable and confidential access to
attorneys, court representatives and Probation Officers. He also confirmed
reasonable access to parents/legal guardians and the private areas and general
visitation area were observed during the comprehensive site review.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility meets this standard.
115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Posted and other Printed PREA Materials
Website Information
Interviews:
Random Staff
Residents
Superintendent
Standard 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 to them 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 Department of Juvenile Justice
(DJJ)/Central Communications Center, call 911, and tell a supervisor and/or
administrator. The DJJ agency 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. Reporting information is also contained in the
Handbook. 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 to. 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. No third-party reports were received during this
audit period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is in compliance with this standard.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
State Statute-Chapter 39, Section 201, Mandatory reports of child abuse, et al.
Interviews:
Random Staff
Superintendent
Mental Health Staff
Medical Staff
Provision (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.
The State statute and policies support 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. Staff members are deemed as
mandated reporters by the State. Trained DJJ agency investigators conduct
administrative investigations and allegations that are criminal in nature are
investigated by trained law enforcement investigators. The facility and agency
policies provide guidance to staff on reporting allegations of sexual abuse and
sexual harassment and the duties of the first responder.
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.
Policies collectively address confidentiality of information and the conditions for
providing information. Once allegations have been appropriately reported, staff will
keep the information confidential regarding what was reported except when
necessary for the investigation and treatment and management decisions.
Additionally, staff receive training regarding confidentiality of resident information
which is a part of the new hire training plan.
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 clinical staff interviewed indicated 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 members are also mandated reporters and required by the
State to report allegations received regarding sexual abuse and sexual harassment,
in accordance with policy and State requirements.
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 to the investigative entities,
including the Department of Juvenile Justice (DJJ) Central Communications Center,
and parents/legal guardians. Policy and interview with the Superintendent confirmed
that a resident’s caseworker rather than a parent would be notified where indicated
by the resident being under the guardianship of the Florida Department of Children
and Families. The resident’s attorney would be notified of an allegation of sexual
abuse within 14 days, where applicable and in accordance with policy.
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 Office
of the Inspector General (OIG) through the Central Communications Center.
Administrative investigations are conducted by a DJJ/OIG Investigator. Sexual abuse
and sexual harassment allegations that are criminal in nature are referred for
investigation to law enforcement. Third-party and anonymous reports received must
be reported and documented by staff as confirmed through interviews. The
interviews confirmed all allegations are reported to the DJJ Central Communications
Center, Florida Department of Children and Families, and to law enforcement when
the allegation is criminal in nature.
Conclusion:
The review of evidence and interviews indicate the facility is in compliance with this
standard.
115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Grievance Form
Sick Call Request Form
Speak Out Form
Interviews:
Superintendent
Random Staff
Residents
Agency Head Designees
Provision (a):
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 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; one-
on-one supervision; and contacting administrators, supervisors and other staff.
The help request forms (Grievance, Sick Call Request, Speak Out) are displayed in
the living areas for residents to complete to gain assistance. The facility
environment encourages residents to complete a help request form, talk to a
trusted staff member, talk to a parent/guardian or other approved outside contact,
or make a report using the abuse reporting hotline regarding allegations of sexual
abuse and sexual harassment.
The expectation is that any action to protect a resident would be taken immediately
as deemed from interviews. During the intake process, residents are asked about
how they feel about their safety as part of the inquiries by staff completing the
primary sexual safety instrument, VSAB. No resident was identified to be at
substantial risk of imminent sexual abuse in the past 12 months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, 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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Superintendent
Contract Agency Head Designee
Provisions (a), (b), (c), (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.
Policies and interviews provide that when an allegation of sexual abuse is received
that a resident was sexually abused while confined at another facility, the
Superintendent will notify the head of the facility or appropriate office of the agency
where the alleged abuse occurred. The notification will be made as soon as possible
and within 72 hours and documented in accordance with policy.
The Superintendent is required to make a report to the Department of Juvenile
Justice, Central Communications Center. The interviews support that allegations of
sexual abuse or sexual harassment from a resident regarding their stay in another
facility will be reported and investigated as required, in accordance with policy. In
the past 12 months, there were no allegations reported of sexual abuse occurring at
another facility.
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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Coordinated Response Plan
Interviews:
Random Staff
Superintendent
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.
The interviews and review of the Coordinated Response Plan support the familiarity
with appropriate intervention. There were no allegations of sexual abuse in the last
12 months that required first responder intervention. Policy, training and practice
document that upon learning of an allegation that a resident was sexually abused
the general staff response basically includes but not be limited to the following:
a. Separate the victim and alleged abuser.
b. Preserve and protect the scene until appropriate steps can be taken to collect any
evidence.
c. Request that the alleged victim not take any actions that could destroy physical
evidence.
d. Take actions to ensure the alleged abuser does not take any actions that could
destroy physical evidence.
e. Ensure the safety of the victim.
f. Make the required notifications.
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 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 and interviews, the
Auditor determined the facility is compliant with this standard.
115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Coordinated Response Plan
Interviews:
Random Staff
Superintendent
Provision (a):
The facility shall develop a written institutional plan to coordinate actions taken in
response to an incident of sexual abuse among staff first responders, medical and
mental health practitioners, investigators, and facility leadership.
The Coordinated Response Plan outlines the steps to be implemented in the event
of an allegation or incident of sexual abuse. The Plan identify the actions that should
be taken by identified staff positions such as the first responder; supervisors;
medical; mental health; and management/leadership staff; and when to contact
such. Additionally, policy provides guidance to staff regarding the actions to take
when there is an alleged incident of sexual abuse. Staff members interviewed were
familiar with their role regarding the response to an allegation of sexual abuse.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with the standard.
Preservation of ability to protect residents from contact with
115.366
abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Interviews:
Superintendent
Contract Agency Head Designee
Provisions (a) and (b):
Provision(a): Neither the agency nor any other governmental entity responsible for
collective bargaining on the agency’s behalf shall enter into or renew any collective
bargaining agreement or other agreements that limits the agency’s ability to
remove alleged staff sexual abusers form contact with residents pending the
outcome of an investigation or of a determination of whether and to what extent
discipline is warranted. Provision (b): Nothing is this standard shall restrict the
entering into on renewal of agreements that govern:
(1) The conduct of the disciplinary process, at long as such agreements are not
inconsistent with the provisions of §115.372 and §115.376; or
(2) Whether a no-contact assignment that is imposed pending the outcome of an
investigation shall be expunged from or retained in the staff member’s personnel
file following a determination that the allegation of sexual abuse is not
substantiated.
The facility is not involved in any collective bargaining agreements.
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Superintendent
Retaliation Monitor
Agency Head Designees
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. A higher level staff member has been
charged with conducting and/or ensuring the occurrence of retaliation monitoring.
The retaliation monitor is familiar with the role of retaliation monitoring and its
purpose as also indicated by previous interviews with the agency head designees of
the State agency and contract agency. There has not been a case of retaliation
during the past 12 months.
Provision (b):
The agency shall employ multiple protection measures, such as housing changes or
transfers for resident victims or abusers, removal of alleged staff or resident
abusers from contact with victims, and emotional support services for residents or
staff that fear retaliation for reporting sexual abuse or sexual harassment or for
cooperating with investigations.
Protective measures were generally identified during the interview with the
retaliation monitor and Superintendent and were aligned with policy.
Implementation measures to protect residents from retaliation include but are not
limited to housing changes for resident victims or abusers; removing alleged staff or
resident from the facility, which may be temporary; closer monitoring; and change
in shift assignments. The retaliation monitoring will include follow-up checks with
the parties involved to ensure safe feelings and identify whether retaliation is
occurring. The interviews confirm measures are taken to detect and protect staff
and residents from retaliation.
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 and the interview with the retaliation monitor provide that the monitoring will
occur for at least 90 days to see if there are any changes that may suggest possible
retaliation is occurring. The monitoring period could last longer, according to the
retaliation monitor for up to a month beyond the 90 days and longer than that if
needed. The interviews collectively identified items that would be monitored to
assess retaliation and included interactions between the involved parties; review of
write-ups for staff and residents; point card discrepancies; and complaints by the
resident and/or staff.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
Policy and the interview with the retaliation monitor indicate that status checks
occur as a part of retaliation monitoring. The interview revealed that initial and
follow-up contact is made.
Provision (e):
If any other individual who cooperates with an investigation expresses a fear of
retaliation, the agency shall take appropriate measures to protect that individual
against retaliation.
Application of the policy is extended to those who cooperate with an investigation if
there is a concern regarding retaliation. The interview and policy indicate 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.
The obligation to monitor for retaliation terminates, if it is determined that the
allegation is determined Unfounded upon completion of an investigation. The
interviews determined familiarity with the requirements regarding retaliation
monitoring.
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
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Superintendent
Mental Health Staff
Medical Staff
The 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 is not used in the facility to protect residents who alleged to
have suffered sexual abuse. The interviews were aligned with this premise. No
segregated area was observed or identified during the comprehensive site review.
Conclusion:
Based upon the review 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:
Facility Policy 1.06, Incident Reporting
Agency Policy FDJJ 1919, PREA
Training Curriculum
PREA Compliance Form
Investigative Reports
Interviews:
Superintendent/PREA Compliance Manager
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.
The administrative investigations are conducted by the investigators with the
Department of Juvenile Justice (DJJ), Office of Inspector General (OIG). Based on
policies and other documentation and interviews, trained investigators conduct
administrative investigations as prescribed by policies. Allegations that are criminal
in nature are referred to local law enforcement and the Department of Children and
Families and all allegations are reported through the Central Communications
Center. Investigations are conducted thoroughly and objectively and the agency’s
policy provides for the training of investigators.
Provision (b) and (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 DJJ investigative staff is trained through the OIG. The DJJ Investigator will turn
over any evidence found to law enforcement investigators since they generally do
not handle direct evidence. The DJJ investigators, among other activities, may
review video, gather witness statements, and review logs during the administrative
investigation of an allegation. The law enforcement investigator and/or qualified
medical practitioner are responsible for collecting direct physical and DNA
evidence.
The facility staff and DJJ investigators are trained on how to assist in preserving
general evidence. The agency, DJJ, provides each facility with the PREA Form which
is provided to law enforcement investigators referencing the PREA standards
regarding conducting investigations in accordance with the standards. The DJJ
investigators follow the OIG guidelines governing PREA related investigations, in
accordance with agency policy.
There were three allegations of sexual abuse during this audit period. All allegations
were reported to the investigative entities: Department of Families and Children, DJJ
Central Communications Center, and law enforcement. All allegations received an
administrative investigation conducted by DJJ investigators. Criminal investigations
found no criminal violations or were closed as Information Only. There were one
staff-on-youth allegation that was closed as Unfounded and two youth-on-youth
allegations, with one determining the activity was consensual and closed as
Information Only.
Provision (d):
The agency shall not terminate an investigation solely because the source of the
allegation recants the allegation.
The interviews and review of documentation confirm that an investigation is not
terminated if the source recants an allegation of sexual abuse or sexual
harassment. This premise has also been confirmed by a previous interview with
investigative staff.
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 DJJ agency investigators do not conduct compelled interviews.
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 the previous interview of investigative staff and in accordance with
policy. Credibility may be influenced by past history; what can be verified; what
other evidence can corroborate the information; body language; and/or whether or
not the person is answering questions or being dismissive. 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.
Provisions (g) and (h):
Provision (g): Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act
contributed to the abuse.
(2) Shall be documented in written reports that include a description of the physical
and testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings.
Provision (h): Criminal investigations shall be documented in a written report that
contains a thorough description of physical, testimonial, and documentary evidence
and attaches copies of all documentary evidence where feasible.
The interviews support that PREA investigations include an effort to determine
whether staff actions or failures to act contributed to the abuse. Investigations in all
facilities are completed with written reports that include a description of the
evidence and investigative facts and findings as gleaned from the previous
interview with investigative staff. The report also contains information regarding the
initial reporting of the allegation; list of interviews; list of exhibits; logbook
information; critique of any video; and a host of other information as described by
the Chief of Investigations.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be referred for
prosecution.
The DJJ agency investigators do not conduct criminal investigations. It is the
responsibility of 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 written investigative reports are maintained for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years as stated in policy.
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.
The previous interview and review of documentation confirmed that upon the start
of an investigation, it 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 investigative agencies are aware of the PREA standards requirements through
the initial sharing of PREA information regarding completing investigations, PREA
Compliance Form, and subsequent interactions with investigators from the other
agencies.
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.
The policies and interviews indicate that staff cooperate with investigators and that
the agency/facility is kept informed of the progress of an investigation. The
Superintendent will maintain contact with the investigator from the applicable
investigative entity and will also be updated through the DJJ/OIG or the statewide
PREA Coordinator.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the
Auditor determined the facility is compliant with this standard.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document Reviewed:
Agency Policy FDJJ 1919, PREA
Provision (a):
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 Florida Department of Juvenile Justice/Office of Inspector General, responsible
for administrative investigations, imposes a standard of a preponderance of the
evidence for determining whether allegations are substantiated. Agency policy is
aligned with the standard.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the
facility is compliant with this standard.
115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Superintendent
Assistant Superintendent
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.
It is required that the resident be informed when a sexual abuse investigation is
completed and the outcome of the investigation provided to the resident who made
the allegation. The interviews revealed awareness of the requirement and provided
that the resident is informed by facility staff.
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 remains abreast of an investigation conducted by law
enforcement through contact with the agency through the provision of the assigned
case number and by the Department of Juvenile Justice (DJJ) Investigator or
statewide PREA Coordinator and will be provided results of investigations. The
results of the investigation will be provided to the resident by facility treatment
staff.
Provision (c):
Following a resident’s allegation that a staff member has committed sexual abuse
against the resident, the agency shall subsequently inform the resident (unless the
agency has determined that the allegation is unfounded) whenever:
(1) The staff member is no longer posted within the resident’s unit;
(2) The staff member is no longer employed at the facility;
(3) The agency learns that the staff member has been indicted on a charge related
to sexual abuse within the facility; or
(4) The agency learns that the staff member has been convicted on a charge related
to sexual abuse within the facility.
The administrators are familiar with policy requirements. Policy requires that
following a resident’s allegation that a staff member committed sexual abuse
against a 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 posted 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 in the
facility; and/or
d. The staff member has been convicted on a charge related to sexual abuse in the
facility.
The staff-on-youth allegation of sexual abuse was closed as Unfounded after the
completion of an administrative investigation by DJJ. The allegation was reported to
the three investigative entities. Law enforcement determined that no criminal
violations occurred and the Department of Children and Families did not accept the
allegation for investigations. The two youth-on-youth sexual abuse investigations
were reported to the three investigative entities and both were closed as
Information Only through an administrative investigation.
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 of being sexually abused by
another resident the alleged victim shall be informed whenever:
a. The alleged abuser is criminally charged related to the sexual abuse.
b. The alleged abuser is adjudicated on a charge related to sexual abuse within the
facility.
The Facility Administrator is familiar with the requirements of the Policy and the
Standard provisions.
Provision (e):
All such notifications or attempted notifications shall be documented.
Policy provides for the notification to the resident be documented. The
administrators are familiar with the requirements of policy and PREA requirements
however the notification was not specifically documented. There are clinical
progress notes of where youth making and/or involved in the allegations meet with
their Therapists. None of the residents involved in the sexual abuse allegations were
present in the facility during the onsite audit phase. One of the two youth-on-youth
allegations did not identify specific youth.
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 policy provides that the agency’s obligation to report under this
standard terminates if the resident is released from the agency’s custody. None of
the residents involved in the sexual abuse allegations were present in the facility
during the onsite audit phase. One of the two youth-on-youth allegations did not
identify specific youth.
Conclusion:
The interviews and review of policy and other documentation confirmed the facility
is compliant with this standard.
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Employee Handbook
Interview:
Superintendent
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for
violating agency sexual abuse or sexual harassment policies.
The policy and interview support that staff be subject to disciplinary sanctions up to
and including termination for violating facility sexual abuse and sexual harassment
policies.
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 with a resident. There was no staff member found to have violated
policy regarding sexual abuse or sexual harassment during this audit period.
Provision (c):
Disciplinary sanctions for violations of agency policies relating to sexual abuse or
sexual harassment 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.
Any staff with findings other than actually engaging in sexual abuse will be subject
to termination, and other measures appropriate to the circumstance of the incident
and the other components of the provision and remedial in-service if permitted to
return to work. Disciplinary sanctions for violations of policies relating to sexual
abuse or sexual harassment (other than engaging in sexual abuse) will be
commensurate with the act committed, the staff member’s disciplinary history, and
the similar history of other staff.
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 terminations for violations of the facility’s sexual abuse or
sexual harassment policies or resignations by staff that would have been terminated
if not for their resignation, will be reported to law enforcement, unless the activity is
clearly not criminal. In addition, such will be reported to relevant licensing bodies,
where applicable. Notification to a licensing body will occur where indicated.
Conclusion:
Based upon the review of 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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Training Curriculum
Interviews:
Volunteers (2)
Contractors (2)
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.
Policies provide for contractors and volunteers who engage in sexual abuse with a
resident to be reported to law enforcement and to relevant licensing bodies. The
interviews confirmed a clear understanding that sexual misconduct with a resident
is prohibited. Any contractor or volunteer who violates the agency’s sexual abuse or
sexual harassment policies is prohibited from contact with residents. During this
audit period, there have been no allegation of sexual abuse and no allegation of
sexual harassment regarding a contractor or volunteer. The volunteers provide
religious services and the contractors provide education services.
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 and interviews confirm the appropriate remedial measures will be taken and
include prohibiting further contact with residents and/or termination in the case of
any violation of the sexual abuse and sexual harassment policies by a contractor or
volunteer. In the past 12 months, no contractor or volunteer was reported for
allegations of sexual abuse or sexual harassment.
Conclusion:
Based upon the review of the documentation and interviews, 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:
Facility Policy 5-19. PREA
Agency Policy FDJJ 1919, PREA
Employee Handbook
Investigative Report
Interviews:
Superintendent
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.
An administrative process exists for dealing with violations and hold residents
accountable for their actions. Residents may be subject to disciplinary sanctions
only after formal proceedings regarding resident-on-resident sexual abuse, if they
remain in the program and not receive a new charge. 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 and may result in charges being filed and
the resident being removed from the facility.
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.
Disciplinary sanctions, applicable to the offense, are commensurate with the nature
and circumstances of the offense committed; considers resident’s disciplinary
history; considers similar disciplinary history of other residents. The interview with
the Superintendent and review of policy support there will be consideration of
mental disabilities or mental illness contributing to the behavior. PREA related
violations may result in charges filed and the resident transported to a detention
facility 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 as a disciplinary sanction.
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.
Disciplinary and other processes consider whether a resident’s mental disabilities or
mental illness contributed to a resident’s behavior regarding the application of
disciplinary measures.
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.
According to the mental health staff interview, consideration would be given
regarding offering a perpetrator intervention services that are designed to address
and correct underlying reasons or motivations for abuse participation. The facility
would not require participation in such interventions as a condition for participation
in the behavior management system or to access general programming or
education. Staff members within the mental health unit are equipped to address
past trauma and make referrals upon discharge to address underlying reasons or
motivations for abuse with alleged victims and offending residents. Psychiatric and
psychological services are also provided onsite for the residents.
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 that a resident may be disciplined for sexual contact with staff only
upon a 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.
Any resident reporting in good faith shall be immune from any civil or criminal
liability. 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.
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 that is not
coerced is subject to disciplinary action as a rule violation. Referrals are made to the
investigative entities and court processes occur after determination the sexual
activity was coerced.
Conclusion:
Based on the available evidence and interviews, the Auditor concluded the facility is
compliant with the standard.
115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior (VSAB)
Referral Form
Interviews:
Medical Staff
Mental Health Staff
Staff Responsible for Risk Screening
Provision (a) and (b):
Provision (a): If the screening pursuant to §115.341 indicates that a resident has
experienced prior sexual victimization, whether it occurred in an institutional setting
or in the community, 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.
Policies and practice provide that a resident be referred to mental health or medical
staff within 14 days if identified as having been a victim or perpetrator of sexual
abuse. The interviews with clinical staff revealed that the issues are identified and
addressed. 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 and follow-
up is provided immediately. The youth is seen on the next business day if for some
reason he is not seen on the day of admission.
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.
Information related to sexual victimization or abusiveness that occurred in an
institutional setting is limited to clinical and treatment staff and to other staff, based
on their need to know, to make effective management decisions. During the onsite
review, the files were observed to be maintained in a secure manner behind lock
and key and records maintained electronically are password protected with limited
access.
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. The medical and mental
health practitioners are aware of informed consent.
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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Mental Health Staff
Medical Staff
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 policies including that the nature and scope of
their services are determined according to their professional judgment. Residents
are informed of clinical services and meet with those practitioners and are provided
services during the intake process and throughout their stay in the facility. The
allegations of sexual abuse did not require a forensic medical examination or mental
health services.
An alleged victim will get services within the facility as well as timely services in the
community. An alleged victim will be transported to the local hospital for a forensic
medical examination that will be conducted by a qualified medical practitioner. The
examination will be performed at no cost to the victim, in accordance with policy, in
response to an allegation of sexual abuse. Observations revealed that medical and
mental health staff members maintain secondary materials and documentation of
encounters with residents at the facility.
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.
Interviews confirm that residents have access to unimpeded access to emergency
services. Policies 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 documentation; observations of the interactions among residents and staff
during the onsite audit phase; and the interviews indicated unimpeded medical and
crisis intervention services are available to an alleged victim of sexual abuse. Staff
training also prepare staff members to properly report sexual abuse, protect the
alleged victim and notify the appropriate staff and investigative entities.
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 may be
provided by the facility’s medical and mental health staff members to provide
support services coordinated by staff as needed, including but not limited to follow-
up by the medical doctor and assistance in helping to process what happened.. The
standard of care within the facility ensures the appropriate medical and mental
health follow-up 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.
The interviews and policies provide that treatment services will be provided to the
victim without financial cost to the victim regardless of whether the victim names
the abuser, or cooperate with any investigation arising out of the incident.
Conclusion:
Based on the evidence reviewed and interviews, the Auditor determined the facility
is compliant with this standard.
Ongoing medical and mental health care for sexual abuse victims
115.383
and abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Interviews:
Medical Staff
Mental Health Staff
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.
Policies and interviews support that medical and mental health evaluation and
treatment will be offered to resident victims of sexual abuse. Follow-up services will
be provided that include but are not limited to trauma and nursing assessments,
counseling services; identify triggers; and medical services as needed.
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
contract and referral services. Medical staff will ensure the medical discharge orders
are followed.
Provision (c):
The facility shall provide such victims with medical and mental health services
consistent with the community level of care.
Review of policies, interviews and observations during the site review indicated
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 and observations during the site review emphasized 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.
The is an all male facility.
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.
The facility has a male population.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for
sexually transmitted infections as medically appropriate.
The interviews and policies ensure that victims of sexual abuse will be provided
tests for sexually transmitted infections as medically appropriate as confirmed by
the clinical staff members. There have been no allegations of sexual abuse during
this audit period. The medical staff in the facility may also conduct tests for sexually
transmitted infections.
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 and whether or not
the victim names the abuser of cooperates with the investigation, supported by
policy and 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.
A resident will get a mental health evaluation immediately upon staff learning of
resident-on-resident abuse history and offer appropriate treatment. Policy does
provide for the mental health evaluation to be conducted within 60 days.
Additionally, medical and mental health evaluations and addressing trauma will be
offered to resident victims of sexual abuse.
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:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, 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. There were three
allegations of sexual abuse that received administrative investigations. The
investigations determined two were closed as Information Only with one being a
rule violation rather than PREA related; the other investigation was closed as
Unfounded.
The interviews reflected an understanding of the role of the incident review team. A
review of policies and interviews confirmed incident reviews will be conducted at
the conclusion of an investigation of an allegation of sexual abuse, unless
determined to be unfounded. The interviews confirm this premise and the DJJ
statewide PREA Coordinator serves as the facilitator of the PREA incident review
team meetings.
Provision (b):
Such review shall ordinarily occur within 30 days of the conclusion of the
investigation.
Policy requires that the review occurs within 30 days of the conclusion of the
investigation. The interviews and incident review team meeting minutes confirm
incident reviews occur within the stated time period. The interviews revealed
knowledge of the purpose of the incident review process. One of the three
allegations met the criteria for an incident review team meeting to be held and the
meeting was conducted within the 30-day period.
Provision (c):
The incident review team shall include upper-level management officials, with input
from line supervisors, investigators, and medical or mental health practitioners.
Policy and interview with Superintendent collectively identify members of the
incident review team to include upper-level management, Department of Juvenile
Justice (DJJ) district staff, input from line supervisors, mental health and medical
practitioners, and investigator if needed. The DJJ statewide PREA Coordinator
facilitates the incident review team meetings.
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 and interviews collectively outline 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 process is documented and is facilitated by the DJJ statewide PREA
Coordinator. The meeting minutes for an incident review team meeting are recorded
by the DJJ statewide PREA Coordinator and the written report also includes any
recommendations for improvement. Based on statewide practice, the minutes from
an incident review team meeting will be documented and consideration will be
given in accordance with this provision of the Standard.
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 requirements. 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 the DJJ
statewide PREA Coordinator and include recommendations where indicated. There
were no recommendations made during the incident review team meeting during
this audit period.
Conclusion:
Based upon the review of policy and other documentation and interviews, the
Auditor determined the facility is compliant with this standard.
115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Facility Policy 5-19, PREA
Agency Policy FDJJ 1919, PREA
Agency Policy FDJJ 2020, Incident Operations Center and Management Reviews
Agency Incident Report Logs
Interviews:
Superintendent
Provisions (a) & (c):
Provision (a): 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. Provision (c): 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.
Policies provide for the collection of accurate and uniform data for every allegation
of sexual abuse from incident-based documents. The agency collects the data and
completes an annual report with the compilation of data gleaned from the facilities
through the central reporting system of the Department of Juvenile Justice, Central
Communications Center. 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 conducted by the
Department of Justice.
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 collected from State-run detention centers and
contract residential facilities, including Deep Creek Youth Academy. The aggregated
data contributes to the development of the annual reports for the agency which is
supported by the reviewed data and policy.
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 data is collected and various types of data are identified and related documents
regarding PREA information as applicable. Policy requires that statistical information
is maintained for various service areas and occurrences, including major incidents
and medical and mental health emergencies. The agency collects and maintains
data for state-run and contract facilities and aggregates the data which culminates
into the agency’s annual report.
Provision (e):
The agency also shall obtain incident-based and aggregated data from every private
facility with which it contracts for the confinement of its residents.
The agency collects and maintains data for state-run and contract facilities and
aggregates the data which culminates into the annual report. The data is collected
from the contract facilities and is included in the agency’s annual reports. The data
is aggregated at the agency’s central office level.
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 to the Department of Justice in a timely manner based on the year of
the most recent version of the Survey of Sexual Victimization. A request has not yet
been made.
Conclusion:
Based upon the review and analysis of the documentation and the interviews, 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, PREA
Annual Reports, PREA
Interview:
Statewide PREA Coordinator
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 this agency as a whole.
The interview with the statewide PREA Coordinator and previous interview with the
Agency Head Designee support the review of data and its use to improve the
agency’s PREA efforts and initiatives. The interviews and review of documentation
revealed the collection of various types of data, including PREA related information.
Data is reviewed to assess and improve the effectiveness of prevention, detection
and response within the agency as well as individual facilities. The data is also
primary to preparing annual reports.
Provisions (b), (c), (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 Department of Juvenile Justice statewide PREA
Coordinator for the agency and includes data from all state-run and contract
facilities within the agency. The annual reports are approved by the DJJ agency
head/designee. There are no personal identifiers in the report. The annual report
contains PREA related data that represents previous calendar years allowing for the
comparison of data. The overarching annual report for the agency is posted on the
agency’s website, accessible to the public.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the agency is compliant with this standard.
115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents Reviewed:
Agency Policy FDJJ 1316, Records and Information Management Procedures
Agency Policy FDJJ 1919, PREA
Agency Annual Report
Interviews:
Statewide PREA Coordinator
Contract Agency PREA Coordinator
Provision (a), (b), (c), (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.
The 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 behind locked doors with key control and electronic records are
password protected with limited and identified staff access. The interviews support
the premise and policies.
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
The PREA Pre-Audit Questionnaire and supporting documentation was uploaded in
the online audit system. The Auditor was provided additional information by email
and onsite, as requested. The Department of Juvenile Justice ensured the
completion of PREA audits for each state-run and contract facility as required,
including this facility.
During the site review, all areas of the facility were included. The areas containing
posted information were observed. The Facility Administrator and Assistant Facility
Administrators were cooperative in providing information and participating in or
assisting in coordinating the interviews. All interviews were conducted in private.
The PREA notices provided the general information and included instructions and
Auditor contact information regarding how to provide confidential information to the
Auditor. The facility has a process in place for confidential correspondence for the
residents however no correspondence was received by the Auditor from residents or
staff.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Annual Reports
Interview:
Superintendent
Provision (f):
The agency shall ensure that the auditor’s final report is published on the agency’s
website if it has one, or is otherwise made readily available to the public.
The posted PREA audit reports do not contain any personal identifying information
other than names and job titles as requested as a part of the report. The facility and
agency policies and additional documentation, practices and interviews with the
Facility Administrator, Assistant Facility Administrator and other staff were reviewed
regarding compliance with the standards and have been identified in the reports.
The interview with the Facility Administrator and communication with the statewide
PREA Coordinator confirm the final PREA audit reports are posted on the agency's
website. The audit findings were based on a review of policies, procedures,
supporting documentation, observations, and interviews. There were no conflicts of
interest regarding the completion of this audit.
Conclusion:
Based on the documentation, interviews and observations, the Auditor found the
facility in compliance with this Standard.
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, yes
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 yes
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 yes
juvenile sexual abuse victims? (N/A if the agency does not conduct
any form of administrative or criminal sexual abuse investigations.
See 115.321(a).)
Does this specialized training include: Proper use of Miranda and yes
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 yes
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 yes
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 yes
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 yes
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 no
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” no
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 yes
ensure that at least two-thirds of each facility type operated by
the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle?
(N/A if this is not the third year of the current audit cycle.)
115.401
Frequency and scope of audits
(h)
Did the auditor have access to, and the ability to observe, all yes
areas of the audited facility?
115.401
Frequency and scope of audits
(i)
Was the auditor permitted to request and receive copies of any yes
relevant documents (including electronically stored information)?
115.401
Frequency and scope of audits
(m)
Was the auditor permitted to conduct private interviews with yes
inmates, residents, and detainees?
115.401
Frequency and scope of audits
(n)
Were inmates, residents, and detainees permitted to send yes
confidential information or correspondence to the auditor in the
same manner as if they were communicating with legal counsel?
115.403
Audit contents and findings
(f)
The agency has published on its agency website, if it has one, or yes
has otherwise made publicly available, all Final Audit Reports. The
review period is for prior audits completed during the past three
years PRECEDING THIS AUDIT. The pendency of any agency
appeal pursuant to 28 C.F.R. § 115.405 does not excuse
noncompliance with this provision. (N/A if there have been no Final
Audit Reports issued in the past three years, or, in the case of
single facility agencies, there has never been a Final Audit Report
issued.)

report_type: PREA

pdf_url: https://www.djj.state.fl.us/content/download/1176779/file/Florida_Deep Creek Youth Academy_Year2Cycle4.pdf?version=1

program_name_raw: Deep Creek Youth Academy

cycle: Year 2 Cycle 4