state: FL

facility_name: challenge juvenile residential facility

summary: PREA

raw_content:
REA AUDIT: AUDITOR’S SUMMARY REPORT
JUVENILE FACILITIES
Name of Facility: Eckerd Youth Challenge Program
Physical Address: 201 Culbreath Road, Brooksville, FL 34609
Date report submitted: May 10, 2015
Auditor information: Shirley L. Turner
Address: 3199 Kings Bay Circle, Decatur, GA 30034
Email: shirleyturner3199@comcast.net
Telephone number: 678-895-2829
Date of facility visit: April 13-14, 2015
Facility Information
Facility Mailing Address: 201 Culbreath Road, Brooksville, FL 34609
Telephone Number: (352) 799-5621
The Facility is: Military County Federal
Private for profit Municipal State
X Private not for profit
Facility Type: Detention Correction X Other: Residential
Name of PREA Compliance Manager: J. Patrick Girdner Title: Senior Director
Email Address: pgirdner@eckerd.org Telephone Number:
(727) 482-7513
Agency Information
Name of Agency: Eckerd, Inc.
Governing Authority or Parent Agency: NA
Physical Address of Agency: 100 N. Starcrest Dr., Clearwater, FL 33765
Mailing Address: Same as Above
Telephone Number: (727) 461-1236
Agency Chief Executive Officer
Name: David Dennis Title: Chief Executive Officer
Telephone (727) 461-2990
Email Address: ddennis@eckerd.org
Number:
Agency Wide PREA Coordinator
Name: Elaine Woods Title: Director of Quality
Email Address: ewoods@eckerd.org Telephone Number: ( 7 2 7 ) 4 2 4 - 3 6 0 1
AUDIT FINDINGS
NARRATIVE:
The Eckerd Youth Challenge Program, located in Brooksville, Florida, is a 60-bed residential facility
that houses low and moderate risk male juvenile offenders in the age range of 14-19. The facility is
operated by Eckerd, Incorporated through a contract with the Florida Department of Juvenile Justice
(FDJJ). Program services include Mental Health Overlay Services and Substance Abuse Overlay
Services; the average length of stay is seven months. At least 103 residents have been admitted to the
facility in the past 12 months. The average length of stay is seven months.
On-site medical services are provided by a full-time Registered Nurse; part-time Licensed Practical
Nurse; and a contract physician who visits the facility once a week. Mental health services are
provided on-site under the supervision of the Clinical Services Coordinator with the unit consisting of
Therapists, Case Managers, and a Program Specialist. The contract psychiatrist visits the facility
twice a month. The facility offers education and vocational services on-site, where credits may be
earned at the end of each semester for the course work completed within the school program. Direct
care staff provides direct supervision to residents as they move to and engage in activities throughout
the program.
Parents and legal guardians are encouraged to be involved in the resident’s treatment plan.
Additionally, contact between the parents/legal guardians and the residents is encouraged and
facilitated through letter writing; program visits; support groups; phone calls; teleconferences for
treatment meetings when parents cannot attend on-site; and home visits. Family workshops are
conducted at the facility each month where the resident and parent participate in the training together.
After the workshop, each parent may have lunch on-site with their child.
DESCRIPTION OF FACILITY CHARACTERISTICS:
The program is located on vast acreage in a wooded area consisting of 13 buildings. The
administration building contains the entrance foyer and front desk; administrative offices; conference
room; medical clinic area; kitchen; and a large dining area. There are six dormitories that house 10
residents each. The dormitories have bathrooms that provide residents a reasonable amount of
privacy while they shower, change clothes and perform bodily functions. Each dormitory also has a
laundry room. Attractive murals accentuate the walls in the dormitories and each one has a telephone
and access for emergency telephone calls. There are four education buildings that contain a total of
seven classrooms, including a computer lab.
There is ample space on the outside grounds for the storage buildings and the grounds can
accommodate an array of recreation and other activities. Included on the grounds are a volleyball
court, basketball court, four separate playing fields, and a gazebo. Reportedly, the program utilizes
50-60 acres of the property. At least 55 employees, who may have contact with residents, are
employed at the facility.
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SUMMARY OF AUDIT FINDINGS:
An initial conference call was held with facility staff, FDJJ PREA Coordinator and the Auditor to
review the on-site audit process and data gathering. The notifications of the on-site audit were
posted in various parts of the facility at least six weeks prior to the site visit. Photographs were taken
of the various sites where the notices had been posted and the photographs were electronically sent
to the Auditor, noting their locations. The Pre-Audit Questionnaire and the supporting
documentation were uploaded to a flash drive, which was received approximately four weeks prior
to the on-site audit. After reviewing the information on the flash drive, follow-up conversations
were held with facility staff. Additional information was provided or clarified as requested. The
Senior Director serves as the PREA Compliance Manager.
The on-site audit was conducted April 13-14, 2015. An entrance meeting was held with the Senior
Director, Program Director, and Education Administrator. After the meeting a comprehensive tour
of the facility was conducted by the Senior Director and the Program Director. During the tour, staff
members were observed to be directly supervising the residents. There were two staff from the
corporate office present at the facility on the first day of the audit, including the Director of Quality
who also serves as the PREA Coordinator for the agency. Random staff, specialized staff and
residents were interviewed during the on-site audit process. While on-site, additional information
was provided as needed and in a prompt manner. A close-out meeting was held at the conclusion of
the audit and a summary of the audit findings was provided.
Number of Standards Exceeded: 0
Number of Standards Met: 37
Number of Standards Not Met: 0
Number of Standards Not Applicable: 4
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Standard 115.311 Zero Tolerance of Sexual Abuse and Sexual Harassment.
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
The facility has a primary Policy, 6.0, and supporting policies that provide guidelines for
implementing the agency’s approach to complying with the requirements of the PREA
standards. Policy 6.0 provides a zero-tolerance approach toward all forms of sexual abuse and
sexual harassment. The Policy contains definitions of the prohibited behaviors and addresses
sanctions for those who participate in such behaviors. The Florida Department of Juvenile
Justice Policy 1919 (FDJJ 1919) is also used and adhered to in complying with the PREA
standards.
Standard 115.312 Contract With Other Entities for the Confinement of Residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
The facility does not contract with other facilities for the confinement of their residents.
Standard 115.313 Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 provides for a staffing plan to protect residents against sexual abuse. The
documented staffing plan ratios are aligned with the current program contract which will be
reviewed in October 2015. The facility reported no deviations from the current staffing plan
in the past 12 months. The annual assessment of the staffing plan and other areas has been
conducted to determine whether adjustments are needed in accordance with the standard. A
review of the staffing has been documented through the completion of the Staffing Plan
Assessment form.
Unannounced rounds for the maintenance of a safe environment are conducted and
documented by appropriate staff. Interviews and a review of documentation confirmed the
practice of unannounced rounds. Policy 6.0 prohibits staff from alerting other staff that the
unannounced rounds are occurring and that sanctions shall be applied if this occurs.
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Standard 115.315 Limits to Cross Gender Viewing and Searches
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 5.05-5.06, 6.0 and the Training Guide address this standard. Policy 6.0 prohibits
cross gender pat-down and strip searches, except in exigent circumstances; there have been
no cross gender searches during this audit period. Policy 6.0 and FDJJ 1919 have been
implemented that provide for residents to shower, perform bodily functions, and change
clothing without being observed by non-medical opposite gender staff. Interviews with staff
and residents confirm the practices. Policy 6.0 states that staff shall not search a transgender
or intersex resident to determine the resident’s genital status.
Standard 115.316 Residents with Disabilities and Residents Who are Limited English Proficient
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 addresses that support will be provided to residents with disabilities and residents
who are limited English proficient so that they may benefit from and participate in PREA
education. Resident education materials are available in dominant languages other than
English and the facility has access to interpreters through Language Line Services. Support
and resources are also available through the education unit.
Policy 6.0 ensures that the facility will not rely on resident interpreters or resident readers. A
review of documentation and staff interviews confirmed that outside resources would be
used to assist residents. The facility has a form, PREA Communication for Youth with
Disabilities or Limited English Proficiency, which will be used to document the resident’s
required accommodations and note the accommodations that were provided.
Standard 115.317 Hiring and Promotion Decisions
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 address this standard and provides for background checks on all
employees and contractors through a process that is aligned with the standard and is a
statewide requirement of FDJJ. Prior to the hiring of an employee or contractor, background
checks are conducted.
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Standard 115.318 Upgrades to Facilities and Technology
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable; the facility does not have a camera monitoring system.
Standard 115.321 Evidence Protocol and Forensic Medical Examinations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 address this standard and in addition to the other requirements,
state that forensic medical examinations will be completed at no financial cost to the victim.
Additionally, the Policies direct staff to cooperate with investigations. The facility has a
Memorandum of Understanding (MOU) with the Dawn House of Hernando County which
provides victim advocacy services that include but are not limited to accompaniment to
forensic examinations, counseling, crisis hotline, and training for staff and residents. There
have been no forensic examinations conducted during this audit period.
E-mail correspondence exist showing that the Hernando County Sheriff’s Department has
received from the facility the guidelines regarding PREA related investigations. The
representative from the Sheriff’s Department confirms their knowledge of the procedures.
Standard 115.322 Policies to Ensure Referrals of Allegations for Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0, FDJJ 1919 and staff interviews provide for staff reporting all allegations of
sexual abuse and sexual harassment. The appropriate investigative entity will be contacted
regarding allegations of sexual abuse or sexual harassment. There has not been an allegation
reported during this audit period. The abuse hotline number is on the agency’s web page for
the facility. The FDJJ website contains information regarding the referral of allegations for
investigations of sexual abuse. The facility posts related information in areas accessible to
the public.
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Standard 115.331 Employee Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 provide for the PREA training of all staff. The facility staff
received the FDJJ training and in-house training in the key areas referenced in the standard.
Documentation of staff participating in training is maintained and staff interviews reflected
that PREA training has occurred.
Standard 115.332 Volunteer and Contractor Training
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 contain information regarding the training of volunteers and
contractors who have contact with residents. Receipt of the training is documented and it
contains a review of the agency’s zero-tolerance policy.
Standard 115.333 Resident Education
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Resident education is addressed in Policies 1.03-1.04 and 6.0. Documentation and interviews
with residents and staff confirmed that residents participate in PREA education sessions.
Documentation of a residents’ participation in these sessions is maintained on an Orientation
Checklist. Through reviewed resources, interviews and based on Policy 6.0, the facility will
provide support services in accessible formats for residents who are limited English
proficient; deaf; visually impaired; or otherwise disabled.
Standard 115.334 Specialized Training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
FDJJ 1919 provides that investigators are trained on the related policies and procedures regarding
the handling of sexual misconduct incidents and reports. Training is provided to investigative staff
regarding conducting investigations in the FDJJ settings.
Standard 115.335 Specialized Training: Medical and Mental Health Care
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 address PREA training for medical and mental health staff. A
review of documentation and staff interviews confirmed their training. The full-time
Registered Nurse has also received additional training in Evidence Collection and
Preservation in a Healthcare Setting through a continuing education course. The facility
nurses do not conduct forensic medical examinations.
Standard 115.341 Screening for Risk of Victimization and Abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 6.0 and 3.04 address this standard. A review of documentation and staff and resident
interviews confirmed that screening for risk of sexual abuse victimization or sexual
abusiveness toward other residents is being conducted on each resident. The initial screening
is done during the intake process and Policy 3.04 provides guidance for reassessments to be
conducted.
Standard 115.342 Use of Screening Information
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 prohibits placing gay, bisexual, transgender, or intersex residents into
confinement based solely on such identification or status. The Policy provides that housing
and program assignments require determinations on each transgender or intersex resident on
a case by case basis. Additionally, the facility prohibits considering gay, bisexual,
transgender, or intersex identification or status as an indicator of likelihood of being sexually
abusive.
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An Initial Risk/Crisis Assessment Plan is also completed on each resident, considering
numerous factors including the score from the screening instrument used to determine the
risk of sexual abuse victimization or sexual abusiveness toward other residents. Isolation is
not used at this facility.
Standard 115.351 Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 6.0 and staff and resident interviews, there are internal ways a resident
may report allegations of sexual abuse; sexual harassment; retaliation for reporting; and staff
neglect or other violations that lead to abuse. A resident may complete a grievance form;
complete a Youth Communication Request form where a resident seeks to talk to specific
staff; talk to any staff member; and third parties may report allegations.
PREA related information is posted in each dormitory and in other areas of the facility.
Residents are provided access to a telephone in each dormitory to report allegations of sexual
abuse and sexual harassment. The abuse hotline number is also accessible from any office
phone in the administration building. Interviews revealed that staff members are aware of
their responsibility to report sexual abuse and sexual harassment. They are also aware that
they are to accept reports of sexual abuse and sexual harassment made verbally, in writing,
anonymously, and from third parties in accordance with Policies 6.0 and FDJJ 1919.
Standard 115.352 Exhaustion of Administrative Remedies
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 6.0 and 2.27-2.29 address the grievance process and information is provided to the
residents in the Student Handbook. Residents may put a completed grievance form in the
locked grievance box. Residents are not required to attempt resolution to a grievance
alleging sexual abuse or sexual harassment. The facility reports that there have been no
grievances submitted relating to sexual abuse or sexual harassment during this audit period.
Reporting procedures will be implemented when a grievance is received alleging sexual
abuse or sexual harassment.
Standard 115.353 Resident Access to Outside Confidential Support Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
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Auditor Comments:
Policy 6.0 requires the facility to provide the residents with access to outside victim advocacy
services. The documented MOU provides for services that will be delivered by the Dawn
Center of Hernando County, a rape crisis center. A telephone conversation with the Executive
Director confirmed that victim services will be provided to the facility when requested and
that no services have been requested.
Residents are allowed to see their parents at visitation on the weekends and they are also
allowed to make weekly phone calls. An additional phone call may be earned through the
behavior management system. Attorneys or other legal representation may visit the facility
and may visit in a confidential manner.
Standard 115.354 Third-Party Reporting
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 addresses third-party reporting. The DJJ website provides the public with
information regarding third-party reporting of abuse. Parents receive information about
reporting incidents of sexual abuse through information posted in the facility, accessible to
the public. The facility’s agency website has the abuse reporting hotline number posted.
Staff and resident interviews supported that allegations may be received by third parties.
Standard 115.361 Staff and Agency Reporting Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 addresses this standard. Staff members are to immediately report any knowledge,
suspicion or information they receive regarding sexual abuse or sexual harassment;
retaliation against residents or staff who report any incidents; or any staff neglect or violation
of responsibilities that may have contributed to an incident or retaliation. Staff interviews
supported the Policy.
Standard 115.362 Agency Protection Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 addresses this standard and provides that when the facility staff learns that a
resident is subject to substantial risk of imminent sexual abuse, it takes immediate action to
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protect the resident. Staff interviews supported the Policy. There have been no incidents
during this audit period where the facility took any action in regards to a resident being in
substantial risk of imminent sexual abuse.
Standard 115.363 Reporting to Other Confinement Facilities
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
According to Policy 6.0 and interview, upon receiving an allegation that a resident was
sexually abused while confined in another facility, the Senior Director or his designee will
notify the head of the facility where the alleged incident occurred within 72 hours. The
Senior Director /designee will also contact the appropriate investigative agency, according to
facility and FDJJ policies.
Standard 115.364 Staff First Responder Duties
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 addresses the first responder duties and provides an account of duties and
responses. There has not been an allegation by a resident regarding sexual abuse during this
audit period. Staff interviews reflected staff members’ knowledge of the first responder
duties.
Standard 115.365 Coordinated Response
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
A review of the coordinated response plan and interviews with staff confirmed knowledge of
the protocols. The plan coordinates the actions to be taken among staff including first
responders, leadership, and medical and mental health staffs in response to an incident of
sexual abuse.
Standard 115.366 Preservation of Ability to Protect Residents from Contact with Abusers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
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Auditor Comments:
This standard is not applicable; the facility does not maintain any collective bargaining
agreements.
Standard 115.367 Agency Protection Against Retaliation
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 addresses protection against retaliation for residents and staff who report
allegations of sexual abuse or sexual harassment. The Senior Director has been identified as
the staff member designated with monitoring for possible retaliation. If the conduct is
identified the Policy and interview state that the monitoring is for 90 days and longer if
needed.
Standard 115.368 Post Allegation Protective Custody
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
X Standard Not Applicable
Auditor Comments:
This standard is not applicable; isolation is not used at this facility.
Standard 115.371 Criminal and Administrative Agency Investigations
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 address this standard. Administrative investigations are conducted
by the FDJJ Office of Inspector General (OIG) and criminal investigations are conducted
by the Department of Children and Families and local law enforcement. Both Policies direct
facility staff to cooperate with the investigations. An investigation is not terminated solely
because the source of the investigation recants the allegation and substantiated allegations of
conduct that appear to be criminal are referred for prosecution.
Standard 115.372 Evidentiary Standards for Administrative Investigations
Exceeds Standard (substantially exceeds requirement of standard)
12
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy FDJJ 1919 supports that a standard of the preponderance of the evidence is used for
determining if allegations are substantiated.
Standard 115.373 Reporting to Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 provide the process for and the details of notifying the victim or
victim’s parents/legal guardians following the conclusion of an investigation. Notification
includes whether an allegation has been determined to be substantiated, unsubstantiated, or
unfounded. All such notifications are required to be documented.
Standard 115.376 Disciplinary Sanctions for Staff
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 provide for disciplinary sanctions for staff to be up to and
including termination for violation of the sexual abuse and sexual harassment policies. The
policies require that the violation be reported to local law enforcement, unless the activity
was clearly not criminal, and provides for contacting relevant licensing bodies. In the past 12
months, no staff has been terminated or has resigned for violating PREA related policies.
Standard 115.377 Corrective Action for Contractors and Volunteers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 provide that the incident will be reported as required. The policies
inform that measures are taken to prohibit future contact with residents in the case of any
violation of the facility’s PREA related policies by contractors or volunteers. During the past
12 months, no contractor or volunteer has been reported to law enforcement or any
investigative entity for allegations of sexual abuse.
13
Standard 115.378 Disciplinary Sanctions for Residents
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 provides that any resident found in violation of the facility’s zero- tolerance policy
against sexual abuse may be subject to disciplinary action, following an administrative
finding of resident-on-resident sexual abuse. Policy 6.0 further states 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. During the past 12 months there have been no incidents of sexual
abuse.
Standard 115.381 Medical and Mental Health Screenings; History of Sexual Abuse
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policies 3.04 and 4.02 address this standard. Residents who disclose a history of sexual
abuse or who disclose previously perpetrating sexual abuse will be offered a follow-up
meeting with a medical or mental health practitioner within 14 days of the intake screening.
Staff interviewed confirmed knowledge and practice of the Policies and the requirements of
the standard. The referral summary is documented and a form, PREA Tracking Log, is
maintained that also documents the occurrence of follow-up meetings.
Standard 115.382 Access to Emergency Medical and Mental Health Services
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 and FDJJ 1919 provide that timely access to emergency medical treatment and
crisis intervention services for victims of sexual abuse will be provided. The nature and
scope of the services are determined by medical and mental health practitioners according to
their professional judgment.
Standard 115.383 Ongoing Medical and Mental Health Care for Sexual Abuse Victims and
Abusers
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
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Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 provides for ongoing medical and mental health care for sexual abuse victims. It
also provides for medical and mental health evaluations and appropriate treatment in
accordance with the standard. According to staff interviews and a review of documentation,
health services are consistent with the community level of care.
Standard 115.386 Sexual Abuse Incident Reviews
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
Policy 6.0 will serve as the guide for staff in conducting sexual abuse incident reviews. The
incident review team has been identified in the Policy. Staff interviews indicated that the role
of the incident review team is understood. The PREA Sexual Abuse Incident Review form
will be used to document the proceedings.
Standard 115.387 Data Collection
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 requires the collection of accurate, uniform data for every allegation of sexual
assault. The FDJJ has developed a data collection instrument that includes the required data.
Standard 115.388 Data Review for Corrective Action
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 requires the review of data for corrective action towards improving the
effectiveness of the agencies’ prevention, protection and response policies, practices, and
training regarding PREA.
Standard 115.389 Data Storage, Publication and Destruction
Exceeds Standard (substantially exceeds requirement of standard)
X Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
15
Does Not Meet Standard (requires corrective action)
Auditor Comments:
FDJJ 1919 requires that data is collected and securely retained for 10 years. The aggregated
PREA data is reviewed and all personal identifiers are removed.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of her knowledge and no
conflict of interest exists with respect to her ability to conduct an audit of the agency under review.
May 10, 2015
Auditor Signature Date
16

source: DJJ

program_name_raw: challenge juvenile residential facility