summary: SPEP - FY22-23

raw_content:
Standardized Program Evaluation
Protocol [SPEP] Report
Youth Environmental Services
AMIkids, Inc
(Contract Provider)
4337 Saffold Road
Wimauma, Florida 33598
Primary Service: Aggression Replacement Training
SPEP Review Period: 11/01/21-10/31/22
SPEP Review Conducted: 11/01/22
Florida Department of Juvenile Justice
Report Date: 2/2/23
Introduction
The Standardized Program Evaluation Protocol (SPEP) is data-driven rating system for
evaluating program effectiveness. The SPEP was developed by relying on hundreds of studies
that have examined key characteristics of programs that demonstrated their ability to reduce
recidivism. To determine a SPEP score, the program’s services are compared to characteristics
of effective programs in the research of a similar type.
The SPEP score is composed of four principle characteristics that have been shown to predict
reductions in youth recidivism; service type, quality of service, dosage (amount of service), and
youth level of risk.
• Service Type: service type points are awarded based on the group category that the
service falls within
• Quality of Service: quality points are awarded by determining the extent to which the
program is delivered in what research suggests is a high-quality manner
• Amount of Service: or “dosage” refers to the amount and duration of services that were
received
• Risk Level: refers to the level of criminogenic risk for youth involved in the intervention.
The final output of the SPEP review is the Program Optimization Percentage (POP). This rate is
derived from the Basic Score and Program Optimization Score. The POP rate is a percentage
score that indicates how the service rates in effectiveness when compared to the potential
effectiveness if optimized to match the most effective services in the research. This means the
POP rate represents how close the program’s Primary Service is to its potential for that Primary
Service Type. For example, a POP rate of 55% would indicate that the program’s Primary
Service is operating at 55% of its potential effectiveness for recidivism reduction based on the
SPEP research.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 2
Basic Score: 35 Points
1. Primary Service and Supplemental Service Types POS: 35 Points
POP: 100%
There are five Primary Service Types that have been classified into Groups with a maximum
number of points possible for rating purposes. Some Primary Service Types may also have
qualifying Supplemental Service Types that could earn a program an additional 5 points.
The Primary Service for this program is Aggression Replacement Training.
The program was awarded 30 points because the Primary Service is identified as a Group 5
Service. The specific Sub-Component Service Type identified is Cognitive Behavioral Therapy.
The Primary Service was identified as this type of service as it is intended to correct faulty
cognitions and perceptions and provides skills individuals can use to monitor thought patterns and
correct behaviors.
An additional 5 points was awarded based on a Qualifying Supplemental Service. The Qualifying
Supplemental Service was identified as None (automatic 5 points added to score), which was not
demonstrated to have been implemented.
The Primary and Supplemental Service Raw Score is equal to the sum of the Primary Service
points plus the Qualifying Supplemental Service points.
Note: Quality information is evaluated during quarterly and annual reviews.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 3
Basic Score: 20 Points
2. Overall Quality of Service Delivery Score POS: 20 Points
POP: 100%
The Quality of Service Delivery Score is the sum of the scores for the seven treatment quality
indicators. The Program Optimization Percentage Rating determines the Overall Quality of
Service Level:
Indicator Sum Score 0-3 = Low; Sum Score 4-7 = Medium; Sum Score 8-10 = High.
Sum of all Indicator Scores (a – g below): 10 Points
Overall Quality of Service Delivery Level:
Low (Raw Score = 5)
Medium (Raw Score = 10)
High (Raw Score = 20 Points)
Basic Score: 1 Point(s)
a. Facilitator Training
Maximum Possible Score: 1 Point
All facilitator(s) of the Primary Service must have received formal training specific to the
intervention or model/protocol.
The intervention being evaluated is Aggression Replacement Training (ART) for the annual review
period 11/1/21-10/31/22. The program has a formal training protocol for the curriculum. Staff
attend a two day in-person training conducted by official trainers through AMIKids. The training
consists of learning the curriculum and conducting mock groups. Due to the Covid19 Pandemic,
the most recent facilitators for ART were trained through TEAMS and had to complete a post-test
demonstrating knowledge of the materials in order to receive a certificate. The program had five
staff members trained to facilitate ART- three Mental Health Therapists, one Transition
Coordinator and one Direct Care Staff (possessing the necessary qualifications to provide a
clinical service). Two staff facilitated the group during the review period, one Mental
HealthTherapist and one Direct Care Staff member. A third staff trained in the ART curriculum
conducted fidelity monitoring for each facilitator monthly.
Basic Score: 2 Point(s)
b. Treatment Manual/Protocol
Maximum Possible Score: 2 Points
There is a specific written manual/protocol detailing delivery of the Primary Service.
The program uses a brand-name manual for the group, Aggression Replacement Training-A
Comprehensive Intervention for Aggressive Youth, 3rd Edition curriculum. There is a facilitator
manual only and no student manual. The ART manual provides a script, is detailed and explains
how each specific session is to be delivered, and includes an outline for each group session. The
facilitators maintain a copy of their group's sign in sheets and have their own manual. This closed
group is held on Mondays, Tuesdays and Wednesdays from 2:30 p.m-3:30 p.m.
The program maintains their records for this intervention in a SPEP Binder that is individually
tabbed and includes staff training, evaluations, sign in sheets, fidelity monitoring and all other
relevant SPEP documentation. Youth are reviewed once they arrive at the program to see if they
qualify to be placed in ART. The criteria are lack of pro-social skills, aggression and poor decision
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 4
making. After completing the Comprehensive Assessment and Master Treatment Plan, the
Therapist decides whether or not to place them in the group.
Basic Score: 1 Point(s)
c. Observed Adherence to the Manual/Protocol
Maximum Possible Score: 1 Point
Upon observation of the Primary Service by the Quality Improvement reviewer, the facilitator of
that service adhered to the written protocol/manual.
A session of Aggression Replacement Training observed on Tuesday, 11/01/22, from 2:30 p.m. to
3:30 p.m., via Microsoft Teams. There were seven youth and two staff members present. The
lesson was from Week 10, Social Skills. A copy of the lesson was provided to the reviewer prior to
the observation. The youth learned about how to respond to failure. The facilitator followed the
lesson according to the manual, did not read the lesson verbatim, but rather used her own words.
She was easy for the youth to follow and adhered to the lesson plan in every aspect. She was
very knowledgeable of the materials and ensured the youth grasped each section prior to moving
on in the lesson.
Basic Score: 2 Point(s)
d. Facilitator Turnover
Maximum Possible Score: 2 Points
Measures the extent to which facilitators of the specific intervention/service have changed as
well as gaps in service of that Primary Service.
A review of documentation provided and an interview with the Director of Treatment confirmed
there was no facilitator turnover during the review period. In the event of facilitator turnover, the
program would utilize administrative or other trained staff to facilitate the Aggression Replacement
Training (ART) curriculum. There were no gaps in service during cohorts of ART.
The program completed two cohorts of ART and there was one cohort ongoing at the time of this
review. The dates of the cohorts were 11/15/21-02/16/22 with seven youth and two facilitator;
02/21/22-05/04/22 with eight youth and two facilitators; the current group started on 08/22/22 with
eight youth and two facilitators.
Basic Score: 2 Point(s)
e. Internal Fidelity Monitoring
Maximum Possible Score: 2 Points
The program has a process to monitor the delivery of the intervention to examine how closely
actual implementation matches the model protocol.
One Mental Health Therapist and one Direct Care Staff facilitated the Aggression Replacement
Training (ART) group during the review period. The trained staff conducted fidelity monitoring for
each other and have received certification by a qualified trainer in the Aggression Replacement
Training curriculum and fidelity monitoring. The program provided internal fidelity monitoring
records for the review period for each facilitator during the months groups were held. The program
uses an internal fidelity checklist specific to ART to document the monitoring. The program
completed checklists for all facilitators for each month they completed their ART groups.
All completed fidelity checklists are maintained in a binder entitled "Fidelity Monitoring for ART",
which is organized by monthly tabs. Each tab had a copy of the fidelity checklist completed on the
facilitator or facilitators who performed groups during the specific month.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 5
Basic Score: 1 Point
f. Corrective Action based on Fidelity Monitoring
Maximum Possible Score: 1 Point
The program has a process by which corrective action is applied and demonstrated based on
the fidelity monitoring of the delinquency intervention/therapeutic service.
The program has a process by which corrective action is acknowledged and demonstrated based
on the fidelity monitoring of Aggression Replacement Training (ART). The program uses internal
fidelity monitoring/corrective action checklists specific to the ART curriculum. Each completed
checklist includes feedback specifying either the facilitator did not require any corrective action or,
if the facilitator did require corrective action, it would include recommendations for future
improvement. The following month's checklist would include comments the previous month's
recommendations were applied and demonstrated.
An interview with the Director of Treatment and a review of the documentation verified the
program did not take any corrective action during the review period.
g. Evaluation of Facilitator Skill Delivering the Basic Score: 1 Point
Intervention Maximum Possible Score: 1 Point
Performance evaluations of the facilitators of the specific intervention/service include
evaluation of skill in delivering the intervention/service.
A review of evaluations for the facilitators found all received an evaluation within the last year. The
performance evaluations of the trained facilitators were reviewed and entries were found
documenting the staff's performance in delivering Aggression Replacement Training. These
included comments on any strengths or weaknesses of which the facilitator should be aware.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 6
3. Amount of Service - Duration
Basic Score: 10 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 100%
Research indicates the target duration of 10 weeks for this type of service. Of the 23 youth in the
sample, 100% (23 of 23) reached at least the indicated target duration. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (duration) is calculated from the Juvenile Justice Information System
(JJIS) Evidence-Based Services module. Duration is included for the youth in the SPEP sample.
4. Amount of Service – Contact Hours
Basic Score: 10 Points
Program Optimization Score: 10 Points
Program Optimization Percentage: 100%
Research indicates a target of 30 contact hours for this type of service. Of the 23 youth in the
sample, 100% (23 of 23) reached the indicated target contact hours. Further explanation is
detailed in the Summary and Recommendations below.
Note: Dosage information (contact hours) is calculated from the Juvenile Justice Information
System (JJIS) Evidence-Based Services module. Contact hours are included for the youth in the
SPEP sample.
5. Risk Level of Youth Served:
Basic Score: 20 Points
Program Optimization Score: 25 Points
Program Optimization Percentage: 80%
Percentage of Youth with Moderate, Moderate-High, and High-Risk Levels to Reoffend: 83%
Moderate to High Score: 7 Points
Program Optimization Score: 12 Points
Program Optimization Percentage: 58%
Table 1
Moderate = 3 youth
Moderate-High = 9 youth
High = 7 youth
Total Youth in Sample = 23 youth
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 7
Percentage of Youth with High-Risk Level to Reoffend: 30%
High Score: 10 Points
Program Optimization Score: 13 Points
Program Optimization Percentage: 77%
Table 2
High = 7 youth
Total Youth in Sample = 23 youth
The risk level score is compiled by calculating the total percent of the SPEP sample that score
Moderate to High-Risk to reoffend and also the total percent of the SPEP sample that score High-
Risk to reoffend.
Of the SPEP sample, 83% (19 of 23) youth scored Moderate to High-Risk to reoffend, for a score
of 7 points.
Of the SPEP sample, 30% (7 of 23) youth scored High-Risk to reoffend, for a score of 10 points.
Note: The latest Community Assessment Tool (CAT) prior to the placement date was used in the
derivation of the risk level score. This CAT provides the best indication of the risk to re-offend
level of the youth when the youth was first placed in the program.
Summary and Recommendations
Program Program
Category Basic Score Optimization Optimization
Score Percentage
Primary and Supplemental Service Type 35 35 100%
Quality of Service Delivery 20 20 100%
Amount of Service: Duration 10 10 100%
Amount of Service: Contact Hours 10 10 100%
Risk Level of Youth Served 20 25 80%
Totals 95 100 95%
This SPEP report evaluates Aggression Replacement Training, an intervention delivered at Youth
Environmental Services.
28 youth completed the program during the review period.
The program scored High for Quality of Service Delivery.
The targeted number of weeks for this specific intervention is 10 weeks; the targeted number of
hours for this specific intervention is 30 hours. After additional review and discussion with the
Peabody Research Institute at Vanderbilt University, the Department determined it was within
SPEP standards to deviate from the standard dosage targets for Group 5 services (15 weeks; 45
hours).
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 8
The program earned 10 points for Amount of Service: Duration. Of the 23 total youth sampled, all
23 included dosage with end dates in the EBS Module. Of those youth, 23 received at least the
recommended weeks of service. Youth in the sample completed between 10 and 14 weeks of
service, with an average of 12 weeks.
The program earned 10 points for Amount of Service: Contact Hours. Of the 23 total youth
sampled, all 23 included dosage in the EBS Module. Of those youth, 23 received at least the
recommended hours of service. Youth in the sample completed 30 hours of service.
The program was awarded 20 available points for Risk Level of Youth Served. This is calculated
using data from the Community Assessment Tool (CAT). This score reflects youths' most recent
CAT score prior to placement at the program. The program itself has no control over youths' CAT
risk level because the scored assessment was administered prior to the youths' admission.
Had the percentage of youth served with Moderate-High and High risk to reoffend been higher,
and this report awarded each 25 of the available points for this section, the Program Optimization
Percentage for this service would increase to 100%. As stated previously, the Risk Level of Youth
Served score is not under the control of the program.
RECOMMENDATION(S):
Youth Environmental Services can maintain their SPEP Quality of Service Delivery score by
continuing the practices in place at the time of this review.
Youth Environmental Services can optimize their SPEP Amount of Service score by ensuring
dosage for all youth is recorded accurately in EBS and by ensuring youth receive the full targeted
dosage of service.
Department of Juvenile Justice | Standardized Program Evaluation Protocol [SPEP] Report 9

file_name: FY2022-23 YES ART.pdf


state: FL

facility_name: spring lake youth academy

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY REPORT
JUVENILE FACILITIES
Name of Facility: Spring Lake Youth Academy
Physical Address: 8806 SW Start Center St., Arcadia, FL 34266
Date report submitted January 14 , 2015
Auditor information : Dan McGehee
Address PO Box 595 White Rock, SC 29177
Email: mc72fsud@aol.com
Telephone number: 803-331-0264
Date of facility visit : July 21-22, 2014
Facility Information
Facility Mailing Address: Same as Above
(if different from above)
Telephone Number: 863-993-2600
The Facility is: Military County Federal
Pr ivate for profit Municipal State
Private not for profit
Facility Type: Detention C orrection Other:
Name of PREA Compliance Manager: Jarrid Robinson Title: Facility or
Administrator
Email Address: jarrrid.robinson@us.g4s.com Telephone Number: 863-993-2600
Agency Information
Name of Agency: G4S Youth Services, LLC
Governing Authority or G4S
Parent Agency: (if
applicable)
Physical Address: 6302 Benjamin Road, Suite 400; Tampa, FL 33634
Mailing Address: (if
different from above) Same as Above
Telephone Number: 813-514-6275
Agency Chief Executive Officer
Name: James C. Hill, Jr. Title: President
Telephone 813-514-6275, ext. 202
Email Address: jim.hill@us.g4s.com
Number:
Agency Wide PREA Coordinator
Name: Bobbi Pohlman-Rogers Title: JJDPA/PREA Director
Telephone
Email Address: bobbi.pohlman@us.gus.com 954-818-5131
Number:
PREA AUDIT: AUDITOR’S SUMMARY REPORT 1
AUDIT FINDINGS
PROGRAM DESCRIPTION:
The department of Juvenile Justice contracts with G4S Youth Services, LLC to operate Spring Lake
Youth Academy (SLYA), a thirty-bed, low-risk residential program for male youth aged fifteen to
eighteen. The anticipated length of stay for each youth is sixty to ninety days. All thirty beds were utilized
on the days of the PREA audit. The program is located in Desoto County, Florida. The campus has an
administration building; a maintenance building; a school building with offices for the teachers; a building
that houses the kitchen and dining hall and a large building containing three dormitory areas, medical, case
management and therapist offices, one classroom and a social hall. The on-site management of this
program is the responsibility of the facility administrator; the management staff includes an assistant
facility administrator, one treatment director, one dietary manager, one physical plant manager, one human
resource manager, one licensed practical nurse, and one lead teacher.
The facility administrator and the assistant facility administrator live on site, and are therefore able to
respond to any issues that may arise, twenty-four hours per day. The facility administrator conducts daily
management meetings to address safety and security issues, daily activities within the facility, any
problems regarding the youth, and any issues of which the management team needs to be aware. A
personnel and training file is maintained for each staff. Training provided to staff is through a combination
of instructor-led and web-based courses. All new staff complete pre-service orientation training at a
training academy located at another program operated by the provider.
The program has two full-time case managers that are supervised by the facility administrator. The case
managers are responsible for conducting all case management functions, such as completing the Residential
Positive Achievement Change Tool (R-PACT) assessments and the Youth Needs Assessment Summary
(YNAS), performance planning, writing performance summaries, and leading the treatment team. The case
managers are also responsible for transition planning, to include submitting the Pre-Release Notification
and conducting the exit conference.
Upon admission to the program, each youth receives a resident handbook and is provided with an
orientation to the program. The resident handbook is available in three languages: English, Spanish, and
Creole. The youth are allowed weekly telephone and letter writing privileges. Visitation is held every
weekend for immediate family members; special visitation arrangements are made for families when
necessary. Quarterly family days are held, during which siblings or additional family members of the youth
are permitted. The program staff conducts restorative justice groups, gender-specific groups, and life and
social skills groups. Evidence-based curricula are utilized, to include Impact of Crime (IOC), The Council
for Boys and Young Men, and Skillstreaming for the Adolescent. The educational services are provided to
the youth by the provider, with oversight by the Desoto County School System. The program provides
youth with educational opportunities such as earning high school credits or working towards their General
Education Development (GED) test.
DESCRIPTION OF FACILITY:
Spring Lake Youth Academy is a stand-alone facility located in rural Desoto County near Arcadia, FL. The
facility consists of six buildings which include administration, cafeteria, maintenance, education,
residential/offices/and multi-purpose room. The residential building consists of three 10-bed rooms, stark in
appearance with bunk beds. The facility is located on the banks of Horse Creek. There is no perimeter
fence.
The facility has a total of 23 cameras in the following locations:
PREA AUDIT: AUDITOR’S SUMMARY REPORT 2
1. Classroom Stairs 9. Cafeteria 17. Med Room
2. Courtyard 10. Med Foyer 18. Dorm Stairs
3. Entryway 11. Med Stairwell 19. Classroom 2
4. Admin 12. Dorm Foyer 1 20. Social hall 2
5. Recreation Field 13. Social Hall 1 21. Back stairs
6. Cafeteria Ramp 14. Bravo Dorm 22. Charlie Dorm
7. Classroom Hallway 15. Social Hall Porch 23. Admin Ramp
8. Classroom 1 16. Alpha Dorm
The camera system was completed less than two weeks prior to the audit. The images of all the cameras
are available in the facility administrator’s office and only accessed by the facility administrator and his
assistant.
SUMMARY OF AUDIT FINDINGS:
The audit of the Spring Lake Youth Academy (SLYA) was conducted on July 21 and 22, 2014 by Dan
McGehee, assisted by Richard Bazzle, both certified PREA auditors. The audit began at 8:30 a.m. with an
in-briefing with the facility administrator.
Prior to the audit, the agency mailed a thumb drive containing the information for the facility. It was
received three weeks before the audit rather than the four weeks required by contract. The information had
the Pre-audit questionnaire with no specific policies referenced as required. Most electronic files also
contained policies none of which were highlighted nor referenced by standard. Approximately 214 policies
from the facility/corporation were also attached none of which were referenced for specific standards.
The chair, Mr. McGehee, emailed the facility administrator requesting highlighted policies and supporting
documentation for the standards as required by the Pre-audit questionnaire. The company Vice President,
also a certified PREA auditor, requested a conference call to discuss. The conference call was conducted
on Monday, July 7, with Flora Boyd from CMCG facilitating. Ms. Boyd, also a certified PREA auditor,
confirmed that it is the agency’s responsibility to provide specific policy references for the standards, as
well as supporting documentation. The vice president of G4S finally agreed to “let me see what I can do.”
As a result of the conference call, no additional information was received from the agency by the audit
team.
When the audit team arrived at the facility, there was no information presented for auditors to review. As a
result, the audit team had to spend a substantial amount of time in the two days at the facility asking for
documentation, waiting for it to be presented, and then evaluating it for standards compliance.
All areas of the facility were toured on the beginning of the first day of the audit. The facility consists of
five buildings—administration; dorms/counseling/bathrooms; education; cafeteria, and maintenance.
Juveniles were under constant supervision. At night a staff member is assigned in each room of 10. For
education, teachers are provided by the Desoto County School Board but hired by G4S. All school
instruction is provided on-site. Following the tour, auditors began going through each standard asking the
facility director for needed documentation. While he began to assemble necessary documentation, the
auditors interviewed staff and residents as required.
Auditors reviewed documentation as it was available to determine compliance with PREA standards.
Facility staff was most accommodating in assisting the auditors with documentation and the audit process.
A close-out with the facility administrator was conducted at approximately 4:00 p.m. on Tuesday, July 22,
2014. The audit chair reviewed those standards in non-compliance. The audit chair then reviewed the
development of an action plan, as well as reported on the reporting process.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 3
Number of standards exceeded: 0 Number
of standards met: 38 Number of standards
not met: 0
Number of standards Not Applicable: 3
Standard 115.311 – Zero To tolerance of sexual abuse and sexual harassment.
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)
G4S Spring Lake Youth Academy (SLYA) Policy 10-25 dated April 25, 2014, mirrors that of its contracting
agency, Florida Department of Juvenile Justice, Policy 1919 revised April 10, 2014. Page 3 of the SLYA policy
has necessary written language mandating a zero tolerance for all forms of sexual abuse and sexual harassment.
Within the 10 page policy, the agency’s approach to preventing, detecting, and responding to acts of sexual abuse
and harassment is outlined.
The agency, G4S, has a PREA Coordinator who oversees PREA compliance efforts for the agency. Page 3 of
policy 10-25 designates the SLYA Facility Administrator as the PREA Compliance Manager and outlines the
specific related duties. When interviewed, both the PREA Coordinator and PREA Compliance Manager indicated
they had authority and sufficient time to manage PREA compliance related responsibilities.
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)
Not Applicable
SLYA is a G4S Youth Services, LLC program that operates under contract with the Florida Department of
Juvenile Justice (FDJJ) and does not contract with other entities for the confinement of residents.
Standard 115.313 - Supervision and Monitoring
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)
SLYA is a G4S Youth Services, LLC program that became operational June 30, 2011 and exists through contractual
arrangement with the Florida Department of Juvenile Justice (FDJJ). A review of the Staffing Plan Assessment and
other secondary documentation such as the Facility Administrator Weekly Management Report and the Monthly
Fidelity Compliance Scorecard validated that ratios were in compliance with Standard requirements. There are no
PREA AUDIT: AUDITOR’S SUMMARY REPORT 4
findings of inadequacies from judicial, federal investigative agencies, nor internal or external oversight bodies; and
there were no documented deviations from the staffing plan.
The Staffing Plan Assessment and interviews with staff served to validate that in establishing and maintaining the
agreed upon ratios, consideration was given to needs of the residents to be served, physical location and layout of the
facility, as well as the location of available video surveillance cameras. The facility has 23 cameras, both interior and
exterior, which supplement the Staffing Plan.
SLYA Policy 10-25 mandates that facility supervisors shall conduct unannounced rounds of all areas of the facility at a
minimum of one time per shift and that the rounds must be documented on all shifts. However, rounds of the facility
administrator and his deputy were not documented.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.315 - Limits to cross gender viewing and searches
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)
SLYA policies numbers10-25, 10-3, and 8-14 outline all mandates in compliance with this standard. Policy requires
that only in exigent circumstances will cross-gender searches be conducted and that any such search will be
documented as to the reason for the search and why a same sex staff was not available. SLYA Policy 10-3, states that
strip searches must be conducted in a private room with two staff members of the same sex as the resident. SLYA
Policy 10-3 further states that body cavity searches must be approved by the Facility Administrator or the Operations
Administrator only when it is strongly suspected that a youth has concealed contraband in the body cavity. All body
cavity searches must be conducted by trained medical personnel in an emergency room setting. Program staff is not
authorized to conduct a body cavity search of a youth. During the past 12 months, there were no cross-gender strip
and body cavity searches and no cross-gender pat-down searches.
Policy prohibits searching or examining a transgender or intersex resident for the sole purpose of determining the
resident’s genital status.
Further, policy also mandates that residents have access to shower, perform bodily functions, and change clothing
without non-medical staff of the opposite gender viewing; and that staff of the opposite sex shall announce their
presence when entering resident housing facility or an area where residents are likely to be showering or performing
bodily functions or changing clothing. Interviews with staff and residents verified that these practices are in place at
SLYA.
Standard 115.316 - Residents with disabilities and residents who are limited English proficient
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)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 5
SLYA Policy 10-25 requires the PREA Facility Compliance Manager to ensure residents with disabilities and
residents who are limited English proficient have 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 harassment. The policy also states the facility
will take steps to provide interpreters who can interpret effectively, accurately, and impartially.
The policy prohibits the use of youth or staff as interpreters, readers, or other assistant to perform such functions
except in limited circumstances where an extended delay in obtaining interpreters services could jeopardize residents’
safety. The facility does not use resident assistants and there were no instances of resident interpreter or readers being
used in the past 12 months. Staff and resident interviews validated compliance with policy.
Documentation of contracts or agreements for interpreters or other professionals hired to ensure services for
disabled and/or limited English proficient residents was not provided.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.317 - Hiring and promotion decisions
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)
Elements required by this standard are outlined in SLYA Policies10-25, 3-16 and FDJJ Policy 1919. Persons desiring
employment with SLYA complete the application packet; a portion of which is sent from SLYA to the FDJJ Office of
the Inspector General for background screening. Details of the screening are described on the FDJJ’s website and
include conducting two background screenings; the Level II pre-employment screening and a 5-year re-screening.
Upon request, background screening is conducted on state and contract provider directors, owners, applicants,
employees, volunteers, mentors, and interns. The term contract provider includes grant recipient employees,
volunteers, mentors, and interns. Background screenings consist of a state and national fingerprint check through the
Florida Department of Law Enforcement and the Federal Bureau of Investigation, and a demographic search of the
Florida Clerk of the Courts. As a criminal justice agency, the Department has access to juvenile, sealed, and expunged
criminal history information.
Interview with Human Resources (HR) staff confirmed that the policy is in practice for staff and contractors. The
auditor’s review of sample staff files validated at 100% that criminal background records checks were completed, and
applicants seeking employment are asked about previous misconduct outlined in section (a) of this standard.
Consistent with the PREA requirement and Florida Statutes 768.096 and 435.10, SLYA has in place a process for
contacting prior employers for information before hiring and sharing information with employers.
Of assigned employees, only 3 have anniversary dates of over 5 years. The HR Staff confirmed that background
checks had indeed been conducted on the 3.
The policy states that staff being considered for promotion shall disclose any sexual misconduct and material
omission regarding such misconduct, or the provision of materially false information shall be grounds for termination.
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
PREA AUDIT: AUDITOR’S SUMMARY REPORT 6
for the relevant review period)
Does Not Meet Standard (requires corrective action)
SLYA has not acquired any new facilities, or done any expansion or modification since August 20, 2012. Within the
last 30 days, the 23 cameras were installed in the facility to supplement the Staffing Plan and to assist with better
supervision.
Standard 115.321- Evidence protocol and forensic medical examinations
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)
SLYA does not conduct administrative or criminal sexual abuse investigations and by policy upon learning of such an
event SLYA staff must immediately make a report through the Florida Department of Juvenile Justice (FDJJ) Central
Communications Center (CCC) hotline. Policy also mandates a call to local law enforcement and the Florida
Department of Children and Families Abuse Registry hotline. Criminal investigations are conducted by the Desoto
County Sheriff’s Office.
Written on the Youth Acknowledgement and Notification of Prison Rape Elimination Act form is this statement, “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.” Staff interviews validated this practice.
There were no forensic medical examinations conducted in the past 12 months. There is no MOU with a rape crisis
center or other such agency to provide the services required by section C of this standard. Therefore, no
documentation could be provided.
Documentation that the agency has requested the responsible agencies follow requirements in paragraph
115.321 (c) through (f) of the standards was not made available to the auditor.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115. 322 - Policies to ensure referrals of allegations for investigations
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)
SLYA policy 10.25 requires that any staff receiving a report of sexual misconduct or possible sexual misconduct must
ensure that it is immediately reported to their supervisor who shall ensure that it is reported to local law enforcement,
(the Desoto County Sheriff’s Office) if criminal in nature. During the past 12 months, there has been one allegation of
sexual assault by a juvenile against an employee. An investigation was begun by the facility director and notifications
were made to FDJJ and the Department of Children and Families as required. The internal investigation has
been completed and the determination of an unfounded allegation has been found. The investigation has not been
closed with the Department of Children and Families or with FDJJ at this time.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 7
The FDJJ Policy 1919 describes the agency’s investigative responsibilities and duties for its facilities and is published
on the DJJ website.
Standard 115.331 - Employee training
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)
SLYA Policies 10-25 and 5.1.5 (C) and FDJJ Policy 1919 outline training requirements for staff that is consistent with
this standard. The regional trainer provided a written statement that all employees at Spring Lake Youth Academy
have received the required PREA training. Additionally, three sample DJJ forms 1919 were provided which were
signed by staff stating that they had received all required training. The In-service curriculum was also reviewed
showing PREA training which was taught for one hour with both Pre- and Post-test scores recorded. Staff interviews
also served to further validate that training occurred. The training curriculum provided was consistent with the
elements of 115.331(a) except for number 6 and 11.
SLYA school teachers are provided by the Desoto County School Board and under F39.201, school teachers and other
school officials or personnel are mandated reporters. Staff advised that SLYA school personnel signed a form
declaring that they are aware of the sexual abuse/assault policies governed by G4S Youth Services, LLC, the Florida
Department of Juvenile Justice and PREA and that they have read and understand those policies.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115. 332 - Volunteer and contractor training
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)
SLYA Policy requires that all persons providing volunteer or contractor services at SLYA be trained at a minimum on
the agency’s zero-tolerance policy regarding sexual abuse and harassment and how to report such incidents. Additional
training provided to volunteers and contractors is based on the service they provide and the level of contact they have
with residents.
Contractors such as dentist, psychiatrist, and medical doctors sign the Acknowledgement of the Prison Rape
Elimination Act form declaring they have been informed and understand that SLYA has a zero tolerance and that
sexual contact of any kind is forbidden, the possible penalties for such behaviors, and that they have a duty to report.
Standard 115.333 - Resident education
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)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 8
SLYA Policy 10-25 requires that during intake all residents will be provided with information on zero-tolerance
regarding sexual misconduct including how to report sexual abuse and suspicion of any sexual misconduct. Policy
also requires that within 10 days of intake, all residents will be provided with additional comprehensive training
regarding their rights to be free from sexual misconduct; their right to be free from retaliation for reporting; and the
agency’s sexual misconduct response policies and procedures. As a part of the training, residents are given a handout
entitled, “You Have the Right to Be Safe” from Sexual Violence. The handout provides information on preventing,
detecting, and responding to sexual assault and harassment. At the end of the training session residents acknowledge
through signature that they understand their right to be Safe from Sexual Misconduct, Abuse, and Harassment.
Interviews with 5 residents (at least one from each living units) validated that they receive education at intake and
later. Interviews with intake and clinical staff verified that youth are provided with PREA required education in
individual sessions with staff the day they arrive at the facility.
During the tour of the facility, posters outlining the sexual abuse zero tolerance policy, duty to report, and instructions
for reporting, were posted in various locations including the living units; however, the posters are letter size and only
visible from a short distance.
Documentation for 115.333 (d)-1 was not made available to the auditor. Larger sized posters would likely
provide for better visibility.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.334 - Specialized training: Investigations
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)
Not Applicable
SLYA does not employ facility investigators. Investigations are referred to outside agencies.
Standard 115.335 - Specialized training: Medical and mental health care
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)
SLYA Policy 10-25 and FDJJ Policy 1919 mandates training for medical and mental health workers consistent with
section (a) of this policy.
There was no documentation that medical and mental health staff had received any specialized training other
than the PREA information received by all staff.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 9
Standard 115.341 - Screening for risk of victimization and abusiveness
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)
SLYA Policy 9-1 describes the process staff is to use for screening for Vulnerability to Victimization and Sexual
Aggressive Behavior (VSAB). Within 24 hours of a resident’s arrival at the facility, trained staff meets with
residents and complete the VSAB form. The instrument is scored prior to housing placement. Those residents who
score vulnerable to victimization or sexually aggressive are included in the alert system, and referred for further
assessments, as identified. Residents who are identified or report as prior sexual victims are referred to the medical
and mental health professionals within 14 days. Interviews with the clinical director and PREA Compliance Manager
confirmed that policy is in practice and that information from the VSAB is disseminated on a “Need to Know” basis.
The screening for vulnerability to sexual victimization and sexual aggressive behavior instrument met the 11
minimum required elements outlined in section (c) of the standard. An examination of resident records indicated that
the practice is followed.
Standard 115. 342 - Use of screening information
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)
SLYA Policy10-25 states that the information gathered from screening for vulnerability to sexual victimization and
abusiveness shall be used to guide treatment plans and security and management decisions, including housing, bed,
work, education, and program assignments. Policy 10-18 directs SLYA staff to maintain a continually updated internal
alert system that is easily accessible to program staff and keeps them alerted about youth who are security or safety
risks in multiple categories including sexual predator risks. Facility tour and interviews with staff verified compliance.
SLYA Policy 8-14.5 directs staff in the treatment of LGBTI residents consistent with those outlined in sections (c)
through (g) of this standard. Interviews with staff indicated they are aware of the policy and intend to comply.
Standard 115. 351 - Resident Reporting
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)
SLYA Policy 8.3.4 (B) Abuse and Neglect Reporting – states that all youth shall have unimpeded access to the Florida
Abuse Hotline without interference or retaliation of any kind and further outlines in detail that residents are to be
provided with the Abuse hotline number which is provided at intake, included in the resident handbook and posted
throughout the facility. A review of FDJJ Quality Improvement Report in February of 2014 indicates that Hotline
numbers are posted and given to residents.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 10
SLYA provides instruction and multiple ways for residents to report sexual abuse and harassment including telling a
staff member, writing a grievance, asking to speak with the Facility Administrator, calling the Florida Abuse Hotline.
A review of the resident guide indicates several hotline numbers that can be called and includes their numbers;
however, these numbers were not posted in other locations in the facility.
Staff and residents validated that they have access to the tools necessary to make a report. Also, policy outlines
procedures for staff to follow when a youth desires making a report including assisting the youth by dialing the number.
However, staff interviews revealed conflicting ways for residents to access the hotline number.
Interviews with staff validated that they would accept and document reports made verbally, in writing, anonymously,
and from third parties.
SLYA is not compliant with section (b) of the standard because it does not 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 abuse and harassment to agency officials allowing the
resident to remain anonymous upon request. Residents must exhaust written remedies before asking to use the
phone to access the hotline. Then, staff would dial the number, place the phone on speaker, and monitor the
phone call between the juvenile and the hotline staff.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.352 - Exhaustion of administrative remedies
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)
SLYA Polices 8-4 and 10-25 failed to address procedural issues for residents to submit grievances alleging sexual
abuse without submitting it to the staff member who is the subject of the complaint nor should it be referred to
the staff member who is the subject of the complaint. Additionally, policies do not address third party
grievances or emergency grievances with appropriate timelines.
During the past 12 months no sexual abuse grievance was filed. Interviews with residents validated their knowledge of
how to file a grievance for sexual abuse or harassment. During the facility tour a locked grievance box was visible in
the living unit.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.353 - Resident access to outside confidential support services and legal representation
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)
SLYA has no MOUs or other agreements establishing or attempting to establish a relationship with
community service providers that are able to provide residents with emotional support services related to
PREA AUDIT: AUDITOR’S SUMMARY REPORT 11
sexual abuse.
Residents are not provided reasonable confidential communication between residents and outside victim
advocates. A resident wanting to call 1-800 hotline must make request to staff, staff places call and remains
with resident during conversation between resident and advocate.
SLYA does not detain residents solely for immigration purposes.
Interviews with residents and observations of posting in the facility suggest SLYA does not provide mailing
addresses and telephone numbers of local or national victim advocacy or rape crisis organizations.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.354 - Third-party reporting
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)
SLYA does not provide a method that is publically distributed on how to receive third-party reports of resident
sexual abuse or sexual harassment on behalf of the residents.
As of January 14, 2015, the policy, procedure and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.361- Staff and agency reporting duties,
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)
The employees at SLYA are mandatory reporters and SLYA Policy 10-25 directs staff to immediately report any
abuse, knowledge, suspicion or information they receive regarding an incident of sexual abuse or sexual harassment.
Policy also directs staff to report any retaliation against residents or other staff who reported an incident; and any staff
neglect or violation of responsibilities that may have contributed to an incident of abuse or retaliation. SLYA policies
further direct staff in complying with the elements outlined in sections (b) through (f) of this standard. Interviews with
Health Services Coordinator, Facility Administrator/PREA Compliance Manager, and random selected staff served to
validate that the staff are aware of the policies and their duty to report.
Standard 115.362 - Agency protection duties
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)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 12
SLYA Policy 10-25 requires that when staff learns that a resident is subject to a substantial risk of imminent sexual
abuse it shall take immediate action to protect the resident from harm or further threat. During the past 12 months no
residents were identified to be of such risk. Interviews with the Agency Head Designee, Facility
Administrator/PREA Compliance Manager and random sample of staff validated that staff is aware of their mandate
to immediately take steps necessary to keep the resident safe.
Standard 115.363 - Reporting to other confinement facilities
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)
SLYA policy does not address the requirement of facility upon receiving an allegation that a resident was
sexually abused while confined at another facility, that the head of the facility receiving the allegation shall
notify the head of the facility where the alleged abuse occurs, and also notify the appropriate investigative
agency. Notification should be provided no later than 72 hours with notification being documented.
During the past 12 months SLYA staff did not receive any reported allegations that a SLYA resident was abused
while confined at another facility. Likewise, SLYA did not receive any reports of allegations of sexual abuse from
other facilities that residents previously confined at SLYA were sexually abused.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.364 - Staff first responder duties
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)
SLYA policy 10-25 (dated 4-25-2014 supersedes 10-01-2013) does not direct staff first responders to take
specific steps of requesting victim of alleged sexual abuse that occurred within a time period that still allows
for collection of physical evidence not to take any actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or eating.
Also steps should be taken to ensure that alleged abuser does not take any the above actions that could
destroy physical evidence.
During the past 12 months SLYA had one allegation that a resident was sexually abused or harassed and in no
instance was a non-security staff member the first responder.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.365 - Coordinated response
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)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 13
SLYA facility does not have a coordinated response plan that clearly states specific duties of responding staff
and in what order, to include interface with investigators and follow up responsibilities as outlined in the
Standard.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
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)
Not Applicable
Spring Lake Youth Academy does not participate in collective bargaining.
Standard 115.367 - Agency protection against retaliation
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)
SLYA Policies 10-25 and 8-3 establish that residents and staff are to be protected from retaliation for reporting sexual
abuse or harassment and/or cooperating with investigations of sexual abuse and harassment. The monitoring will take
place for a period of at least 90 days and at each 30 day interval the Facility Administrator/PREA Compliance
Manager will determine if retaliation is occurring by reviewing such items as disciplinary reports, status checks,
housing or program changes, and negative performance reviews or staff reassignment. There were no incidents of
retaliation in the past 12 months reported.
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)
SLYA does not have isolation rooms or segregated housing. The resident housing at SLYA consists of three 10-bed
wards in the Dorm Building that comprises the living unit. Isolation is prohibited.
Standard 115.371 - Criminal and administrative agency investigations
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)
SLYA does not employ facility investigators. All allegations of abuse are reported to the Florida Department of
Children and Families, the Desoto County Sheriff’s Office, and the FDJJ Office of the Inspector General – Central
Communications Center.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 14
The PREA Coordinator was interviewed and indicated she has access to reports and comments on them for the
agency.
Standard 115.372 - Evidentiary standards for administrative investigations
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)
SLYA does not conduct administrative investigations. All allegations of abuse are reported to FDJJ Office of the
Inspector General – Central Communications Center. Staff from the Inspector General’s office conducts the
administrative investigation and provides a report back to SLYA.
Standard 115.373 - Reporting to 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)
SLYA policy 10-25 does not require notification of victim after completion of investigation of alleged sexual
abuse by another resident or staff member (unless allegation is determined to be unfounded) and notification
shall be documented.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.376 - Disciplinary sanctions for staff
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)
SLYA Policy 10-25 states that sexual activity between staff and youth, as well as between youth is prohibited and
subject to administrative and criminal disciplinary sanctions. The policy also mandates that violations be reported to
law enforcement.
The G4S Employee Handbook makes clear that employee sexual harassment is prohibited and when an allegation is
substantiated, disciplinary action up to and including termination will be imposed.
During the past 12 months no staff from SLYA has been terminated or resigned for violating agency sexual abuse or
harassment policies. At the time of the audit, no SLYA staff had been reported to law enforcement or licensing
boards for violating agency sexual abuse and sexual harassment policies.
Standard 115.377 - Corrective Action for contractors and volunteers
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)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 15
SLYA has no policy that requires any contractor or volunteer who engages in sexual abuse to be reported to
law enforcement agencies and to relevant licensing bodies.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.378 - Disciplinary sanctions for 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)
During the past 12 months there has been no administrative finding of resident-on-resident sexual abuse; and no
criminal finding of guilt for resident-on-resident sexual abuse at SLYA. Interviews with the Facility Administrator,
medical, and mental health staff verified that residents are informed that in the event of such findings charges would be
pressed and if not prosecuted, then the Treatment Team would make decision for any necessary treatment
modification.
Standard 115.381 - Medical and mental health screenings; history of sexual abuse
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)
SLYA Policy 10-25 requires that if during intake screening, health/mental health screening, or health history, a
resident discloses prior sexual victimization or perpetrated sexual abuse, whether it occurred in a facility setting or in
the community, staff shall ensure the youth is referred for medical and mental health services within 14 day of the
screening. Policy also mandates that sensitive information shall be on a need-to-know basis and shall not be
exploited to the resident’s detriment by staff or other residents. There were no residents who disclosed prior
victimization during their initial screening process. Interviews with the medical and mental health staff and
documentation review verified
compliance with this standard.
Standard 115.382 - Access to emergency medical and mental health services
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)
SLYA Policy 7-30 requires that residents who are victims of sexual assault shall have immediate medical care.
There were no sexual assault victims during the past 12 months. The medical personnel verified that any sexual
assault victim would be provided unimpeded access to emergency medical treatment immediately; according to the
medical personnel’s professional judgment, the victim would be offered timely information about access to sexually
transmitted infection prophylaxis; and that the services would be provided without cost to the victim.
Standard 115.383 - Ongoing medical and mental health care for sexual abuse victims and abusers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
PREA AUDIT: AUDITOR’S SUMMARY REPORT 16
for the relevant review period)
Does Not Meet Standard (requires corrective action)
SLYA Policy 10-25 mandates ongoing medical and mental health care for sexual abuse victims and abusers to include
mental health evaluations and services as appropriate and medical health care services consistent with the community
level of care. There has not been any sexual abuse victim during the last 12 months. Interviews with the medical
personnel and Clinical Director verified that there are procedures in place compliant with the requirements of this
standard.
Standard 115.386 - Sexual abuse incident reviews
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)
SLYA Policy 10-25, page eight mandates that the facility shall create a Review Team with specific staff consistent
with those outlined in section (c) of the standard. The policy further mandates that the Review Team shall ordinarily
conduct the incident review within 30 days of the conclusion of every sexual misconduct investigation or
administrative review. Page nine of the policy outlines the specifics of the Review Team’s duties the same as those in
section (d) of the standard; and directs that Review Team recommendation must be implemented or justification
provided for not implementing the recommendations. Interview with Facility Administrator/PREA Compliance
Manager verified that the facility is in compliance with this standard.
Standard 115.387 - Data collection
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)
SLYA provided no information or documentation that indicated collection of data addressed in the Standard.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.388 Data review for corrective action
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)
SLYA provided no information that indicated the existence of a document that contained review of data
collected as addressed in the Standard.
As of January 14, 2015, the policy, procedure, and practice developed by the agency are now in compliance with the
requirements of the standard.
Standard 115.389 Data storage, publication and destruction
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
PREA AUDIT: AUDITOR’S SUMMARY REPORT 17
for the relevant review period)
Does Not Meet Standard (requires corrective action)
SLYA Policy 10-25 directs that the facility shall ensure records are maintained and the Facility Administrator shall
ensure that requests for additional information from the FDJJ PREA Coordinator are responded to in a timely manner.
No additional information was provided.
Any questions about PREA standards, required documentation or process please refer to the PREA Resource Center
website under Juvenile Standards.
AUDITOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and no conflict of interest
exists with respect to his or her ability to conduct an audit of the agency under review.
January 14, 2015
Auditor Signature Date
PREA AUDIT: AUDITOR’S SUMMARY REPORT 18

source: DJJ

report_type: PREA

program_name_raw: spring lake youth academy