facility_name: Pasco Juvenile Detention Center

summary: PREA - Year 2 Cycle 3

raw_content:
Prison Rape Elimination Act (PREA) Audit Report
Juvenile Facilities
☐ ☒
Interim Final
☒
Date of Interim Audit Report: Click or tap here to enter text. N/A
If no Interim Audit Report, select N/A
Date of Final Audit Report: December 21, 2020
Auditor Information
Name: Shirley L. Turner Email: shirleyturner3199@comcast.net
Company Name: Correctional Management and Communications Group, LLC
Mailing Address: P. O. Box 370003 City, State, Zip: Decatur, GA 30037
Telephone: 678-895-2829 Date of Facility Visit: November 30, 2020
Agency Information
Name of Agency: TrueCore Behavioral Solutions, LLC
Governing Authority or Parent Agency (If Applicable):
Address: 3109 W. Dr. MLK, Jr. Boulevard City, State, Zip: Tampa, FL 33607
Mailing Address: Same as Above City, State, Zip: Same as Above
The Agency Is:
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Military
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Private for Profit
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Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Agency Website with PREA Information: truecorebehavioral.com/services/
Agency Chief Executive Officer
Name: Jim Martin, Chief Executive Officer and President
Email: Jim.Martin@truecorebehavioralhealth.com Telephone: 813-461-4345
Agency-Wide PREA Coordinator
Name: Kirstie Naoom, Assistant State Director
Email: kirstie.naoom@truecorebehavioral.com Telephone: 813-623-6286
PREA Coordinator Reports to Robbin Berry, State Number of Compliance Managers who report to the PREA
Director Coordinator: 16
1
Facility Information
Name of Facility: Central Pasco Girls Academy
Physical Address: 2953 Wilson Road City, State, Zip: Land O’Lakes, FL 34639
Mailing Address: Same as Above City, State, Zip: Same as Above
☐ ☒ ☐
The Facility Is: Military Private for Profit Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Facility Website with PREA Information: www.djj.state.fl.us/partners/prison-rape-elimination-act(prea)
☒ ☐
Has the facility been accredited within the past 3 years? Yes No
qu
If the facility has completed any internal or external audits other than those that resulted in accreditation, please describe:
Annual compliance audit which is based on agency policies, procedures, and practices, conducted by the Florida Department of Juvenile Justice.
Facility Administrator/Superintendent/Director
Name: Tynequia Roberts
Email: tynequia.roberts@truecorebehavioral.com Telephone: 813-477-8696
Facility PREA Compliance Manager
Name: Tynequia Roberts
Email: tynequia.roberts@truecorebehavioral.com Telephone: 813-477-8696
☐
Facility Health Service Administrator N/A
Name: Tammy Kuta
Email: tammy.kuta@truecorebehavioral.com Telephone: 813-909-7800, ext. 254
Facility Characteristics
Designated Facility Capacity: 32
Current Population of Facility: 15
Average daily population for the past 12 months: 20
Has the facility been over capacity at any point in the ☐ ☒
Yes No
past 12 months?
Which population(s) does the facility hold?
☒
Females
☐
Males
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Both Females and Males
2
Age range of population: 13-18
Average length of stay or time under supervision 6-9 months
Facility security levels/resident custody levels Staff Secure
Number of residents admitted to facility during the past 12 months 20
Number of residents admitted to facility during the past 12 months whose length of
20
stay in the facility was for 72 hours or more:
Number of residents admitted to facility during the past 12 months whose length of
20
stay in the facility was for 10 days or more:
Does the audited facility hold residents for one or more other agencies (e.g., a State
correctional agency, U.S. Marshals Service, Bureau of Prisons, U.S. Immigration and
☐
Yes
☒
No
Customs Enforcement)?
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Federal Bureau of Prisons
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U.S. Marshals Service
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U.S. Immigration and Customs Enforcement
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Bureau of Indian Affairs
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U.S. Military branch
Select all other agencies for which the audited ☐ State or Territorial correctional agency
facility holds residents: Select all that apply (N/A if
☐
the audited facility does not hold residents for any County correctional or detention agency
other agency or agencies):
☐
Judicial district correctional or detention facility
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City or municipal correctional or detention facility (e.g., police lockup or
city jail)
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Private corrections or detention provider
☐
Other - please name or describe: Click or tap here to enter text.
☒
N/A
Number of staff currently employed by the facility who may have contact with
35
residents:
Number of staff hired by the facility during the past 12 months who may have contact
30
with residents:
Number of contracts in the past 12 months for services with contractors who may
3
have contact with residents:
Number of individual contractors who have contact with residents, currently
5
authorized to enter the facility:
Number of volunteers who have contact with residents, currently authorized to enter
the facility:
17
3
Physical Plant
Number of buildings:
Auditors should count all buildings that are part of the facility, whether residents are
formally allowed to enter them or not. In situations where temporary structures have
been erected (e.g., tents) the auditor should use their discretion to determine whether
to include the structure in the overall count of buildings. As a general rule, if a 6
temporary structure is regularly or routinely used to hold or house residents, or if the
temporary structure is used to house or support operational functions for more than a
short period of time (e.g., an emergency situation), it should be included in the overall
count of buildings.
Number of resident housing units:
Enter 0 if the facility does not have discrete housing units. DOJ PREA Working Group
FAQ on the definition of a housing unit: How is a "housing unit" defined for the
purposes of the PREA Standards? The question has been raised in particular as it
relates to facilities that have adjacent or interconnected units. The most common
concept of a housing unit is architectural. The generally agreed-upon definition is a
space that is enclosed by physical barriers accessed through one or more doors of
various types, including commercial-grade swing doors, steel sliding doors,
interlocking sally port doors, etc. In addition to the primary entrance and exit,
additional doors are often included to meet life safety codes. The unit contains
2
sleeping space, sanitary facilities (including toilets, lavatories, and showers), and a
dayroom or leisure space in differing configurations. Many facilities are designed with
modules or pods clustered around a control room. This multiple-pod design provides
the facility with certain staff efficiencies and economies of scale. At the same time, the
design affords the flexibility to separately house residents of differing security levels,
or who are grouped by some other operational or service scheme. Generally, the
control room is enclosed by security glass, and in some cases, this allows residents
to see into neighboring pods. However, observation from one unit to another is
usually limited by angled site lines. In some cases, the facility has prevented this
entirely by installing one-way glass. Both the architectural design and functional use
of these multiple pods indicate that they are managed as distinct housing units.
Number of single resident cells, rooms, or other enclosures: 0
Number of multiple occupancy cells, rooms, or other enclosures: 8
Number of open bay/dorm housing units: 0
Number of segregation or isolation cells or rooms (for example, administrative,
1
disciplinary, protective custody, etc.):
Does the facility have a video monitoring system, electronic surveillance system, or ☒ ☐
Yes No
other monitoring technology (e.g., cameras, etc.)?
Has the facility installed or updated a video monitoring system, electronic surveillance ☒ ☐
Yes No
system, or other monitoring technology in the past 12 months?
4
Medical and Mental Health Services and Forensic Medical Exams
Are medical services provided on-site?
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Yes
☐
No
Are mental health services provided on-site?
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Yes
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No
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On-site
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Where are sexual assault forensic medical exams Local hospital/clinic
provided? Select all that apply. ☒
Rape Crisis Center
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Other (please name or describe:
Investigations
Criminal Investigations
Number of investigators employed by the agency and/or facility who are responsible
for conducting CRIMINAL investigations into allegations of sexual abuse or sexual 0
harassment:
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Facility investigators
When the facility received allegations of sexual abuse or sexual harassment (whether
☐
staff-on-resident or resident-on-resident), CRIMINAL INVESTIGATIONS are conducted Agency investigators
by: Select all that apply.
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An external investigative entity
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Local police department
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Local sheriff’s department
Select all external entities responsible for CRIMINAL ☐
State police
INVESTIGATIONS: Select all that apply (N/A if no
external entities are responsible for criminal ☐
A U.S. Department of Justice component
investigations)
☐ Other (please name or describe: Click or tap here to enter text.)
☐
N/A
Administrative Investigations
Number of investigators employed by the agency and/or facility who are responsible
for conducting ADMINISTRATIVE investigations into allegations of sexual abuse or 0
sexual harassment?
When the facility receives allegations of sexual abuse or sexual harassment (whether ☐
Facility investigators
staff-on-resident or resident-on-resident), ADMINISTRATIVE INVESTIGATIONS are
☐
conducted by: Select all that apply. Agency investigators
☒
An external investigative entity
☐
Local police department
☐
Local sheriff’s department
Select all external entities responsible for
☐
ADMINISTRATIVE INVESTIGATIONS: Select all that State police
apply (N/A if no external entities are responsible for ☐
A U.S. Department of Justice component
administrative investigations)
☒ Other (please name or describe: (Florida Department of Juvenile Justice)
☐
N/A
5
Audit Findings
Audit Narrative (including Audit Methodology)
The auditor’s description of the audit methodology should include a detailed description of the following
processes during the pre-onsite audit, onsite audit, and post-audit phases: documents and files reviewed,
discussions and types of interviews conducted, number of days spent on-site, observations made during the
site-review, and a detailed description of any follow-up work conducted during the post-audit phase. The
narrative should describe the techniques the auditor used to sample documentation and select interviewees,
and the auditor’s process for the site review.
The Central Pasco Girls Academy, located in Land O’Lakes, Florida, serves adolescent female
juvenile offenders. Program services include but is not limited to providing individual, group,
and family therapy and psychiatric services. The facility is managed by TrueCore Behavioral
Solutions, LLC through a contract with the Florida Department of Juvenile Justice (DJJ). The
facility serves a population from 13 to 18 years of age and is staff secure. The Prison Rape
Elimination Act (PREA) Audit was conducted by Shirley Turner, certified US Department of
Justice PREA Auditor and a colleague assisted with the interviews.
The audit was attained and assigned to the Auditor by Correctional Management and
Communications Group, LLC (CMCG) located in Minneola, Florida. There were no known
existing conflicts of interest regarding the completion of this audit. There were no barriers in
completing any phase of the audit. Scheduling considerations were implemented out of an
abundance of caution due to the spread of the global pandemic and the threat and effects of
Hurricane/Tropical Storm Eta and caused delays in the schedule. The facility staff and
residents were evacuated to another facility/area due to Hurricane/Tropical Storm Eta. Due to
COVID-19 safety concerns, all interviews were conducted remotely which included video
arrangements. The virtual interviews were conducted November 10, 16, 18, 2020 and the site
visit was conducted on November 30, 2020. A PREA audit was previously conducted in 2017.
The facility is accredited by the Commission on Accreditation of Rehabilitation Facilities.
The agency had a vested interest in the audit being completed within the current year and
ensured that the challenges of COVID-19 concerns would not eliminate the occurrence of the
audit and that safety measures could be implemented. The agency, facility and Auditor
supported the use of the alternative method regarding the interviews as a safety measure to
protect all parties involved. Limiting direct contact among the Auditor, residents and all staff
during the pandemic was instrumental in the attempts to complete a safe audit by applying
measures that would reduce and prevent COVID-19 transmission.
Information about programs, services and activities conducted at the facility are also
summarized on the parent agency and the contract agency, Florida Department of Juvenile
Justice (DJJ), websites. There are links to the DJJ and PREA Resource Center websites
located on the TrueCore website’s PREA page. Detailed information, specific to the facility, is
found on the DJJ website and includes how to report allegations, facility reports and policy that
may be accessed by the general public. The DJJ website provides a specific overview of each
contract facility for the State of Florida and all related PREA information.
6
Pre-Onsite Audit Phase
Key Processes and Methodology
The initial planning for the audit was conducted with the DJJ statewide PREA Coordinator, Jeff
Wenhold, and the CMCG Senior Vice President of Program Reviews and Audits, Flora Boyd.
There was follow-up communication with the Auditor and the statewide PREA Coordinator. A
conference call was facilitated by the PREA Coordinator with the Facility Administrator,
Tynequia Roberts who also serves as the PREA Compliance Manager. The methodology,
logistics and site review plans were discussed, and the Auditor provided the opportunity for
questions and clarification of information as needed.
After the initial communication, PREA documents were provided to the Auditor. During follow-
up conversations with Ms. Roberts and the Assistant Facility Administrator, Shantica London,
the audit processes and logistics were reviewed. Communication was maintained with the
statewide PREA Coordinator and the facility Administrators throughout the duration of the
audit. The audit dates were adjusted as restrictions and concerns related to COVID-19 and
Hurricane/Tropical Storm Eta.
All parties involved supported the use of the alternative method of virtual interviewing to
eliminate direct contact among residents, staff, and Auditor out of an abundance of caution and
agency restrictions in an effort to minimize anyone contracting or spreading the coronavirus. A
final date was agreed upon for the interviews and the site review. The virtual interviews were
conducted on November 10, 16, 18, 2020 by the Auditor and associate using two separate
computers. The interviews did not reveal any information that warranted further inquiry during
the in-person site review which was conducted on November 30, 2020.
The Auditor maintained communication with the Facility Administrator and the Assistant Facility
Administrator regarding the virtual interviews; site review; access to the various staff members;
and goals and expectations of the audit process. The facility staff members and residents were
receptive to the alternative method for conducting the interviews. Staff members were familiar
with the PREA audit process, having participated in and/or aware of the previous PREA audits.
The PREA audit notice was copied and posted in various areas of the facility prior to the onsite
audit phase, at least six weeks prior to the audit. The pictures of the notices were taken in their
various locations and emailed to the Auditor by the Facility Administrator. The audit notices
were in a format that was easy to see and read and were posted at varying eye levels and
easy to see. They were strategically posted, accessible to residents, staff, any visitors, and
contractors during this time period. The notices contained the Auditor’s contact information and
information regarding confidentiality of information. No correspondence was received during
any phase of the audit and the facility has a process in place to ensure confidential
communication by residents. Verification of the postings was made through observations
during the comprehensive site review and as indicated through the interviews conducted with
residents and staff.
The completed PREA Pre-Audit Questionnaire, agency and facility policies and procedures,
and supporting documentation were uploaded to a flash drive and mailed overnight to the
7
Auditor. The documentation on the flash drive was organized by each standard. This
information was received by the Auditor prior to the site review. An initial assessment was
conducted of the information and the Auditor conducted a telephonic review with the
Administrators who provided the information requested before and after the completion of the
interviews and site review.
The Auditor provided a document to the Facility Administrator that assisted in the completion of
the interview schedule titled, “Information Requested to Determine Staff and Residents to be
Interviewed During the On-Site PREA Audit.” The document, which was completed and
returned to the Auditor, requested shift assignments; identification of staff members who
served and performed in specific PREA related specialized roles; and volunteers and
contractors who have contact with residents. The additional information requested prior to the
site review was provided to the Auditor.
The Auditor requested, through the interview document, a list of direct care staff and their
scheduled shifts and the additional direct care staff, where applicable, and a current resident
population roster. The written request included information regarding residents who may be in
vulnerable categories such as disabled; limited English proficient; intersex, gay, bisexual
and/or transgender residents; and residents housed in isolation. The information regarding the
residents and staff was made available to the Auditor prior to the onsite audit phase and
contributed to the development of the interview schedules.
Staff and residents were randomly selected by the Auditor based on the interview
requirements. The interview schedule was developed by the Auditor with input through the
Facility Administrator. All interviews were conducted in private. When the residents were
interviewed, the interviewer ensured that there was no staff in the room with the resident and
understood that the residents were not coerced to be interviewed. A view of the room and the
residents confirmed that no staff member was present during the interviews. The Facility
Administrator also provided assurance the interviews were conducted in private. The areas
where staff and resident interviews occurred were observed during the site review.
The Auditor communicated with the Facility Administrator and Assistant Facility Administrator
to confirm the interview and site review schedules. Assistance was provided to the Auditor by
the Administrators in clarifying specialized PREA roles and there was collaboration in
identifying residents in vulnerable categories. A resident roster was provided to the Auditor and
as a result of the information received, the interview schedules of specialized and random
staffs and residents were constructed. The resident roster provided by the Facility
Administrator was organized by housing unit, laying the foundation for the selection of a
diverse group of residents. The Auditor solicited and received input from the Administrators
regarding conflicts in staff coverage and availability of staff from all shifts and residents.
The Auditor reviewed the documents provided initially on the flash drive and subsequently by
email and conferred with the Administrators for clarity of information as needed. A
representative sample of residents and staff interviews were conducted to ensure the reliability
of the triangulated data gleaned from the interviews; review of policies, procedures, and other
documents; and observations. Once the interview schedules were developed and provided by
8
the Auditor, all interviews were conducted objectively and none of the interviewees were
coerced in participating.
The Facility Administrator provided documents that assisted with the following determinations
and interview selections:
Information Comments
Resident Roster Provided
Youthful Inmates/detainees Youthful inmates/detainees are not housed
in this facility.
Residents with Physical Disabilities None Identified
Residents who are Limited English Proficient None Identified
LGBTI Residents Identified
Residents in segregated housing Not Used
Residents in Isolation Not Used for Protective Custody
Residents who reported sexual abuse None Identified
Residents who reported sexual victimization Identified
during risk screening.
Residents with Cognitive Disabilities None Identified
Staff Roster Provided
Specialized Staff Provided
Contractors/Volunteers that have contact with Provided
residents.
All grievances/allegations made in the 12 None
months preceding the audit.
All allegations of sexual abuse and sexual Provided
harassment reported for investigation in the
12 months preceding the audit.
Hotline calls made during the 12 months None
preceding the audit.
Number of sexual abuse and sexual Provided
harassment allegations in the 12 months
preceding the audit
The agenda for the site review was reviewed by the Auditor with the Administrators and the
statewide PREA Coordinator. There was assurance by the Auditor that the process would be
as non-intrusive as possible where these actions did not interfere with the completion of the
sight review while also providing consideration due to COVID-19 concerns. The site review
included taking the paths that residents take within the facility while pointing out the restricted
areas where residents may go only with staff supervision and areas where residents are not
allowed.
The site review was scheduled and conducted by the Auditor after the return and settling in of
all staff and residents after the evacuation to another facility due to Hurricane/Tropical Storm
Eta. The Auditor discussed with the Administrators, the logistics of the site visit prior to arrival
and the Administrators had no primary concerns.
9
Site Review
Key Processes and Methodology
The site review was conducted by the Assistant Facility Administrator. The facility has a sign-in
and search process for visitors entering the facility. The site review included observation of
buildings and areas of the facility that included the lobby of the main building; administrative
building; control room; medical and education building; classroom buildings; offices; housing
units within the main building; bathrooms; laundry room; and dining room and kitchen which
are located in the main building. Staff was observed interacting with residents as the residents
moved from the classroom building to the main building and from the main building to group
sessions.
Printed notifications of the PREA site visit were observed posted in the areas previously
identified in the pictures sent to the Auditor, visible to residents, staff, contractors, and visitors.
The notices contained large enough print to make them noticeable and easy to see and read
and were observed posted in the administrative and main buildings in the general areas. The
Assistant Facility Administrator and residents stated that male staff announce their presence
upon entering the housing units. Residents’ files were observed to be maintained in a secure
manner and computers are password protected. The resident population during the site review
was 15.
There are signs posted throughout the facility regarding PREA information and materials are
available and accessible that contain contact information of the assisting agencies for reporting
allegations and seeking help regarding sexual abuse and sexual harassment. The posted
information includes instructions on accessing assistance; filing a grievance; youth rights; and
safety information regarding sexual abuse and sexual harassment. Staff cannot deny a
resident use of the telephone to access the Florida abuse reporting hotline.
Forensic medical examinations and victim advocacy services will be provided by the Crisis
Center of Tampa Bay, located in Tampa, Florida. The services to be provided were confirmed
by the Director of Nursing. An advocate will accompany a Sexual Assault Nurse Examiner as
accompaniment and will also provide accompaniment during the investigation interview.
Information about the Crisis Center has been posted in the dayrooms, accessible to residents
and staff. The community support interview was conducted by telephone during the Post Audit
Phase. The interview confirmed the accessibility of advocacy services to the residents if
needed and verified that the forensic medical and victim advocacy services will be provided as
indicated in the written agreement.
Victim advocacy services for a resident will be a response to an alleged victim due to the
agency involvement in performing a forensic medical examination or may be contacted for
advocacy services by the resident, staff, or law enforcement. The advocacy services include
the services already mentioned and including emotional support and referral services. Forensic
medical services will be provided at the Crisis Center or may be conducted at the facility if
indicated, according to the Director of Nursing at the Crisis Center.
10
The Assistant Facility Administrator answered questions regarding resident activities and staff
duties as the site review progressed throughout the campus. The discussions during the site
review included but were not limited to the intake process; daily activities; treatment services;
staff supervision; alternative methods of communication with parents/guardians during the
pandemic; staff ratios; recreation activities; and other processes and activities.
Residents have access to writing materials as observed and determined from the interviews of
residents and staff. Signage was posted providing PREA information in both English and
Spanish. Cameras are strategically installed to supplement direct staff supervision. A
reasonable amount of privacy is provided to residents when they use the toilet, change clothes
and shower. Residents are provided privacy when they use the bathroom. Grievance forms,
Sick Call forms, Chatty Cathy forms to request to speak to specific staff, and locked
receptacles for the forms are posted in the cafeteria. Each resident receives a handbook which
is also accessible in Spanish and other languages as needed. The PREA information is also
provided in Spanish.
Investigations
During the past 12 months, there were four allegations of sexual harassment. Allegations that
are criminal in nature will be reported to the Pasco County Sheriff’s Office and to the Florida
Department of Juvenile Justice (DJJ), Office of Inspector General (OIG). The Department of
Children and Families is also contacted regarding allegations of sexual abuse. All of the
allegations were reported through the Central Communications Center and investigated by the
DJJ/OIG. Three of the cases have been closed as Information Only and the fourth case is still
open.
Interviews
The interviews with residents and staff assisted the Auditor in understanding and confirming
the facility’s practices. The interviews with residents helped the Auditor to determine how
knowledgeable the residents were about the facility’s efforts to keep them safe from sexual
abuse and sexual harassment. Thirty-five staff members are currently employed at the facility
that may have contact with residents. A total of 14 residents were in the facility on the day of
the site review. Ten residents were interviewed through the use of controlled video by the
interviewers after being randomly selected by the Auditor. Six interviews were targeted which
considered information regarding the make-up of the population information obtained and by
utilizing the methodology in the PREA Auditor Handbook.
A total of 12 random staff members were interviewed covering all shifts. Eleven individual
specialized staff members were interviewed based on their job duties related to the PREA
roles, including two contractors and one volunteer. Although 10 individuals were interviewed,
11 interview protocols for specialized staff were used due to an additional specialized PREA
role by the Assistant Facility Administrator. The Facility Administrator was interviewed in the
roles of Superintendent, PREA Compliance Manager, and Retaliation Monitor however the
interviews in her respective roles of Facility Administrator (Superintendent) and PREA
Compliance Manager were not counted as specialized staff.
The Administrators and direct care staff ensured that all resident and staff interviews were
conducted in private and residents were not coerced to participate in the interviews. Specific
11
questions were asked of residents to confirm no one else was in the room with them and the
description of where a staff member was posted outside of the room. The room was also
viewed to confirm there was no one in the room with the resident. During the site review, the
areas where the interviews were conducted were observed. Some of the residents and staff,
including contractors, encountered from the virtual interviews were pointed out to the Auditor
as the site review progressed.
The contractors interviewed provide educational services to the residents and the volunteer
interviewed, who serves as the lead volunteer provides and coordinates mentoring services.
Random and specialized staff and resident interviews were conducted in the privacy of offices
which was verified by the interviewer and interviewees. The Facility Administrator and
Assistant Facility Administrator managed the accessibility of staff and residents for the
interviews. The Auditor identified the residents and staff for the interviews and did not rely on
the facility or agency staff to make selections. All interviews conducted were voluntary by the
selected participants.
The following number of staff interviews were conducted:
Category of Staff Number of Interviews
Medical Staff 1
Mental Health Staff 1
Administrative (Human Resources) Staff 1
Intermediate or Higher-level Facility Staff (Unannounced Rounds) 1
Contractors Who Have Contact with Residents 2
Volunteers Who Have contact with Residents 1
Staff who Perform Screening for Risk of Victimization and
1
Abusiveness
Staff on the Incident Review Team 1
Designated Staff Member Charged with Monitoring Retaliation 1
Intake Staff 1
Number of Specialized Staff Interviews 11
Number of Random Staff Interviews 12
Total Random and Specialized Interviews 23
Total interviews including with the Facility Administrator in the roles
25
of Superintendent and PREA Compliance Manager.
The community support interview was conducted by telephone during the Post Audit Phase
with the Director of Nursing, Crisis Center of Tampa Bay. The interview confirmed the
accessibility of advocacy services to the residents and verified the performance of a forensic
medical examination by a Sexual Assault Nurse Examiner at the Crisis Center of Tampa Bay.
The Director of Nursing stated that the examination may be conducted at the facility if deemed
necessary.
The interviews with the residents revealed the need for a PREA refresher education session
specifically focusing on the advocacy agency and the available services. It was determined
12
that a general refresher would be beneficial in building the knowledge base and provide
consistency and uncontradicted information. The Auditor collaborated with the Assistant
Facility Administrator regarding the implementation of a corrective action plan to address the
provision of additional PREA education to residents focusing on the advocacy services
provided by advocates of the Crisis Center of Tampa Bay. Corrective actions were
implemented that provided refresher education and training which focused on the possible
needs of the residents. The resource information presented, and sign-in logs were provided to
the Auditor by the Assistant Facility Administrator who presented and confirmed the refresher
sessions for the residents.
Document Review
The Auditor received documentation for each standard as part of the pre-onsite audit phase
data gathering process. Additional documentation was provided as requested until the
completion of the audit report. The PREA Pre-Audit Questionnaire, facility policies and
procedures and supporting documentation were reviewed prior to the interviews and the site
review and afterwards.
The supporting documentation reviewed included but was not limited to various forms
documenting service delivery and activities; vulnerability assessments; PREA education and
training materials; training certificates; training logs; checklists; evidence of unannounced
rounds; coordinated response plan; related written communication; annual staffing plan
assessment; written agreement; staff schedules; investigation reports; personnel records; and
organization chart. PREA training was documented by training logs, acknowledgement
statements; training materials; and policies.
Exit Meeting
An exit meeting was held with the Assistant Facility Administrator at the conclusion of the site
review. The exit meeting served to review the process and provided the Auditor the opportunity
to share the notes and request additional information resulting from the review of policies and
procedures and other documents, interviews, and observations during the site review.
The Assistant Facility Administrator was given the opportunity to ask additional questions
about the audit process and provided the timelines regarding the interim and final reports. The
Auditor also reviewed the documents needed to show the implementation of the corrective
actions to address provision of the PREA education refresher courses to the residents and
direct care staff.
Post Site Review Phase
Key Processes and Methodology
The Director of Nursing confirmed advocacy services in a telephone interview. The services
include but are not limited to accompaniment during the forensic medical examination and
investigative interview, access to support services, confidential emotional support, and referral
services.
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The Auditor maintained communication with the Facility Administrator, Assistant Facility
Administrator and the DJJ statewide PREA Coordinator until all requested additional
information was received. The additional information included documentation showing the
implementation of a corrective action plan which was the provision of PREA refresher
education sessions for residents and in order for residents to receive clear and un-contradicted
information regarding the advocacy agency and services provided. The documentation
provided to the Auditor included a training roster and the flyer and written agreement.
The documentation and information provided prior to and after the onsite audit phase,
including corrective actions implemented; consideration of all interviews; and observations
made during the site review verified the standards were met. The final report was concluded
and submitted to the DJJ statewide PREA Coordinator for subsequent delivery to the facility.
Facility Characteristics
The auditor’s description of the audited facility should include details about the facility type, demographics
and size of the inmate, resident or detainee population, numbers and type of staff positions, configuration
and layout of the facility, numbers of housing units, description of housing units including any special
housing units, a description of programs and services, including food service and recreation. The auditor
should describe how these details are relevant to PREA implementation and compliance.
The facility consists of six buildings that include but are not limited to containing the following
areas: administration; living units; control room; dining hall/kitchen; school; intake area; and
clinic. The facility uses space for indoor leisure activities and has ample outdoor space for
recreation activities and large muscle exercise. There two living units are located in the
building with the control room, dining hall, kitchen, and office space. Each housing unit has a
dayroom area and bathroom facilities. The bathrooms provide a reasonable amount of privacy
for the residents and only one resident is allowed in the bathroom at a time. There are eight
multiple occupancy rooms and no open bay/dormitory housing units within the facility. There
are full bathrooms located between a set of rooms; each bathroom has a door and there is a
curtain surrounding the bathtub/shower.
The administration building contains a large open area surrounded by offices, conference
room, and file room. The primary entrance to the program is the separate aforementioned
building that contains the control room. Visitors are received at the front of the control room
just inside the perimeter fence and are required to sign-in/out at the window of the control
room. The security camera system is monitored periodically from the control room and
cameras are strategically placed inside and outside of the buildings. The Facility Administrator
and Assistant Facility Administrator have the capacity to monitor the cameras from their
offices.
The camera system has received upgraded software since the last PREA audit in 2017. The
cameras can store data for up to 30 days. Direct supervision is provided by staff and all
resident movement is monitored by staff and may be observed electronically by staff through
the camera system. Cameras do not interfere with a resident’s privacy during personal hygiene
14
activities. The cameras do not provide a view of the inside of the bathrooms or the bedrooms.
There are 35 cameras located at the facility and all cameras were operational during the time
of the site visit.
The outside grounds provide areas ample enough to accommodate an array of activities and
contains a pond at the heart of the campus. There is also a garden area that is maintained by
the teachers and residents. The vegetables are harvested from the garden by the residents
and teachers and are included in the lunch meals.
During the comprehensive site review, posters and signs were observed in various areas
regarding reporting allegations of sexual abuse and sexual harassment. Grievance, sick call,
and other forms were observed. The forms were previously kept in the staff breakroom and
provided to residents upon their request. After the recommendation by the Auditor, the forms
are now located in the dayroom/multi-purpose area, implemented by the Assistant Facility
Administrator.
The program provides gender-responsive services that are tailored to the special needs of the
population. Onsite medical and mental health services also address the individual needs of the
residents. Each resident receives case management services and is assigned a Therapist. An
individualized treatment plan is developed with each resident and goals are identified. The
length of stay at the facility is six to nine months and is based on the resident’s pace of
success in completing her individualized treatment plan and goals.
An array of treatment and program services are provided at the facility and include but are not
limited to the following:
1) Education
2) Mental Health
3) Medical
4) Individual, Group and Family Therapy
5) General Counseling
6) Religious
7) Restorative Justice Activities
8) Completing Court Sanctions
9) Transition services
Physical fitness and recreational activities are designed to offer residents a chance to learn
and practice new skills and engage in athletic events or other activities which promote good
health and fitness. Each resident is provided the opportunity for daily recreational activities, for
a period of at least one hour, which permits large muscle activity. The residents are given the
opportunity to learn more about the human body during the physical fitness and recreational
activities. The program offers educational courses which include English, Mathematics,
Science, Social Studies, Reading, and one elective course. Education services are provided by
the Pasco County School District.
15
The program has a behavior management system which is also used to assist in changing a
resident’s behavior. The system rewards residents for making good choices. Residents have
the opportunity to earn points by demonstrating such behavior throughout the day. Positive
behavior has incentives attached and there are consequences for negative behavior.
Residents are also provided the opportunity to learn positive ways of dealing with stressful
situations and ultimately transition back to their local communities.
Residents have the opportunity to communicate with family which includes mother, father,
guardian, and grandparents. Residents also have the opportunity also communicate with Case
Workers with the Florida Department of Children and Families where that agency is the
guardian. Telephone calls are generally scheduled weekly and made on specific days
according to level or treatment team assignment. Residents are allowed to write and receive
letters from an approved mailing list. Visitation is conducted on the weekends. Special visits
will be scheduled during the week where deemed necessary and approved by the Facility
Administrator.
The interviews and observations during the comprehensive site review and discussions with
staff confirmed that residents are afforded access to visitors, attorneys and court workers and
visits may be conducted in private as needed. During the suspension and restrictions of
visitation during COVID-19 restrictions, residents were allowed to visit through video calls, in
addition to telephone calls. Residents also have access to writing materials to make contact
with parents, guardians, attorneys, court personnel, and other approved persons.
Third-party reporting information is available and accessible to visitors, residents, contractors,
volunteers, and employees through the posting of the hotline numbers and information
contained on the TrueCore Behavioral Solutions, LLC and DJJ websites. Administrative
investigations are conducted by the DJJ investigators. When it is determined an allegation of
sexual abuse or sexual harassment is criminal in nature, the case is referred to the local law
enforcement agency. The Auditor observed postings within the facility that contain the
information for reporting sexual abuse and sexual harassment.
The PREA education materials were reviewed and general PREA information is included in the
resident handbook. The victim advocacy information is posted in the dayroom/multi-purpose
area and has been reviewed with residents during a refresher PREA education session.
Information on the DJJ website is specific to each state-run and contract facility. The TrueCore
Behavioral Solutions, LLC website also contains information about the facility and has links to
the DJJ website and PREA Resource Center. Upon a resident’s request to make a telephone
call to report an allegation of sexual abuse or sexual harassment, the staff must ensure this
occurs without impediment.
The mental health staff include the Clinical Director, three Clinical Therapists and a Recreation
Therapist. A contract psychiatrist and psychologist provide services weekly. Mental health
services include but are not limited to individual, group, and family therapy; group services;
evaluations and services; and psychiatric medication management. The therapy sessions are
aligned with the individualized performance plan. Medical services are provided and
coordinated by the Health Service Administrator (HSA). In addition to the HSA, the medical
16
unit includes three Licensed Practical Nurses. A contract physician provides services at the
facility weekly. New admissions receive a nursing assessment, physical examination, and a
review of their immunization record. The Pasco County Health Department assists in keeping
the resident’s immunizations current. During the resident’s stay at the facility, she receives
routine medical care as needed. Nursing sick call is held regularly on weekdays; only medical
emergencies are handled on the weekends.
The Case Managers oversee all aspects of the resident’s program involvement and serves as
a liaison to all service areas within the facility. Direct care staff members are responsible for
the daily and direct supervision of residents and manage them during daily activities. The staff
to resident ratio was observed to be met during the site review. There is a host of staff
members consisting of management, supervisory, support, volunteer and contract who provide
oversite of or participation in processes and activities that contribute to the facility operations
and service delivery.
Documentation and staff and resident interviews confirmed the provision of the programs and
services described. The residents indicated during the interviews that they could communicate
with their parents/guardians. Communication is maintained through telephone calls, video
calls, and visitation. Observations during the site review revealed adequate space for
conducting the programs and services described and regular and special visitation.
17
Summary of Audit Findings
The summary should include the number and list of standards exceeded, number of standards met, and
number and list of standards not met.
Auditor Note: No standard should be found to be “Not Applicable” or “NA”. A compliance determination
must be made for each standard.
Standards Exceeded
Number of Standards Exceeded: 0
List of Standards Exceeded: Click or tap here to enter text.
Standards Met
Number of Standards Met: 41
Standards Not Met
Number of Standards Not Met: 0
List of Standards Not Met: Click or tap here to enter text.
18
PREVENTION PLANNING
Standard 115.311: Zero Tolerance of Sexual Abuse and Sexual Harassment;
PREA Coordinator
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.311 (a)
▪ Does the agency have a written policy mandating zero tolerance toward all forms of sexual
abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the written policy outline the agency’s approach to preventing, detecting, and responding
to sexual abuse and sexual harassment? ☒ Yes ☐ No
115.311 (b)
▪ Has the agency employed or designated an agency-wide PREA Coordinator? ☒ Yes ☐ No
▪ Is the PREA Coordinator position in the upper-level of the agency hierarchy? ☒ Yes ☐ No
▪ Does the PREA Coordinator have sufficient time and authority to develop, implement, and
oversee agency efforts to comply with the PREA standards in all of its facilities? ☒ Yes ☐ No
115.311 (c)
▪ If this agency operates more than one facility, has each facility designated a PREA compliance
manager? (N/A if agency operates only one facility.) ☒ Yes ☐ No ☐ NA
▪ Does the PREA compliance manager have sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards? (N/A if agency operates only one facility.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
19
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Facility Policy 3-36
Facility Policy 3-5
Agency Policy FDJJ 1919
Organization Charts
Interviews:
Facility Administrator
Random Staff
Residents
Provision (a):
An agency shall have a written policy mandating zero tolerance toward all forms of sexual abuse and
sexual harassment and outlining the agency’s approach to preventing, detecting, and responding to
such conduct.
The facility Policies and DJJ agency Policy collectively provide direction to staff regarding the facility’s
approach to preventing, detecting, and responding to allegations of sexual abuse and sexual
harassment. The Policies provide and address conduct that violates the zero-tolerance approach
regarding all forms of sexual abuse and sexual harassment. Definitions of prohibited behaviors of
sexual abuse and sexual harassment are contained in Policy and include sanctions for those found to
have participated in the prohibited behaviors. The DJJ agency Policy, FDJJ 1919, serves as the
overarching PREA Policy for the state-run and contract facilities. The facility also has additional policies
which support adherence to the PREA standards.
Staff training, resident education, and intake screening assist in detecting sexual abuse and sexual
harassment. The identified and other supporting Policies include but are not limited to responding to
sexual abuse and sexual harassment through prevention; responsive planning; training and education;
reporting; investigations; medical and mental care; assessments; disciplinary sanctions for residents
and staff; and data collection and review. The interviews confirmed knowledge of the zero-tolerance of
sexual abuse and sexual harassment.
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA Coordinator with sufficient
time and authority to develop, implement, and oversee agency efforts to comply with the PREA
standards in all of its facilities.
The Facility Administrator serves as the PREA Compliance Manager and serves on the facility’s
management team with direct access to the facility’s leadership staff and the DJJ statewide PREA
Coordinator regarding PREA related issues. The Facility Administrator has knowledge of the standards
and their implementation and the audit processes. The facility policy designates a corporate staff as the
PREA Coordinator however the position was vacant during the vast majority of the audit processes.
The position was filled toward the conclusion of the audit. The DJJ statewide PREA Coordinator lends
support to all of the contract facilities as determined from observations, review of documentation and
previous interview and continual communication between the Auditor and the statewide PREA
Coordinator.
20
Provision (c):
Where an agency operates more than one facility, each facility shall designate a PREA Compliance
Manager with sufficient time and authority to coordinate the facility’s efforts to comply with the PREA
standards.
The Facility Administrator has been designated as the PREA Compliance Manager and indicated she
has the time to fulfill the PREA duties and it was determined that she has the authority required to fulfill
those duties. Interviews conducted with all staff revealed their awareness of the role of the PREA
Compliance Manager. Observations confirmed she has the support of the Assistant Facility
Administrator, facility staff, and the DJJ statewide PREA Coordinator. The facility and agency policies
provide for the designation of the PREA Compliance Manager within the facility.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and observations, it was
determined there is compliance with this standard.
Standard 115.312: Contracting With Other Entities for the Confinement of
Residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.312 (a)
▪ If this agency is public and it contracts for the confinement of its residents with private agencies
or other entities including other government agencies, has the agency included the entity’s
obligation to adopt and comply with the PREA standards in any new contract or contract
renewal signed on or after August 20, 2012? (N/A if the agency does not contract with private
agencies or other entities for the confinement of residents.) ☒ Yes ☐ No ☐ NA
115.312 (b)
▪ Does any new contract or contract renewal signed on or after August 20, 2012 provide for
agency contract monitoring to ensure that the contractor is complying with the PREA standards?
(N/A if the agency does not contract with private agencies or other entities for the confinement
of residents OR the response to 115.312(a)-1 is "NO".) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
21
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Contract Log
PREA Audit Reports
Interviews:
Facility Administrator
Statewide PREA Coordinator
Provision (a) and (b):
Provision (a): A public agency that contracts for the confinement of its residents with private agencies
or other entities, including other government agencies, shall include in any new contract or contract
renewal the entity’s obligation to adopt and comply with the PREA standards.
Provision (b): Any new contract or contract renewal shall provide for agency contract monitoring to
ensure that the contractor is complying with the PREA standards.
The public agency contracts for the confinement of its residents. Contracts exist that inform the
contractors of the requirements by the Florida Department of Juvenile Justice to comply with the PREA
Standards and participate in PREA audits. The practice was also confirmed by previous and current
interviews and completed PREA audit reports for this facility and other contract sites.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined compliance with
this standard.
Standard 115.313: Supervision and Monitoring
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.313 (a)
▪ Does the agency ensure that each facility has developed a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility has implemented a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility has documented a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
22
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: The
prevalence of substantiated and unsubstantiated incidents of sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring:
Generally accepted juvenile detention and correctional/secure residential practices?
☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
judicial findings of inadequacy? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
findings of inadequacy from Federal investigative agencies? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
findings of inadequacy from internal or external oversight bodies? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: All
components of the facility’s physical plant (including “blind-spots” or areas where staff or
residents may be isolated)? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: The
composition of the resident population? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: The
number and placement of supervisory staff? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring:
Institution programs occurring on a particular shift? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
applicable State or local laws, regulations, or standards? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
other relevant factors? ☒ Yes ☐ No
115.313 (b)
23
▪ Does the agency comply with the staffing plan except during limited and discrete exigent
circumstances? ☒ Yes ☐ No
▪ In circumstances where the staffing plan is not complied with, does the facility document all
deviations from the plan? (N/A if no deviations from staffing plan.) ☐ Yes ☐ No ☒ NA
115.313 (c)
▪ Does the facility maintain staff ratios of a minimum of 1:8 during resident waking hours, except
during limited and discrete exigent circumstances? (N/A only until October 1, 2017.)
☒ Yes ☐ No ☐ NA
▪ Does the facility maintain staff ratios of a minimum of 1:16 during resident sleeping hours,
except during limited and discrete exigent circumstances? (N/A only until October 1, 2017.)
☒ Yes ☐ No ☐ NA
▪ Does the facility fully document any limited and discrete exigent circumstances during which the
facility did not maintain staff ratios? (N/A only until October 1, 2017.) ☒ Yes ☐ No ☐ NA
▪ Does the facility ensure only security staff are included when calculating these ratios? (N/A only
until October 1, 2017.) ☒ Yes ☐ No ☐ NA
▪ Is the facility obligated by law, regulation, or judicial consent decree to maintain the staffing
ratios set forth in this paragraph? ☐ Yes ☒ No
115.313 (d)
▪ In the past 12 months, has the facility, in consultation with the agency PREA Compliance Manager,
assessed, determined, and documented whether adjustments are needed to: The staffing plan
established pursuant to paragraph (a) of this section? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Compliance
Manager, assessed, determined, and documented whether adjustments are needed to:
Prevailing staffing patterns? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Compliance
Manager, assessed, determined, and documented whether adjustments are needed to: The
facility’s deployment of video monitoring systems and other monitoring technologies? ☒ Yes
☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Compliance
Manager, assessed, determined, and documented whether adjustments are needed to: The
resources the facility has available to commit to ensure adherence to the staffing plan? ☒ Yes
☐ No
115.313 (e)
24
▪ Has the facility implemented a policy and practice of having intermediate-level or higher-level
supervisors conduct and document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? (N/A for non-secure facilities) ☒ Yes ☐ No ☐ NA
▪ Is this policy and practice implemented for night shifts as well as day shifts? (N/A for non-secure
facilities) ☒ Yes ☐ No ☐ NA
▪ Does the facility have a policy prohibiting staff from alerting other staff members that these
supervisory rounds are occurring, unless such announcement is related to the legitimate
operational functions of the facility? (N/A for non-secure facilities) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-9
Facility Policy 10-25
Staffing Plan
Work Schedules
Annual Staffing Assessment
PREA Unannounced Rounds
Interviews:
Facility Administrator
Assistant Facility Administrator
Provision (a):
The agency shall ensure that each facility it operates shall develop, implement, and document a staffing
plan that provides for adequate levels of staffing, and, where applicable, video monitoring, to protect
residents against sexual abuse. In calculating adequate staffing levels and determining the need for
video monitoring, facilities shall take into consideration:
(1) Generally accepted juvenile detention and correctional/secure residential practices;
(2) Any judicial findings of inadequacy;
(3) Any findings of inadequacy from Federal investigative agencies;
(4) Any findings of inadequacy from internal or external oversight bodies;
25
(5) All components of the facility’s physical plant (including “blind spots” or areas where staff or
residents may be isolated);
(6) The composition of the resident population;
(7) The number and placement of supervisory staff;
(8) Institution programs occurring on a particular shift;
(9) Any applicable State or local laws, regulations, or standards;
(10) The prevalence of substantiated and unsubstantiated incidents of sexual abuse; and
(11) Any other relevant factors.
The Policies and staffing plan provide details for maintaining the staffing ratios and the staffing plan
outlines the staffing requirements. The facility’s staffing plan, internal controls and management
ensures that the PREA staffing ratios of 1:8 during the waking hours and 1:16 during the sleeping hours
are maintained or exceeded. Direct supervision is provided to residents during the daily activities and
program services. The number of staff increases as needed due to program activities, one-on-one
supervision indicated, or other relevant factors. Observations during the site review and interviews
indicated the staffing ratios are maintained. The facility maintains a mandatory hold-over system to
ensure adherence to the staffing ratios and staffing plan.
The camera system is located in the control room in the main building and is periodically monitored.
The Facility Administrator and Assistant Facility Administrator have the capability to monitor the
cameras from their offices. Provisions of the standard are taken into consideration regarding adequate
staffing levels as confirmed through the interviews which outline staffing requirements. The work
schedules are based on the facility’s staffing plan of 1:6 during the waking hours and 1:8 during the
sleeping hours. The interview with the Facility Administrator revealed collaboration and review of the
work schedules on a regular basis. In addition to program activities and special needs of residents, the
shift schedules are made regarding the considerations that ensure adequate shift coverage including
standard security practices; composition of the resident population; inclement weather; and
emergencies.
Provision (b):
The agency shall comply with the staffing plan except during limited and discrete exigent
circumstances, and shall fully document deviations from the plan during such circumstances.
The facility reports no deviations from the staffing ratios in the past 12 months. A coordinated effort was
described in maintaining the staffing ratios which meets or exceeds the PREA ratios. The operations of
the facility provide for staff to be held-over on identified mandated hold-over days. The facility is
prepared to document any deviations from the staffing requirements. The Facility Administrator
regularly monitors the effectiveness of the work schedules based on the staffing plan requirements. The
staffing plan shows the required staffing ratios. The staffing plan provides for the staffing ratios to be
met and can provide for additional staff for days and times when increased staffing is required.
Provision (c):
Each secure juvenile facility shall maintain staff ratios of a minimum of 1:8 during resident waking hours
and 1:16 during resident sleeping hours, except during limited and discrete exigent circumstances,
which shall be fully documented. Only security staff shall be included in these ratios. Any facility that, as
of the date of publication of this final rule, is not already obligated by law, regulation, or judicial consent
decree to maintain the staffing ratios set forth in this paragraph shall have until October 1, 2017, to
achieve compliance.
Staffing ratios for the facility are provided by the direct care staff. The security practices and policies
ensure the PREA ratios of 1:8 during the waking hours and 1:16 during the sleeping hours. The ratios
26
were discussed and observed for and met during the site review and review of documentation. Direct
care staff members provide direct observation of residents. Since the last PREA audit the average daily
number of residents is 20. Since the last PREA audit, the average daily number of residents on which
the staffing plan was predicated is 20. The facility is not involved in any lawsuits or consent decrees.
Provision (d):
Whenever necessary, but no less frequently than once each year, for each facility the agency operates,
in consultation with the PREA Compliance Manager required by §115.311, the agency shall assess,
determine, and document whether adjustments are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this section;
(2) Prevailing staffing patterns;
(3) The facility’s deployment of video monitoring systems and other monitoring technologies; and
(4) The resources the facility has available to commit to ensure adherence to the staffing plan.
The formally documented assessment data was completed by the DJJ statewide PREA Coordinator
who also facilitated the process, in collaboration with the Assistant Facility Administrator acting as the
designee for the Facility Administrator/PREA Compliance Manager. The document reviews but is not
limited to the following areas: prevailing staffing patterns and review of staffing plan; electronic
monitoring system; and review of other areas related to adequate supervision. The review considers
any adjustments that need to be made by the construction and implementation of a corrective action
plan where indicated through findings of recommendations. The annual assessment documents the
summarization of the review including the staffing, physical plant and electronic monitoring system and
no corrective actions were recommended.
Provision (e):
Each secure facility shall implement a policy and practice of having intermediate-level or higher-level
supervisors conduct and document unannounced rounds to identify and deter staff sexual abuse and
sexual harassment. Such policy and practice shall be implemented for night shifts as well as day shifts.
Each secure facility shall have a policy to prohibit staff from alerting other staff members that these
supervisory rounds are occurring, unless such announcement is related to the legitimate operational
functions of the facility.
Policy provides for the occurrence of unannounced rounds that are conducted by management staff
members (Administrative Duty Officer). The documents show the rounds are made at various times. A
form is used which records the areas visited and considerations and observations may be included.
The walkthrough may also be documented in the logbook. The interviews with the Assistant Facility
Administrator and Facility Administrator confirmed the unannounced rounds occur.
The staff is not informed of when the rounds will occur, and the visits are not conducted at scheduled
times in accordance with Policy 10-9. The unannounced rounds are conducted throughout the facility to
identify and deter sexual abuse and sexual harassment. Staff members are prohibited from alerting
other staff when the rounds are occurring. The facility reports there were no deviations from the staffing
plan which was also supported by the Staffing Plan Assessment.
Conclusion:
Based upon the review and analysis of the available evidence and the staff interview, the Auditor
determined the facility is adhering to this standard.
Standard 115.315: Limits to Cross-Gender Viewing and Searches
27
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.315 (a)
▪ Does the facility always refrain from conducting any cross-gender strip or cross-gender visual
body cavity searches, except in exigent circumstances or by medical practitioners?
☒ Yes ☐ No
115.315 (b)
▪ Does the facility always refrain from conducting cross-gender pat-down searches in non-exigent
circumstances? ☒ Yes ☐ No ☐ NA
115.315 (c)
▪ Does the facility document and justify all cross-gender strip searches and cross-gender visual
body cavity searches? ☒ Yes ☐ No
▪ Does the facility document all cross-gender pat-down searches? ☒ Yes ☐ No
115.315 (d)
▪ Does the facility implement policies and procedures that enable residents to shower, perform
bodily functions, and change clothing without nonmedical staff of the opposite gender viewing
their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is
incidental to routine cell checks? ☒ Yes ☐ No
▪ Does the facility require staff of the opposite gender to announce their presence when entering
a resident housing unit? ☒ Yes ☐ No
▪ In facilities (such as group homes) that do not contain discrete housing units, does the facility
require staff of the opposite gender to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions, or changing clothing? (N/A for
facilities with discrete housing units) ☒ Yes ☐ No ☐ NA
115.315 (e)
▪ Does the facility always refrain from searching or physically examining transgender or intersex
residents for the sole purpose of determining the resident’s genital status? ☒ Yes ☐ No
▪ If a resident’s genital status is unknown, does the facility determine genital status during
conversations with the resident, by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted in private by a medical
practitioner? ☒ Yes ☐ No
115.315 (f)
28
▪ Does the facility/agency train security staff in how to conduct cross-gender pat down searches
in a professional and respectful manner, and in the least intrusive manner possible, consistent
with security needs? ☒ Yes ☐ No
▪ Does the facility/agency train security staff in how to conduct searches of transgender and
intersex residents in a professional and respectful manner, and in the least intrusive manner
possible, consistent with security needs? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Facility Policy 10-3
Agency Policy FDJJ 1919
Training Curricula
Statement of Preference Form
Acknowledgement Statements
Electronic Training Records
Interviews
Random Staff
Facility Administrator
Residents
Provision (a):
The facility shall not conduct cross-gender strip searches or cross-gender visual body cavity searches
(meaning a search of the anal or genital opening) except in exigent circumstances or when performed
by medical practitioners.
These type cross-gender searches are prohibited. Cross-gender pat-sown searches are not permitted,
except in exigent circumstances and they must be documented. Policy and training provide guidance to
staff on how the searches are to be conducted. The practice is that cross-gender pat searches are not
conducted. There is no evidence of cross-gender searches of any type occurring at the facility in the
29
last 12 months. Based on the review of the Pre-audit questionnaire and according to the interviews,
cross-gender searches have not been conducted at the facility during the past 12 months.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent circumstances.
Policy does not support staff conducting cross-gender pat-down searches, except in exigent
circumstances. All searches and the reason for the search must be documented. Responses included
that a female staff only conduct searches. There would have to be contraband which indicated an
immediate threat for a cross-gender pat-down search to occur. The training materials show staff
receives training on how to conduct searches; staff participation in the training is documented. Staff
interviews confirmed awareness of searches. No residents or staff interviewed reported the occurrence
of any cross-gender searches. The evidence shows cross-gender pat-down searches have not
occurred at the facility during the last 12 months.
Provision (c):
The facility shall document and justify all cross-gender strip searches, cross-gender visual body cavity
searches, and cross-gender pat-down searches.
Cross-gender strip and cross-gender visual body cavity searches are prohibited. Policy provides for
documenting the occurrence of searches and the reasons for each type of search. All interviews
confirmed that no cross-gender searches have not occurred at the facility during this audit period. Staff
members are instructed to document all searches. There was no evidence documenting any cross-
gender searches.
Provision (d):
The facility shall implement policies and procedures that enable residents to shower, perform bodily
functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts,
buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell
checks. Such policies and procedures shall require staff of the opposite gender to announce their
presence when entering a resident housing unit. In facilities (such as group homes) that do not contain
discrete housing units, staff of the opposite gender shall be required to announce their presence when
entering an area where residents are likely to be showering, performing bodily functions, or changing
clothing.
Residents are able to shower, perform bodily functions, and change clothes without staff of the opposite
gender viewing them, supported by policy and interviews. This practice was confirmed through
interviews with residents and staff. No residents interviewed reported ever having been naked in full
view of the opposite gender staff while showering, changing clothes, and performing bodily functions.
During the site review, the Assistant Facility Administrator explained how hygiene practices are
conducted and the bathroom procedures. It was observed that residents have a reasonable amount of
privacy during use of the bathroom. Residents use the bathroom one at a time and shower curtains
cover the bathtub which also doubles as the shower.
Staff members of the opposite gender must announce their presence when entering the residents’
housing units and signs are posted. The residents stated that male staff announce their presence upon
entering the living units. The practice of opposite gender announcement was confirmed by the random
staff interviews. The evidence shows residents shower, perform bodily functions, and change clothing
without nonmedical staff of the opposite gender viewing their buttocks or genitalia. The staff interviews
and observations supported that viewing of the camera monitors does not show residents when they
are showering, using the toilet, or changing clothes. The shower and toilet area do not allow staff to get
30
a view of the resident’s body. Hygiene practices are performed with the expectations of reasonable
privacy for each resident.
Provision (e):
The facility shall not search or physically examine a transgender or intersex resident for the sole
purpose of determining the resident’s genital status. If the resident’s genital status is unknown, it may
be determined during conversations with the resident, by reviewing medical records, or, if necessary,
by learning that information as part of a broader medical examination conducted in private by a medical
practitioner.
Policy and the training curriculum prohibit the search of transgender or intersex residents solely for the
purpose of determining the residents’ genital status and staff interviews verified no such searches have
occurred or would occur at the facility. The facility reports that staff received the training on conducting
searches and searches of transgender and intersex youth. Staff interviews confirmed they are aware
that Policy prohibits staff from conducting a physical examination of transgender or intersex youth
solely for the purpose of determining the resident’s genital status. When the genital status of a resident
is unknown, learning this information would be part of a broader medical examination conducted by a
medical practitioner in private. The facility will utilize the Statement of Preference Form where indicated
when a youth indicates the gender of the staff preferred to conduct the search.
Provision (f):
The agency shall train security staff in how to conduct cross-gender pat-down searches, and searches
of transgender and intersex residents, in a professional and respectful manner, and in the least
intrusive manner possible, consistent with security needs.
The training curricula for staff provides information on conducting cross-gender pat-down searches and
searches of transgender and intersex youth. Electronic training records, interviews and training
materials indicate the provision of search techniques consistent with the security needs. A dedicated
form, Statement of Preference, may be used for a youth to identify the sexual preference of the staff to
perform the searches. The training materials and interviews indicate staff receive the training. No such
searches have been conducted during the past 12 months.
Conclusion:
Based on the reviewed documentation and interviews, the Auditor determined compliance with this
standard.
Standard 115.316: Residents with Disabilities and Residents Who Are
Limited English Proficient
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.316 (a)
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who are deaf or hard
of hearing? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
31
and respond to sexual abuse and sexual harassment, including: Residents who are blind or
have low vision? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who have intellectual
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who have psychiatric
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who have speech
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Other? (if "other," please
explain in overall determination notes.) ☒ Yes ☐ No
▪ Do such steps include, when necessary, ensuring effective communication with residents who
are deaf or hard of hearing? ☒ Yes ☐ No
▪ Do such steps include, when necessary, providing access to interpreters who can interpret
effectively, accurately, and impartially, both receptively and expressively, using any necessary
specialized vocabulary? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Have
intellectual disabilities? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Have
limited reading skills? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Are
blind or have low vision? ☒ Yes ☐ No
115.316 (b)
▪ Does the agency take reasonable steps to ensure meaningful access to all aspects of the
agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment to
residents who are limited English proficient? ☒ Yes ☐ No
32
▪ Do these steps include providing interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any necessary specialized vocabulary?
☒ Yes ☐ No
115.316 (c)
▪ Does the agency always refrain from relying on resident interpreters, resident readers, or other
types of resident assistants except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s safety, the performance of
first-response duties under §115.364, or the investigation of the resident’s allegations?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Facility Policy 9-2
Agency Policy FDJJ 1919
Interviews:
Residents
Random Staff
Facility Administrator
Assistant Facility Administrator
Provision (a):
The agency shall take appropriate steps to ensure that residents with disabilities (including, for
example, residents who are deaf or hard of hearing, those who are blind or have low vision, or those
who have intellectual, psychiatric, or speech disabilities), have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual abuse and
sexual harassment. Such steps shall include, when necessary to ensure effective communication with
residents who are deaf or hard of hearing, providing access to interpreters who can interpret effectively,
accurately, and impartially, both receptively and expressively, using any necessary specialized
vocabulary. In addition, the agency shall ensure that written materials are provided in formats or
33
through methods that ensure effective communication with residents with disabilities, including
residents who have intellectual disabilities, limited reading skills, or who are blind or have low vision. An
agency is not required to take actions that it can demonstrate would result in a fundamental alteration in
the nature of a service, program, or activity, or in undue financial and administrative burdens, as those
terms are used in regulations promulgated under title II of the Americans With Disabilities Act, 28 CFR
35.164.
Policies address the provision of support services for Limited English Proficient and disabled residents
by providing residents the equal opportunity to participate in or benefit from all aspects of the facility’s
efforts to prevent, detect, and respond to sexual abuse and sexual harassment. Residents are not used
as readers or interpreters, confirmed by staff interviews. The facility has bilingual staff that will assist
with interpreting.
Policy provides for interpreter and translation services, including the services for the Deaf. The facility’s
parent agency has a contract for services with Language Line Solutions. An additional resource for the
facility is a Nationally Certified Interpreter through the Florida Registry of Interpreters for the Deaf. The
education and school district provides support services, especially through certified teachers with the
educational background to modify/adapt information for all residents to understand. Assistance may
also be provided by the treatment staff to ensure all residents’ understanding of the PREA information.
Posted and other PREA information is in English and Spanish.
Provision (b):
The agency shall take reasonable steps to ensure meaningful access to all aspects of the agency’s
efforts to prevent, detect, and respond to sexual abuse and sexual harassment to residents who are
limited English proficient, including steps to provide interpreters who can interpret effectively,
accurately, and impartially, both receptively and expressively, using any necessary specialized
vocabulary.
Professional interpreting services are available. Each resident has an equal opportunity to participate in
or benefit from all aspects of the facility’s efforts to prevent, detect and respond to sexual abuse and
sexual harassment. PREA information is accessible to residents in English, Spanish and other
languages are obtainable where indicated. The facility is capable of providing access to support
services for preventing, detecting, and responding to sexual abuse and sexual harassment to residents
who are Limited English Proficient, including taking steps to provide interpreters who can interpret
effectively, accurately, and impartially.
Provision (c):
The agency shall not rely on resident interpreters, resident readers, or other types of resident assistants
except in limited circumstances where an extended delay in obtaining an effective interpreter could
compromise the resident’s safety, the performance of first-response duties under §115.364, or the
investigation of the resident’s allegations.
Policies prohibit the use of resident readers and interpreters except in limited circumstances where an
extended delay in obtaining an interpreter could compromise a resident’s safety; performance of first
responder duties; or investigation of allegations of sexual abuse or sexual harassment. The facility
documents that there is access to services. The school system and teachers assist, and facility mental
health staff members have the capabilities to provide support services. Information regarding reporting
allegations of sexual abuse and sexual harassment is posted and accessible in both English and
Spanish. The facility has the resources available to get the PREA information translated and printed in
the additional languages as needed.
34
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the facility is compliant
with this standard.
Standard 115.317: Hiring and Promotion Decisions
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.317 (a)
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who: Has engaged in sexual abuse in a prison, jail, lockup, community confinement
facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who: Has been convicted of engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or coercion, or if the victim did
not consent or was unable to consent or refuse? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who: Has been civilly or administratively adjudicated to have engaged in the activity
described in the question immediately above? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact
with residents who: Has engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact
with residents who: Has been convicted of engaging or attempting to engage in sexual activity in
the community facilitated by force, overt or implied threats of force, or coercion, or if the victim
did not consent or was unable to consent or refuse? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact
with residents who: Has been civilly or administratively adjudicated to have engaged in the
activity described in the question immediately above? ☒ Yes ☐ No
115.317 (b)
▪ Does the agency consider any incidents of sexual harassment in determining whether to hire or
promote anyone, or to enlist the services of any contractor, who may have contact with
residents? ☒ Yes ☐ No
115.317 (c)
▪ Before hiring new employees, who may have contact with residents, does the agency: Perform
a criminal background records check? ☒ Yes ☐ No
35
▪ Before hiring new employees, who may have contact with residents, does the agency: Consult
any child abuse registry maintained by the State or locality in which the employee would work?
☒ Yes ☐ No
▪ Before hiring new employees, who may have contact with residents, does the agency:
Consistent with Federal, State, and local laws, makes its best efforts to contact all prior
institutional employers for information on substantiated allegations of sexual abuse or any
resignation during a pending investigation of an allegation of sexual abuse? ☒ Yes ☐ No
115.317 (d)
▪ Does the agency perform a criminal background records check before enlisting the services of
any contractor who may have contact with residents? ☒ Yes ☐ No
▪ Does the agency consult applicable child abuse registries before enlisting the services of any
contractor who may have contact with residents? ☒ Yes ☐ No
115.317 (e)
▪ Does the agency either conduct criminal background records checks at least every five years of
current employees and contractors who may have contact with residents or have in place a
system for otherwise capturing such information for current employees? ☒ Yes ☐ No
115.317 (f)
▪ Does the agency ask all applicants and employees who may have contact with residents directly
about previous misconduct described in paragraph (a) of this section in written applications or
interviews for hiring or promotions? ☒ Yes ☐ No
▪ Does the agency ask all applicants and employees who may have contact with residents directly
about previous misconduct described in paragraph (a) of this section in any interviews or written
self-evaluations conducted as part of reviews of current employees? ☒ Yes ☐ No
▪ Does the agency impose upon employees a continuing affirmative duty to disclose any such
misconduct? ☒ Yes ☐ No
115.317 (g)
▪ Does the agency consider material omissions regarding such misconduct, or the provision of
materially false information, grounds for termination? ☒ Yes ☐ No
115.317 (h)
▪ Unless prohibited by law, does the agency provide information on substantiated allegations of
sexual abuse or sexual harassment involving a former employee upon receiving a request from
an institutional employer for whom such employee has applied to work? (N/A if providing
36
information on substantiated allegations of sexual abuse or sexual harassment involving a
former employee is prohibited by law.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 3-16
Facility Policy 10-25
Agency Policy FDJJ 1800
Agency Policy FDJJ 1919
Employee Handbook
Interview:
Human Resources Manager
Provision (a) & (f):
Provision (a): The agency shall not hire or promote anyone who may have contact with residents, and
shall not enlist the services of any contractor who may have contact with residents, who—
(1) Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile
facility, or other institution (as defined in 42 U.S.C. 1997).
(2) Has been convicted of engaging or attempting to engage in sexual activity in the community
facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was
unable to consent or refuse; or
(3) Has been civilly or administratively adjudicated to have engaged in the activity described in
paragraph (a)(2) of this section.
Provision (f): The agency shall also ask all applicants and employees who may have contact with
residents directly about previous misconduct described in paragraph (a) of this section in written
applications or interviews for hiring or promotions and in any interviews or written self-evaluations
conducted as part of reviews of current employees. The agency shall also impose upon employees a
continuing affirmative duty to disclose any such misconduct.
The collective Policies address hiring and other personnel matters, including and not limited to
promotion processes and decisions, position descriptions, and background checks, including child
abuse registries. The background checks occur initially and every five years thereafter, aligned with
Policy and the Standard. The personnel files include the completed background checks and hiring
37
documents. Background checks are obtained through the Florida Department of Juvenile Justice,
Background Screening Unit.
Through the employment application process, prior to hire and promotion, applicants are asked to
verify, in writing, the following information which is a part of the background screening information
packet:
• Have engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile
facility, or other institution (as defined in 42 U.S.C. 1997).
• Have been convicted of engaging or attempting to engage in sexual activity in the community
facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent
or was unable to consent or refuse; or,
• Have been civilly or administratively adjudicated to have engaged in the activity described above.
The interview and a review of Policies provided details about the hiring process, completion of
background checks, and grounds for termination. The forms completed and included in the personnel
files are responsive to the provisions of this standard. All applicants are asked about any prior
misconduct involving any sexual activity. The documentation, interview and Policies support the facility
does not hire anyone who has engaged in sexual abuse or anyone who has used or attempted to use
force in the community to engage in sexual abuse. This documentation is a part of the background
information packet, required for conducting the background checks.
Provision (b):
The agency shall consider any incidents of sexual harassment in determining whether to hire or
promote anyone, or to enlist the services of any contractor, who may have contact with residents.
The Policies support that the facility does not hire or promote anyone who has been civilly or
administratively adjudicated or have been convicted of engaging in or attempted to engage in sexual
activity by any means. The interview was aligned with the standard and the documentation shows the
inquiries made during the application process regarding previous misconduct.
Policy and the interview indicate the facility considers any incidents of sexual harassment in
determining whether to hire or promote anyone, or to enlist the services of any contractor or volunteer,
who may have contact with residents. No applicant will be considered for employment if a background
check reveals any history of inappropriate sexual behavior or arrest for inappropriate sexual behavior.
Provisions (c) & (d):
Provision (c): Before hiring new employees, who may have contact with residents, the agency shall:
(1) Perform a criminal background record check;
(2) Consult any child abuse registry maintained by the State or locality in which the employee would
work; and
(3) Consistent with Federal, State, and local law, make its best efforts to contact all prior institutional
employers for information on substantiated allegations of sexual abuse or any resignation during a
pending investigation of an allegation of sexual abuse.
Provision (d): The agency shall also perform a criminal background records check, and consult
applicable child abuse registries, before enlisting the services of any contractor who may have contact
with residents.
The background check process includes consulting a child abuse registry as confirmed during the
interview. The prospective employee or contractor also has to be cleared through the Florida
Department of Children and Families. Best efforts would be made to identify information of incidents or
allegations of sexual abuse by a prospective employee.
38
Provision (e):
The agency shall either conduct criminal background records checks at least every five years of current
employees and contractors who may have contact with residents or have in place a system for
otherwise capturing such information for current employees.
Initial background checks are conducted and are conducted every five years thereafter, in accordance
with Policy. The interview, review of documentation and a review of the Policies provide details about
the hiring process, completion of background checks, and the grounds for termination in accordance
with the PREA standard.
Provision (g):
Material omissions regarding such misconduct, or the provision of materially false information, shall be
grounds for termination.
The omission of sexual misconduct information or providing false information is grounds for termination
in accordance with Policy. According to the interview, this information is also covered in the new
employee orientation. Staff members have a continuing duty to report related misconduct as indicated
in the Employee Handbook. According to the interview, employees are informed during new employee
orientation that they have a continuing affirmative duty to disclose any such misconduct. Additionally,
DJJ notifies the facility if an employee is arrested.
Provision (h):
Unless prohibited by law, the agency shall provide information on substantiated allegations of sexual
abuse or sexual harassment involving a former employee upon receiving a request from an institutional
employer for whom such employee has applied to work.
The interview revealed that when a former employee applies for work at another institution, upon the
request from that institution, she will verify employment, provide the hire date and whether the person
would be re-hired.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility
meets the provisions of the standard.
Standard 115.318: Upgrades to Facilities and Technologies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.318 (a)
▪ If the agency designed or acquired any new facility or planned any substantial expansion or
modification of existing facilities, did the agency consider the effect of the design, acquisition,
expansion, or modification upon the agency’s ability to protect residents from sexual abuse?
(N/A if agency/facility has not acquired a new facility or made a substantial expansion to existing
facilities since August 20, 2012, or since the last PREA audit, whichever is later.)
☐ Yes ☐ No ☒ NA
115.318 (b)
39
▪ If the agency installed or updated a video monitoring system, electronic surveillance system, or
other monitoring technology, did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if agency/facility has not installed
or updated a video monitoring system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit, whichever is later.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Interview:
Facility Administrator
Provision (a):
If the agency designed or acquired any new facility or planned any substantial expansion or
modification of existing facilities, did the agency consider the effect of the design, acquisition,
expansion, or modification upon the agency’s ability to protect residents from sexual abuse?
The facility has not completed major renovations since the last PREA audit conducted in 2017.
Provision (b):
If the agency installed or updated a video monitoring system, electronic surveillance system, or other
monitoring technology, the agency considered how such technology may enhance the agency’s ability
to protect residents from sexual abuse.
The camera system supplements direct supervision provided to residents by staff. The system has
received a software update including DVR since the last PREA audit conducted in 2017.
RESPONSIVE PLANNING
Standard 115.321: Evidence Protocol and Forensic Medical Examinations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
40
115.321 (a)
▪ If the agency is responsible for investigating allegations of sexual abuse, does the agency follow
a uniform evidence protocol that maximizes the potential for obtaining usable physical evidence
for administrative proceedings and criminal prosecutions? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.)
☐ Yes ☐ No ☒ NA
115.321 (b)
▪ Is this protocol developmentally appropriate for youth where applicable? (N/A if the
agency/facility is not responsible for conducting any form of criminal OR administrative sexual
abuse investigations.) ☐ Yes ☐ No ☒ NA
▪ Is this protocol, as appropriate, adapted from or otherwise based on the most recent edition of
the U.S. Department of Justice’s Office on Violence Against Women publication, “A National
Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly
comprehensive and authoritative protocols developed after 2011? (N/A if the agency/facility is
not responsible for conducting any form of criminal OR administrative sexual abuse
investigations.) ☐ Yes ☐ No ☒ NA
115.321 (c)
▪ Does the agency offer all residents who experience sexual abuse access to forensic medical
examinations, whether on-site or at an outside facility, without financial cost, where evidentiarily
or medically appropriate? ☒ Yes ☐ No
▪ Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual
Assault Nurse Examiners (SANEs) where possible? ☒ Yes ☐ No
▪ If SAFEs or SANEs cannot be made available, is the examination performed by other qualified
medical practitioners (they must have been specifically trained to conduct sexual assault
forensic exams)? ☒ Yes ☐ No
▪ Has the agency documented its efforts to provide SAFEs or SANEs? ☒ Yes ☐ No
115.321 (d)
▪ Does the agency attempt to make available to the victim a victim advocate from a rape crisis
center? ☒ Yes ☐ No
▪ If a rape crisis center is not available to provide victim advocate services, does the agency
make available to provide these services a qualified staff member from a community-based
organization, or a qualified agency staff member? ☒ Yes ☐ No
▪ Has the agency documented its efforts to secure services from rape crisis centers?
☒ Yes ☐ No
41
115.321 (e)
▪ As requested by the victim, does the victim advocate, qualified agency staff member, or
qualified community-based organization staff member accompany and support the victim
through the forensic medical examination process and investigatory interviews? ☒ Yes ☐ No
▪ As requested by the victim, does this person provide emotional support, crisis intervention,
information, and referrals? ☒ Yes ☐ No
115.321 (f)
▪ If the agency itself is not responsible for investigating allegations of sexual abuse, has the
agency requested that the investigating entity follow the requirements of paragraphs (a) through
(e) of this section? (N/A if the agency/facility is responsible for conducting criminal AND
administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA
115.321 (g)
▪ Auditor is not required to audit this provision.
115.321 (h)
▪ If the agency uses a qualified agency staff member or a qualified community-based staff
member for the purposes of this section, has the individual been screened for appropriateness
to serve in this role and received education concerning sexual assault and forensic examination
issues in general? (Check N/A if agency attempts to make a victim advocate from a rape crisis
center available to victims per 115.321(d) above.) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy1800
Agency Policy FDJJ 1919
42
Agreement
PREA Compliance Form
Interviews:
Random Staff
Health Service Administrator
Facility Administrator
Assistant Facility Administrator
Director of Nursing, Crisis Center of Tampa Bay
Provisions (a) & (b):
Provision (a): To the extent the agency is responsible for investigating allegations of sexual abuse, the
agency shall follow a uniform evidence protocol that maximizes the potential for obtaining usable
physical evidence for administrative proceedings and criminal prosecutions.
Provision (b): The protocol shall be developmentally appropriate for youth and as appropriate, shall be
adapted from or otherwise based on the most recent edition of the U.S. Department of Justice’s Office
on Violence Against Women publication, “A National Protocol for Sexual Assault Medical Forensic
Examinations, Adults/Adolescents,” or similarly comprehensive and authoritative protocols developed
after 2011.
Administrative investigations are investigated by the Florida Department of Juvenile Justice (DJJ),
Office of Inspector General (OIG), agency investigators. All allegations that are criminal in nature will be
referred to the Pasco County Sheriff’s Office. The Policy will be followed regarding investigations of
sexual abuse in accordance with the standard. The investigator’s interview from a previous audit and
random staff members’ interviews confirmed awareness of protocol for obtaining usable physical
evidence and knowledge of the entities responsible for conducting investigations. The protocol for
investigations is appropriate for youth. The PREA Compliance Form is shared with local law
enforcement investigators outlining the PREA standards that must be adhered to regarding an
investigation of an allegation of sexual abuse. The DJJ investigators are also aware of the PREA
Compliance Form and investigation protocols.
Provision (c):
The agency shall offer all residents who experience sexual abuse access to forensic medical
examinations whether on-site or at an outside facility, without financial cost, where evidentiarily or
medically appropriate. Such examinations shall be performed by Sexual Assault Forensic Examiners
(SAFEs) or Sexual Assault Nurse Examiners (SANEs) where possible. If SAFEs or SANEs cannot be
made available, the examination can be performed by other qualified medical practitioners. The agency
shall document its efforts to provide SAFEs or SANEs.
Forensic medical examinations will be conducted by a Sexual Assault Nurse Examiner at the Crisis
Center of Tampa Bay. Continuity of care will be provided at the facility. Forensic examinations will be
provided at no cost to the victim in accordance with Policy, interviews, and written agreement with the
Crisis Center of Tampa Bay. No forensic medical examinations were conducted during this audit period.
Provisions (d) & (e):
Provision (d): The agency shall attempt to make available to the victim a victim advocate from a rape
crisis center. If a rape crisis center is not available to provide victim advocate services, the agency shall
make available to provide these services a qualified staff member from a community-based
organization or a qualified agency staff member. Agencies shall document efforts to secure services
from rape crisis centers. For the purpose of this standard, a rape crisis center refers to an entity that
provides intervention and related assistance, such as the services specified in 42 U.S.C.
43
14043g(b)(2)(C), to victims of sexual assault of all ages. The agency may utilize a rape crisis center
that is part of a governmental unit as long as the center is not part of the criminal justice system (such
as a law enforcement agency) and offers a comparable level of confidentiality as a nongovernmental
entity that provides similar victim services.
Provision (e): As requested by the victim, the victim advocate, qualified agency staff member, or
qualified community-based organization staff member shall accompany and support the victim through
the forensic medical examination process and investigatory interviews and shall provide emotional
support, crisis intervention, information, and referrals.
Victim advocacy services have been arranged and outlined in a written agreement between the facility
and the Crisis Center of Tampa Bay. The Center provides a range of programs and services including
forensic examinations, advocacy, and resource assistance for survivors of sexual assault. The advocacy
agency follows all applicable laws and regulations with respect to confidentiality and the privacy policy is
posted on the agency’s website. The advocacy services include:
• 24-hour hotline;
• Counseling;
• Follow-up support services;
• Accompaniment for forensic medical examination;
• Accompaniment for investigation interview;
Information regarding victim advocacy services is provided to the residents during the intake process,
according to staff, and is provided through the accessibility of posted information. Victim advocacy
services are provided at no cost to the victim. The Director of Nursing confirmed the items contained in
the written agreement of services.
Provisions (f) & (g):
Provision (f): To the extent the agency itself is not responsible for investigating allegations of sexual
abuse, the agency shall request that the investigating agency follow the requirements of paragraphs (a)
through (f) of this section.
Provision (g): The requirements of paragraphs (a) through (f) of this section shall also apply to:
(1) Any State entity outside of the agency that is responsible for investigating allegations of sexual
abuse in juvenile facilities; and
(2) Any Department of Justice component that is responsible for investigating allegations of sexual
abuse in juvenile facilities.
Florida DJJ OIG investigators from its central office will conduct administrative investigations in
accordance with agency Policy, standard and the protocols as outlined on the PREA Compliance Form.
Investigations of allegations of sexual abuse or sexual harassment that are criminal in nature will be
referred to the Pasco County Sheriff’s Office in accordance with Policies and the provisions of the
Standard.
Provision (h):
For the purposes of this standard, a qualified agency staff member or a qualified community-based staff
member shall be an individual who has been screened for appropriateness to serve in this role and has
received education concerning sexual assault and forensic examination issues in general.
The facility has made arrangements for victim advocacy services with the Crisis Center of Tampa Bay,
confirmed through the interviews and written agreement. The background and training of some
44
treatment staff provide them with familiarity of general sexual assault and forensic examination issues,
and they may be of service to a youth as an advocate if needed.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is in
compliance with the provisions of this standard.
Standard 115.322: Policies to Ensure Referrals of Allegations for
Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.322 (a)
▪ Does the agency ensure an administrative or criminal investigation is completed for all
allegations of sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure an administrative or criminal investigation is completed for all
allegations of sexual harassment? ☒ Yes ☐ No
115.322 (b)
▪ Does the agency have a policy and practice in place to ensure that allegations of sexual abuse
or sexual harassment are referred for investigation to an agency with the legal authority to
conduct criminal investigations, unless the allegation does not involve potentially criminal
behavior? ☒ Yes ☐ No
▪ Has the agency published such policy on its website or, if it does not have one, made the policy
available through other means? ☒ Yes ☐ No
▪ Does the agency document all such referrals? ☒ Yes ☐ No
115.322 (c)
▪ If a separate entity is responsible for conducting criminal investigations, does such publication
describe the responsibilities of both the agency and the investigating entity? [N/A if the
agency/facility is responsible for criminal investigations. See 115.321(a).]
☒ Yes ☐ No ☐ NA
115.322 (d)
▪ Auditor is not required to audit this provision.
115.322 (e)
▪ Auditor is not required to audit this provision.
45
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
FDJJ Agency Directive 3-05
Agency Policy FDJJ 1919
Websites
Interviews:
Random Staff
Facility Administrator
Assistant Facility Administrator
Provision (a):
The agency shall ensure that an administrative or criminal investigation is completed for all allegations
of sexual abuse and sexual harassment.
Policies provide that staff report all allegations of sexual abuse and sexual harassment and to
document reports; staff members are aware of the requirements. The facility reports no allegations of
sexual abuse and four allegations of sexual harassment. Sexual abuse and sexual harassment
allegations are referred to the FDJJ OIG, Florida Department of Children and Families, and the Pasco
County Sheriff’s Office, if criminal in nature. The allegations of sexual harassment were resident-on-
resident and was investigated by a FDJJ/OIG investigator. The results of the investigation determined
the allegations resulted in gathering information only. Policies and interviews provide for investigations
of all allegations of sexual abuse and sexual harassment.
Provision (b) and (c):
Provision (b): The agency shall have in place a policy to ensure that allegations of sexual abuse or
sexual harassment are referred for investigation to an agency with the legal authority to conduct
criminal investigations unless the allegation does not involve potentially criminal behavior. The agency
shall publish such policy on its website or, if it does not have one, make the policy available through
other means. The agency shall document all such referrals.
Provision (c): If a separate entity is responsible for conducting criminal investigations, such publication
shall describe the responsibilities of both the agency and the investigating entity.
46
Policy and reporting information are located on the DJJ and facility’s parent agency websites and
posted within the facility and accessible to the public. Policies and interviews confirmed allegations of
sexual abuse and sexual harassment are investigated. Administrative investigations are conducted by
DJJ/OIG investigators from the central office that are trained. Allegations that are criminal in nature are
referred to the Pasco County Sheriff’s Office.
Provision (d):
Any State entity responsible for conducting administrative or criminal investigations of sexual abuse or
sexual harassment in juvenile facilities shall have in place a policy governing the conduct of such
investigations.
The DJJ/OIG has policies/directive governing investigations. The agency utilizes trained investigators.
A previous interview with an investigator and agency records confirm that administrative investigations
are conducted by a trained investigator and allegations that are criminal in nature will be referred to the
Pasco County Sheriff’s Office.
Provision (e):
Any Department of Justice component responsible for conducting administrative or criminal
investigations of sexual abuse or sexual harassment in juvenile facilities shall have in place a policy
governing the conduct of such investigations.
The Department of Justice is not responsible for conducting administrative or criminal investigations of
sexual abuse or sexual harassment in this facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is
compliant with this standard.
TRAINING AND EDUCATION
Standard 115.331: Employee Training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.331 (a)
▪ Does the agency train all employees who may have contact with residents on: Its zero-tolerance
policy for sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to fulfill their
responsibilities under agency sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: Residents’ right
to be free from sexual abuse and sexual harassment ☒ Yes ☐ No
47
▪ Does the agency train all employees who may have contact with residents on: The right of
residents and employees to be free from retaliation for reporting sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The dynamics of
sexual abuse and sexual harassment in juvenile facilities? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The common
reactions of juvenile victims of sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to detect
and respond to signs of threatened and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to avoid
inappropriate relationships with residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to
communicate effectively and professionally with residents, including lesbian, gay, bisexual,
transgender, intersex, or gender nonconforming residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to comply
with relevant laws related to mandatory reporting of sexual abuse to outside authorities?
☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: Relevant laws
regarding the applicable age of consent? ☒ Yes ☐ No
115.331 (b)
▪ Is such training tailored to the unique needs and attributes of residents of juvenile facilities?
☒ Yes ☐ No
▪ Is such training tailored to the gender of the residents at the employee’s facility? ☒ Yes ☐ No
▪ Have employees received additional training if reassigned from a facility that houses only male
residents to a facility that houses only female residents, or vice versa? ☒ Yes ☐ No
115.331 (c)
▪ Have all current employees who may have contact with residents received such training?
☒ Yes ☐ No
▪ Does the agency provide each employee with refresher training every two years to ensure that
all employees know the agency’s current sexual abuse and sexual harassment policies and
procedures? ☒ Yes ☐ No
▪ In years in which an employee does not receive refresher training, does the agency provide
refresher information on current sexual abuse and sexual harassment policies? ☒ Yes ☐ No
48
115.331 (d)
▪ Does the agency document, through employee signature or electronic verification that
employees understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Facility 3-36
Facility Policy 5-1
Facility Policy 5-2
Agency Policy FDJJ 1919
Training Curriculum
Training Logs
Interviews:
Random Staff
Assistant Facility Administrator
Provisions (a) and (c):
Provision (a): The agency shall train all employees who may have contact with residents on:
(1) Its zero-tolerance policy for sexual abuse and sexual harassment;
(2) How to fulfill their responsibilities under agency sexual abuse and sexual harassment prevention,
detection, reporting, and response policies and procedures;
(3) Residents’ right to be free from sexual abuse and sexual harassment;
(4) The right of residents and employees to be free from retaliation for reporting sexual abuse and
sexual harassment;
(5) The dynamics of sexual abuse and sexual harassment in juvenile facilities;
(6) The common reactions of juvenile victims of sexual abuse and sexual harassment;
(7) How to detect and respond to signs of threatened and actual sexual abuse and how to distinguish
between consensual sexual contact and sexual abuse between residents;
(8) How to avoid inappropriate relationships with residents;
(9) How to communicate effectively and professionally with residents, including lesbian, gay, bisexual,
transgender, intersex, or gender nonconforming residents; and
49
(10) How to comply with relevant laws related to mandatory reporting of sexual abuse to outside
authorities;
(11) Relevant laws regarding the applicable age of consent.
Provision (c): All current employees who have not received such training shall be trained within one
year of the effective date of the PREA standards, and the agency shall provide each employee with
refresher training every two years to ensure that all employees know the agency’s current sexual abuse
and sexual harassment policies and procedures. In years in which an employee does not receive
refresher training, the agency shall provide refresher information on current sexual abuse and sexual
harassment policies.
The Policies address PREA related training for staff which is provided initially and annually. Interviewed
staff members were generally familiar with the PREA information. Facility Policy 5-2 provides for
refresher training to occur annually. PREA training is provided to staff, as indicated by a review of
facility and agency Policies, training documents and interviews. The facility reports 40 staff members
that may have contact with residents were trained or re-trained on the PREA requirements.
Provision (b):
Such training shall be tailored to the unique needs and attributes of residents of juvenile facilities and to
the gender of the residents at the employee’s facility. The employee shall receive additional training if
the employee is reassigned from a facility that houses only male residents to a facility that houses only
female residents, or vice versa.
The facility houses females and staff training consider the needs of the population served as indicated
by the interviews. The Policies and interviews support training being tailored to the needs and attributes
of the population served. All staff within the facility are provided PREA training.
Provision (d):
The agency shall document, through employee signature or electronic verification that employees
understand the training they have received.
The PREA training reviewed was documented electronically and manually through sign-in sheets and
verified through staff interviews.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is in
compliance with the standard.
Standard 115.332: Volunteer and Contractor Training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.332 (a)
▪ Has the agency ensured that all volunteers and contractors who have contact with residents
have been trained on their responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and procedures? ☒ Yes ☐ No
115.332 (b)
▪ Have all volunteers and contractors who have contact with residents been notified of the
agency’s zero-tolerance policy regarding sexual abuse and sexual harassment and informed
50
how to report such incidents (the level and type of training provided to volunteers and
contractors shall be based on the services they provide and level of contact they have with
residents)? ☒ Yes ☐ No
115.332 (c)
▪ Does the agency maintain documentation confirming that volunteers and contractors
understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Facility Policy 3-36
Agency Policy FDJJ 1919
Training Curriculum
Acknowledgement Statements
Interviews:
Contractors
Facility Administrator
Provision (a):
The agency shall ensure that all volunteers and contractors who have contact with residents have been
trained on their responsibilities under the agency’s sexual abuse and sexual harassment prevention,
detection, and response policies and procedures.
Volunteers and contractors who have contact with residents must be trained on PREA and their
responsibilities regarding sexual assault prevention, detection, and response to allegations of sexual
abuse and sexual harassment. A review of documents, training curriculum, interviews and observation
confirm the training occurs. The training curriculum includes but is not limited to information in the
following areas: reporting allegations of sexual abuse and sexual harassment; related definitions;
detecting sexual abuse and sexual harassment; and maintaining professional relationships with
residents.
51
Provision (b):
The level and type of training provided to volunteers and contractors shall be based on the services
they provide and level of contact they have with residents, but all volunteers and contractors who have
contact with residents shall be notified of the agency’s zero-tolerance policy regarding sexual abuse
and sexual harassment and informed how to report such incidents.
The interviews and review of documentation revealed the PREA training informs the participants of their
role in reporting allegations of sexual abuse and sexual harassment. The participants are informed of
their responsibilities regarding sexual abuse prevention, detection, and response to an allegation of
sexual abuse or sexual harassment. The training is based on the services provided by the contractors
and volunteers.
The interviews with the contractors revealed their familiarity with the zero-tolerance policy regarding
sexual abuse and sexual harassment of residents, including how to report. The interviews confirmed
that the review of the zero-tolerance policy for the facility and agency is included in the PREA training.
The contractors interviewed provide education services to the residents and the volunteer coordinates a
group that provides mentoring services. PREA education is available within the facility, DJJ online
courses and through the school system.
Provision (c):
The agency shall maintain documentation confirming that volunteers and contractors understand the
training they have received.
The training documentation and interviews confirmed the receipt and awareness of PREA training by
contractors and volunteers. The interviews indicated the contractors and volunteers understand the
training received. The DJJ online training course is made available to volunteers and contractors prior
to providing services within the facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is
compliant with the provisions of this standard.
Standard 115.333: Resident Education
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.333 (a)
▪ During intake, do residents receive information explaining the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ During intake, do residents receive information explaining how to report incidents or suspicions
of sexual abuse or sexual harassment? ☒ Yes ☐ No
▪ Is this information presented in an age-appropriate fashion? ☒ Yes ☐ No
115.333 (b)
52
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Their rights to be free from sexual abuse
and sexual harassment? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Their rights to be free from retaliation for
reporting such incidents? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Agency policies and procedures for
responding to such incidents? ☒ Yes ☐ No
115.333 (c)
▪ Have all residents received such education? ☒ Yes ☐ No
▪ Do residents receive education upon transfer to a different facility to the extent that the policies
and procedures of the resident’s new facility differ from those of the previous facility?
☒ Yes ☐ No
115.333 (d)
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are limited English proficient? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are deaf? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are visually impaired? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are otherwise disabled? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Have limited reading skills? ☒ Yes ☐ No
115.333 (e)
▪ Does the agency maintain documentation of resident participation in these education sessions?
☒ Yes ☐ No
115.333 (f)
▪ In addition to providing such education, does the agency ensure that key information is
continuously and readily available or visible to residents through posters, resident handbooks,
or other written formats? ☒ Yes ☐ No
53
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 9-2
Facility Policy 10-25
Agency Policy FDJJ 1919
Orientation Checklist
Acknowledgement Statements
Training Logs/Sign-in Sheets
Training Materials
Brochures
Interviews:
Residents
Case Manager
Assistant Facility Administrator
Provisions (a) and (b):
Provision (a): During the intake process, residents shall receive information explaining, in an age-
appropriate fashion, the agency’s zero tolerance policy regarding sexual abuse and sexual harassment
and how to report incidents or suspicions of sexual abuse or sexual harassment.
Provision (b): Within 10 days of intake, the agency shall provide comprehensive age-appropriate
education to residents either in person or through video regarding their rights to be free from sexual
abuse and sexual harassment and to be free from retaliation for reporting such incidents, and regarding
agency policies and procedures for responding to such incidents.
Policies provide that all residents admitted receive PREA education. Residents receive directions on
how to report allegations of sexual abuse and sexual harassment; and the right to be free from
retaliation for reporting, according to the documentation and interview with the Case Manager who
provides PREA education to residents. A review of the education materials indicated the information
provided to the residents is age appropriate. The Case Manager revealed that PREA refresher
education sessions are conducted during group sessions as a rotating topic among treatment topics
covered in group activities. The Case Manager also addresses questions that a resident may have
regarding PREA.
54
The residents initially sign acknowledgement statements which represent receipt of the PREA
information provided. The interviews with the residents revealed the need for a refresher education
session focusing on the advocacy agency and the services provided to victims of sexual abuse to
ensure the residents’ clear and un-contradicted understanding of the information provided.
Corrective Action: The corrective action of the refresher PREA education session regarding the victim
advocacy services and agency, Crises Center of Tampa Bay, was implemented. The Assistant Facility
Administrator provided documentation of training log/sign-in sheet which included the training topic
which supported the occurrence of the refresher PREA education session. The sign-in sheet was also
signed by the Assistant Facility Administrator indicating the occurrence of the refresher education
session conducted by her.
Provision (c):
Current residents who have not received such education shall be educated within one year of the
effective date of the PREA standards and shall receive education upon transfer to a different facility to
the extent that the policies and procedures of the resident’s new facility differ from those of the previous
facility.
Based on the evidence shown documenting the PREA education sessions in Provisions (a) and (b),
including corrective actions and interviews, residents received PREA education. The facility reports that
20 youth were admitted to the facility during the past 12 months and that all participated in PREA
education sessions. Acknowledgement statements and the interviews indicate that general PREA
education is provided and the corrective action supplemented the general education by providing
customized information regarding outside advocacy services.
Provision (d):
The agency shall provide resident education in formats accessible to all residents, including those who
are limited English proficient, deaf, visually impaired, or otherwise disabled, as well as to residents who
have limited reading skills.
The facility has the capability to provide the PREA education in formats accessible to all residents
including those who may be hearing impaired; Deaf; have intellectual, psychiatric and speech
disabilities; low vision; blind; limited reading, limited English proficient, and based on the individual need
of the resident. The education unit is also a resource for accessibility of translation services and other
accommodations.
Policy provides for interpreter and translation services. There is documentation and Policy that provide
information and accessibility for the accommodations for residents with special needs in this area. The
education unit also provides support services, especially through certified teachers with the educational
background to modify/adapt information for all residents to understand. Additional services, as
necessary, will be supported by the school district. Assistance may also be provided by the treatment
staff to ensure all residents’ understanding of the PREA information. Posted and other PREA
information is in English and Spanish. The facility also has bilingual staff. The facility’s parent agency
has a contract with Language Line Services that may be used by their facilities as needed.
The Facility Administrator revealed a practice of residents not used as translators or readers for other
residents. The facility has knowledge of the youth’s arrival to the facility prior to the admission date.
This time period provides for the identified staff to make plans to accommodate the special needs of
residents. The special arrangements are coordinated by treatment team staff in collaboration with the
Facility Administrator. PREA posters and information sheets are collectively readily available in English;
Spanish; Creole; Vietnamese; French; and Hebrew.
55
During formal treatment team meetings, residents are asked about feelings of safety and whether they
are being threatened or intimidated by anyone. PREA information is included in the resident handbook
an information sheets that are provided to each resident. The information sheets and handbook are
accessible in languages other than English, as needed.
Provision (e):
The agency shall maintain documentation of resident participation in these education sessions.
Signed acknowledgement statements were reviewed which supported the residents’ involvement in
PREA education sessions. The residents’ interviews revealed the exposure to PREA through the PREA
education sessions. The residents were aware of how to report allegations of sexual abuse and sexual
harassment and that they would not be punished for reporting such. The refresher PREA education
session and receipt of advocacy agency information provides enhanced PREA education sessions.
Provision (f):
In addition to providing such education, the agency shall ensure that key information is continuously
and readily available or visible to residents through posters, resident handbooks, or other written
formats.
The PREA education materials provide residents information on how to report allegations of sexual
harassment and sexual abuse. PREA information is posted and provided to residents to assist in
eliminating incidents of sexual abuse and sexual harassment. The printed materials provide information
on sexual abuse and sexual harassment; steps victims may take; and reporting information. Each
resident is provided a handbook which also contains PREA information which was also observed
posted within the facility.
Conclusion:
Based upon the review and analysis of the available evidence, interviews, and observations, the
Auditor determined the facility is compliant with the provisions of this standard.
Standard 115.334: Specialized Training: Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.334 (a)
▪ In addition to the general training provided to all employees pursuant to §115.331, does the
agency ensure that, to the extent the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such investigations in confinement settings?
[N/A if the agency does not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).] ☒ Yes ☐ No ☐ NA
115.334 (b)
▪ Does this specialized training include: Techniques for interviewing juvenile sexual abuse
victims? [N/A if the agency does not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).] ☒ Yes ☐ No ☐ NA
▪ Does this specialized training include: Proper use of Miranda and Garrity warnings? [N/A if the
agency does not conduct any form of administrative or criminal sexual abuse investigations.
See 115.321(a).] ☒ Yes ☐ No ☐ NA
56
▪ Does this specialized training include: Sexual abuse evidence collection in confinement
settings? [N/A if the agency does not conduct any form of administrative or criminal sexual
abuse investigations. See 115.321(a).] ☒ Yes ☐ No ☐ NA
▪ Does this specialized training include: The criteria and evidence required to substantiate a case
for administrative action or prosecution referral? [N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See 115.321(a).] ☒ Yes ☐ No ☐ NA
115.334 (c)
▪ Does the agency maintain documentation that agency investigators have completed the
required specialized training in conducting sexual abuse investigations? [N/A if the agency does
not conduct any form of administrative or criminal sexual abuse investigations. See 115.321(a).]
☒ Yes ☐ No ☐ NA
115.334 (d)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documentation Reviewed:
Agency Policy FDJJ 1919
Agency Policy FDJJ 1800
Training Curriculum
Interview:
Facility Administrator
Provision (a) & (b):
Provision (a): In addition to the general training provided to all employees pursuant to §115.331, the
agency shall ensure that, to the extent the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such investigations in confinement settings.
Provision (b): Specialized training shall include techniques for interviewing juvenile sexual abuse
57
victims, proper use of Miranda and Garrity warnings, sexual abuse evidence collection in confinement
settings, and the criteria and evidence required to substantiate a case for administrative action or
prosecution referral.
Administrative investigations are conducted by the Florida Department of Juvenile Justice (DJJ), Office
of Inspector General (OIG) PREA training is required in addition to the specialized training regarding
conducting administrative investigations. Allegations that are criminal in nature are referred for
investigation by local law enforcement. The previously conducted interview with an agency investigator
and review of documents confirmed administrative investigations are conducted by trained investigators
within the OIG of the contract agency, DJJ. The specialized training includes but is not limited to
interviewing techniques; proper use of Garrity and Miranda warnings/specifically Garrity; preserving
evidence; and criteria for supporting a finding of substantiated, unsubstantiated, or unfounded.
Provision (c):
The agency shall maintain documentation that agency investigators have completed the required
specialized training in conducting sexual abuse investigations.
Documentation of training logs and any training certificates of the investigators are maintained by the
contract agency, DJJ. Allegations that are criminal in nature are referred to local law enforcement, in
accordance with Policy.
Provision (d):
Any State entity or Department of Justice component that investigates sexual abuse in juvenile
confinement settings shall provide such training to its agents and investigators who conduct such
investigations.
The Florida Department of Juvenile Justice provides training to its investigators who will conduct
administrative investigations at the facility which was confirmed by interviews. Local law enforcement is
responsible for training their investigators who conduct sexual abuse investigations that are criminal in
nature.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is
compliant with this standard.
Standard 115.335: Specialized Training: Medical and Mental Health Care
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.335 (a)
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How to detect and assess signs of
sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How to preserve physical evidence of
sexual abuse? ☒ Yes ☐ No
58
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How and to whom to report allegations
or suspicions of sexual abuse and sexual harassment? ☒ Yes ☐ No
115.335 (b)
▪ If medical staff employed by the agency conduct forensic examinations, do such medical staff
receive appropriate training to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams.) ☐ Yes ☐ No ☒ NA
115.335 (c)
▪ Does the agency maintain documentation that medical and mental health practitioners have
received the training referenced in this standard either from the agency or elsewhere?
☒ Yes ☐ No
115.335 (d)
▪ Do medical and mental health care practitioners employed by the agency also receive training
mandated for employees by §115.331? ☒ Yes ☐ No
▪ Do medical and mental health care practitioners contracted by and volunteering for the agency
also receive training mandated for contractors and volunteers by §115.332? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Facility Policy 5-1
Agency Policy FDJJ 1919
59
Training Curricula
Training Logs
Interviews:
Clinical Director
Health Service Administrator
Provision (a):
The agency shall ensure that all full- and part-time medical and mental health care practitioners who
work regularly in its facilities have been trained in:
(1) How to detect and assess signs of sexual abuse and sexual harassment;
(2) How to preserve physical evidence of sexual abuse;
(3) How to respond effectively and professionally to juvenile victims of sexual abuse and sexual
harassment; and
(4) How and to whom to report allegations or suspicions of sexual abuse and sexual harassment.
Medical and mental health staff members receive the regular PREA training as well as the specialized
training provided through the Florida Department of Juvenile Justice. Electronic training logs and
interviews document regular PREA training and the specialized training for medical and mental health
staff members and the interviews confirmed the training.
Provision (b):
If medical staff employed by the agency conduct forensic examinations, such medical staff shall receive
the appropriate training to conduct such examinations.
Forensic examinations are not conducted at the facility.
Provision (c):
The agency shall maintain documentation that medical and mental health practitioners have received
the training referenced in this standard either from the agency or elsewhere.
Electronic training logs and interviews with medical and mental health staffs confirmed receipt of the
regular and specialized training. The regular and specialized PREA training is provided online by the
Florida Department of Juvenile Justice. Regular PREA training is also provided at the facility through
refresher sessions incorporated in staff meetings.
Provision (d):
Medical and mental health care practitioners shall also receive the training mandated for employees
under Standard 115.331 or for contractors and volunteers under Standard 115.332, depending upon
the practitioner’s status at the agency.
Medical and mental health staff completed the general training that is provided for all employees as
indicated by training documentation and the interviews. The standard PREA training is provided to all
employees and the specialized training is provided online by the Florida Department of Juvenile Justice
and the records are maintained electronically.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is
compliant with this standard.
60
SCREENING FOR RISK OF SEXUAL VICTIMIZATION
AND ABUSIVENESS
Standard 115.341: Screening for Risk of Victimization and Abusiveness
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.341 (a)
▪ Within 72 hours of the resident’s arrival at the facility, does the agency obtain and use
information about each resident’s personal history and behavior to reduce risk of sexual abuse
by or upon a resident? ☒ Yes ☐ No
▪ Does the agency also obtain this information periodically throughout a resident’s confinement?
☒ Yes ☐ No
115.341 (b)
▪ Are all PREA screening assessments conducted using an objective screening instrument?
☒ Yes ☐ No
115.341 (c)
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Prior sexual victimization or abusiveness? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Any gender nonconforming appearance or manner or identification
as lesbian, gay, bisexual, transgender, or intersex, and whether the resident may therefore be
vulnerable to sexual abuse? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Current charges and offense history? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Age? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Level of emotional and cognitive development? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Physical size and stature? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Mental illness or mental disabilities? ☒ Yes ☐ No
61
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Intellectual or developmental disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Physical disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: The resident’s own perception of vulnerability? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Any other specific information about individual residents that may
indicate heightened needs for supervision, additional safety precautions, or separation from
certain other residents? ☒ Yes ☐ No
115.341 (d)
▪ Is this information ascertained: Through conversations with the resident during the intake
process and medical mental health screenings? ☒ Yes ☐ No
▪ Is this information ascertained: During classification assessments? ☒ Yes ☐ No
▪ Is this information ascertained: By reviewing court records, case files, facility behavioral records,
and other relevant documentation from the resident’s files? ☒ Yes ☐ No
115.341 (e)
▪ Has the agency implemented appropriate controls on the dissemination within the facility of
responses to questions asked pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or other residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 9-1
62
Facility Policy 10-25
Agency Policy FDJJ 1919
Vulnerability Assessments
Interviews:
Therapist
Residents
Provision (a):
The Policy provides that upon arrival or within 72 hours of the resident’s arrival at the facility and
periodically throughout a resident’s confinement, the agency shall obtain and use information about
each resident’s personal history and behavior to reduce the risk of sexual abuse by or upon a resident.
The Policies provide for each resident to be screened for risk of victimization or abusiveness, prior to
room assignment in order to reduce the risk of sexual abuse by or upon a resident. The interviews and
practice indicate the risk assessment is completed on the day of admission. According to the Therapist,
the youth is asked questions and explanations of a question is provided as needed and probing may be
required depending on the youth. The youth is interviewed to obtain information about personal history
and behavior.
The intake screening instrument, Screening for Vulnerability, Victimization and Sexually Aggressive
Behavior (VSAB) is used to document such information. The interviews revealed the practice of the risk
screening being conducted in accordance with the Policies. Screening instruments and interview with
the Therapist confirmed the information obtained includes but is not limited to:
• Prior sexual victimization or abusiveness;
• Resident’s own perception of vulnerability;
• Current charges and offense history;
• Self-identification of resident;
• Intellectual or developmental disabilities;
• Physical disabilities;
• Mental illness or mental disabilities
• Information regarding relationships with other youth
• Confirmation of size and stature
• Confirmation of Age
Facility Policy addresses the occurrence and criteria regarding formal reassessments of residents. It is
reported that the number of youths admitted to the facility within the past 12 months who were
screened during the admission process for risk of sexual victimization and the risk of sexually abusing
other residents is 20. The risk assessments are accessible to the clinical and case management staff.
The resident files were observed to be maintained in a confidential manner in a locked file room.
Provision (b):
Such assessments shall be conducted using an objective screening instrument.
An objective screening instrument is used to obtain the information required by the standard, including
but not limited to prior sexual victimization or abusiveness; self-identification; current charges and
offense history; disabilities; and a resident’s concern regarding his/her own safety. The instrument,
VSAB, is tabulated based on the information received where identified responses can identify any
special needs and safety concerns. Assessments are conducted through the use of the objective
63
instrument containing items that collectively provide a presumptive determination of risk for victimization
or abusiveness.
Provision (c):
At a minimum, the agency shall attempt to ascertain information about:
(1) Prior sexual victimization or abusiveness;
(2) Any gender nonconforming appearance or manner or identification as lesbian, gay, bisexual,
transgender, or intersex, and whether the resident may therefore be vulnerable to sexual abuse;
(3) Current charges and offense history;
(4) Age;
(5) Level of emotional and cognitive development;
(6) Physical size and stature;
(7) Mental illness or mental disabilities;
(8) Intellectual or developmental disabilities;
(9) Physical disabilities;
(10) The residents’ own perception of vulnerability; and
(11) Any other specific information about individual residents that may indicate heightened needs for
supervision, additional safety precautions, or separation from certain other residents.
The Auditor reviewed the screening instrument and determined the items required by this provision of
the standard are included within the instrument. The interview with the Therapist confirmed awareness
of the elements of the risk screening instrument. The resident interviews also confirmed the
administration of the screening instrument and the general inquiries made. The interviews revealed the
practice is that the instrument is administered the first day of the youth’s admission to the facility. The
VSAB screening instrument is administered by the resident’s assigned Therapist.
Provision (d):
This information shall be ascertained through conversations with the resident during the intake process
and medical and mental health screenings; during classification assessments; and by reviewing court
records, case files, facility behavioral records, and other relevant documentation from the resident’s
files.
The information to complete the risk screening instrument is gleaned from various sources. Information
in determining the risk for victimization or abusiveness is obtained through interviewing the youth.
Additional information to complete the screening instrument includes review of commitment packet and
interviews with parents/guardians. The facility is aware of the youth’s pending arrival to the facility and
treatment staff has the opportunity to review the residents electronic record in an effort to preliminarily
prepare for the needs prior to arrival. Additional assessments are completed after the youth is admitted
to the facility to obtain supportive information for treatment planning and keeping the youth safe.
Provision (e):
The agency shall implement appropriate controls on the dissemination within the facility of responses to
questions asked pursuant to this standard in order to ensure that sensitive information is not exploited
to the resident’s detriment by staff or other residents.
Appropriate controls are taken to ensure that sensitive information is protected and not exploited by
maintaining the files securely in a locked file room and the online information on computers is password
protected. The online information is only accessible to identified staff. The Therapist addressed the
management of sensitive information and the expectation of confidentiality by staff. The treatment and
case management staffs have access to the risk screening instruments.
64
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is
compliant with this standard.
Standard 115.342: Use of Screening Information
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.342 (a)
▪ Does the agency use all of the information obtained pursuant to §115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Housing
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to §115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Bed
assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Work
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Education
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Program
Assignments? ☒ Yes ☐ No
115.342 (b)
▪ Are residents isolated from others only as a last resort when less restrictive measures are
inadequate to keep them and other residents safe, and then only until an alternative means of
keeping all residents safe can be arranged? ☒ Yes ☐ No
▪ During any period of isolation, does the agency always refrain from denying residents daily
large-muscle exercise? ☒ Yes ☐ No
▪ During any period of isolation, does the agency always refrain from denying residents any
legally required educational programming or special education services? ☒ Yes ☐ No
▪ Do residents in isolation receive daily visits from a medical or mental health care clinician?
☒ Yes ☐ No
▪ Do residents also have access to other programs and work opportunities to the extent possible?
☒ Yes ☐ No
65
115.342 (c)
▪ Does the agency always refrain from placing: Lesbian, gay, and bisexual residents in particular
housing, bed, or other assignments solely on the basis of such identification or status?
☒ Yes ☐ No
▪ Does the agency always refrain from placing: Transgender residents in particular housing, bed,
or other assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from placing: Intersex residents in particular housing, bed, or
other assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from considering lesbian, gay, bisexual, transgender, or
intersex identification or status as an indicator or likelihood of being sexually abusive?
☒ Yes ☐ No
115.342 (d)
▪ When deciding whether to assign a transgender or intersex resident to a facility for male or
female residents, does the agency consider on a case-by-case basis whether a placement
would ensure the resident’s health and safety, and whether a placement would present
management or security problems (NOTE: if an agency by policy or practice assigns residents
to a male or female facility on the basis of anatomy alone, that agency is not in compliance with
this standard)? ☒ Yes ☐ No
▪ When making housing or other program assignments for transgender or intersex residents,
does the agency consider on a case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would present management or security
problems? ☒ Yes ☐ No
115.342 (e)
▪ Are placement and programming assignments for each transgender or intersex resident
reassessed at least twice each year to review any threats to safety experienced by the resident?
☒ Yes ☐ No
115.342 (f)
▪ Are each transgender or intersex resident’s own views with respect to his or her own safety
given serious consideration when making facility and housing placement decisions and
programming assignments? ☒ Yes ☐ No
115.342 (g)
▪ Are transgender and intersex residents given the opportunity to shower separately from other
residents? ☒ Yes ☐ No
115.342 (h)
66
▪ If a resident is isolated pursuant to paragraph (b) of this section, does the facility clearly
document: The basis for the facility’s concern for the resident’s safety? (N/A for h and i if facility
doesn’t use isolation?) ☐ Yes ☐ No ☒ NA
▪ If a resident is isolated pursuant to paragraph (b) of this section, does the facility clearly
document: The reason why no alternative means of separation can be arranged? (N/A for h and
i if facility doesn’t use isolation?) ☐ Yes ☐ No ☒ NA
115.342 (i)
▪ In the case of each resident who is isolated as a last resort when less restrictive measures are
inadequate to keep them and other residents safe, does the facility afford a review to determine
whether there is a continuing need for separation from the general population EVERY 30
DAYS? ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 8-14
Facility Policy 9-2
Facility Policy 10-25
Agency Policy FDJJ 1919
Vulnerability Assessments
Interviews:
Therapist
Clinical Director
Health Service Administrator
Residents
Facility Administrator
Random Staff
Assistant Facility Administrator
67
Provision (a):
The agency shall use all information obtained pursuant to §115.341 and subsequently to make housing,
bed, program, education, and work assignments for residents with the goal of keeping all residents safe
and free from sexual abuse.
Policies collectively provide guidance to staff regarding the use of the information obtained from the
screening instrument. The interviews with the Facility Administrator and Therapist indicate the
screening information is used to inform staff of information based on the need to know, housing and
program assignments, and assist in identifying treatment and any special services.
Provision (b):
Residents may be isolated from others only as a last resort when less restrictive measures are
inadequate to keep them and other residents safe, and then only until an alternative means of keeping
all residents safe can be arranged. During any period of isolation, agencies shall not deny residents
daily large-muscle exercise and any legally required educational programming or special education
services. Residents in isolation shall receive daily visits from a medical or mental health care clinician.
Residents shall also have access to other programs and work opportunities to the extent possible.
Protective custody is not used regarding a potential or victim of sexual abuse. Controlled observation is
used as short-term management strategy for acting out behavior. Due to alleged sexual harassment
allegations, a resident was provided a sleeping area in the dining hall since there are no single
residential rooms in the facility. During the waking hours, the resident received services which included
education, medical and mental health services and was closely supervised. The practice is that the
facility does not use isolation as identified through the interviews. Residents may be placed in
“controlled observation” for a cooling-off period. The interviews supported the practice of a cooling-off
period. The staff interviews indicated that protective measures would be taken immediately when
needed and includes separating residents and notifying supervisors and administrators. There were not
any residents at risk of sexual victimization placed in isolation in the 12 months preceding the audit.
Provision (c):
Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in particular housing, bed,
or other assignments solely on the basis of such identification or status, nor shall agencies consider
lesbian, gay, bisexual, transgender, or intersex identification or status as an indicator of likelihood of
being sexually abusive.
Gay, bisexual, transgender, or intersex residents are not placed in specific housing solely based on
how the residents identify or their status. Staff members are prohibited from considering the
identification as an indicator that these residents may be more likely to be sexually abusive. During the
site review, there were no rooms or units observed or identified to be reserved for LGBTI youth.
Housing assignments are made on a case-by-case basis as supported by Policy, interviews, and
practice.
Provision (d):
In deciding whether to assign a transgender or intersex resident to a facility for male or female
residents, and in making other housing and programming assignments, the agency shall consider on a
case-by-case basis whether a placement would ensure residents’ health and safety, and whether the
placement would present management or security problems.
Policy and practice support that housing and program assignments for transgender or intersex
residents are made on a case-by-case basis which was evident from staff interviews and observations.
68
The interview with the Therapist confirmed that staff considers on a case-by-case basis whether a
placement would ensure a resident’s health and safety, and whether the placement would present
management or security problems. The interviews indicate staffs’ awareness and efforts in keeping
residents safe, including transgender and intersex youth.
Provision (e):
Placement and programming assignments for each transgender or intersex resident shall be
reassessed at least twice each year to review any threats to safety experienced by the resident.
Policy provides placement and programming assignments for each transgender or intersex resident be
reassessed twice per year to determine any threats to safety experienced by the resident. The interview
with the Therapist confirmed awareness of Policy. The practice of reassessments occurring with all
residents provides that the reassessment of transgender and intersex youth would occur at least twice
per year.
Provision (f):
A transgender or intersex resident’s own view with respect to his or her own safety shall be given
serious consideration.
The resident’s concern for her own safety is taken into account through the administration of the risk
vulnerability screening instrument, treatment team meetings and individual sessions and interactions
with Therapists and Case Managers. The interviews with staff and review of documentation were
aligned with the Policy. Targeted interviews were conducted in this area and no problems or issues
were identified.
Provision (g):
Transgender and intersex residents shall be given the opportunity to shower separately from other
residents.
Transgender or intersex residents are given the opportunity to shower separately from other residents
which is also supported by interviews and Policy. Targeted interviews were conducted in this area and
no problems or issues were identified. The practice is that only one resident at a time use the
bathroom.
Provision (h):
If a resident is isolated pursuant to paragraph (b) of this section, the facility shall clearly document:
(1) The basis for the facility’s concern for the resident’s safety; and
(2) The reason why no alternative means of separation can be arranged.
Agency Policy provides that a resident would only be placed in isolation as a last resort for protection
and it would only be until other arrangements could be made to keep the resident safe. The provisions
of this standard would be provided if such occurs however the practice is that isolation is not used in
this facility. No residents determined at risk of sexual victimization were placed in isolation in the 12
months preceding the audit. An alleged perpetrator was assigned to sleep in the dining hall for a period
of time due to allegations made by residents of sexual harassment; the reason for the sleeping
arrangement was documented. The resident was not denied any program services, including treatment,
education, medical and recreation.
Provision (i):
Every 30 days, the facility shall afford each resident described in paragraph (h) of this section a review
to determine whether there is a continuing need for separation from the general population.
69
Isolation is not used in this facility. No residents at risk of sexual victimization were placed in isolation in
the 12 months preceding the audit.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is
compliant with this standard.
REPORTING
Standard 115.351: Resident Reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.351 (a)
▪ Does the agency provide multiple internal ways for residents to privately report: Sexual abuse
and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report: Retaliation by
other residents or staff for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report: Staff neglect or
violation of responsibilities that may have contributed to such incidents? ☒ Yes ☐ No
115.351 (b)
▪ Does the agency also provide at least one way for residents to report sexual abuse or sexual
harassment to a public or private entity or office that is not part of the agency? ☒ Yes ☐ No
▪ Is that private entity or office able to receive and immediately forward resident reports of sexual
abuse and sexual harassment to agency officials? ☒ Yes ☐ No
▪ Does that private entity or office allow the resident to remain anonymous upon request?
☒ Yes ☐ No
▪ Are residents detained solely for civil immigration purposes provided information on how to
contact relevant consular officials and relevant officials at the Department of Homeland Security
to report sexual abuse or harassment? ☒ Yes ☐ No
115.351 (c)
▪ Do staff members accept reports of sexual abuse and sexual harassment made verbally, in
writing, anonymously, and from third parties? ☒ Yes ☐ No
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▪ Do staff members promptly document any verbal reports of sexual abuse and sexual
harassment? ☒ Yes ☐ No
115.351 (d)
▪ Does the facility provide residents with access to tools necessary to make a written report?
☒ Yes ☐ No
▪ Does the agency provide a method for staff to privately report sexual abuse and sexual
harassment of residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 1-5
Facility Policy 8-3
Facility Policy 10-25
Agency Policy FDJJ 1919
Florida Administrative Code, Rule 63F-11
Resident Handbook
Chatty Cathy Form
Grievance Form
Posted Information
Interviews:
Random Staff
Residents
Facility Administrator
Assistant Facility Administrator
Provision (a):
The agency shall provide multiple internal ways for residents to privately report sexual abuse and
sexual harassment, retaliation by other residents or staff for reporting sexual abuse and sexual
71
harassment, and staff neglect or violation of responsibilities that may have contributed to such
incidents.
Policy provides for internal ways a resident may report allegations of sexual abuse and sexual
harassment, including how to privately report sexual abuse and sexual harassment; retaliation for
reporting; and staff neglect or violations of responsibilities that may have contributed to such. Residents
may report allegations of sexual abuse or sexual harassment by telephone through the 24-hour Florida
abuse reporting hotline. Telephones are made accessible to residents for reporting allegations of
sexual abuse and sexual harassment. Staff members are required to make the use of the telephone
accessible for residents to report allegations of sexual abuse and sexual harassment, and staff neglect
or violation of responsibilities that may have contributed to such incidents.
Policy, posters, brochures, information sheet, and the handbook collectively provide telephone numbers
and instructions for reporting allegations of sexual abuse or sexual harassment. In addition to
accessing a telephone, residents are also informed in the PREA education sessions, determined from
the interviews, that they may tell staff; submit a complaint in writing utilizing the use of a Chatty Cathy
form (a Grievance form may also be used to write the complaint); or use the hotline regarding
allegations of sexual abuse or sexual harassment. The residents interviewed identified someone who
did not work at the facility that they could report to about sexual abuse or sexual harassment. The
random staff and resident interviews collectively revealed residents may use a telephone, submit a
complaint in writing, or talk to staff to privately report allegations of sexual abuse and sexual
harassment. The resident is provided the hotline number in writing on the PREA information sheet,
resident handbook, brochures, and posted information.
Residents have access to writing materials; Grievance, Chatty Cathy, Sick Call forms; and locked
boxes for receipt of the forms which are accessible to all residents for reporting allegations. Written
notes or letters and other completed forms may also be given to staff. If a grievance form is used to
make a written allegation of sexual abuse, the reporting procedures will be implemented in accordance
with Policy. PREA information is posted and each resident is provided a handbook which contains
reporting and other PREA related information. Staff members receive information on how to report
allegations of sexual abuse or sexual harassment through policies and procedures, training, and staff
meetings.
Provision (b):
The agency shall also provide at least one way for residents to report abuse or harassment to a public
or private entity or office that is not part of the agency and that is able to receive and immediately
forward resident reports of sexual abuse and sexual harassment to agency officials, allowing the
resident to remain anonymous upon request. Residents detained solely for civil immigration purposes
shall be provided information on how to contact relevant consular officials and relevant officials at the
Department of Homeland Security.
The Florida abuse reporting hotline may be used by residents and staff to report allegations of sexual
abuse and sexual harassment. The interviews revealed familiarity with Policy and posted information on
how to report allegations. Telephones are accessible to all staff and are made accessible to residents
by staff. The reports of sexual abuse or sexual harassment are accepted and referred for an
investigation. The facility does not detain residents solely for civil immigration purposes according to
written communication from the DJJ legal department.
Provision (c):
Staff shall accept reports made verbally, in writing, anonymously, and from third parties and shall
promptly document any verbal reports.
72
The staff interviews confirmed the methods available to residents for reporting allegations of sexual
abuse and sexual harassment. Staff members are required to accept reports made anonymously, third-
party reports and to document verbal reports. The resident interviews collectively indicated awareness
of reporting either in person, in writing, by telephone, or through a third-party. Documentation reveals
the investigation of reports received. Interviewed staff members were aware of their duty to receive and
document the receipt of verbal reports.
Provision (d):
The facility shall provide residents with access to tools necessary to make a written report.
Interviews and observations revealed writing materials are available for residents to complete
Grievance and other forms or write notes. Each resident is provided a handbook which contains
information regarding reporting by a written method. The interviews, review of documents and facility
practices revealed alignment with the agency and facility policies.
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and sexual harassment of
residents.
The staff interviews revealed staff can privately report allegations of sexual abuse and sexual
harassment through a call to the Florida abuse reporting hotline and notify the Facility Administrator or
Assistant Facility Administrator.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor determined
the facility is compliant with this standard.
Standard 115.352: Exhaustion of Administrative Remedies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.352 (a)
▪ Is the agency exempt from this standard? NOTE: The agency is exempt ONLY if it does not
have administrative procedures to address resident grievances regarding sexual abuse. This
does not mean the agency is exempt simply because a resident does not have to or is not
ordinarily expected to submit a grievance to report sexual abuse. This means that as a matter of
explicit policy, the agency does not have an administrative remedies process to address sexual
abuse. ☐ Yes ☒ No ☐ NA
115.352 (b)
▪ Does the agency permit residents to submit a grievance regarding an allegation of sexual abuse
without any type of time limits? (The agency may apply otherwise-applicable time limits to any
portion of a grievance that does not allege an incident of sexual abuse.) (N/A if agency is
exempt from this standard.) ☒ Yes ☐ No ☐ NA
73
▪ Does the agency always refrain from requiring a resident to use any informal grievance process,
or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse? (N/A if agency
is exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.352 (c)
▪ Does the agency ensure that: A resident who alleges sexual abuse may submit a grievance
without submitting it to a staff member who is the subject of the complaint? (N/A if agency is
exempt from this standard.) ☒ Yes ☐ No ☐ NA
▪ Does the agency ensure that: Such grievance is not referred to a staff member who is the
subject of the complaint? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.352 (d)
▪ Does the agency issue a final agency decision on the merits of any portion of a grievance
alleging sexual abuse within 90 days of the initial filing of the grievance? (Computation of the
90-day time period does not include time consumed by residents in preparing any administrative
appeal.) (N/A if agency is exempt from this standard.) ☐ Yes ☒ No ☐ NA
▪ If the agency determines that the 90-day timeframe is insufficient to make an appropriate
decision and claims an extension of time [the maximum allowable extension of time to respond
is 70 days per 115.352(d)(3)], does the agency notify the resident in writing of any such
extension and provide a date by which a decision will be made? (N/A if agency is exempt from
this standard.) ☐ Yes ☒ No ☐ NA
▪ At any level of the administrative process, including the final level, if the resident does not
receive a response within the time allotted for reply, including any properly noticed extension,
may a resident consider the absence of a response to be a denial at that level? (N/A if agency is
exempt from this standard.) ☐ Yes ☒ No ☐ NA
115.352 (e)
▪ Are third parties, including fellow residents, staff members, family members, attorneys, and
outside advocates, permitted to assist residents in filing requests for administrative remedies
relating to allegations of sexual abuse? (N/A if agency is exempt from this standard.)
☒ Yes ☐ No ☐ NA
▪ Are those third parties also permitted to file such requests on behalf of residents? (If a third
party, other than a parent or legal guardian, files such a request on behalf of a resident, the
facility may require as a condition of processing the request that the alleged victim agree to
have the request filed on his or her behalf, and may also require the alleged victim to personally
pursue any subsequent steps in the administrative remedy process.) (N/A if agency is exempt
from this standard.) ☒ Yes ☐ No ☐ NA
▪ If the resident declines to have the request processed on his or her behalf, does the agency
document the resident’s decision? (N/A if agency is exempt from this standard.)
☒ Yes ☐ No ☐ NA
74
▪ Is a parent or legal guardian of a juvenile allowed to file a grievance regarding allegations of
sexual abuse, including appeals, on behalf of such juvenile? (N/A if agency is exempt from this
standard.) ☒ Yes ☐ No ☐ NA
▪ If a parent or legal guardian of a juvenile files a grievance (or an appeal) on behalf of a juvenile
regarding allegations of sexual abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her behalf? (N/A if agency is
exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.352 (f)
▪ Has the agency established procedures for the filing of an emergency grievance alleging that a
resident is subject to a substantial risk of imminent sexual abuse? (N/A if agency is exempt from
this standard.) ☒ Yes ☐ No ☐ NA
▪ After receiving an emergency grievance alleging a resident is subject to a substantial risk of
imminent sexual abuse, does the agency immediately forward the grievance (or any portion
thereof that alleges the substantial risk of imminent sexual abuse) to a level of review at which
immediate corrective action may be taken? (N/A if agency is exempt from this standard.).
☒ Yes ☐ No ☐ NA
▪ After receiving an emergency grievance described above, does the agency provide an initial
response within 48 hours? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
▪ After receiving an emergency grievance described above, does the agency issue a final agency
decision within 5 calendar days? (N/A if agency is exempt from this standard.)
☐ Yes ☒ No ☐ NA
▪ Does the initial response and final agency decision document the agency’s determination
whether the resident is in substantial risk of imminent sexual abuse? (N/A if agency is exempt
from this standard.) ☒ Yes ☐ No ☐ NA
▪ Does the initial response document the agency’s action(s) taken in response to the emergency
grievance? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
▪ Does the agency’s final decision document the agency’s action(s) taken in response to the
emergency grievance? (N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
115.352 (g)
▪ If the agency disciplines a resident for filing a grievance related to alleged sexual abuse, does it
do so ONLY where the agency demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
75
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Agency Policy FDJJ 1919
Grievance Form
Chatty Cathy Form
Resident Handbook
Interviews:
Random Staff
Residents
Facility Administrator
Provision (a):
An agency shall be exempt from this standard if it does not have administrative procedures to address
resident grievances regarding sexual abuse.
When an emergency grievance is received that contains an allegation of sexual abuse or sexual
harassment, the policy, and procedures for reporting allegations of sexual abuse or sexual harassment
are initiated and a report is made as required by policy. The grievance system does not include a
process for the facility staff to investigate or resolve allegations of sexual abuse or sexual harassment.
The content of the grievance is reported, and an investigation will be conducted by the FDJJ/OIG,
Florida Department of Children and Families, or local law enforcement when the allegation is criminal in
nature.
Provision (b):
(1) The agency shall not impose a time limit on when a resident may submit a grievance regarding an
allegation of sexual abuse.
(2) The agency may apply otherwise-applicable time limits on any portion of a grievance that does not
allege an incident of sexual abuse.
(3) The agency shall not require a resident to use any informal grievance process, or to otherwise
attempt to resolve with staff, an alleged incident of sexual abuse.
(4) Nothing in this section shall restrict the agency’s ability to defend against a lawsuit filed by a
resident on the ground that the applicable statute of limitations has expired.
Policy provides that there is no time limit for completing a Grievance Form to report allegations of
sexual abuse. Residents are not required to use an informal process or give the Grievance or Chatty
Cathy to any staff member regarding allegations of sexual abuse. The general communication to
residents is to use the Chatty Cathy Form to report allegations of sexual abuse or sexual harassment.
76
Locked boxes are located in the dining room for residents to deposit forms or notes if they choose.
Policy does not restrict the facility’s ability to defend against a lawsuit filed by a resident on the ground
that the applicable statute of limitations has expired.
Provision (c):
The agency shall ensure that—
(1) A resident who alleges sexual abuse may submit a grievance without submitting it to a staff member
who is the subject of the complaint, and
(2) Such grievance is not referred to a staff member who is the subject of the complaint.
The regular grievance system does not include investigating allegations of sexual abuse and sexual
harassment. Residents are not required to use an informal process or give the grievance to any staff
member regarding allegations of sexual abuse. The staff member involved in the grievance will not be
involved in reporting the allegation stated in the grievance. To assist in the prompt and proper handling
of the allegation of sexual abuse or sexual harassment, the youth may put the grievance in the
grievance box or give it to staff if she chooses.
The resident handbook informs residents to report allegations of abuse or neglect through the Florida
abuse hotline and the contact information is provided and the resident is informed that she will have
unhindered access to a telephone. The handbook informs residents that, the resident should not use
the informal process regarding a PREA related allegation. The locked boxes are located in the dining
room for depositing Forms. The resident handbook explains the regular grievance system and contains
information regarding reporting allegations of sexual abuse and sexual harassment.
Provision (d):
(1) The agency shall issue a final agency decision on the merits of any portion of a grievance alleging
sexual abuse within 90 days of the initial filing of the grievance.
(2) Computation of the 90-day time period shall not include time consumed by residents in preparing
any administrative appeal.
(3) The agency may claim an extension of time to respond, of up to 70 days, if the normal time period
for response is insufficient to make an appropriate decision. The agency shall notify the resident in
writing of any such extension and provide a date by which a decision will be made.
(4) At any level of the administrative process, including the final level, if the resident does not receive a
response within the time allotted for reply, including any properly noticed extension, the resident may
consider the absence of a response to be a denial at that level.
Initial response is required within 48 hours to inform the resident of receipt of the grievance containing
an allegation of sexual abuse and that it has been referred for investigation. All grievances alleging
sexual abuse or sexual harassment will be referred for an investigation in accordance with policy. The
purpose of the submission of a PREA related grievance provides residents and staff another avenue for
ensuring the reporting of allegations and provides management staff with the opportunity to protect the
resident.
Provision (e):
(1) Third parties, including fellow residents, staff members, family members, attorneys, and outside
advocates, shall be permitted to assist residents in filing requests for administrative remedies relating to
allegations of sexual abuse, and shall also be permitted to file such requests on behalf of residents.
(2) If a third party, other than a parent or legal guardian, files such a request on behalf of a resident, the
facility may require as a condition of processing the request that the alleged victim agree to have the
request filed on his or her behalf and may also require the alleged victim to personally pursue any
subsequent steps in the administrative remedy process.
77
(3) If the resident declines to have the request processed on his or her behalf, the agency shall
document the resident’s decision.
(4) A parent or legal guardian of a juvenile shall be allowed to file a grievance regarding allegations of
sexual abuse, including appeals, on behalf of such juvenile. Such a grievance shall not be conditioned
upon the juvenile agreeing to have the request filed on his or her behalf.
When third-party reports of allegations of sexual abuse or sexual harassment are received, the policies
and procedures for reporting allegations of sexual abuse or sexual harassment are initiated and a
report is made as required by policy. The grievance system does not include a process for facility staff
to investigate or resolve allegations of sexual abuse or sexual harassment. The content of the
grievance is reported, and an investigation will be conducted by the investigative entity as appropriate.
Provision (f):
(1) The agency shall establish procedures for the filing of an emergency grievance alleging that a
resident is subject to a substantial risk of imminent sexual abuse.
(2) After receiving an emergency grievance alleging a resident is subject to a substantial risk of
imminent sexual abuse, the agency shall immediately forward the grievance (or any portion thereof that
alleges the substantial risk of imminent sexual abuse) to a level of review at which immediate corrective
action may be taken, shall provide an initial response within 48 hours, and shall issue a final agency
decision within five calendar days. The initial response and final agency decision shall document the
agency’s determination whether the resident is in substantial risk of imminent sexual abuse and the
action taken in response to the emergency grievance.
Policy provides for emergency grievances to be responded to within 48 hours. The response is to
inform the resident of the receipt of the grievance and the referral for an investigation. If a grievance
alleging sexual abuse is received, it is reported by staff to the appropriate investigative entity. The
response to the grievance will include measures to ensure safety and also include but not limited to
determining an immediate corrective action that would be implemented within 48 hours where
applicable to ensure the safety of the resident.
Provision (g):
The agency may discipline a resident for filing a grievance related to alleged sexual abuse only where
the agency demonstrates that the resident filed the grievance in bad faith.
A resident may be disciplined when it has been determined that a report alleging sexual abuse has
been made in bad faith. There has not been a grievance submitted alleging sexual abuse during this
audit period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor determined
the facility is compliant with this standard.
Standard 115.353: Resident Access to Outside Confidential Support
Services and Legal Representation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.353 (a)
78
▪ Does the facility provide residents with access to outside victim advocates for emotional support
services related to sexual abuse by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll-free hotline numbers where available, of local,
State, or national victim advocacy or rape crisis organizations? ☒ Yes ☐ No
▪ Does the facility provide persons detained solely for civil immigration purposes mailing
addresses and telephone numbers, including toll-free hotline numbers where available of local,
State, or national immigrant services agencies? ☒ Yes ☐ No
▪ Does the facility enable reasonable communication between residents and these organizations
and agencies, in as confidential a manner as possible? ☒ Yes ☐ No
115.353 (b)
▪ Does the facility inform residents, prior to giving them access, of the extent to which such
communications will be monitored and the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws? ☒ Yes ☐ No
115.353 (c)
▪ Does the agency maintain or attempt to enter into memoranda of understanding or other
agreements with community service providers that are able to provide residents with confidential
emotional support services related to sexual abuse? ☒ Yes ☐ No
▪ Does the agency maintain copies of agreements or documentation showing attempts to enter
into such agreements? ☒ Yes ☐ No
115.353 (d)
▪ Does the facility provide residents with reasonable and confidential access to their attorneys or
other legal representation? ☒ Yes ☐ No
▪ Does the facility provide residents with reasonable access to parents or legal guardians?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
79
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Agreement
Facility Policy 8-5
Facility Policy 8-6
Facility Policy 8-7
Posted Information
Interviews:
Residents
Therapist
Facility Administrator
Assistant Facility Administrator
Director of Nursing, Crisis Center of Tampa Bay
Provision (a):
The facility shall provide residents with access to outside victim advocates for emotional support
services related to sexual abuse, by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll free hotline numbers where available, of local, State,
or national victim advocacy or rape crisis organizations, and, for persons detained solely for civil
immigration purposes, immigrant services agencies. The facility shall enable reasonable
communication between residents and these organizations and agencies, in as confidential a manner
as possible.
Interviews revealed that residents required a refresher regarding victim advocacy services. The
agreement with the Crisis Center of Tampa Bay remains in effect, according to the Director of Nursing
of the agency. The residents were in need of a review of the services provided by the advocacy
agency. The implemented corrective action included the refresher education session with residents.
The interview with the Director of Nursing who works with the Crisis Center of Tampa Bay confirmed
the services to be provided when needed.
Provision (b):
The facility shall inform residents, prior to giving them access, of the extent to which such
communications will be monitored and the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws.
Policy, facility staff interviews and the refresher education session provide there will be adherence to
confidentiality measures and this information is shared with residents during PREA education sessions.
Provision (c):
The agency shall maintain or attempt to enter into memoranda of understanding or other agreements
with community service providers that are able to provide residents with confidential emotional support
80
services related to sexual abuse. The agency shall maintain copies of agreements or documentation
showing attempts to enter into such agreements.
The Director of Nursing’s interview document the provision of advocacy services including but not
limited to emotional support, accompaniment through the forensic medical examination and
investigative interview. The Director of Nursing confirmed the information contained in the written
agreement. The advocacy services are activated by a response from a Sexual Assault Nurse Examiner
to conduct a forensic medical examination.
Provision (d):
The facility shall also provide residents with reasonable and confidential access to their attorneys or
other legal representation and reasonable access to parents or legal guardians.
The residents have reasonable and confidential access to attorneys and court workers and reasonable
access to their parents/legal guardians which is supported by Policy and the parent handbook. During
the pandemic when visitation to the facility was suspended, youth have been provided the opportunity
to video chat with parents or guardians and with attorneys and court workers where requested. All
residents interviewed confirmed communication opportunities occur.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor determined
the facility meets this standard.
Standard 115.354: Third-Party Reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.354 (a)
▪ Has the agency established a method to receive third-party reports of sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Has the agency distributed publicly information on how to report sexual abuse and sexual
harassment on behalf of a resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
81
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Resident Handbook
PREA Posters
Printed Materials
Website Information
Interviews:
Random Staff
Residents
Facility Administrator
Standard 115.354:
The agency shall establish a method to receive third-party reports of sexual abuse and sexual
harassment and shall distribute publicly information on how to report sexual abuse and sexual
harassment on behalf of a resident.
Staff members are to receive, document and report allegations of sexual abuse and sexual harassment
made by a third-party. The staff members are aware third-party reporting of sexual abuse or sexual
harassment can be done and indicated the information will be accepted and reported. Staff members
are to document all verbal reports received. The interviews collectively revealed staff may report
allegations privately through the use of the abuse reporting hotline, complete a report, and tell
administrators. The agency website contains the information needed for third parties to report
allegations of sexual abuse and sexual harassment.
Information regarding reporting is posted within the facility and accessible to visitors. Reporting
information is also contained in the resident and parent handbooks. All residents interviewed indicated
knowing someone who did not work at the facility they have contact with. It was determined that a
person outside of the facility may report allegations of sexual abuse and may make a report for a
resident without giving the resident’s name. No third-party reports were received during this audit
period.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor determined
the facility is in compliance with this standard.
OFFICIAL RESPONSE FOLLOWING A RESIDENT REPORT
Standard 115.361: Staff and Agency Reporting Duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.361 (a)
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▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding an incident of sexual abuse or sexual
harassment that occurred in a facility, whether or not it is part of the agency? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding retaliation against residents or staff who
reported an incident of sexual abuse or sexual harassment? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding any staff neglect or violation of responsibilities
that may have contributed to an incident of sexual abuse or sexual harassment or retaliation?
☒ Yes ☐ No
115.361 (b)
▪ Does the agency require all staff to comply with any applicable mandatory child abuse reporting
laws? ☒ Yes ☐ No
115.361 (c)
▪ Apart from reporting to designated supervisors or officials and designated State or local services
agencies, are staff prohibited from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency policy, to make treatment,
investigation, and other security and management decisions? ☒ Yes ☐ No
115.361 (d)
▪ Are medical and mental health practitioners required to report sexual abuse to designated
supervisors and officials pursuant to paragraph (a) of this section as well as to the designated
State or local services agency where required by mandatory reporting laws? ☒ Yes ☐ No
▪ Are medical and mental health practitioners required to inform residents of their duty to report,
and the limitations of confidentiality, at the initiation of services? ☒ Yes ☐ No
115.361 (e)
▪ Upon receiving any allegation of sexual abuse, does the facility head or his or her designee
promptly report the allegation to the appropriate office? ☒ Yes ☐ No
▪ Upon receiving any allegation of sexual abuse, does the facility head or his or her designee
promptly report the allegation to the alleged victim’s parents or legal guardians unless the facility
has official documentation showing the parents or legal guardians should not be notified?
☒ Yes ☐ No
▪ If the alleged victim is under the guardianship of the child welfare system, does the facility head
or his or her designee promptly report the allegation to the alleged victim’s caseworker instead
of the parents or legal guardians? (N/A if the alleged victim is not under the guardianship of the
child welfare system.) ☒ Yes ☐ No ☐ NA
83
▪ If a juvenile court retains jurisdiction over the alleged victim, does the facility head or designee
also report the allegation to the juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation? ☒ Yes ☐ No
115.361 (f)
▪ Does the facility report all allegations of sexual abuse and sexual harassment, including third-
party and anonymous reports, to the facility’s designated investigators? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 1-5
Facility Policy 8-3
Facility Policy 10-25
Agency Policy FDJJ 1919
Florida Administrative Code, Rule 63F-11
Interviews:
Random Staff
Facility Administrator
Health Service Administrator
Clinical Director
Provision (a) and (b):
Provision (a): The agency shall require all staff to report immediately and according to agency policy
any knowledge, suspicion, or information they receive regarding an incident of sexual abuse or sexual
harassment that occurred in a facility, whether or not it is part of the agency; retaliation against
residents or staff who reported such an incident; and any staff neglect or violation of responsibilities that
may have contributed to an incident or retaliation.
Provision (b): The agency shall also require all staff to comply with any applicable mandatory child
abuse reporting laws.
84
Per the direction of the Administrative Code, Policy supports that all staff report any knowledge,
suspicion, information, or receipt of information regarding an incident or allegation of sexual abuse,
sexual harassment, or incidents of retaliation. Staff members are deemed as mandated reporters by the
State. The trained DJJ agency investigators conduct administrative investigations and allegations that
are criminal in nature are referred to local law enforcement. The facility and agency Policies provides
guidance to staff on reporting allegations of sexual abuse and sexual harassment and the duties of the
first responder.
Provision (c):
Apart from reporting to designated supervisors or officials and designated State or local services
agencies, staff shall be prohibited from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency policy, to make treatment,
investigation, and other security and management decisions.
Policy addresses confidentiality of information and the conditions for providing information. Policies
collectively indicate that after allegations have been appropriately reported, staff will keep the
information confidential regarding what was reported except when necessary regarding the
investigation and treatment and management decisions.
Provision (d):
(1) Medical and mental health practitioners shall be required to report sexual abuse to designated
supervisors and officials pursuant to paragraph (a) of this section, as well as to the designated State or
local services agency where required by mandatory reporting laws.
(2) Such practitioners shall be required to inform residents at the initiation of services of their duty to
report and the limitations of confidentiality.
The clinical staff interviewed indicated residents are informed at the initiation of services of the
limitations of confidentiality and the duty of the staff members to report. The clinical staff members are
also mandated reporters and required by the State to report allegations received regarding sexual
abuse and sexual harassment, in accordance with policy and State requirements.
Provision (e):
(1) Upon receiving any allegation of sexual abuse, the facility head or his or her designee shall promptly
report the allegation to the appropriate agency office and to the alleged victim’s parents or legal
guardians, unless the facility has official documentation showing the parents or legal guardians should
not be notified.
(2) If the alleged victim is under the guardianship of the child welfare system, the report shall be made
to the alleged victim’s caseworker instead of the parents or legal guardians.
(3) If a juvenile court retains jurisdiction over the alleged victim, the facility head or designee shall also
report the allegation to the juvenile’s attorney or other legal representative of record within 14 days of
receiving the allegation.
Reports of allegations are made as soon as possible to the investigative entities, including the DJJ
Central Communications Center, and parents/legal guardians. Policy and interview with the Facility
Administrator confirmed that a resident’s caseworker rather than a parent would be notified where
indicated by the resident being under the guardianship of the Florida Department of Children and
Families. The resident’s attorney would be notified within 14 days. There were no allegations of sexual
abuse during this audit period.
85
Provision (f):
The facility shall report all allegations of sexual abuse and sexual harassment, including third-party and
anonymous reports, to the facility’s designated investigators.
Policy and interviews provide for all allegations to be reported and include the Office of the Inspector
General (OIG) through the Central Communications Center. Administrative investigations are
conducted by a DJJ/OIG investigator. Sexual abuse and sexual harassment allegations that are
criminal in nature are referred for investigation to local law enforcement. Third-party and anonymous
reports received must be reported and documented by staff as confirmed through interviews. The
interviews confirmed that all allegations are reported to the DJJ Central Communications Center.
Conclusion:
The review of evidence and interviews indicate the facility is in compliance with this standard.
Standard 115.362: Agency Protection Duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.362 (a)
▪ When the agency learns that a resident is subject to a substantial risk of imminent sexual
abuse, does it take immediate action to protect the resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior
Interviews:
Facility Administrator
Random Staff
Residents
86
Provision (a):
When an agency learns that a resident is subject to a substantial risk of imminent sexual abuse, it shall
take immediate action to protect the resident.
The staff is required to protect the residents through implementing protective measures. Administration
of the risk screening instrument provides information that assists and guide staff in keeping residents
safe through housing and program assignments. Additional assessment instruments provide
information which offer supporting information in determining the risk level of each resident.
The interviews revealed protective measures include but are not limited to separating youth and
contacting management staff and supervisors. The expectation is that any action to protect a resident
would be taken immediately as deemed from interviews with the Facility Administrator and random
staff. During the intake process, residents are asked about how they feel about their safety as part of
the inquiries by staff completing the Screening for Vulnerability, Victimization and Sexually Aggressive
Behavior. No resident was identified to be at substantial risk of imminent sexual abuse in the past 12
months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor determined
the facility is compliant with this standard.
Standard 115.363: Reporting to Other Confinement Facilities
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.363 (a)
▪ Upon receiving an allegation that a resident was sexually abused while confined at another
facility, does the head of the facility that received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse occurred? ☒ Yes ☐ No
▪ Does the head of the facility that received the allegation also notify the appropriate investigative
agency? ☒ Yes ☐ No
115.363 (b)
▪ Is such notification provided as soon as possible, but no later than 72 hours after receiving the
allegation? ☒ Yes ☐ No
115.363 (c)
▪ Does the agency document that it has provided such notification? ☒ Yes ☐ No
115.363 (d)
▪ Does the facility head or agency office that receives such notification ensure that the allegation
is investigated in accordance with these standards? ☒ Yes ☐ No
Auditor Overall Compliance Determination
87
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interview:
Facility Administrator
Provisions (a) - (d):
Provision (a): Upon receiving an allegation that a resident was sexually abused while confined at
another facility, the head of the facility that received the allegation shall notify the head of the facility or
appropriate office of the agency where the alleged abuse occurred and shall also notify the appropriate
investigative agency.
Provision (b): Such notification shall be provided as soon as possible, but no later than 72 hours after
receiving the allegation.
Provision (c): The agency shall document that it has provided such notification.
Provision (d): The facility head or agency office that receives such notification shall ensure that the
allegation is investigated in accordance with these standards.
When an allegation of sexual abuse is received that a resident was sexually abused while confined at
another facility, the Facility Administrator will notify the head of the facility where the alleged abuse
occurred. The notification will be made as soon as possible and within 72 hours in accordance with
Policy. The Facility Administrator is also required to make a report to the Central Communications
Center. The Policy and interview support that allegations of sexual abuse or sexual harassment from a
resident regarding her.367 stay in another facility will be reported and investigated as required. In the
past 12 months, there were no allegations reported of sexual abuse occurring at another facility.
Conclusion:
Based upon the information received and interviews, the Auditor determined the facility is compliant
with this standard.
Standard 115.364: Staff First Responder Duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.364 (a)
88
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Separate the alleged victim and abuser?
☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence? ☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Request that the alleged victim not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
115.364 (b)
▪ If the first staff responder is not a security staff member, is the responder required to request
that the alleged victim not take any actions that could destroy physical evidence, and then notify
security staff? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Sexual Abuse Incident Coordinated Response Plan
89
Interviews:
Random Staff
Facility Administrator
Provision (a):
Upon learning of an allegation that a resident was sexually abused, the first staff member to respond to
the report shall be required to:
(1) Separate the alleged victim and abuser;
(2) Preserve and protect any crime scene until appropriate steps can be taken to collect any evidence;
(3) If the abuse occurred within a time period that still allows for the collection of physical evidence,
request that the alleged victim not take any actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking, drinking, or
eating; and
(4) If the abuse occurred within a time period that still allows for the collection of physical evidence,
ensure that the alleged abuser does not take any actions that could destroy physical evidence,
including, as appropriate, washing, brushing teeth, changing clothes, urinating, defecating, smoking,
drinking, or eating.
The interviews and staff training information support the training areas provided in this standard. There
were no allegations or incidents where staff had to act as a first responder in the last 12 months. Policy
and training provide that upon learning of an allegation that a resident was sexually abused the general
staff response would basically include but not be limited to the following:
a. Separate the victim and alleged abuser.
b. Preserve and protect the scene until appropriate steps can be taken to collect any evidence.
c. Request that the alleged victim not take any actions that could destroy physical evidence.
d. Take actions to ensure the alleged abuser does not take any actions that could destroy physical
evidence.
e. Ensure the safety of the victim.
f. Make the required notifications.
Provision (b):
If the first staff responder is not a security staff member, the responder shall be required to request that
the alleged victim not take any actions that could destroy physical evidence, and then notify security
staff.
The non-security staff who may act as a first responder will request that physical evidence be
preserved and contact direct care staff for assistance, in accordance with policy. There were no
allegations or incidents where a non-security staff member had to act as a first responder in the last 12
months.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor determined
the facility is compliant with this standard.
Standard 115.365: Coordinated Response
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
90
115.365 (a)
▪ Has the facility developed a written institutional plan to coordinate actions among staff first
responders, medical and mental health practitioners, investigators, and facility leadership taken
in response to an incident of sexual abuse? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Sexual Abuse Incident Coordinated Response Plan
Interviews:
Random Staff
Facility Administrator
Provision (a):
The facility shall develop a written institutional plan to coordinate actions taken in response to an
incident of sexual abuse among staff first responders, medical and mental health practitioners,
investigators, and facility leadership.
The facility has a written institutional plan, Sexual Abuse Incident Coordinated Response Plan, to be
implemented in the event of an allegation or incident of sexual abuse. The plan outlines the actions of
the identified staff members such as the first responder; medical; mental health; supervisors; and
management. Policy provides guidance to staff regarding the actions to take when there is an alleged
incident of sexual abuse and requires a written facility plan. The coordinated response to an incident of
sexual abuse is also aligned with the Policy. The staff interviews indicated familiarity regarding the
response to an allegation of sexual abuse.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor determined
the facility is compliant with the standard.
91
Standard 115.366: Preservation of Ability to Protect Residents from Contact
with Abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.366 (a)
▪ Are both the agency and any other governmental entities responsible for collective bargaining
on the agency’s behalf prohibited from entering into or renewing any collective bargaining
agreement or other agreement that limits the agency’s ability to remove alleged staff sexual
abusers from contact with any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is warranted? ☒ Yes ☐ No
115.366 (b)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Interview:
Facility Administrator
Provision (a) and (b):
Provision(a): Neither the agency nor any other governmental entity responsible for collective
bargaining on the agency’s behalf shall enter into or renew any collective bargaining agreement or
other agreements that limits the agency’s ability to remove alleged staff sexual abusers form contact
with residents pending the outcome of an investigation or of a determination of whether and to what
extent discipline is warranted.
Provision (b): Nothing is this standard shall restrict the entering into on renewal of agreements that
govern:
(1) The conduct of the disciplinary process, at long as such agreements are not inconsistent with the
provisions of §115.372 and §115.376; or
(2) Whether a no-contact assignment that is imposed pending the outcome of an investigation shall be
expunged from or retained in the staff member’s personnel file following a determination that the
allegation of sexual abuse is not substantiated.
92
The facility is not involved in any collective bargaining agreements.
Standard 115.367: Agency Protection Against Retaliation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.367 (a)
▪ Has the agency established a policy to protect all residents and staff who report sexual abuse or
sexual harassment or cooperate with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff? ☒ Yes ☐ No
▪ Has the agency designated which staff members or departments are charged with monitoring
retaliation? ☒ Yes ☐ No
115.367 (b)
▪ Does the agency employ multiple protection measures for residents or staff who fears retaliation
for reporting sexual abuse or sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers, removal of alleged staff or resident
abusers from contact with victims, and emotional support services? ☒ Yes ☐ No
115.367 (c)
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
and treatment of residents or staff who reported the sexual abuse to see if there are changes
that may suggest possible retaliation by residents or staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
and treatment of residents who were reported to have suffered sexual abuse to see if there are
changes that may suggest possible retaliation by residents or staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Act promptly to remedy
any such retaliation? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Resident
housing changes? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Resident
program changes? ☒ Yes ☐ No
93
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Negative
performance reviews of staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor:
Reassignments of staff? ☒ Yes ☐ No
▪ Does the agency continue such monitoring beyond 90 days if the initial monitoring indicates a
continuing need? ☒ Yes ☐ No
115.367 (d)
▪ In the case of residents, does such monitoring also include periodic status checks?
☒ Yes ☐ No
115.367 (e)
▪ If any other individual who cooperates with an investigation expresses a fear of retaliation, does
the agency take appropriate measures to protect that individual against retaliation?
☒ Yes ☐ No
115.367 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Retaliation Monitoring (PREA) Form
Interview:
94
Facility Administrator
Provision (a):
The agency shall establish a policy to protect all residents and staff who report sexual abuse or sexual
harassment or cooperate with sexual abuse or sexual harassment investigations from retaliation by
other residents or staff and shall designate which staff members or departments are charged with
monitoring retaliation.
Policy supports protecting residents and staff who report sexual abuse or sexual harassment or
cooperate with sexual abuse or sexual harassment investigations from retaliation by other residents, or
staff. The Facility Administrator is responsible for conducting and ensuring retaliation monitoring. The
Retaliation Monitoring (PREA) form is used to document the monitoring activities. The Facility
Administrator is familiar with the role of retaliation monitor and its purpose.
Provision (b):
The agency shall employ multiple protection measures, such as housing changes or transfers for
resident victims or abusers, removal of alleged staff or resident abusers from contact with victims, and
emotional support services for residents or staff that fear retaliation for reporting sexual abuse or sexual
harassment or for cooperating with investigations.
Protective measures were generally identified during the interviews with random staff and the Facility
Administrator and aligned with Policy. Protective measures include housing changes for resident
victims or abusers; removing alleged staff or resident abusers from contact with victims; change in shift
assignments; and transferring youth, if needed. The retaliation monitoring is documented, and follow-up
checks with the parties involved ensure safe feelings and identifies whether retaliation is occurring. The
interview confirmed the measures to detect and protect staff and residents from retaliation by others.
Provision (c):
For at least 90 days following a report of sexual abuse, the agency shall monitor the conduct or
treatment of residents or staff who reported the sexual abuse and of residents who were reported to
have suffered sexual abuse to see if there are changes that may suggest possible retaliation by
residents or staff and shall act promptly to remedy any such retaliation. Items the agency should
monitor include any resident disciplinary reports, housing, or program changes, or negative
performance reviews or reassignments of staff. The agency shall continue such monitoring beyond 90
days if the initial monitoring indicates a continuing need.
Policy provides that the monitoring will occur for at least 90 days to see if there are any changes that
may suggest possible retaliation is occurring. The monitoring period could last longer if needed,
according to the Facility Administrator. The interview identified items that would be monitored to assess
retaliation and included but were not limited to program and housing changes; shift assignments; point
cards; and staff and resident interactions.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
Policy and the interview with the Facility Administrator indicate that status checks will occur as a part of
retaliation monitoring. The dedicated monitoring form and the interview revealed that initial contact
would be made, and follow-up checks will be documented.
Provision (e):
If any other individual who cooperates with an investigation expresses a fear of retaliation, the agency
shall take appropriate measures to protect that individual against retaliation.
95
Policy encompasses those who cooperate with an investigation if there is a concern regarding
retaliation. The interview indicated that the appropriate measures would be taken to protect any related
individuals against retaliation.
Provision (f):
An agency’s obligation to monitor shall terminate if the agency determines that the allegation is
unfounded.
The obligation to monitor for retaliation terminates if it is determined that the allegation is unfounded.
The interview determined familiarity with the requirements regarding retaliation monitoring.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is
compliant with this standard.
Standard 115.368: Post-Allegation Protective Custody
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.368 (a)
▪ Is any and all use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse subject to the requirements of § 115.342? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interviews:
Facility Administrator
96
Clinical Director
Health Service Administrator
Provision (a):
The use of segregated housing to protect a resident who is alleged to have suffered sexual abuse shall
be subject to the requirements of §115.342.
Policies guide staff on measures to be taken to protect residents but does not include segregated
housing for alleged victims. Segregated housing is not used in the facility to protect residents who
alleged to have suffered sexual abuse. The interviews were aligned with this premise. The Policies
provide for the separation of residents by housing reassignments and other aforementioned strategies.
Conclusion:
Based upon the review of Policy, interviews, and observations, the Auditor determined the facility is
compliant with this standard.
INVESTIGATIONS
Standard 115.371: Criminal and Administrative Agency Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.371 (a)
▪ When the agency conducts its own investigations into allegations of sexual abuse and sexual
harassment, does it do so promptly, thoroughly, and objectively? [N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.
See 115.321(a).] ☒ Yes ☐ No ☐ NA
▪ Does the agency conduct such investigations for all allegations, including third party and
anonymous reports? [N/A if the agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations. See 115.321(a).]
☒ Yes ☐ No ☐ NA
115.371 (b)
▪ Where sexual abuse is alleged, does the agency use investigators who have received
specialized training in sexual abuse investigations involving juvenile victims as required by
115.334? ☒ Yes ☐ No
115.371 (c)
▪ Do investigators gather and preserve direct and circumstantial evidence, including any available
physical and DNA evidence and any available electronic monitoring data? ☒ Yes ☐ No
97
▪ Do investigators interview alleged victims, suspected perpetrators, and witnesses?
☒ Yes ☐ No
▪ Do investigators review prior reports and complaints of sexual abuse involving the suspected
perpetrator? ☒ Yes ☐ No
115.371 (d)
▪ Does the agency always refrain from terminating an investigation solely because the source of
the allegation recants the allegation? ☒ Yes ☐ No
115.371 (e)
▪ When the quality of evidence appears to support criminal prosecution, does the agency conduct
compelled interviews only after consulting with prosecutors as to whether compelled interviews
may be an obstacle for subsequent criminal prosecution? ☐ Yes ☒ No
115.371 (f)
▪ Do agency investigators assess the credibility of an alleged victim, suspect, or witness on an
individual basis and not on the basis of that individual’s status as resident or staff?
☒ Yes ☐ No
▪ Does the agency investigate allegations of sexual abuse without requiring a resident who
alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a
condition for proceeding? ☒ Yes ☐ No
115.371 (g)
▪ Do administrative investigations include an effort to determine whether staff actions or failures to
act contributed to the abuse? ☒ Yes ☐ No
▪ Are administrative investigations documented in written reports that include a description of the
physical evidence and testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings? ☒ Yes ☐ No
115.371 (h)
▪ Are criminal investigations documented in a written report that contains a thorough description
of the physical, testimonial, and documentary evidence and attaches copies of all documentary
evidence where feasible? ☒ Yes ☐ No
115.371 (i)
▪ Are all substantiated allegations of conduct that appears to be criminal referred for prosecution?
☒ Yes ☐ No
115.371 (j)
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▪ Does the agency retain all written reports referenced in 115.371(g) and (h) for as long as the
alleged abuser is incarcerated or employed by the agency, plus five years unless the abuse was
committed by a juvenile resident and applicable law requires a shorter period of retention?
☒ Yes ☐ No
115.371 (k)
▪ Does the agency ensure that the departure of an alleged abuser or victim from the employment
or control of the agency does not provide a basis for terminating an investigation?
☒ Yes ☐ No
115.371 (l)
▪ Auditor is not required to audit this provision.
115.371 (m)
▪ When an outside entity investigates sexual abuse, does the facility cooperate with outside
investigators and endeavor to remain informed about the progress of the investigation? (N/A if
an outside agency does not conduct administrative or criminal sexual abuse investigations. See
115.321(a).) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Sexual Abuse Incident Coordinated Response Plan
PREA Form
Interviews:
Facility Administrator
Assistant Facility Administrator
99
Provision (a):
When the agency conducts its own investigations into allegations of sexual abuse and sexual
harassment, it shall do so promptly, thoroughly, and objectively for all allegations, including third-party
and anonymous reports.
The administrative investigations are conducted by the investigators with the Florida Department of
Juvenile Justice (DJJ), Office of the Inspector General (OIG). Based on the written institutional plan,
Policies and interviews, trained investigators conduct administrative investigations as prescribed by
Policies. Allegations that are criminal in nature are referred to local law enforcement and the Florida
Department of Children and Families. Investigations are conducted thoroughly and objectively, and the
agencies’ Policy provides for the training of investigators.
.
Provision (b) and (c):
Provision (b): Where sexual abuse is alleged, the agency shall use investigators who have received
special training in sexual abuse investigations involving juvenile victims pursuant to §115.334.
Provision (c): Investigators shall gather and preserve direct and circumstantial evidence, including any
available physical and DNA evidence and any available electronic monitoring data; shall interview
alleged victims, suspected perpetrators, and witnesses; and shall review prior complaints and reports of
sexual abuse involving the suspected perpetrator.
The DJJ investigative staff is trained through the Office of the Inspector General (OIG). The Investigator
gathers direct and circumstantial evidence that includes but is not limited to reviewing video; gathering
witness statements; listening to any related telephone calls; and reviewing logs. The law enforcement
investigator and/or qualified medical practitioner are responsible for collecting direct physical and DNA
evidence. The facility staff and DJJ investigators are trained on how to assist in preserving evidence.
The agency, DJJ, provides each facility with the PREA Form which is provided to law enforcement
investigators referencing the PREA standards regarding conducting investigations in accordance with
the standards. The DJJ investigators follow the OIG guidelines governing PREA related investigations,
in accordance with Policy.
Provision (d):
The agency shall not terminate an investigation solely because the source of the allegation recants the
allegation.
The interviews and Policy confirm the provision that an investigation is not terminated if the source
recants an allegation of sexual abuse or sexual harassment. The investigation regarding the allegation
of sexual abuse demonstrates how an investigation is continued until the end and findings are
determined.
Provision (e):
When the quality of evidence appears to support criminal prosecution, the agency shall conduct
compelled interviews only after consulting with prosecutors as to whether compelled interviews may be
an obstacle for subsequent criminal prosecution.
The DJJ agency investigators do not conduct compelled interviews.
Provision (f):
The credibility of an alleged victim, suspect, or witness shall be assessed on an individual basis and
shall not be determined by the person’s status as resident or staff. No agency shall require a resident
who alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a
condition for proceeding with the investigation of such an allegation.
100
The credibility of an alleged victim, suspect, or witness is assessed on an individual basis and is not
determined by the person’s status as a resident or staff as supported by the interviews of the
administrators and a previous interview with an investigator, training, and in accordance with Policy. No
resident who alleges sexual abuse will be subjected to a polygraph examination or other truth telling
device as a condition for proceeding with the investigation of the allegation.
Provisions (g) and (h):
Provision (g): Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act contributed to the abuse.
(2) Shall be documented in written reports that include a description of the physical and testimonial
evidence, the reasoning behind credibility assessments, and investigative facts and findings.
Provision (h): Criminal investigations shall be documented in a written report that contains a thorough
description of physical, testimonial, and documentary evidence and attaches copies of all documentary
evidence where feasible.
The interviews revealed that PREA investigations include an effort to determine whether staff actions or
failures to act contributed to the abuse. All investigations are completed with written reports that
include a description of the evidence and investigative facts and findings as gleaned from review of
investigation reports completed by agency investigators and a previous interview with and agency
investigator.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be referred for prosecution.
The DJJ agency investigators do not conduct criminal investigations. It is the responsibility of local law
enforcement personnel to refer cases for prosecution.
Provision (j):
The agency shall retain all written reports referenced in paragraphs (g) and (h) of this section for as
long as the alleged abuser is incarcerated or employed by the agency, plus five years, unless the
abuse was committed by a juvenile resident and applicable law requires a shorter period of retention.
The written investigative reports are maintained for as long as the alleged abuser is incarcerated or
employed by the agency, plus five years as stated in Policy and as confirmed through interviews and
the maintenance of records.
Provision (k):
The departure of the alleged abuser or victim from the employment or control of the facility or agency
shall not provide a basis for terminating an investigation.
A previous interview with an investigator and the interviews with the administrators confirmed that upon
the start of an investigation, it will not end until the investigation has been completed. The departure of
the alleged abuser or victim from the employment or control of the facility will not terminate the
investigation.
Provision (l):
Any State entity or Department of Justice component that conducts such investigations shall do so
pursuant to the above requirements.
The investigative agencies are aware of the PREA standards requirements through the initial sharing of
PREA information, PREA Compliance Form, and subsequent interactions.
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Provision (m):
When outside agencies investigate sexual abuse, the facility shall cooperate with outside investigators
and shall endeavor to remain informed about the progress of the investigation.
The Policies and interviews indicate that staff cooperate with investigators and that the agency/facility is
kept informed of the progress of an investigation. The Facility Administrator maintains contact with the
investigator from the applicable investigative entity and added that she remains informed through the
DJJ statewide PREA Coordinator.
Conclusion:
Based upon the review and analysis of the available evidence and interviews, the Auditor determined
the facility is compliant with this standard.
Standard 115.372: Evidentiary Standard for Administrative Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.372 (a)
▪ Is it true that the agency does not impose a standard higher than a preponderance of the
evidence in determining whether allegations of sexual abuse or sexual harassment are
substantiated? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Document Reviewed:
Agency Policy FDJJ 1919
Interviews:
Facility Administrator
Assistant Facility Administrator
102
Provision (a):
The agency shall impose no standard higher than a preponderance of the evidence in determining
whether allegations of sexual abuse or sexual harassment are substantiated.
The Florida Department of Juvenile Justice/Office of Inspector General, responsible for administrative
investigations, imposes a standard of a preponderance of the evidence for determining whether
allegations are substantiated.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the facility is compliant
with this standard.
Standard 115.373: Reporting to Residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.373 (a)
▪ Following an investigation into a resident’s allegation that he or she suffered sexual abuse in an
agency facility, does the agency inform the resident as to whether the allegation has been
determined to be substantiated, unsubstantiated, or unfounded? ☒ Yes ☐ No
115.373 (b)
▪ If the agency did not conduct the investigation into a resident’s allegation of sexual abuse in an
agency facility, does the agency request the relevant information from the investigative agency
in order to inform the resident? (N/A if the agency/facility is responsible for conducting
administrative and criminal investigations.) ☒ Yes ☐ No ☐ NA
115.373 (c)
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The staff member is no longer posted within the resident’s unit? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The staff member is no longer employed at the facility? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The agency learns that the staff member has been indicted on a charge related to
sexual abuse in the facility? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
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whenever: The agency learns that the staff member has been convicted on a charge related to
sexual abuse within the facility? ☒ Yes ☐ No
115.373 (d)
▪ Following a resident’s allegation that he or she has been sexually abused by another resident,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been indicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No
▪ Following a resident’s allegation that he or she has been sexually abused by another resident,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been convicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No
115.373 (e)
▪ Does the agency document all such notifications or attempted notifications? ☒ Yes ☐ No
115.373 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Interviews:
Facility Administrator
Assistant Facility Administrator
104
Provision (a):
Following an investigation into a resident’s allegation of sexual abuse suffered in an agency facility, the
agency shall inform the resident as to whether the allegation has been determined to be substantiated,
unsubstantiated, or unfounded.
Policy addresses the resident being informed when a sexual abuse investigation is completed, and the
outcome of the investigation provided in writing. The results of such investigations will be documented
and provided to the resident. The interviews revealed awareness of the requirement.
Provision (b):
If the agency did not conduct the investigation, it shall request the relevant information from the
investigative agency in order to inform the resident.
The Facility Administrator and Assistant Facility Administrator remain abreast of an investigation
conducted by law enforcement or the DJJ investigator and will be provided a copy of completed
investigations. The results of the investigation will be provided to the resident in writing.
Provision (c):
Following a resident’s allegation that a staff member has committed sexual abuse against the resident,
the agency shall subsequently inform the resident (unless the agency has determined that the
allegation is unfounded) whenever:
(1) The staff member is no longer posted within the resident’s unit;
(2) The staff member is no longer employed at the facility;
(3) The agency learns that the staff member has been indicted on a charge related to sexual abuse
within the facility; or
(4) The agency learns that the staff member has been convicted on a charge related to sexual abuse
within the facility.
Policy requires that following a resident’s allegation that a staff member committed sexual abuse
against the resident, the resident will be informed, in writing, of the following, unless it has been
determined that the allegation is unfounded, whenever:
a. The staff member is no longer posted within the resident’s housing unit;
b. The staff member is no longer employed at the facility;
c. The staff member has been indicted on a charge related to sexual abuse in the facility; and/or
d. The staff member has been convicted on a charge related to sexual abuse in the facility.
Provision (d):
Following a resident’s allegation that he or she has been sexually abused by another resident, the
agency shall subsequently inform the alleged victim whenever:
(1) The agency learns that the alleged abuser has been indicted on a charge related to sexual abuse
within the facility; or
(2) The agency learns that the alleged abuser has been convicted on a charge related to sexual abuse
within the facility.
Policy provides that following a resident’s allegation that she has been sexually abused by another
resident the alleged victim shall be informed, in writing, whenever:
a. The alleged abuser is criminally charged related to the sexual abuse.
b. The alleged abuser is adjudicated on a charge related to sexual abuse within the facility.
105
Provision (e):
All such notifications or attempted notifications shall be documented.
The Policy provides that the notifications to the resident be documented and be made by the Facility
Administrator. There is familiarity with the requirement by the Facility Administrator and Assistant
Facility Administrator.
Provision (f):
An agency’s obligation to report under this standard shall terminate if the resident is released from the
agency’s custody.
The agency’s obligation to report under this standard terminates if the resident is released from the
agency’s custody. All notifications or attempted notifications are documented in accordance with DJJ
agency Policy.
Conclusion:
The interviews and review of Policy and other documentation confirmed the facility is compliant with this
standard.
DISCIPLINE
Standard 115.376: Disciplinary Sanctions for Staff
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.376 (a)
▪ Are staffs subject to disciplinary sanctions up to and including termination for violating agency
sexual abuse or sexual harassment policies? ☒ Yes ☐ No
115.376 (b)
▪ Is termination the presumptive disciplinary sanction for staff who have engaged in sexual
abuse? ☒ Yes ☐ No
115.376 (c)
▪ Are disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual
harassment (other than actually engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s disciplinary history, and the sanctions
imposed for comparable offenses by other staff with similar histories? ☒ Yes ☐ No
115.376 (d)
106
▪ Are all terminations for violations of agency sexual abuse or sexual harassment policies, or
resignations by staff who would have been terminated if not for their resignation, reported to:
Law enforcement agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Are all terminations for violations of agency sexual abuse or sexual harassment policies, or
resignations by staff that would have been terminated if not for their resignation, reported to:
Relevant licensing bodies? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 3-3
Facility 10-25
Agency Policy FDJJ 1919
Employee Handbook
Interview:
Facility Administrator
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for violating agency
sexual abuse or sexual harassment policies.
The Policies and interview support that staff be subject to disciplinary sanctions up to and including
termination for violating facility sexual abuse or sexual harassment policies.
Provision (b):
Termination shall be the presumptive disciplinary sanction for staff who has engaged in sexual abuse.
Termination is the presumptive disciplinary sanction for staff who has engaged in sexual abuse with a
resident. The interview was aligned with Policies. The facility reports that no staff member violated
Policy regarding sexual abuse or sexual harassment during this audit period.
107
Provision (c):
Disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual harassment
shall be commensurate with the nature and circumstances of the acts committed, the staff member’s
disciplinary history, and the sanctions imposed for comparable offenses by other staff with similar
histories.
Any staff with findings other than actually engaging in sexual abuse will be subject to termination, and
other measures appropriate to the circumstance of the incident and the other components of the
provision and remedial in-service if permitted to return to work, in accordance with Policy. Disciplinary
sanctions for violations of policies relating to sexual abuse or sexual harassment (other than engaging
in sexual abuse) will be commensurate with the act committed, the staff member’s disciplinary history,
and the similar history of other staff.
Provision (d):
All terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by
staff who would have been terminated if not for their resignation, shall be reported to law enforcement
agencies, unless the activity was clearly not criminal, and to any relevant licensing bodies.
Policy provides that terminations for violations of the facility’s sexual abuse or sexual harassment
policies or resignations by staff that would have been terminated if not for their resignation, will be
reported to law enforcement, unless the activity is clearly not criminal. In addition, such will be reported
to relevant licensing bodies. No staff member has been terminated for violating the facility’s sexual
abuse or sexual harassment policies during this audit period.
Conclusion:
Based upon the review of documentation and the interview, the Auditor determined the facility is
compliant with this standard.
Standard 115.377: Corrective Action for Contractors and Volunteers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.377 (a)
▪ Is any contractor or volunteer who engages in sexual abuse prohibited from contact with
residents? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Law enforcement
agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Relevant licensing
bodies? ☒ Yes ☐ No
115.377 (b)
▪ In the case of any other violation of agency sexual abuse or sexual harassment policies by a
contractor or volunteer, does the facility take appropriate remedial measures, and consider
whether to prohibit further contact with residents? ☒ Yes ☐ No
108
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Acknowledgement Statements
Interviews:
Contractors (2)
Volunteer
Facility Administrator
Provision (a):
Any contractor or volunteer who engages in sexual abuse shall be prohibited from contact with
residents and shall be reported to law enforcement agencies, unless the activity was clearly not
criminal, and to relevant licensing bodies.
Policies provide for contractors and volunteers who engage in sexual abuse with a resident to be
reported to law enforcement and to relevant licensing bodies. Documentation and interviews with
contractors and the volunteer confirm contractors and volunteers receive a clear understanding that
sexual misconduct with a resident is prohibited. Any contractor or volunteer who violates the agency’s
sexual abuse or sexual harassment policies is prohibited from contact with residents. During this audit
period, there have been no allegations of sexual abuse or sexual harassment regarding a contractor or
volunteer.
Provision (b):
The facility shall take appropriate remedial measures and shall consider whether to prohibit further
contact with residents, in the case of any other violation of agency sexual abuse or sexual harassment
policies by a contractor or volunteer.
Policies and the interview confirm that the appropriate remedial measures will be taken and include
prohibiting further contact with residents in the case of any violation of the sexual abuse and sexual
harassment Policies by a contractor or volunteer. In the past 12 months, no contractors or volunteers
were reported for allegations of sexual abuse or sexual harassment.
109
Conclusion:
Based upon the review of the documentation and interviews, the Auditor determined the facility is
compliant with this standard.
Standard 115.378: Interventions and Disciplinary Sanctions for Residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.378 (a)
▪ Following an administrative finding that a resident engaged in resident-on-resident sexual
abuse, or following a criminal finding of guilt for resident-on-resident sexual abuse, may
residents be subject to disciplinary sanctions only pursuant to a formal disciplinary process?
☒ Yes ☐ No
115.378 (b)
▪ Are disciplinary sanctions commensurate with the nature and circumstances of the abuse
committed, the resident’s disciplinary history, and the sanctions imposed for comparable
offenses by other residents with similar histories? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident is not denied daily large-muscle exercise? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident is not denied access to any legally required educational programming or special
education services? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident receives daily visits from a medical or mental health care clinician? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the resident also
have access to other programs and work opportunities to the extent possible? ☒ Yes ☐ No
115.378 (c)
▪ When determining what types of sanction, if any, should be imposed, does the disciplinary
process consider whether a resident’s mental disabilities or mental illness contributed to his or
her behavior? ☒ Yes ☐ No
115.378 (d)
▪ If the facility offers therapy, counseling, or other interventions designed to address and correct
underlying reasons or motivations for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions? ☒ Yes ☐ No
▪ If the agency requires participation in such interventions as a condition of access to any
rewards-based behavior management system or other behavior-based incentives, does it
110
always refrain from requiring such participation as a condition to accessing general
programming or education? ☒ Yes ☐ No
115.378 (e)
▪ Does the agency discipline a resident for sexual contact with staff only upon a finding that the
staff member did not consent to such contact? ☒ Yes ☐ No
115.378 (f)
▪ For the purpose of disciplinary action does a report of sexual abuse made in good faith based
upon a reasonable belief that the alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish evidence sufficient to substantiate
the allegation? ☒ Yes ☐ No
115.378 (g)
▪ Does the agency always refrain from considering non-coercive sexual activity between residents
to be sexual abuse? (N/A if the agency does not prohibit all sexual activity between residents.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
Resident Handbook
Interviews:
Facility Administrator
Clinical Director
Health Service Administrator
111
Provision (a):
A resident may be subject to disciplinary sanctions only pursuant to a formal disciplinary process
following an administrative finding that the resident engaged in resident-on-resident sexual abuse or
following a criminal finding of guilt for resident-on-resident sexual abuse.
Policies support that an administrative process exists for dealing with violations and that residents be
held accountable for their actions. Residents may be subject to disciplinary sanctions only after formal
proceedings regarding resident-on-resident sexual abuse. Residents found in violation of facility rules
are subject to sanctions pursuant to a formal process. The consequences will be administered through
the administrative system, encompassing the behavior management system. Allegations of sexual
abuse are referred for an investigation to the appropriate investigative entities and may result in
charges being filed and the resident being removed from the facility. Sexual activity between residents
is prohibited.
Provision (b):
Any disciplinary sanctions shall be commensurate with the nature and circumstances of the abuse
committed, the resident’s disciplinary history, and the sanctions imposed for comparable offenses by
other residents with similar histories. In the event a disciplinary sanction results in the isolation of a
resident, agencies shall not deny the resident daily large-muscle exercise or access to any legally
required educational programming or special education services. Residents in isolation shall receive
daily visits from a medical or mental health care clinician. Residents shall also have access to other
programs and work opportunities to the extent possible.
The Policies consider that disciplinary sanctions, applicable to the offense, are commensurate with the
nature and circumstances of the offense committed; considers resident’s disciplinary history; considers
similar disciplinary history of other residents. The interview with the Facility Administrator supported
there is consideration of mental disabilities or mental illness contributing to the behavior. PREA related
violations may result in charges filed and the resident transported to a detention facility based on the
circumstances of the incident. Allegations of sexual abuse are referred for an investigation to the
appropriate investigative entities. Isolation is not used as a disciplinary sanction.
Provision (c):
The disciplinary process shall consider whether a resident’s mental disabilities or mental illness
contributed to his or her behavior when determining what type of sanction, if any, should be imposed.
Disciplinary and other processes consider whether a resident’s mental disabilities or mental illness
contributed to a resident’s behavior regarding the application of disciplinary measures. The interviews
with the Facility Administrator and Clinical Director were aligned with this provision and Policy.
Provision (d):
If the facility offers therapy, counseling, or other interventions designed to address and correct
underlying reasons or motivations for the abuse, the facility shall consider whether to offer the offending
resident participation in such interventions. The agency may require participation in such interventions
as a condition of access to any rewards-based behavior management system or other behavior-based
incentives, but not as a condition to access to general programming or education.
The facility would consider whether to offer the offending resident intervention services designed to
address and correct underlying reasons or motivations for the abuse participation, based on the
interview with the Clinical Director. The facility would not require participation in such interventions as a
condition for participation in the behavior management system or to access general programming or
education as determined from the interview. Staff members within the mental health unit are equipped
112
to develop treatment planning and interventions to address underlying reasons or motivations for the
abuse with alleged victims and offending residents. A psychologist and psychiatrist provide services to
the residents on a weekly basis.
Provision (e):
The agency may discipline a resident for sexual contact with staff only upon a finding that the staff
member did not consent to such contact.
Policy provides that a resident may be disciplined for sexual contact with staff only upon a finding that
the staff member did not consent to such contact.
Provision (f):
For the purpose of disciplinary action, a report of sexual abuse made in good faith based upon a
reasonable belief that the alleged conduct occurred shall not constitute falsely reporting an incident or
lying, even if an investigation does not establish evidence sufficient to substantiate the allegation.
Any resident reporting in good faith shall be immune from any civil or criminal liability. A report of sexual
abuse made in good faith based on the belief that the alleged incident occurred does not constitute
falsely reporting an incident or lying, even if an investigation does not establish evidence sufficient to
substantiate the allegation, in accordance with Policy. There were no allegations of sexual abuse
reported during this audit period.
Provision (g):
An agency may, in its discretion, prohibit all sexual activity between residents and may discipline
residents for such activity. An agency may not, however, deem such activity to constitute sexual abuse
if it determines that the activity is not coerced.
Policies prohibit any sexual conduct between residents. All such conduct is subject to disciplinary action
as a rule violation. Referrals are made to the investigative entities and court processes occur after
determination the sexual activity was coerced.
Conclusion:
Based on the available evidence and interviews, the Auditor concluded the facility is compliant with the
standard.
MEDICAL AND MENTAL CARE
Standard 115.381: Medical and Mental Health Screenings; History of Sexual
Abuse
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.381 (a)
▪ If the screening pursuant to § 115.341 indicates that a resident has experienced prior sexual
victimization, whether it occurred in an institutional setting or in the community, do staff ensure
113
that the resident is offered a follow-up meeting with a medical or mental health practitioner
within 14 days of the intake screening? ☒ Yes ☐ No
115.381 (b)
▪ If the screening pursuant to § 115.341 indicates that a resident has previously perpetrated
sexual abuse, whether it occurred in an institutional setting or in the community, do staff ensure
that the resident is offered a follow-up meeting with a mental health practitioner within 14 days
of the intake screening? ☒ Yes ☐ No
115.381 (c)
▪ Is any information related to sexual victimization or abusiveness that occurred in an institutional
setting strictly limited to medical and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions, including housing, bed, work,
education, and program assignments, or as otherwise required by Federal, State, or local law?
☒ Yes ☐ No
115.381 (d)
▪ Do medical and mental health practitioners obtain informed consent from residents before
reporting information about prior sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 7-3
Facility Policy 7-8
Facility Policy 7-28
Facility Policy 10-25
Agency Policy FDJJ 1919
Screening for Vulnerability, Victimization and Sexually Aggressive Behavior
114
Interviews:
Health Service Administrator
Clinical Director
Therapist
Facility Administrator
Residents
Provision (a) and (b):
Provision (a): If the screening pursuant to §115.341 indicates that a resident has experienced prior
sexual victimization, whether it occurred in an institutional setting or in the community, staff shall ensure
that the resident is offered a follow-up meeting with a medical or mental health practitioner within 14
days of the intake screening.
Provision (b): If the screening pursuant to §115.341 indicates that a resident has previously
perpetrated sexual abuse, whether it occurred in an institutional setting or in the community, staff shall
ensure that the resident is offered a follow-up meeting with a mental health practitioner within 14 days
of the intake screening.
Policy and practice provide that a resident be referred to mental health or medical staff within 14 days if
identified as having been a victim or perpetrator of sexual abuse. The interviews with clinical staff
revealed that the issues are identified and addressed. The practice is residents are generally seen by
medical and mental health staff on the same day of admission as part of the intake process and follow-
up is provided immediately. Therapists administer the screening assessment, Screening for
Vulnerability, Victimization and Sexually Aggressive Behavior.
.
Provision (c):
Any information related to sexual victimization or abusiveness that occurred in an institutional setting
shall be strictly limited to medical and mental health practitioners and other staff, as necessary, to
inform treatment plans and security and management decisions, including housing, bed, work,
education, and program assignments, or as otherwise required by Federal, State, or local law.
Policy supports that no information is to be shared with other staff unless it is required for security and
management decisions regarding sexual abuse history. Policy and interviews collectively revealed that
information related to sexual victimization or abusiveness that occurred in an institutional setting is
limited to clinical staff and Case Managers to make effective management decisions. During the site
review, the files are observed to be maintained in a secure manner in a locked file room and
information maintained electronically is password protected.
Provision (d):
Medical and mental health practitioners shall obtain informed consent from residents before reporting
information about prior sexual victimization that did not occur in an institutional setting unless the
resident is under the age of 18.
Policy addresses informed consent being obtained for residents 18 years or over prior to clinical
personnel reporting information disclosed about prior sexual victimization that did not occur in an
institutional setting. Clinical staff members understand the practice of informed consent.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is
compliant with this standard.
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Standard 115.382: Access to Emergency Medical and Mental Health
Services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.382 (a)
▪ Do resident victims of sexual abuse receive timely, unimpeded access to emergency medical
treatment and crisis intervention services, the nature and scope of which are determined by
medical and mental health practitioners according to their professional judgment? ☒ Yes ☐ No
115.382 (b)
▪ If no qualified medical or mental health practitioners are on duty at the time a report of recent
sexual abuse is made, do staff first responders take preliminary steps to protect the victim
pursuant to §115.362? ☒ Yes ☐ No
▪ Do staff first responders immediately notify the appropriate medical and mental health
practitioners? ☒ Yes ☐ No
115.382 (c)
▪ Are resident victims of sexual abuse offered timely information about and timely access to
emergency contraception and sexually transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically appropriate? ☒ Yes ☐ No
115.382 (d)
▪ Are treatment services provided to the victim without financial cost and regardless of whether
the victim names the abuser or cooperates with any investigation arising out of the incident?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
116
Documentation Reviewed:
Facility Policy 7-30
Facility Policy 10-25
Agency Policy FDJJ 1919
Sexual Abuse Incident Coordinated Response Plan
Agreement
Interviews:
Clinical Director
Health Service Administrator
Director of Nursing, Crisis Center of Tampa Bay
Provision (a):
Resident victims of sexual abuse shall receive timely, unimpeded access to emergency medical
treatment and crisis intervention services, the nature and scope of which are determined by medical
and mental health practitioners according to their professional judgment.
The interviews and Policies support the alleged victim will receive timely and unimpeded access to
emergency medical treatment and crisis intervention services. The interviews were aligned with the
Policies including that the nature and scope of their services are determined according to their
professional judgment. Residents are informed of clinical services and meet with those representatives
and experience services during the intake process. There were no allegations of sexual abuse during
this audit period,
The alleged victim will get services within the facility as well as timely services in the community. An
alleged victim will be transported to the Crisis Center of Tampa Bay for a forensic medical examination
that will be conducted by a Sexual Assault Nurse Examiner (SANE). The examination will be performed
at no cost to the victim, and in accordance with Policy, the institutional plan in response to an allegation
of sexual abuse, and the written Agreement. Medical and mental health staff members maintain
secondary materials and documentation of encounters with residents.
Provision (b):
If no qualified medical or mental health practitioners are on duty at the time a report of recent abuse is
made, staff first responders shall take preliminary steps to protect the victim pursuant to §115.362 and
shall immediately notify the appropriate medical and mental health practitioners.
The interviews with clinical staff revealed residents have access to unimpeded access to emergency
services. The Policies and institutional plan provide guidance to staff in protecting residents and for
contacting the appropriate staff and agencies regarding allegations or incidents of sexual abuse,
including contacting treatment staff and investigative entities. A review of the written plan and related
documentation and Policies; observations of the interactions among residents and staff during the site
review; and the interviews indicated unimpeded medical and crisis intervention services are available to
an alleged victim of sexual abuse. Staff training also prepare staff members to appropriately report
sexual abuse, protect the alleged victim and notify the appropriate staff.
Provision (c):
Resident victims of sexual abuse while incarcerated shall be offered timely information about and timely
access to emergency contraception and sexually transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically appropriate.
117
Policy, review of documentation and interviews confirmed processes and services are in place for an
alleged victim to receive timely access to sexually transmitted infection prophylaxis, where medically
appropriate. If needed after an incident, follow-up services may be provided by the facility’s medical
and mental health staff members to provide support services coordinated by staff as needed or
services not available within the facility will be contracted.
Provision (d):
Treatment services shall be provided to the victim without financial cost and regardless of whether the
victim names the abuser or cooperates with any investigation arising out of the incident.
The interviews and Policies provide that treatment services will be provided to the victim without
financial cost to the victim and regardless of whether the victim names the abuser, or cooperate with
any investigation arising out of the incident. The written agreement is clear that services will be
provided at no cost to the victim.
Conclusion:
Based on the evidence reviewed and interviews, the Auditor determined the facility is compliant with
this standard.
Standard 115.383: Ongoing Medical and Mental Health Care for Sexual
Abuse Victims and Abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.383 (a)
▪ Does the facility offer medical and mental health evaluation and, as appropriate, treatment to all
residents who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility? ☒ Yes ☐ No
115.383 (b)
▪ Does the evaluation and treatment of such victims include, as appropriate, follow-up services,
treatment plans, and, when necessary, referrals for continued care following their transfer to, or
placement in, other facilities, or their release from custody? ☒ Yes ☐ No
115.383 (c)
▪ Does the facility provide such victims with medical and mental health services consistent with
the community level of care? ☒ Yes ☐ No
115.383 (d)
▪ Are resident victims of sexually abusive vaginal penetration while incarcerated offered
pregnancy tests? (N/A if all-male facility.) ☒ Yes ☐ No ☐ NA
115.383 (e)
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▪ If pregnancy results from the conduct described in paragraph § 115.383(d), do such victims
receive timely and comprehensive information about and timely access to all lawful pregnancy-
related medical services? (N/A if all-male facility.) ☒ Yes ☐ No ☐ NA
115.383 (f)
▪ Are resident victims of sexual abuse while incarcerated offered tests for sexually transmitted
infections as medically appropriate? ☒ Yes ☐ No
115.383 (g)
▪ Are treatment services provided to the victim without financial cost and regardless of whether
the victim names the abuser or cooperates with any investigation arising out of the incident?
☒ Yes ☐ No
115.383 (h)
▪ Does the facility attempt to conduct a mental health evaluation of all known resident-on-resident
abusers within 60 days of learning of such abuse history and offer treatment when deemed
appropriate by mental health practitioners? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 7-13
Facility Policy 9-3
Facility Policy 9-5
Facility Policy 10-5
Agency Policy FDJJ 1919
Interviews:
Health Service Administrator
Clinical Director
Facility Administrator
119
Provision (a):
The facility shall offer medical and mental health evaluation and, as appropriate, treatment to all
residents who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile facility.
The Policies and interviews support that medical and mental health evaluation and treatment will be
offered to resident victims of sexual abuse. The interviews revealed that follow-up services will be
provided that include but are not limited to additional testing and lab work; medication monitoring;
additional crisis assessments; increased therapy sessions; and contract and referral services as
needed.
Provision (b):
The evaluation and treatment of such victims shall include, as appropriate, follow-up services,
treatment plans, and, when necessary, referrals for continued care following their transfer to, or
placement in, other facilities, or their release from custody.
Interviews and documentation of encounters confirm on-going medical and mental health care will be
provided as appropriate and will include but not be limited to treatment planning; evaluations, and
clinical follow-up and referrals as needed. Specialized treatment may also be provided by clinicians on
site and through contract services. Directions contained in the discharge information will be followed.
Provision (c):
The facility shall provide such victims with medical and mental health services consistent with the
community level of care.
Review of Policies, staff interviews and observations during the site review indicated medical and
mental health services are consistent with the community level of care. Treatment services may be
provided by facility staff and contract services if needed. The interviews and observations during the
site review underscored the treatment services at the facility are consistent with the community level of
care.
Provision (d):
Resident victims of sexually abusive vaginal penetration while incarcerated shall be offered pregnancy
tests.
The interviews and Policy confirm timely information will be provided to a victim regarding pregnancy
test as confirmed by the Health Service Administrator.
Provision (e):
If pregnancy results from conduct specified in paragraph (d) of this section, such victims shall receive
timely and comprehensive information about and timely access to all lawful pregnancy-related medical
services.
The interview with the Health Service Administrator and Policy confirm timely information will be
provided to a victim regarding legal pregnancy related services.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for sexually transmitted
infections as medically appropriate.
120
The interviews and Policies ensure that victims of sexual abuse will be provided tests for sexually
transmitted infections as medically appropriate as confirmed by the Health Service Administrator and
Clinical Director. There have been no allegations of sexual abuse during this audit period.
Provision (g):
Treatment services shall be provided to the victim without financial cost and regardless of whether the
victim names the abuser or cooperates with any investigation arising out of the incident.
All treatment services will be provided at no cost to the victim and whether or not the victim names the
abuser of cooperates with the investigation, according to Policy, interviews and the written agreement
between the facility and the Crisis Center of Tampa Bay.
Provision (h):
The facility shall attempt to conduct a mental health evaluation of all known resident-on-resident
abusers within 60 days of learning of such abuse history and offer treatment when deemed appropriate
by mental health practitioners.
Medical and mental health evaluation and treatment will be offered to resident victims of sexual abuse.
The Clinical Director confirmed that the resident would get a mental health evaluation within 30 days
however Policy does provide for the mental health evaluation to be conducted within 60 days.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined the facility is
compliant with this standard.
DATA COLLECTION AND REVIEW
Standard 115.386: Sexual Abuse Incident Reviews
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.386 (a)
▪ Does the facility conduct a sexual abuse incident review at the conclusion of every sexual abuse
investigation, including where the allegation has not been substantiated, unless the allegation
has been determined to be unfounded? ☒ Yes ☐ No
115.386 (b)
▪ Does such review ordinarily occur within 30 days of the conclusion of the investigation?
☒ Yes ☐ No
115.386 (c)
▪ Does the review team include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners? ☒ Yes ☐ No
121
115.386 (d)
▪ Does the review team: Consider whether the allegation or investigation indicates a need to
change policy or practice to better prevent, detect, or respond to sexual abuse? ☒ Yes ☐ No
▪ Does the review team: Consider whether the incident or allegation was motivated by race;
ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or
perceived status; gang affiliation; or other group dynamics at the facility? ☒ Yes ☐ No
▪ Does the review team: Examine the area in the facility where the incident allegedly occurred to
assess whether physical barriers in the area may enable abuse? ☒ Yes ☐ No
▪ Does the review team: Assess the adequacy of staffing levels in that area during different
shifts? ☒ Yes ☐ No
▪ Does the review team: Assess whether monitoring technology should be deployed or
augmented to supplement supervision by staff? ☒ Yes ☐ No
▪ Does the review team: Prepare a report of its findings, including but not necessarily limited to
determinations made pursuant to §§ 115.386 (d) (1) - (d)(5), and any recommendations for
improvement and submit such report to the facility head and PREA compliance manager?
☒ Yes ☐ No
115.386 (e)
▪ Does the facility implement the recommendations for improvement, or document its reasons for
not doing so? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1919
122
Interviews:
Facility Administrator
DJJ Statewide PREA Coordinator
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion of every sexual abuse
investigation, including where the allegation has not been substantiated, unless the allegation has been
determined to be unfounded.
The facility is required to conduct a sexual abuse incident review at the conclusion of an investigation
unless the allegation was unfounded. The interviews reflected an understanding of the role of the
incident review team. A review of the Policies, documentation and interviews confirmed incident
reviews will be conducted regarding the investigation of an allegation of sexual abuse, unless
unfounded and in accordance with the Policy. The DJJ statewide PREA Coordinator confirms this
premise.
Provision (b):
Such review shall ordinarily occur within 30 days of the conclusion of the investigation.
Policy requires that the review occurs within 30 days of the conclusion of the investigation. The
interviews confirmed incident reviews will occur. The interviews revealed knowledge of the purpose of
the incident review process. There were no allegations of sexual abuse during this audit period.
Provision (c):
The incident review team shall include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners.
Policy and interviews collectively identify members of the incident review team. The DJJ statewide
PREA Coordinator facilitates the incident review. Members of the team are identified, in accordance
with Policy. There will also be input from line supervisors and other staff as needed. The DJJ Office of
Inspector General investigator may also participate in the incident review. The additional staff members
will attend the meeting as needed, related to the incident.
Provision (d):
The review team shall:
(1) Consider whether the allegation or investigation indicates a need to change policy or practice to
better prevent, detect, or respond to sexual abuse;
(2) Consider whether the incident or allegation was motivated by race; ethnicity; gender identity;
lesbian, gay, bisexual, transgender, or intersex identification, status, or perceived status; or, gang
affiliation; or was motivated or otherwise caused by other group dynamics at the facility;
(3) Examine the area in the facility where the incident allegedly occurred to assess whether physical
barriers in the area may enable abuse.
(4) Assess the adequacy of staffing levels in that area during different shifts;
(5) Assess whether monitoring technology should be deployed or augmented to supplement
supervision by staff; and
(6) Prepare a report of its findings, including but not necessarily limited to determinations made
pursuant to paragraphs (d)(1)-(d)(5) of this section, and any recommendations for improvement and
submit such report to the facility head and PREA compliance manager.
The Policies and interviews collectively outline the requirements of the standard for the areas to be
assessed by the incident review team. The interviews and review of Policy confirmed the incident
123
review team is charged with considering the factors identified in this standard provision regarding the
results of the investigation. The incident review process is documented and is facilitated by the DJJ
statewide PREA Coordinator. The written report also includes any recommendations for improvement.
Provision (e):
The facility shall implement the recommendations for improvement or shall document its reasons for not
doing so.
Policy indicates the reasons for not following recommendations are documented. The interviews
revealed familiarity with the Policy requirements. The incident review process allows for the
assessment of the circumstances surrounding the incident. A format for documenting the incident
review process has been developed by the DJJ statewide PREA Coordinator and include
recommendations where indicated as determined from a review of documentation of other reports.
Conclusion:
Based upon the review of Policy and other documentation and interviews, the Auditor has determined
the facility is compliant with this standard.
Standard 115.387: Data Collection
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.387 (a)
▪ Does the agency collect accurate, uniform data for every allegation of sexual abuse at facilities
under its direct control using a standardized instrument and set of definitions? ☒ Yes ☐ No
115.387 (b)
▪ Does the agency aggregate the incident-based sexual abuse data at least annually?
☒ Yes ☐ No
115.387 (c)
▪ Does the incident-based data include, at a minimum, the data necessary to answer all questions
from the most recent version of the Survey of Sexual Violence conducted by the Department of
Justice? ☒ Yes ☐ No
115.387 (d)
▪ Does the agency maintain, review, and collect data as needed from all available incident-based
documents, including reports, investigation files, and sexual abuse incident reviews?
☒ Yes ☐ No
115.387 (e)
▪ Does the agency also obtain incident-based and aggregated data from every private facility with
which it contracts for the confinement of its residents? (N/A if agency does not contract for the
confinement of its residents.) ☐ Yes ☐ No ☒ NA.
124
115.387 (f)
▪ Does the agency, upon request, provide all such data from the previous calendar year to the
Department of Justice no later than June 30? (N/A if DOJ has not requested agency data.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility 10-25
Agency Policy FDJJ 1919
Agency Policy FDJJ 2020
Data Log
Interview:
Facility Administrator
Provisions (a) & (c):
Provision (a): The agency shall collect accurate, uniform data for every allegation of sexual abuse at
facilities under its direct control using a standardized instrument and set of definitions.
Provision (c): The incident-based data collected shall include, at a minimum, the data necessary to
answer all questions from the most recent version of the Survey of Sexual Violence conducted by the
Department of Justice.
The Policies provide for the collection of accurate and uniform data for every allegation of sexual abuse
from incident-based documents. The agency collects the data and completes an annual report with the
compilation of data gleaned from the facilities through the central reporting system. Agency Policy FDJJ
2020 contains a standardized set of definitions and provides support for the collection of accurate and
uniform data. The agency maintains incident-based data complete enough to complete the most recent
version of the instrument formerly identified as the Survey of Sexual Violence and now identified as the
Survey of Sexual Victimization.
Provision (b):
The agency shall aggregate the incident-based sexual abuse data at least annually.
125
The agency aggregates the incident-based, uniform data regarding allegations of sexual abuse and
sexual harassment. The aggregated data contributes to the development of the annual report for the
agency which is supported by the reviewed data and Policy.
Provision (d):
The agency shall maintain, review, and collect data as needed from all available incident-based
documents, including reports, investigation files, and sexual abuse incident reviews.
The data is collected, and various types of data are identified and related documents regarding PREA
information as applicable. The facility Policy requires that statistical information is maintained for
various service areas and occurrences, including major incidents and medical and mental health
emergencies. The agency collects and maintains data for state-run and contract facilities and
aggregates the data which culminates into the annual report.
Provision (e):
The agency also shall obtain incident-based and aggregated data from every private facility with which
it contracts for the confinement of its residents.
The agency collects and maintains data for state-run and contract facilities and aggregates the data
which culminates into the annual report. The data is collected from the contract facilities and is included
in the agency’s annual reports.
Provision (f):
Upon request, the agency shall provide all such data from the previous calendar year to the
Department of Justice no later than June 30.
Upon request, the facility completes all such data from the previous calendar year and submits to the
Department of Justice in a timely manner based on the year of the most recent version of the Survey of
Sexual Victimization.
Conclusion:
Based upon the review and analysis of the documentation and the interviews, the Auditor determined
the facility is compliant with this standard.
Standard 115.388: Data Review for Corrective Action
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.388 (a)
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Identifying problem areas? ☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Taking corrective action on an ongoing basis?
☒ Yes ☐ No
126
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Preparing an annual report of its findings and
corrective actions for each facility, as well as the agency as a whole? ☒ Yes ☐ No
115.388 (b)
▪ Does the agency’s annual report include a comparison of the current year’s data and corrective
actions with those from prior years and provide an assessment of the agency’s progress in
addressing sexual abuse ☒ Yes ☐ No
115.388 (c)
▪ Is the agency’s annual report approved by the agency head and made readily available to the
public through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.388 (d)
▪ Does the agency indicate the nature of the material redacted where it redacts specific material
from the reports when publication would present a clear and specific threat to the safety and
security of a facility? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Agency Policy FDJJ 1919
Annual Reports
Interview:
Facility Administrator
Provision (a): The agency shall review data collected and aggregated pursuant to §115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response policies,
practices, and training, including:
127
(1) Identifying problem areas;
(2) Taking corrective action on an ongoing basis; and
(3) Preparing an annual report of its findings and corrective actions for each facility, as well as this
agency as a whole.
The interviews with the Facility Administrator and a prior interview with the DJJ statewide PREA
Coordinator support the review of data and that it is used to improve the PREA efforts. The interviews
and review of documentation revealed the collection of various types of data, including PREA related
information. Data is reviewed to assess and improve the effectiveness of prevention, detection, and
response within the agency as well as individual facilities. The data is also primary to preparing annual
reports.
Provisions (b)-(d):
Provision (b): Such report shall include a comparison of the current year’s data and corrective actions
with those from prior years and shall provide an assessment of the agency’s progress in addressing
sexual abuse.
Provision (c): The agency’s report shall be approved by the agency head and made readily available
to the public through its website or, if it does not have one, through other means.
Provision (d): The agency may redact specific material from the reports when publication would
present a clear and specific threat to the safety and security of a facility but must indicate the nature of
the material redacted.
The annual report is prepared by the DJJ statewide PREA Coordinator for the agency and includes
data from all state-run and contract facilities within the agency. The annual reports are approved by the
agency head/designee. There are no personal identifiers in the report. The annual report contains
PREA related data that represents previous calendar years allowing for the comparison of data. The
overarching annual report for the agency is posted on the agency’s website, accessible to the public.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined the agency is
compliant with this standard.
Standard 115.389: Data Storage, Publication, and Destruction
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.389 (a)
▪ Does the agency ensure that data collected pursuant to § 115.387 are securely retained?
☒ Yes ☐ No
115.389 (b)
▪ Does the agency make all aggregated sexual abuse data, from facilities under its direct control
and private facilities with which it contracts, readily available to the public at least annually
through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.389 (c)
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▪ Does the agency remove all personal identifiers before making aggregated sexual abuse data
publicly available? ☒ Yes ☐ No
115.389 (d)
▪ Does the agency maintain sexual abuse data collected pursuant to § 115.387 for at least 10
years after the date of the initial collection, unless Federal, State, or local law requires
otherwise? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 10-25
Agency Policy FDJJ 1316
Agency Policy FDJJ 1919
Annual Report
Interview:
Facility Administrator
Provision (a)-(d):
Provision (a): The agency shall ensure that data collected pursuant to §115.387 are securely retained.
Provision (b): The agency shall make all aggregated sexual abuse data, from facilities under its direct
control and private facilities with which it contracts, readily available to the public at least annually
through its website or, if it does not have one, through other means.
Provision (c): Before making aggregated sexual abuse data publicly available, the agency shall
remove all personal identifiers.
Provision (d): The agency shall maintain sexual abuse data collected pursuant to §115.387 for at least
10 years after the date of its initial collection unless Federal, State, or local law requires otherwise.
The data collected is securely stored and maintained for at least 10 years after the date of collection
unless a law requires otherwise, in accordance with Policy. Personal identifiers are removed from
aggregated data before making the data publicly available. The annual report is available to the public
through the DJJ agency website. A review of the annual report verified there are no personal identifiers.
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All facility and agency records are securely stored in locked cabinets behind locked doors and
electronic records are password protected. The interviews support the premise and policies.
Conclusion:
Based upon the review and analysis of the documentation, interviews and observations, the Auditor
determined the facility is compliant with this standard.
AUDITING AND CORRECTIVE ACTION
Standard 115.401: Frequency and Scope of Audits
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.401 (a)
▪ During the prior three-year audit period, did the agency ensure that each facility operated by the
agency, or by a private organization on behalf of the agency, was audited at least once? (Note:
The response here is purely informational. A "no" response does not impact overall compliance
with this standard.) ☒ Yes ☐ No
115.401 (b)
▪ Is this the first year of the current audit cycle? (Note: a “no” response does not impact overall
compliance with this standard.) ☐ Yes ☒ No
▪ If this is the second year of the current audit cycle, did the agency ensure that at least one-third
of each facility type operated by the agency, or by a private organization on behalf of the
agency, was audited during the first year of the current audit cycle? (N/A if this is not the
second year of the current audit cycle.) ☒ Yes ☐ No ☐ NA
▪ If this is the third year of the current audit cycle, did the agency ensure that at least two-thirds of
each facility type operated by the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle? (N/A if this is not the third year
of the current audit cycle.) ☐ Yes ☐ No ☒ NA
115.401 (h)
▪ Did the auditor have access to, and the ability to observe, all areas of the audited facility?
☒ Yes ☐ No
115.401 (i)
▪ Was the auditor permitted to request and receive copies of any relevant documents (including
electronically stored information)? ☒ Yes ☐ No
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115.401 (m)
▪ Was the auditor permitted to conduct private interviews with inmates, residents, and detainees?
☒ Yes ☐ No
115.401 (n)
▪ Were residents permitted to send confidential information or correspondence to the auditor in
the same manner as if they were communicating with legal counsel? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The previous audit was conducted in 2017. The PREA Pre-Audit Questionnaire and supporting
documentation was initially provided to the Auditor on a flash drive. The Auditor was provided additional
information by email, as requested. During the post audit phase, the Assistant Facility Administrator
provided the Auditor with evidence that the corrective action of refresher education for residents was
implemented. The FDJJ ensured the completion of PREA audits for each state-run and contract facility
as required, including this facility.
The site review was led by the Assistant Facility Administer; all buildings were included, and detailed
observations were conducted of the living units and program areas. The areas containing posted
information were observed, including the areas where the virtual interviews were conducted. The
Facility Administrator, Assistant Facility Administrator and DJJ statewide PREA Coordinator were
cooperative in providing information and participating in or assisting in coordinating the interviews.
The virtual interviews were conducted in private with the residents and staff. The PREA notices
provided the general information and included instructions and Auditor contact information regarding
how to provide confidential information to the Auditor. The facility has a process in place for confidential
correspondence for the residents however no correspondence was received by the Auditor from
residents or from staff.
Standard 115.403: Audit Contents and Findings
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
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115.403 (f)
▪ The agency has published on its agency website, if it has one, or has otherwise made publicly
available, all Final Audit Reports within 90 days of issuance by auditor. The review period is for
prior audits completed during the past three years PRECEDING THIS AGENCY AUDIT. In the
case of single facility agencies, the auditor shall ensure that the facility’s last audit report was
published. The pendency of any agency appeal pursuant to 28 C.F.R. § 115.405 does not
excuse noncompliance with this provision. (N/A if there have been no Final Audit Reports issued
in the past three years, or in the case of single facility agencies that there has never been a
Final Audit Report issued.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Annual Report
Interview:
Facility Administrator
DJJ Statewide PREA Coordinator
Provision (f):
The agency shall ensure that the auditor’s final report is published on the agency’s website if it has one
or is otherwise made readily available to the public.
The posted PREA reports do not contain any personal identifying information other than names and job
titles. The facility and agency policies and additional documentation, practices and interviews with the
Facility Administrator, Assistant Facility Administrator and other staff were reviewed regarding
compliance with the standards and have been identified in the reports.
The audit findings were based on a review of policies, procedures, supporting documentation,
observations, and interviews. There were no conflicts of interest regarding the completion of this audit.
This report does not contain any personal identifying information other than names and job titles of
facility and agency staff and the community resource staff member.
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AUDITOR CERTIFICATION
I certify that:
☒ The contents of this report are accurate to the best of my knowledge.
☒ No conflict of interest exists with respect to my ability to conduct an audit of the agency
under review, and
☒ I have not included in the final report any personally identifiable information (PII) about
any resident or staff member, except where the names of administrative personnel are
specifically requested in the report template.
Auditor Instructions:
Type your full name in the text box below for Auditor Signature. This will function as your official
electronic signature. Auditors must deliver their final report to the PREA Resource Center as a
searchable PDF format to ensure accessibility to people with disabilities. Save this report document
into a PDF format prior to submission.1 Auditors are not permitted to submit audit reports that have
been scanned.2 See the PREA Auditor Handbook for a full discussion of audit report formatting
requirements.
Shirley L. Turner December 21, 2020
Auditor Signature Date
1 See additional instructions here: https://support.office.com/en-us/article/Save-or-convert-to-PDF-d85416c5-7d77-4fd6-
a216-6f4bf7c7c110 .
2 See PREA Auditor Handbook, Version 1.0, August 2017; Pages 68-69.
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report_type: PREA

cycle: Year 2 Cycle 3