state: FL

summary: PREA

raw_content:
PREA AUDIT: AUDITOR’S SUMMARY REPORT
JUVENILE FACILITIES
Name of Facility: Central Pasco Girls Academy
Physical Address: 2953 Wilson Road; Land O'Lakes, Florida 34638
Date report submitted January 12, 2015
Auditor information : Lois Jenkins
Address 2820 Weybourne Way; Columbia, SC 29223
Email: lljenk2@bellsouth.net
Telephone number: 803-463-9554
Date of facility visit : June 23-24, 2014
Facility Mailing Address: Same as Above
(if different from above)
Telephone Number: 813-909-7800
County
Municipal
C orrection
Name of PREA Compliance Manager: Kirstie Naoom Title: Facility Administrat or
Email Address: kristie.naoom@us.g4s.com Telephone Number: 813.909.7800
Name of Agency: G4S Youth Services, LLC
Governing Authority or
G4S
Parent Agency: (if
applicable)
Physical Address: 6302 Benjamin Road, Suite 400; Tampa, FL 33634
Mailing Address: (if
different from above) Same as Above
Telephone Number: 813-514-6275
Name: James C. Hill, Jr. Title: President
Email Address: jim.hill@us.g4s.com Telephone 813-514-6275, ext. 202
Number:
Name: Bobbi Pohlman-Rogers Title: JJDPA/PREA Director
Telephone
Email Address: bobbi.pohlman@us.gus.com 954-818-5131
Number:
PREA AUDIT: AUDITOR’S SUMMARY REPORT 1
AUDIT FINDINGS
NARRATIVE:
Central Pasco Girls Academy (CPGA) is a G4S Youth Services, LLC operated program located in Land
O’Lakes, Florida. The Academy operates under contract with the Florida Department of Juvenile Justice
(FDJJ) and all residents are placed there by the FDJJ. The current program began in January of 2013
providing intensive mental health treatment services for girls ages thirteen to eighteen. It operates as a
secure 32-bed residential moderate-risk program with an expected stay of six to nine months.
CPGA employs a multi-disciplined staff to address the many needs of girls in custody. Daily operational
oversight is provided by a full-time Facility Administrator and Assistant Facility Administrator, and a cadre
of direct care service providers focusing on safety, security, order, and treatment with support and services
from the Director of Clinical Services, Health Services Administrator, and Human Resources Manager.
Programming for CPGA is gender-specific. Staff is trained and uses the Girl Matters and “Savvy Sisters”
curriculum that is tailored to the unique needs of the population. Gender specific treatment focus areas
address sexual abuse, trauma, substance abuse, crime specific topics, as well as relational and emotional
topics. The on-site health care providers are available to address the individual medical needs of each
resident. Additionally, when assessed to be necessary, residents may be taken off-site for medical attention.
Residents at the Central Pasco Girls Academy receive year round on-site education via classroom
instruction provided by teachers from the Pasco County School District.
DESCRIPTION OF FACILITY CHARACTERISTICS:
Central Paso Girls Academy is a standalone facility surrounded by a security perimeter fence. The complete
facility consists of four well-spaced buildings which include an Administration Building, Education and
Nursing Building, Maintenance Building and the Main/Dorm Building. The Administration Building
houses the offices of the Facility Administrator, Clinical Director, Human Resources Director, clinical staff,
and a conference room. The Education and Nursing Building provide office and work space for education
and medical staff; and a medical exam room with bath room. The Main/Dorm building has two wings that
comprise the residents’ living units named Gems and Jewels, dayrooms, master control room, the kitchen,
cafeteria, laundry rooms, and Assistant Facility Administrator Office. Within the living units up to four
residents may be assigned to share a room. Included on one wing of the resident living unit is what the staff
refers to as a controlled observation room. The staff reports that under supervisory authority, this room is
used infrequently for short periods of time when a resident is disruptive and poses a threat to safety and
security.
There is adequate recreational space with the out-door recreation area located at the back of the property
near the Education/Nursing and Maintenance buildings. The Maintenance building also houses the Sewing
Center, Yoga Room, and Residents’ Boutique.
The facility has a total of 27 surveillance cameras in various locations both inside the buildings and outside
of buildings.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 2
SUMMARY OF AUDIT FINDINGS:
The notification of the on-site audit was posted on May 12, 2014, six weeks prior to the first date of the on-
site audit. The posting of the notice was verified by photographs received electronically from the Facility
Administrator/PREA Compliance Manager. The photographs indicated notices were posted in various
locations throughout the facility including the housing unit and administrative areas.
The Pre-Audit Questionnaire, policies and some supporting documentation were received via e-mail from
the PREA Compliance Manager on June 3, 2014. The information received was well organized and easy to
navigate but many of the files were empty or lacked sufficient documentation as requested by the Pre-Audit
Questionnaire and some of the scanned documentation was difficult to read. Upon review of the
information, it became clear that the facility, a for- profit operated by G4S Youth Services, LLC, completed
the Questionnaire as if The Florida Department of Juvenile Justice was the agency. Between phone calls
and e-mails, this was addressed and on June 16, 2014, one week prior to the scheduled date of the on-site
audit, a flash drive was delivered with uploaded policies and supporting documentation. A follow-up call
was placed on June 18, 2014 to discuss the Pre-Audit Questionnaire and explain the on-site audit process.
The on-site audit was conducted June 23-24, 2014, and began with a meeting with the Facility
Administrator/PREA Compliance Manager. After the meeting we took a tour of the facility and I was able
to observe all of the physical plant and grounds. While touring I observed that the residents were in school
and under supervision of teachers and security staff. Observation of the master control surveillance system
showed there are blind spots and they were noted. There are no cameras in the residents’ rooms or
bathrooms so the surveillance system does not show these areas, allowing residents to shower and toilet in
private.
During the two-day on-site visit, 14 staff was interviewed, including workers from all three shifts. For the
most part, staff interviews revealed they have been trained on PREA Standards and understand their
responsibilities and duties to prevent, detect, and respond to sexual abuse and harassment. Ten random
residents were interviewed; five from each of the two living units. The residents were informed of their
right to be free from sexual abuse and harassment, how to report sexual abuse and harassment, but
generally did not know services provided by community-based victims’ advocates’ or how to contact them.
The facility is in the process of negotiating a contract for victim advocacy services through the Crisis
Center of Tampa Bay.
Through the pre-audit and on-site audit processes, it was determined that nine standards were not met. A
corrective plan for compliance was developed, agreed upon, and implemented bringing Central Pasco Girls
Academy into full compliance with PREA standards. Details of corrective actions are written under each
applicable standard within this report.
Number of standards exceeded: 0
Number of standards met: 38
Number of standards not met: 0
Number of standards Not Applicable: 3
PREA AUDIT: AUDITOR’S SUMMARY REPORT 3
Standard 115.311 – Zero To tolerance of sexual abuse and sexual harassment.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
G4S Central Pasco Girls Academy (CPGA) Policy 10-25 dated April 25, 2014, mirrors that of its contracting agency,
Florida Department of Juvenile Justice, Policy 1919 revised April 10, 2014. Page 3 of the CPGA policy has clearly
written language mandating a zero tolerance for all forms of sexual abuse and sexual harassment. Within the 10 page
policy, the agency’s approach to preventing detecting and responding to acts of sexual abuse and harassment is
outlined.
The agency, G4S, has a PREA Coordinator who oversees PREA compliance efforts for the agency. Page 3 of policy
10-25 designates the CPGA Facility Administrator as the PREA Compliance Manager and outlines the specific
related duties. When interviewed, both the PREA Coordinator and PREA Compliance Manager indicated they had
authority and sufficient time to manage PREA compliance related responsibilities.
Standard 115.312 - Contract with other entities for the confinement of residents.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable
CPGA is a G4S Youth Services, LLC program that operates under contract with the Florida Department of Juvenile
Justice (FDJJ) and does not contract with other entities for the confinement of residents.
Standard 115.313 - Supervision and Monitoring
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA is a G4S Youth Services, LLC program that became operational January 2013 and exists through contractual
arrangement with the Florida Department of Juvenile Justice (FDJJ). A staffing ratio of 1:6 during day and evening
hours and 1:8 during sleep hours is written into the contract between the two entities. Review of the Staffing Plan
Assessment and other secondary documentation such as the Facility Administrator Weekly Management Report and
the Monthly Fidelity Compliance Scorecard, validated this ratio. There are no findings of inadequacies from judicial,
federal investigative agencies, nor internal or external oversight bodies; and there were no documented deviations from
the staffing plan.
The Staffing Plan Assessment and interviews with staff served to validate that in establishing and maintaining the
agreed upon ratios, consideration was given to needs of the residents to be served, physical location and layout of the
facility, as well as the location of available video surveillance cameras. The Staffing Plan Assessment documents a
total of 27 cameras and notes where they are located. During the facility tour said cameras were observed but it was
determined that there are portions of the facility that cannot be seen on the master control monitor and are considered to
be “blind spots.” Specifically, there are no cameras in the 2 schoolrooms, the kitchen, laundry room, or observation
room. Additionally, the hallway in the Gems living unit shows completely dark on the master control surveillance
PREA AUDIT: AUDITOR’S SUMMARY REPORT 4
during daylight hours; and blind spots exists outside of the administration building; in the educational testing lab, the
area outside the two classrooms, the recreation area located between and around school rooms and maintenance
buildings, and the outside area along the pathway around the lake leading from the administration building to the back
of the property towards the recreation court and maintenance building.
CPGA Policy 10-25 mandates that facility supervisors shall conduct unannounced rounds of all areas of the facility at a
minimum of one time per shift and that the rounds must be documented but falls short of compliance with the standard
by not including that such practice shall be implemented for night shifts as well as day shifts. Limited documentation
of unannounced rounds insufficient for compliance to this standard was provided for random times and various
locations by the Assistant Facility Administrator via 10 Youth Supervision Fidelity Check forms dated from March
2014 through June 2014 for first and second shift but not third shift. Documentation of staff interaction fidelity checks
and random camera10 minute validation checks were also provided for the same time frame for the Assistant Facility
Administrator.
Corrective Action: G4S PREA Coordinator provided policy 10-9 which included that unannounced rounds would be
conducted on each shift and provided documentation of unannounced rounds occurring on all shifts at Central Pasco
Girls Academy.
Standard 115.315 - Limits to cross gender viewing and searches
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA policies numbers10-25, 10-3, and 8-14 outline all mandates in compliance with this standard. Policy requires
that only in exigent circumstances will cross-gender searches be conducted and that any such search will be
documented as to the reason for the search and why a same sex staff was not available. CPGA Policy 10-3, states that
strip searches must be conducted in a private room with two staff members of the same sex as the resident. CPGA
Policy 10-3 further states that body cavity searches must be approved by the Facility Administrator or the Operations
Administrator only when it is strongly suspected that a youth has concealed contraband in the body cavity. All body
cavity searches must be conducted by trained medical personnel in an emergency room setting. Program staff is not
authorized to conduct a body cavity search of a youth. During the past 12 months, there were no cross-gender strip
and body cavity searches and no cross-gender pat-down searches.
Policy prohibits searching or examining a transgender or intersex resident for the sole purpose of determining the
resident’s genital status.
Further, policy also mandates that residents have access to shower, perform bodily functions, and change clothing
without non-medical staff of the opposite gender viewing; and that staff of the opposite sex shall announce their
presence when entering resident housing facility or an area where residents are likely to be showering or performing
bodily functions or changing clothing. Interviews with staff and residents verified that these practices are in place at
CPGA.
Standard 115.316 - Residents with disabilities and residents who are limited English proficient
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 requires the PREA Facility Compliance Manager to ensure residents with disabilities and
residents who are limited English proficient have an equal opportunity to participate in or benefit from all aspects of
the facility’s efforts to prevent, detect, and respond to sexual abuse and harassment. The policy also states the facility
PREA AUDIT: AUDITOR’S SUMMARY REPORT 5
will take steps to provide interpreters who can interpret effectively, accurately, and impartially.
The policy prohibits the use of youth or staff as interpreters, readers, or other assistant to perform such functions
except in limited circumstances where an extended delay in obtaining interpreters services could jeopardize residents’
safety. The facility does not use resident assistants and there were no instances of resident interpreter or readers being
used in the past 12 months. Resident interviews validated compliance.
Documentation of contracts or agreements for interpreters or other professionals hired to ensure services for disabled
and/or limited English proficient residents was not provided.
Corrective Action: Documentation for interpreter services was provided by the PREA Coordinator.
Standard 115.317 - Hiring and promotion decisions
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Elements required by this standard are outlined in CPGA Policies10-25, 3-16 and FDJJ Policy 1919. Persons desiring
employment with CPGA completes the application packet; a portion of which is sent from CPGA to the FDJJ Office of
the Inspector General for background screening. Details of the screening are described on the FDJJ’s website and
include conducting two background screenings; the Level II pre-employment screening and a 5-year re-screening.
Upon request, background screening is conducted on state and contract provider directors, owners, applicants,
employees, volunteers, mentors, and interns. The term contract provider includes grant recipient employees,
volunteers, mentors, and interns. Background screenings consist of a state and national fingerprint check through the
Florida Department of Law Enforcement and the Federal Bureau of Investigations, and a demographic search of the
Florida Clerk of the Courts. As a criminal justice agency, the Department has access to juvenile, sealed, and expunged
criminal history information.
Interview with Human Resources (HR) staff affirmed that the policy is in practice for staff and contractors. The
auditor’s review of 9 HR staff files validated at 100% that criminal background records checks were completed, and
applicants seeking employment are asked about previous misconduct outlined in section (a) of this standard.
Consistent with the PREA requirement and Florida Statutes 768.096 and 435.10, CPGA has in place a process for
contacting prior employers for information before hiring and sharing information with employers.
Of 36 employees, only 3 (either previously employed with FDJJ or transferred from another G4S facility) had hire
dates that met the 5 year threshold and documentation revealed background checks were completed.
The policy states that staff being considered for promotion shall disclose any sexual misconduct and material
omission regarding such misconduct, or the provision of materially false information shall be grounds for termination.
Standard 115.318 - Upgrades to facilities and technology
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA has not acquired any new facilities, or done any expansion or modification since August 20, 2012. As of the
date of this audit, the facility has not updated the video monitoring system, however, interviews and documentation in
the Staffing Plan Assessment validated that there are plans to update the current monitoring system and that
PREA AUDIT: AUDITOR’S SUMMARY REPORT 6
consideration was given to enhancing the facility’s ability to protect residents.
Standard 115.321- Evidence protocol and forensic medical examinations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA does not conduct administrative or criminal sexual abuse investigations and by policy upon learning of such an
event CPGA staff must immediately make a report through the Florida Department of Juvenile Justice (FDJJ) Central
Communications Center (CCC) hotline. Policy also mandates a call to local law enforcement and the Florida
Department of Children and Families Abuse Registry hotline. Criminal investigations are conducted by the Pasco
County Sheriff’s Office.
Written on the Youth Acknowledgement and Notification of Prison Rape Elimination Act form is this statement, “The
agency shall offer all residents who experience sexual abuse access to forensic medical examinations whether on-site
or at an outside facility, without financial cost.” Staff interviews validated this practice.
There were no forensic medical examinations conducted in the past 12 months. G4S is in the process of finalizing an
agreement with the Crisis Center of Tampa Bay to provide the services required by section (c) of this standard, but no
documentation was provided.
Documentation that the agency has requested the responsible agencies follow requirements in paragraph 115.321 (c)
through (f) of the standards was not made available to the auditor.
Corrective Action: A Memorandum of Understanding between G4S and Tampa Bay Crisis Center to provide the
services required to be compliant with the standard was provided by the PREA Coordinator.
Standard 115. 322 - Policies to ensure referrals of allegations for investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA policy 10.25 requires that any staff receiving a report of sexual misconduct or possible sexual misconduct must
ensure that it is immediately reported to their supervisor who shall ensure that it is reported to local law enforcement,
(the Pasco County Sheriff’s Office) if criminal in nature. During the past 12 months, CPGA received three
complaints against staff allegations and all three were reported as required through the FDJJ Office of the Inspector
General Central (OIG) Communications Center hotline. In each case the OIG conducted an administrative
investigation. As stated in policy, the FDJJ does not conduct criminal investigations of youth-related sexual
misconduct reports. In Florida, local law enforcement agencies and the Department of Children and Families handle
such investigations. Documentations showed that two of the allegations were made the same date by one resident
accuser against two different staff. The Pasco County Sheriff’s office and the Florida Department of Children and
Families were notified of the allegations and reported to the facility to investigate. After investigation, the case was
administratively closed and documentation provided to CPGA by the FDJJ Office of the Inspector General. The third
allegation was determined not to be criminal in nature. It was administratively investigated and closed by the FDJJ
Office of the Inspector General with a finding of unsubstantiated.
The FDJJ Policy 1919 describes the agency’s investigative responsibilities and duties for its facilities and is published
on the website.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 7
Standard 115.331 - Employee training
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policies 10-25 and 5.1.5 (C) and FDJJ Policy 1919 outline training requirements for staff that is consistent
with this standard. Review of 11 staff training records validated through the 2014 Pre-Service Orientation Plan and
employee training Acknowledgement Form that new hires and current employees were trained. Staff interviews also
served to further validate that training occurred. The training curriculum provided was consistent with the elements
of 115.331(a) except for number 6 and 11, and it was not specifically tailored to the unique needs of staff working
with a female resident population in a juvenile confinement/treatment setting.
CPGA school teachers are provided by the Pasco County School Board and under F39.201, school teachers and other
school official or personnel are mandated reporters. Documentation showed that CPGA school personnel signed a
form declaring that they are aware of the sexual abuse/assault policies governed by G4S Youth Services, LLC, the
Florida Department of Juvenile Justice and PREA and that they have read and understand those policies.
Corrective Action: Documentation of additional CPGA staff training that occurred with training curriculum covering
elements 6 and 11 was provided to the auditor.
Standard 115. 332 - Volunteer and contractor training
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy requires that all persons providing volunteer or contractor services at CPGA to be trained at a minimum
on the agency’s zero-tolerance policy regarding sexual abuse and harassment and how to report such incidents.
Additional training provided to volunteers and contractors is based on the service they provide and the level of contact
they have with residents. Before volunteers can have access to CPGA and provide services they must take the FDJJ
PREA training, “A Course for Volunteers” and upon completion, sign the form acknowledging that they have
completed the course and understand FDJJ PREA Policy 1919. This was verified through review of 41
acknowledgement forms dated from October 2012 to June 2014. Additionally, volunteer information is entered and
maintained in a database for tracking purposes and training is one of the data sets tracked and monitored for
compliance.
Contractors such as dentist, psychiatrist, and medical doctors sign the Acknowledgement of the Prison Rape
Elimination Act form declaring they have been informed and understand that CPGA has a zero tolerance and that
sexual contact of any kind is forbidden, the possible penalties for such behaviors, and that they have a duty to report.
Standard 115.333 - Resident education
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 8
CPGA Policy 10-25 requires that during intake all residents will be provided with information on zero-tolerance
regarding sexual misconduct including how to report sexual abuse and suspicion of any sexual misconduct. Policy
also requires that within 10 days of intake, all residents will be provided with additional comprehensive training
regarding their rights to be free from sexual misconduct; their right to be free from retaliation for reporting; and the
agency’s sexual misconduct response policies and procedures. As a part of the training, residents are given a handout
entitled, “You Have the Right to Be Safe from Sexual Violence. The handout provides information on preventing
detecting and responding to sexual assault and harassment. At the end of the training session residents acknowledge
through signature that they understand their right to be Safe from Sexual Misconduct, Abuse and Harassment.
Interviews with 10 residents (5 from each of the 2 housing units) validated that they receive education at intake and
later. Some residents stated that additional training reference sexual violence is provided as a part of Savvy Sisters
groups with staff. Interviews with intake and clinical staff verified that youth are provided with PREA required
education in individual sessions with staff the day they arrive at the facility.
During the tour of the facility, posters in multiple languages outlining the sexual abuse zero tolerance policy, duty to
report, and instructions for reporting, were posted in various locations including the living units and cafeteria.
Documentation for 115.333 (d)-1 was not made available to the auditor.
Corrective Action: Youth Education handouts in multiple languages (including English, Spanish, Hebrew,
Vietnamese, and French) were provided to the auditor.
Standard 115.334 - Specialized training: Investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable
CPGA does not employ facility investigators. Investigations are referred to outside agencies.
Standard 115.335 - Specialized training: Medical and mental health care
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 and FDJJ Policy 1919 mandates training for medical and mental health workers consistent with
section (a) of this policy.
CPGA Policy 5.1.5(G) requires specialized training for medical and mental health personnel. Certificates of
Completion documented that nurses took the National Institute of Corrections on-line course titled, PREA: Medical
Health Care for Sexual Assault Victims in a Confinement Setting. Staff interviews verified that CPGA medical staff
does not conduct forensic examinations.
Certificates of Completion documented that the clinical director and one intake staff took the National Institute of
Corrections on-line course titled, PREA: Behavioral Health Care for Sexual Assault Victims in a Confinement Setting.
Standard 115.341 - Screening for risk of victimization and abusiveness
Exceeds Standard (substantially exceeds requirement of standard)
PREA AUDIT: AUDITOR’S SUMMARY REPORT 9
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 9-1 describes the process staff is to use for screening for Vulnerability to Victimization and Sexual
Aggressive Behavior (VSAB). Within 24 hours of a resident’s arrival at the facility, trained staff meets with
residents and complete the VSAB form. The instrument is scored prior to housing placement. Those residents who
score vulnerable to victimization or sexually aggressive are included in the alert system, and referred for further
assessments, as identified. Residents who are identified or report as prior sexual victims are referred to the medical
and mental health professionals within 14 days. Interviews with the clinical director and PREA Compliance Manager
confirmed that policy is in practice and that information from the VSAB is disseminated on a “Need to Know” basis.
The screening for vulnerability to sexual victimization and sexual aggressive behavior instrument met the 11
minimum required elements outlined in section (c) of the standard.
Standard 115. 342 - Use of screening information
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy10-25 clearly states that the information gathered from screening for vulnerability to sexual victimization
and abusiveness shall be to guide treatment plans and security and management decisions, including housing bed,
work, education and program assignments. Policy 10-18 directs CPGA staff to maintain a continually updated internal
alert system that is easily accessible to program staff and keeps them alerted about youth who are security or safety
risks in multiple categories including sexual predator risks. Facility tour, interviews with staff and review of secondary
documentation validated that in this case practice mirrors policy.
The resident housing at CPGA consists of two wings that comprise the living units. Within the living units up to four
residents may be assigned to share a room. Isolation is prohibited. There is a controlled observation room without bed
or toileting facilities that is viewed as a behavioral intervention used under supervisory authority for short periods of
time when a resident is disruptive and poses a threat to safety and security. During the facility tour the room was not
in use. Interviews with clinical and medical staff verified they visit residents in controlled observation.
CPGA Policy 8-14.5 directs staff in the treatment of LGBTI residents consistent with those outlined in sections (c)
through (g) of this standard. There were no identified LGBTI residents in the population at the time of the audit.
Interviews with staff indicated they are aware of the policy and would comply.
Standard 115. 351 - Resident Reporting
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 8.3.4 (B) Abuse and Neglect Reporting – states clearly that all youth shall have unimpeded access to the
Florida Abuse Hotline without interference or retaliation of any kind and further outlines in detail that residents are to
be provided with the Abuse hotline number which is provided at intake, included in the resident handbook and posted
throughout the facility.
CPGA provides instruction and multiple ways for residents to report sexual abuse and harassment including telling a
PREA AUDIT: AUDITOR’S SUMMARY REPORT 10
staff member, writing a grievance, asking to speak with the Facility Administrator, calling the Florida Abuse Hotline,
the Florida Council against Sexual Violence Rape Crisis Hotline, or the Crisis Center of Tampa Bay Florida Referral
Line. The abuse hotline number is included in the resident handbook.
Staff and residents validated that they have access to the tools necessary to make a report. Also, policy outlines
procedures for staff to follow when a youth desires making a report including assisting the youth by dialing the number.
Interviews with staff validated that they would accept and document reports made verbally, in writing, anonymously,
and from third parties.
Further clarification is needed for section (b) of the standard requiring for residents to report abuse or harassment to a
public or private entity or office that is not part of the agency and that is able to receive and immediately forward
resident reports of abuse and harassment to agency officials allowing the resident to remain anonymous upon request.
Corrective Action: Policy 8.3 was revised dated September 22, 2014 and documentation of staff training in
November, 2014 was provided.
Standard 115.352 - Exhaustion of administrative remedies
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 8-4 outlines the administrative procedures for resident grievances regarding sexual abuse or sexual
harassment. The policy aligns nicely with this standard including no time limit for a resident to file a grievance; and
any grievance received that alleges a resident is substantially at risk for imminent sexual abuse shall be immediately
directed to the Facility Administrator, who shall provide immediate response to the grievance.
During the past 12 months no sexual abuse grievance was filed. Interviews with residents validated their knowledge of
how to file a grievance for sexual abuse or harassment. During the facility tour a locked grievance box was visible in
the living unit.
Standard 115.353 - Resident access to outside confidential support services and legal representation
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy10-25, page 5 of 10 requires that residents shall have access to outside victim advocates, the facility shall
make accessible mailing addresses and telephone numbers, including hotline numbers of victim advocacy or rape crisis
organizations, and residents shall have reasonable and confidential access to attorneys, parents or legal guardians.
CPGA reports an agreement with Crisis Center of Tampa Bay to provide the services required in this standard is in the
process of being finalized. Documentation was not made available to the auditor.
CPGA does not detain residents solely for immigration purposes.
Interviews with residents suggest CPGA does not provide mailing addresses and telephone numbers of local, state, or
national victim advocacy or rape crisis organizations.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 11
Corrective Action: A Memorandum of Understanding between G4S and Tampa Bay Crisis Center to provide the
services required to be compliant with the standard was provided by the PREA Coordinator. Also, provided, was the
youth education handout, “You Have the Right to Be Safe from Sexual Violence,” which included the mailing address
and telephone numbers of victim advocacy/rape crisis organization.
Standard 115.354 - Third-party reporting
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA is a FDJJ contracted facility and CPGA through the FDJJ website informs the public with information regarding
third-party reporting of sexual abuse and harassment on behalf of facility residents. The FDJJ website also has a
section dedicated to parents and among other information includes this statement, “Abuse and neglect are serious
issues that need to be handled with care. In the event of an emergency abuse situation, ALWAYS call 911 FIRST and
call the Florida Abuse Hotline second at 1-800-962-2873. In a non-emergency situation, contact the Florida Abuse
Hotline via phone, fax, or web to receive assistance.”
CPGA can receive third-party reports of sexual abuse and harassment through the Florida Department of Children and
Families Abuse hotline and the FDJJ Office of the Inspector General - Central Communications Center hotline.
Interviews with residents revealed they are aware sexual abuse or harassment may be reported through a third party.
Standard 115.361- Staff and agency reporting duties
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
The employees at CPGA are mandatory reporters and CPGA Policy 8-3 directs staff to immediately report any abuse,
knowledge, suspicion or information they receive regarding an incident of abuse or harassment. Policy also directs
staff to report any retaliation against residents or other staff who reported an incident; and any staff neglect or violation
of responsibilities that may have contributed to an incident of abuse or retaliation. CPGA policies further direct staff in
complying with the elements outlined in sections (b) through (f) of this standard. Interviews with Health Services
Administrator, Facility Administrator/PREA Compliance Manager, and random selected staff served to validate that
the staff are aware of the policies and their duty to report.
Standard 115.362 - Agency protection duties
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 requires that when staff learns that a resident is subject to a substantial risk of imminent sexual
abuse it shall take immediate action to protect the resident from harm or further threat. During the past 12 months no
residents were identified to be of such risk. Interviews with the Agency Head Designee, Facility Administrator/PREA
Compliance Monitor and random sample of staff validated that staff is aware of their mandate to immediately take
steps necessary to keep the resident safe.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 12
Standard 115.363 - Reporting to other confinement facilities
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
During the past 12 months CPGA staff did not receive any reported allegations that a CPGA resident was abused while
confined at another facility. Likewise, CPGA did not receive any reports of allegations of sexual abuse from other
facilities that residents previously confined at CPGA were sexually abused.
CPGA and FDJJ policies require that facility leadership ensure that all allegations are immediately reported to the
FDJJ Office of the Inspector General - Central Communications Center within a 2 hour window of learning of the
allegation. Notification to the facility management overseeing the facility where the alleged abuse occurred will be
provided by the OIG’s office.
Standard 115.364 - Staff first responder duties
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 mandates in responding to sexual abuse that staff take specific steps consistent with those outlined
in sections (a) and (b) of this standard. These steps include keeping the victim safe and separate from the alleged
perpetrator, preserving any crime scene within a period that still allows for the collection of physical evidence;
requesting the alleged victim not take any action that could destroy physical evidence; and ensuring the alleged abuser
does not take any action to destroy physical evidence. CPGA does not have investigators so beyond the steps already
mentioned, staff are directed to report and cooperate with the investigators when they arrive. Staff was able to
articulate these duties and responsibilities during interviews which indicated they have been trained and is aware of
the policies.
During the past 12 months CPGA had 3 allegations that a resident was sexually abused or harassed and in no instance
was a non-security staff member the first responder.
Standard 115.365 - Coordinated response
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 7-30 provides some guidance for a coordinated response to sexual assault among staff first responders,
medical and mental health practitioners, and facility leadership but falls short of stating how they will coordinate with
investigators and the follow-up responsibilities after the abuse. Interview with the Facility Administrator/PREA
Compliance Manager revealed knowledge of the policy and responsibilities and duties of staff.
There is no documentation of a plan specific to CPGA for a coordinated response that addresses all of the elements.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 13
Corrective Action: A coordinated response plan specific to CPGA was developed and submitted to the auditor along
with documentation of staff training.
Standard 115.366 - Preservation of ability to protect residents from contact with abusers.
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
Not Applicable
Central Pasco Girls Academy does not participate in collective bargaining.
Standard 115.367 - Agency protection against retaliation
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policies 10-25 and 8-3 establish that residents and staff are to be protected from retaliation for reporting sexual
abuse or harassment and/or cooperating with investigations of sexual abuse and harassment. The monitoring will take
place for a period of at least 90 days and at each 30 day interval the Facility Administrator/PREA Compliance manager
will determine if retaliation is occurring by reviewing such items as disciplinary reports, status checks, housing or
program changes, and negative performance reviews or staff reassignment. There were no incidents of retaliation in the
past 12 months reported.
Standard 115.368 - Post allegation protective custody
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA does not have isolation rooms or segregated housing. The resident housing at CPGA consists of two wings in the
Main/Dorm Building that comprise the living units. Within the living units up to four residents may be assigned to
share a room. Isolation is prohibited. There is a controlled observation room without bed and toileting facilities that is
viewed as a short-term behavioral intervention used under supervisory authority.
Standard 115.371 - Criminal and administrative agency investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA does not employ facility investigators. All allegations of abuse are reported to the Florida Department of
Children and Families, the Pasco County Sheriff’s Office, and the FDJJ Office of the Inspector General – Central
PREA AUDIT: AUDITOR’S SUMMARY REPORT 14
Communications Center. CPGA does not report any sustained allegations of conduct appearing to be criminal that
were referred for prosecution since August 20, 2012.
The PREA Coordinator was interviewed and indicated she has access to reports and comments on them for the
agency.
.
Standard 115.372 - Evidentiary standards for administrative investigations
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA does not conduct administrative investigations. All allegations of abuse are reported to FDJJ Office of the
Inspector General – Central Communications Center. Staff from the Inspector General’s office conducts the
administrative investigation and provides a report back to CPGA.
Standard 115.373 - Reporting to residents
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 page 9 reads, “At the conclusion of any law enforcement investigation where a sexual abuse
incident has been reported, the victim or victim’s parents or legal guardians should be notified that the investigation
is concluded, either by the investigating law enforcement agency or through a victim service agency officer or
representative. At the conclusion of the OIG administrative investigation, the victim’s parents or legal guardians
will be notified by receipt of a final administrative investigative report”
There were three reported allegations and three investigations. During interview the PREA Compliance Manager was
knowledgeable of the reporting requirement and verified that notification was provided.
Standard 115.376 - Disciplinary sanctions for staff
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
It is written in G4S CPGA Policy 10-25 that sexual activity between staff, volunteers or contracted personnel and
youth, as well as between youth is prohibited and subject to administrative and criminal disciplinary sanctions. The
policy also mandates that violations be reported to law enforcement.
The G4S Employee Handbook makes clear that employee sexual harassment is prohibited and when an allegation is
substantiated, disciplinary action up to and including termination will be imposed.
During the past 12 months no staff from CPGA has been terminated or resigned for violating agency sexual abuse or
harassment policies. Likewise, no CPGA staff has been reported to law enforcement or licensing boards for violating
agency sexual abuse and sexual harassment policies.
PREA AUDIT: AUDITOR’S SUMMARY REPORT 15
Standard 115.377 - Corrective Action for contractors and volunteers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 requires that like staff, volunteers and contracted personnel in violation of the facility’s policies
and procedures regarding sexual abuse and harassment of residents will be reported to local law enforcement.
Documentation of the specific language that they be reported to relevant licensing bodies or that they be prohibited
from contact with youth was not provided.
CPGA reports not having any allegations of sexual abuse or harassment by contractors or volunteers therefore no
reports to law enforcement or licensing bodies and no remedial measures were taken. Interviews with the Facility
Administrator/PREA Compliance Manager revealed knowledge of the remedial measures that would be taken.
Corrective Action: Policy 10.22 was revised dated September 22, 2014 and now includes language required by the
standard.
Standard 115.378 - Disciplinary sanctions for residents
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA is designated as a treatment facility. During the past 12 months there has been no administrative finding of
resident-on-resident sexual abuse; and no criminal finding of guilt for resident-on-resident sexual abuse at CPGA. No
residents were placed in isolation. Interviews with the Facility Administrator, medical, and mental health staff verified
that residents are informed that in the event of such findings charges would be pressed and if not prosecuted, then the
Treatment Team would make decision for any necessary treatment modification.
Standard 115.381 - Medical and mental health screenings; history of sexual abuse
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 requires that if during intake screening, health/mental health screening, or health history, a
resident discloses prior sexual victimization or perpetrated sexual abuse, whether it occurred in a facility setting or in
the community, staff shall ensure the youth is referred for medical and mental health services within 14 day of the
screening. Policy also mandates that sensitive information shall be on a need-to-know basis and shall not be exploited
to the resident’s detriment by staff or other residents. There were four residents who disclosed prior victimization
during their initial screening process. Interviews with the medical and mental health staff and documentation review
verified compliance with this standard.
Standard 115.382 - Access to emergency medical and mental health services
PREA AUDIT: AUDITOR’S SUMMARY REPORT 16
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 7-30 requires that residents who are victims of sexual assault shall have immediate medical care.
There were no sexual assault victims during the past 12 months. The Health Services Administrator verified that any
sexual assault victim would be provided unimpeded access to emergency medical treatment immediately; according to
the medical personnel’s professional judgment; the victim would be offered timely information about access to
emergency contraception and sexually transmitted infection prophylaxis; and that the services would be provided
without cost to the victim.
Standard 115.383 - Ongoing medical and mental health care for sexual abuse victims and abusers
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 mandates ongoing medical and mental health care for sexual abuse victims and abusers to include
mental health evaluations and services as appropriate and medical health care services consistent with the community
level of care. There has not been any sexual abuse victim during the last 12 months. Interviews with the Health
Services Administrator and Clinical Director verified that there are procedures in place compliant with the
requirements of this standard.
Standard 115.386 - Sexual abuse incident reviews
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25, page 8 mandates that the facility shall create a Review Team with specific staff consistent with
those outlined in section (c) of the standard. The policy further mandates that the Review Team shall ordinarily
conduct the incident review within 30 days of the conclusion of every sexual misconduct investigation or
administrative review. Page 9 of the policy outlines the specifics of the Review Team’s duties the same as those in
section (d) of the standard; and directs that Review Team recommendation must be implemented or justification
provided for not implementing the recommendations. Interview with Facility Administrator/PREA Compliance
Manager verified that the facility is in compliance with this standard.
Standard 115.387 - Data collection
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 directs that the facility shall ensure records are maintained and the Facility Administrator shall
ensure that requests for additional information from the FDJJ PREA Coordinator are responded to in a timely manner.
FDJJ Policy 1919 requires the Department to collect uniform data in the Office of the Inspector General’s – Central
PREA AUDIT: AUDITOR’S SUMMARY REPORT 17
Communications Center for every allegation of sexual misconduct at its facilities, both state-operated and those under
contracted providers. Upon request, the PREA Coordinator will provide all sexual misconduct data collected in the
Central Communications Center to the Department of Justice no later than June 30 of each year
Interview with the G4S Agency Head Designee verified that G4S maintains an Incident Report (IR) Tracking system
and that G4S facilities such as CPGA feed data to FDJJ and FDJJ publishes the Annual Report.
Standard 115.388 Data review for corrective action
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
FDJJ Policy 1919 requires the PREA Coordinator to review data collected and aggregated in order to assess and
improve the effectiveness of the Department’s sexual misconduct prevention, detection and response policies, practices,
and training. Policy also requires that FDJJ will prepare an annual report of sexual misconduct incidents, findings, and
corrective actions for all facilities, state and contracted, and the Department as a whole; the report will include a
comparison of the current years’ data and corrective actions with those from prior years and will provide an assessment
of progress in addressing sexual misconduct; the report will be reviewed and approved by the agency head and made
available to the public through the FDJJ website; and information that may present a clear and specific threat to the
safety and security of the facility may be redacted, but will indicate the nature of the information redacted.
Standard 115.389 Data storage, publication and destruction
Exceeds Standard (substantially exceeds requirement of standard)
Meets Standard (substantial compliance; complies in all material ways with the standard
for the relevant review period)
Does Not Meet Standard (requires corrective action)
CPGA Policy 10-25 directs that the facility shall ensure records are maintained and the Facility Administrator shall
ensure that requests for additional information from the FDJJ PREA Coordinator are responded to in a timely manner.
Interview with the G4S Agency Head Designee verified that G4S maintains an Incident Report (IR) Tracking system
and that G4S facilities such as CPGA feed data to FDJJ and FDJJ publishes the Annual Report. FDJJ Policy 1919
established that aggregated sexual abuse data be reviewed annually and placed on the facility’s website after all
personal identifiers are removed. All data collected will be maintained for at least 10 years after the date of the initial
collection.
AUDITORTOR CERTIFICATION:
The auditor certifies that the contents of the report are accurate to the best of his/her knowledge and no conflict of interest
exists with respect to his or her ability to conduct an audit of the agency under review.
January 12, 2015
Auditor Signature Date
PREA AUDIT: AUDITOR’S SUMMARY REPORT 18

source: DJJ

program_name_raw: central pasco girls academy