facility_name: DOVE Academy

summary: PREA - Year 2 Cycle 4

raw_content:
PREA Facility Audit Report: Final
Name of Facility: DOVE Academy
Facility Type: Juvenile
Date Interim Report Submitted: NA
Date Final Report Submitted: 04/07/2024
Auditor Certification
The contents of this report are accurate to the best of my knowledge.
No conflict of interest exists with respect to my ability to conduct an audit of the
agency under review.
I have not included in the final report any personally identifiable information (PII)
about any inmate/resident/detainee or staff member, except where the names of
administrative personnel are specifically requested in the report template.
Auditor Full Name as Signed: Shirley Turner Date of Signature: 04/07/2024
AUDITOR INFORMATION
Auditor name: Turner, Shirley
Email: shirleyturner3199@comcast.net
Start Date of On- 03/19/2024
Site Audit:
End Date of On-Site 03/20/2024
Audit:
FACILITY INFORMATION
Facility name: DOVE Academy
Facility physical 5270 Ezell Road, Graceville, Florida - 32440
address:
Facility mailing
address:
Primary Contact
Name: Kim Vance
Email Address: khill@twinoaksfl.org
Telephone Number: 850-263-7550
Superintendent/Director/Administrator
Name: Kim Vance
Email Address: khill@twinoakfl.org
Telephone Number: 850-26-7550 Cell 850
Facility PREA Compliance Manager
Name: Kimberly Vance
Email Address: khill@twinoaksfl.org
Telephone Number: O: 850-263-7550 ext 10
Facility Health Service Administrator On-Site
Name: Ashley Pridgen
Email Address: ashley.pridgen@twinoaksfl.org
Telephone Number: 334-796-3050
Facility Characteristics
Designed facility capacity: 40
Current population of facility: 38
Average daily population for the past 12 36
months:
Has the facility been over capacity at any Yes
point in the past 12 months?
Which population(s) does the facility hold? Females
Age range of population: 14 - 18
Facility security levels/resident custody Non secure
levels:
Number of staff currently employed at the 70
facility who may have contact with
residents:
Number of individual contractors who have 2
contact with residents, currently
authorized to enter the facility:
Number of volunteers who have contact 0
with residents, currently authorized to
enter the facility:
AGENCY INFORMATION
Name of agency: Twin Oaks Juvenile Development, Inc.
Governing authority
or parent agency (if
applicable):
Physical Address: 11939 Florida 20, Bristol, Florida - 32321
Mailing Address:
Telephone number:
Agency Chief Executive Officer Information:
Name:
Email Address:
Telephone Number:
Agency-Wide PREA Coordinator Information
Name: Jean Horton Email Address: jhorton@twinoaksfl.org
Facility AUDIT FINDINGS
Summary of Audit Findings
The OAS automatically populates the number and list of Standards exceeded, the number of
Standards met, and the number and list of Standards not met.
Auditor Note: In general, no standards should be found to be "Not Applicable" or "NA." A
compliance determination must be made for each standard. In rare instances where an auditor
determines that a standard is not applicable, the auditor should select "Meets Standard” and
include a comprehensive discussion as to why the standard is not applicable to the facility being
audited.
Number of standards exceeded:
0
Number of standards met:
43
Number of standards not met:
0
POST-AUDIT REPORTING INFORMATION
GENERAL AUDIT INFORMATION
On-site Audit Dates
1. Start date of the onsite portion of the 2024-03-19
audit:
2. End date of the onsite portion of the 2024-03-20
audit:
Outreach
10. Did you attempt to communicate Yes
with community-based organization(s)
or victim advocates who provide
No
services to this facility and/or who may
have insight into relevant conditions in
the facility?
a. Identify the community-based Refuge House, Inc.
organization(s) or victim advocates with
whom you communicated:
AUDITED FACILITY INFORMATION
14. Designated facility capacity: 40
15. Average daily population for the past 36
12 months:
16. Number of inmate/resident/detainee 6
housing units:
17. Does the facility ever hold youthful Yes
inmates or youthful/juvenile detainees?
No
Not Applicable for the facility type audited
(i.e., Community Confinement Facility or
Juvenile Facility)
Audited Facility Population Characteristics on Day One of the Onsite
Portion of the Audit
Inmates/Residents/Detainees Population Characteristics on Day One of the Onsite Portion
of the Audit
36. Enter the total number of inmates/ 39
residents/detainees in the facility as of
the first day of onsite portion of the
audit:
38. Enter the total number of inmates/ 0
residents/detainees with a physical
disability in the facility as of the first
day of the onsite portion of the audit:
39. Enter the total number of inmates/ 9
residents/detainees with a cognitive or
functional disability (including
intellectual disability, psychiatric
disability, or speech disability) in the
facility as of the first day of the onsite
portion of the audit:
40. Enter the total number of inmates/ 0
residents/detainees who are Blind or
have low vision (visually impaired) in the
facility as of the first day of the onsite
portion of the audit:
41. Enter the total number of inmates/ 0
residents/detainees who are Deaf or
hard-of-hearing in the facility as of the
first day of the onsite portion of the
audit:
42. Enter the total number of inmates/ 0
residents/detainees who are Limited
English Proficient (LEP) in the facility as
of the first day of the onsite portion of
the audit:
43. Enter the total number of inmates/ 17
residents/detainees who identify as
lesbian, gay, or bisexual in the facility as
of the first day of the onsite portion of
the audit:
44. Enter the total number of inmates/ 0
residents/detainees who identify as
transgender or intersex in the facility as
of the first day of the onsite portion of
the audit:
45. Enter the total number of inmates/ 0
residents/detainees who reported sexual
abuse in the facility as of the first day of
the onsite portion of the audit:
46. Enter the total number of inmates/ 0
residents/detainees who disclosed prior
sexual victimization during risk
screening in the facility as of the first
day of the onsite portion of the audit:
47. Enter the total number of inmates/ 0
residents/detainees who were ever
placed in segregated housing/isolation
for risk of sexual victimization in the
facility as of the first day of the onsite
portion of the audit:
48. Provide any additional comments The facility does not use segregated housing/
regarding the population characteristics isolation.
of inmates/residents/detainees in the
facility as of the first day of the onsite
portion of the audit (e.g., groups not
tracked, issues with identifying certain
populations):
Staff, Volunteers, and Contractors Population Characteristics on Day One of the Onsite
Portion of the Audit
49. Enter the total number of STAFF, 76
including both full- and part-time staff,
employed by the facility as of the first
day of the onsite portion of the audit:
50. Enter the total number of 2
VOLUNTEERS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
51. Enter the total number of 2
CONTRACTORS assigned to the facility as
of the first day of the onsite portion of
the audit who have contact with
inmates/residents/detainees:
52. Provide any additional comments No text provided.
regarding the population characteristics
of staff, volunteers, and contractors who
were in the facility as of the first day of
the onsite portion of the audit:
INTERVIEWS
Inmate/Resident/Detainee Interviews
Random Inmate/Resident/Detainee Interviews
53. Enter the total number of RANDOM 10
INMATES/RESIDENTS/DETAINEES who
were interviewed:
54. Select which characteristics you Age
considered when you selected RANDOM
INMATE/RESIDENT/DETAINEE Race
interviewees: (select all that apply)
Ethnicity (e.g., Hispanic, Non-Hispanic)
Length of time in the facility
Housing assignment
Gender
Other
None
55. How did you ensure your sample of Reviewed the population rosters and
RANDOM INMATE/RESIDENT/DETAINEE collaborated with staff.
interviewees was geographically
diverse?
56. Were you able to conduct the Yes
minimum number of random inmate/
resident/detainee interviews?
No
57. Provide any additional comments No text provided.
regarding selecting or interviewing
random inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews,
barriers to ensuring representation):
Targeted Inmate/Resident/Detainee Interviews
58. Enter the total number of TARGETED 5
INMATES/RESIDENTS/DETAINEES who
were interviewed:
As stated in the PREA Auditor Handbook, the breakdown of targeted interviews is intended to
guide auditors in interviewing the appropriate cross-section of inmates/residents/detainees who
are the most vulnerable to sexual abuse and sexual harassment. When completing questions
regarding targeted inmate/resident/detainee interviews below, remember that an interview with
one inmate/resident/detainee may satisfy multiple targeted interview requirements. These
questions are asking about the number of interviews conducted using the targeted inmate/
resident/detainee protocols. For example, if an auditor interviews an inmate who has a physical
disability, is being held in segregated housing due to risk of sexual victimization, and disclosed
prior sexual victimization, that interview would be included in the totals for each of those
questions. Therefore, in most cases, the sum of all the following responses to the targeted
inmate/resident/detainee interview categories will exceed the total number of targeted inmates/
residents/detainees who were interviewed. If a particular targeted population is not applicable in
the audited facility, enter "0".
60. Enter the total number of interviews 0
conducted with inmates/residents/
detainees with a physical disability using
the "Disabled and Limited English
Proficient Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff and observed
to determine if this population exists in population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
61. Enter the total number of interviews 0
conducted with inmates/residents/
detainees with a cognitive or functional
disability (including intellectual
disability, psychiatric disability, or
speech disability) using the "Disabled
and Limited English Proficient Inmates"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff and observed
to determine if this population exists in population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
62. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Blind or have low
vision (i.e., visually impaired) using the
"Disabled and Limited English Proficient
Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff and observed
to determine if this population exists in population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
63. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Deaf or hard-of-
hearing using the "Disabled and Limited
English Proficient Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff and observed
to determine if this population exists in population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
64. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are Limited English
Proficient (LEP) using the "Disabled and
Limited English Proficient Inmates"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff and observed
to determine if this population exists in population.
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
65. Enter the total number of interviews 17
conducted with inmates/residents/
detainees who identify as lesbian, gay,
or bisexual using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
66. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who identify as transgender
or intersex using the "Transgender and
Intersex Inmates; Gay, Lesbian, and
Bisexual Inmates" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
67. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who reported sexual abuse in
this facility using the "Inmates who
Reported a Sexual Abuse" protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff, reviewed incident
to determine if this population exists in information uploaded in PAQ, and reviewed
the audited facility (e.g., based on population rosters.
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
68. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who disclosed prior sexual
victimization during risk screening using
the "Inmates who Disclosed Sexual
Victimization during Risk Screening"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff.
to determine if this population exists in
the audited facility (e.g., based on
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
69. Enter the total number of interviews 0
conducted with inmates/residents/
detainees who are or were ever placed
in segregated housing/isolation for risk
of sexual victimization using the
"Inmates Placed in Segregated Housing
(for Risk of Sexual Victimization/Who
Allege to have Suffered Sexual Abuse)"
protocol:
a. Select why you were unable to Facility said there were "none here" during
conduct at least the minimum required the onsite portion of the audit and/or the
number of targeted inmates/residents/ facility was unable to provide a list of these
detainees in this category: inmates/residents/detainees.
The inmates/residents/detainees in this
targeted category declined to be interviewed.
b. Discuss your corroboration strategies Collaborated with staff; formal staff
to determine if this population exists in interviews; and observations during the
the audited facility (e.g., based on comprehensive site review.
information obtained from the PAQ;
documentation reviewed onsite; and
discussions with staff and other inmates/
residents/detainees).
70. Provide any additional comments Segregated housing/isolation is not used in
regarding selecting or interviewing this facility.
targeted inmates/residents/detainees
(e.g., any populations you oversampled,
barriers to completing interviews):
Staff, Volunteer, and Contractor Interviews
Random Staff Interviews
71. Enter the total number of RANDOM 12
STAFF who were interviewed:
72. Select which characteristics you Length of tenure in the facility
considered when you selected RANDOM
STAFF interviewees: (select all that Shift assignment
apply)
Work assignment
Rank (or equivalent)
Other (e.g., gender, race, ethnicity,
languages spoken)
None
73. Were you able to conduct the Yes
minimum number of RANDOM STAFF
interviews?
No
74. Provide any additional comments No text provided.
regarding selecting or interviewing
random staff (e.g., any populations you
oversampled, barriers to completing
interviews, barriers to ensuring
representation):
Specialized Staff, Volunteers, and Contractor Interviews
Staff in some facilities may be responsible for more than one of the specialized staff duties.
Therefore, more than one interview protocol may apply to an interview with a single staff
member and that information would satisfy multiple specialized staff interview requirements.
75. Enter the total number of staff in a 5
SPECIALIZED STAFF role who were
interviewed (excluding volunteers and
contractors):
76. Were you able to interview the Yes
Agency Head?
No
77. Were you able to interview the Yes
Warden/Facility Director/Superintendent
or their designee?
No
78. Were you able to interview the PREA Yes
Coordinator?
No
79. Were you able to interview the PREA Yes
Compliance Manager?
No
NA (NA if the agency is a single facility
agency or is otherwise not required to have a
PREA Compliance Manager per the Standards)
80. Select which SPECIALIZED STAFF Agency contract administrator
roles were interviewed as part of this
audit from the list below: (select all that Intermediate or higher-level facility staff
apply) responsible for conducting and documenting
unannounced rounds to identify and deter
staff sexual abuse and sexual harassment
Line staff who supervise youthful inmates
(if applicable)
Education and program staff who work with
youthful inmates (if applicable)
Medical staff
Mental health staff
Non-medical staff involved in cross-gender
strip or visual searches
Administrative (human resources) staff
Sexual Assault Forensic Examiner (SAFE) or
Sexual Assault Nurse Examiner (SANE) staff
Investigative staff responsible for
conducting administrative investigations
Investigative staff responsible for
conducting criminal investigations
Staff who perform screening for risk of
victimization and abusiveness
Staff who supervise inmates in segregated
housing/residents in isolation
Staff on the sexual abuse incident review
team
Designated staff member charged with
monitoring retaliation
First responders, both security and non-
security staff
Intake staff
Other
81. Did you interview VOLUNTEERS who Yes
may have contact with inmates/
residents/detainees in this facility?
No
a. Enter the total number of 2
VOLUNTEERS who were interviewed:
b. Select which specialized VOLUNTEER Education/programming
role(s) were interviewed as part of this
audit from the list below: (select all that Medical/dental
apply)
Mental health/counseling
Religious
Other
82. Did you interview CONTRACTORS Yes
who may have contact with inmates/
residents/detainees in this facility?
No
a. Enter the total number of 1
CONTRACTORS who were interviewed:
b. Select which specialized CONTRACTOR Security/detention
role(s) were interviewed as part of this
audit from the list below: (select all that Education/programming
apply)
Medical/dental
Food service
Maintenance/construction
Other
83. Provide any additional comments No text provided.
regarding selecting or interviewing
specialized staff.
SITE REVIEW AND DOCUMENTATION SAMPLING
Site Review
PREA Standard 115.401 (h) states, "The auditor shall have access to, and shall observe, all areas
of the audited facilities." In order to meet the requirements in this Standard, the site review
portion of the onsite audit must include a thorough examination of the entire facility. The site
review is not a casual tour of the facility. It is an active, inquiring process that includes talking
with staff and inmates to determine whether, and the extent to which, the audited facility's
practices demonstrate compliance with the Standards. Note: As you are conducting the site
review, you must document your tests of critical functions, important information gathered
through observations, and any issues identified with facility practices. The information you
collect through the site review is a crucial part of the evidence you will analyze as part of your
compliance determinations and will be needed to complete your audit report, including the Post-
Audit Reporting Information.
84. Did you have access to all areas of Yes
the facility?
No
Was the site review an active, inquiring process that included the following:
85. Observations of all facility practices Yes
in accordance with the site review
component of the audit instrument (e.g.,
No
signage, supervision practices, cross-
gender viewing and searches)?
86. Tests of all critical functions in the Yes
facility in accordance with the site
review component of the audit
No
instrument (e.g., risk screening process,
access to outside emotional support
services, interpretation services)?
87. Informal conversations with inmates/ Yes
residents/detainees during the site
review (encouraged, not required)?
No
88. Informal conversations with staff Yes
during the site review (encouraged, not
required)?
No
89. Provide any additional comments No text provided.
regarding the site review (e.g., access to
areas in the facility, observations, tests
of critical functions, or informal
conversations).
Documentation Sampling
Where there is a collection of records to review-such as staff, contractor, and volunteer training
records; background check records; supervisory rounds logs; risk screening and intake
processing records; inmate education records; medical files; and investigative files-auditors must
self-select for review a representative sample of each type of record.
90. In addition to the proof Yes
documentation selected by the agency
or facility and provided to you, did you
No
also conduct an auditor-selected
sampling of documentation?
91. Provide any additional comments No text provided.
regarding selecting additional
documentation (e.g., any documentation
you oversampled, barriers to selecting
additional documentation, etc.).
SEXUAL ABUSE AND SEXUAL HARASSMENT ALLEGATIONS AND
INVESTIGATIONS IN THIS FACILITY
Sexual Abuse and Sexual Harassment Allegations and Investigations
Overview
Remember the number of allegations should be based on a review of all sources of allegations
(e.g., hotline, third-party, grievances) and should not be based solely on the number of
investigations conducted. Note: For question brevity, we use the term “inmate” in the following
questions. Auditors should provide information on inmate, resident, or detainee sexual abuse
allegations and investigations, as applicable to the facility type being audited.
92. Total number of SEXUAL ABUSE allegations and investigations overview during
the 12 months preceding the audit, by incident type:
# of allegations
# of
# of that had both
sexual # of criminal
administrative criminal and
abuse investigations
investigations administrative
allegations
investigations
Inmate- 1 0 1 0
on-
inmate
sexual
abuse
Staff- 0 0 0 0
on-
inmate
sexual
abuse
Total 1 0 1 0
93. Total number of SEXUAL HARASSMENT allegations and investigations overview
during the 12 months preceding the audit, by incident type:
# of allegations
# of sexual # of that had both
# of criminal
harassment administrative criminal and
investigations
allegations investigations administrative
investigations
Inmate-on- 0 0 0 0
inmate
sexual
harassment
Staff-on- 0 0 0 0
inmate
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Outcomes
Sexual Abuse Investigation Outcomes
Note: these counts should reflect where the investigation is currently (i.e., if a criminal
investigation was referred for prosecution and resulted in a conviction, that investigation
outcome should only appear in the count for “convicted.”) Do not double count. Additionally, for
question brevity, we use the term “inmate” in the following questions. Auditors should provide
information on inmate, resident, and detainee sexual abuse investigation files, as applicable to
the facility type being audited.
94. Criminal SEXUAL ABUSE investigation outcomes during the 12 months preceding
the audit:
Referred Indicted/
Convicted/
Ongoing for Court Case Acquitted
Adjudicated
Prosecution Filed
Inmate-on- 0 0 0 0 0
inmate sexual
abuse
Staff-on- 0 0 0 0 0
inmate sexual
abuse
Total 0 0 0 0 0
95. Administrative SEXUAL ABUSE investigation outcomes during the 12 months
preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 1 0 0 0
sexual abuse
Staff-on-inmate 0 0 0 0
sexual abuse
Total 1 0 0 0
Sexual Harassment Investigation Outcomes
Note: these counts should reflect where the investigation is currently. Do not double count.
Additionally, for question brevity, we use the term “inmate” in the following questions. Auditors
should provide information on inmate, resident, and detainee sexual harassment investigation
files, as applicable to the facility type being audited.
96. Criminal SEXUAL HARASSMENT investigation outcomes during the 12 months
preceding the audit:
Indicted/
Referred
Court Convicted/
Ongoing for Acquitted
Case Adjudicated
Prosecution
Filed
Inmate-on- 0 0 0 0 0
inmate sexual
harassment
Staff-on- 0 0 0 0 0
inmate sexual
harassment
Total 0 0 0 0 0
97. Administrative SEXUAL HARASSMENT investigation outcomes during the 12
months preceding the audit:
Ongoing Unfounded Unsubstantiated Substantiated
Inmate-on-inmate 0 0 0 0
sexual
harassment
Staff-on-inmate 0 0 0 0
sexual
harassment
Total 0 0 0 0
Sexual Abuse and Sexual Harassment Investigation Files Selected for
Review
Sexual Abuse Investigation Files Selected for Review
98. Enter the total number of SEXUAL 0
ABUSE investigation files reviewed/
sampled:
a. Explain why you were unable to The investigation is ongoing.
review any sexual abuse investigation
files:
99. Did your selection of SEXUAL ABUSE Yes
investigation files include a cross-
section of criminal and/or administrative No
investigations by findings/outcomes?
NA (NA if you were unable to review any
sexual abuse investigation files)
Inmate-on-inmate sexual abuse investigation files
100. Enter the total number of INMATE- 0
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
101. Did your sample of INMATE-ON- Yes
INMATE SEXUAL ABUSE investigation
files include criminal investigations?
No
NA (NA if you were unable to review any
inmate-on-inmate sexual abuse investigation
files)
102. Did your sample of INMATE-ON- Yes
INMATE SEXUAL ABUSE investigation
files include administrative No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual abuse investigation
files)
Staff-on-inmate sexual abuse investigation files
103. Enter the total number of STAFF- 0
ON-INMATE SEXUAL ABUSE investigation
files reviewed/sampled:
104. Did your sample of STAFF-ON- Yes
INMATE SEXUAL ABUSE investigation
files include criminal investigations?
No
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
105. Did your sample of STAFF-ON- Yes
INMATE SEXUAL ABUSE investigation
files include administrative
No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual abuse investigation
files)
Sexual Harassment Investigation Files Selected for Review
106. Enter the total number of SEXUAL 0
HARASSMENT investigation files
reviewed/sampled:
a. Explain why you were unable to There were no allegations of sexual
review any sexual harassment harassment during this audit period.
investigation files:
107. Did your selection of SEXUAL Yes
HARASSMENT investigation files include
a cross-section of criminal and/or No
administrative investigations by
findings/outcomes?
NA (NA if you were unable to review any
sexual harassment investigation files)
Inmate-on-inmate sexual harassment investigation files
108. Enter the total number of INMATE- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
109. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT files
include criminal investigations? No
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
110. Did your sample of INMATE-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative No
investigations?
NA (NA if you were unable to review any
inmate-on-inmate sexual harassment
investigation files)
Staff-on-inmate sexual harassment investigation files
111. Enter the total number of STAFF- 0
ON-INMATE SEXUAL HARASSMENT
investigation files reviewed/sampled:
112. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include criminal No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
113. Did your sample of STAFF-ON- Yes
INMATE SEXUAL HARASSMENT
investigation files include administrative No
investigations?
NA (NA if you were unable to review any
staff-on-inmate sexual harassment
investigation files)
114. Provide any additional comments There was one allegation of youth-on-youth
regarding selecting and reviewing sexual abuse and the investigation is ongoing.
sexual abuse and sexual harassment There were no allegations of sexual
investigation files. harassment.
SUPPORT STAFF INFORMATION
DOJ-certified PREA Auditors Support Staff
115. Did you receive assistance from any Yes
DOJ-CERTIFIED PREA AUDITORS at any
point during this audit? REMEMBER: the
No
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
Non-certified Support Staff
116. Did you receive assistance from any Yes
NON-CERTIFIED SUPPORT STAFF at any
point during this audit? REMEMBER: the
No
audit includes all activities from the pre-
onsite through the post-onsite phases to
the submission of the final report. Make
sure you respond accordingly.
AUDITING ARRANGEMENTS AND COMPENSATION
121. Who paid you to conduct this audit? The audited facility or its parent agency
My state/territory or county government
employer (if you audit as part of a consortium
or circular auditing arrangement, select this
option)
A third-party auditing entity (e.g.,
accreditation body, consulting firm)
Other
Identify the name of the third-party Correctional Management and
auditing entity Communications Group, LLC
Standards
Auditor Overall Determination Definitions
• Exceeds Standard
(Substantially exceeds requirement of standard)
• Meets Standard
(substantial compliance; complies in all material ways with the stand for the relevant
review period)
• Does Not Meet Standard
(requires corrective actions)
Auditor Discussion Instructions
Auditor discussion, including the evidence relied upon in making the compliance or non-
compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions.
This discussion must also include corrective action recommendations where the facility does not
meet standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Zero tolerance of sexual abuse and sexual harassment; PREA
115.311
coordinator
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ Policy 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Agency Organization Chart
Facility Organization Chart
Interviews:
PREA Coordinators
PREA Compliance Manager
Superintendent
Random Staff
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.
Policy provides 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
includes sanctions for those found to have participated in the prohibited behaviors.
The Department of Juvenile Justice agency Policy, FDJJ 1919, serves as the
overarching PREA Policy for the state-run and contract facilities. Dove Academy is
operated by Twin Oaks Youth Development, Incorporated through a contract with
the Florida Department of Juvenile Justice (DJJ). The facility also has additional
policies and procedures that support adherence to the PREA standards.
Staff training, resident education, and intake screening assist in detecting sexual
abuse and sexual harassment. The supporting policies and procedures include but
are not limited to responding to sexual abuse and sexual harassment through
prevention; responsive planning; training and education; reporting; investigations;
medical and mental care; assessments; disciplinary sanctions for residents and
staff; and data collection and review. The interviews confirmed knowledge of the
zero-tolerance and other related policies regarding sexual abuse and sexual
harassment.
Provision (b):
An agency shall employ or designate an upper-level, agency-wide PREA Coordinator
with sufficient time and authority to develop, implement, and oversee agency
efforts to comply with the PREA standards in all of its facilities.
The facility is a juvenile correctional residential facility that serves females only. The
Florida Department of Juvenile Justice (DJJ) and Twin Oaks (TO) Youth Development
Incorporated employ a PREA Coordinator who is in an upper-level management
position within the respective agencies, as provided by policy and procedures. The
TO Administrator of Special Projects serves as the agency’s PREA Coordinator with
the support of the Chief Operating Officer. The DJJ statewide PREA Coordinator
manages the PREA implementation efforts statewide and ensures compliance in
State-run juvenile detention centers and privately managed juvenile residential
facilities. The statewide PREA Coordinator's role serves in the office of the Deputy
Secretary of DJJ. Both PREA Coordinators have knowledge of the standards,
implementation, and audit processes. Collaboration exists with the PREA
Coordinators, PREA Compliance Manager, and facility administrator. Interviews and
observations with the PREA Coordinators revealed sufficient time and authority to
develop, implement, and oversee the efforts to comply with the PREA standards.
Provision (c):
Where an agency operates more than one facility, each facility shall designate a
PREA compliance manager with sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards.
The Facility Administrator (Superintendent) serves as the PREA Compliance
Manager. The interview revealed she has sufficient time to oversee the facility’s
PREA compliance efforts and to perform other duties. The interview revealed that
PREA compliance is a coordinated effort among staff. She further stated that
educating staff is important and PREA is always mentioned in staff meetings.
Through the coordinated effort, all staff want to contribute to the application of the
Standards and compliance. Observations confirmed the PREA Compliance Manager
has the support of the facility staff and TO corporate staff. The PREA Compliance
Manager and the Twin Oaks PREA Coordinator collaborate in the PREA efforts as
determined from interviews and observations. Communication and collaboration
exists among the Superintendent/PREA Compliance Manager, TO PREA Coordinator,
and DJJ statewide PREA Coordinator.
Conclusion:
Based upon the review and analysis of the available documentation, interviews, and
observations, the Auditor determined the facility is compliant with this standard.
115.312 Contracting with other entities for the confinement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Contract
Interviews:
Superintendent
Statewide PREA Coordinator
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.
All contracts with private vendors for the Department of Juvenile Justice (DJJ)
informs the vendor of the requirement to comply with the PREA Standards and the
requirement of participation in PREA audits. The PREA Coordinators confirmed this
premise as well as a previous interview with DJJ contract staff. The facility does not
contract with other facilities or agencies for the confinement of the residents
assigned by DJJ.
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.
A review of the contract language and interviews confirm agency contract
monitoring occurs to ensure implementation and compliance regarding the PREA
Standards.
Conclusion:
Based on the available evidence, the Auditor determined the facility is compliant
with this standard.
115.313 Supervision and monitoring
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Staffing Plan
Staffing Plan Assessment
Resident Roster
Staff Roster
Unannounced Rounds
Interviews:
Superintendent/PREA Compliance Manager
Intermediate or Higher-Level Staff
PREA Coordinator
Random Staff
Provision (a):
The agency shall ensure that each facility it operates shall develop, implement, and
document a staffing plan that provides for adequate levels of staffing, and, where
applicable, video monitoring, to protect residents against sexual abuse. In
calculating adequate staffing levels and determining the need for video monitoring,
facilities shall take into consideration:
(1) Generally accepted juvenile detention and correctional/secure residential
practices;
(2) Any judicial findings of inadequacy;
(3) Any findings of inadequacy from Federal investigative agencies;
(4) Any findings of inadequacy from internal or external oversight bodies;
(5) All components of the facility’s physical plant (including “blind spots” or areas
where staff or residents may be isolated);
(6) The composition of the resident population;
(7) The number and placement of supervisory staff;
(8) Institution programs occurring on a particular shift;
(9) Any applicable State or local laws, regulations, or standards;
(10) The prevalence of substantiated and unsubstantiated incidents of sexual
abuse; and
(11) Any other relevant factors.
The policy 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 ensure the PREA ratios of 1:8 during the waking
hours and 1:8 during the sleeping hours. The ratio for residents classified as
Intensive Mental Health is 1:6 day and night. Direct supervision is provided to
residents during the daily activities and program services, including off-campus
activities. The number of residents per staff decreases with off-site activities. In
addition to the direct care staff, support staff provide direct contact with residents in
the provision of treatment and supportive services onsite. Observations during the
site review, review of documentation, and interviews indicated the staffing ratios
are maintained.
The provisions of the standard are taken into consideration regarding adequate
staffing levels as confirmed through the interviews requirements. The work
schedules are based on the facility’s overall staffing plan. The master schedules are
made regarding the considerations that ensure adequate shift coverage including
but not limited to standard security practices; composition of the resident
population; inclement weather; emergencies; and programs and activities occurring
on a particular shift. The cameras are used to enhance direct staff supervision.
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 staffing plan is based on the average daily population of 36. Policy and
procedures require the facility to document deviations from the staffing plan; there
were no deviations from the staffing for the past 12 months. The facility has a
holdover practice that addresses the required staff coverage and is included in the
staffing plan. The holdover system requires a staff member to come in early, stay
later, of come in when called.
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.
The Superintendent confirmed there is no law, regulation or judicial decree to
maintain any staffing ratios. Observations during the comprehensive site review and
subsequent walkthroughs revealed the staff to residents’ ratio requirements are
met; the internal ratio and PREA ratio requirements. The facility's contract
documents provide for the staffing ratios based on the program missions within the
facility.
Provision (d):
Whenever necessary, but no less frequently than once each year, for each facility
the agency operates, in consultation with the PREA coordinator 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 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. Documentation of the
annual assessment of the staffing plan was reviewed and found to be in compliance
with all elements of this provision. The Statewide PREA Coordinator and the
Superintendent/PREA Compliance Manager reviewed the staffing plan to determine
if adjustments are needed; however, no adjustments were made or 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
regularly by the shift supervisors while on their shift; Assistant Superintendent; and
periodically by the Superintendent. The documents and interview with the
intermediate or higher-level staff reveal the rounds are made at various times and
are documented in the logbooks. Unannounced rounds made by the shift
supervisors are written in the logbooks.
The interviews with the higher-level staff and Superintendent 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. 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 camera monitor was explored with the Assistant Superintendent
to observe staff monitoring. The cameras support direct care staff supervision and
have been strategically placed to enhance general supervision and to provide sight
in identified blind spots
Conclusion:
Based upon the review and analysis of the available evidence and the staff
interview, the Auditor determined the facility is adhering to this standard.
115.315 Limits to cross-gender viewing and searches
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Training Curriculum
Training Sign-in Sheets
Electronic Training Records
Posted Signs
Interviews:
Superintendent
PREA Coordinator
Random Staff
Residents
Provision (a):
The facility shall not conduct cross-gender strip searches or cross-gender visual
body cavity searches (meaning a search of the anal or genital opening) except in
exigent circumstances or when performed by medical practitioners.
Cross-gender strip, visual body cavity and pat-down searches are prohibited and
searches must be documented. Policy and training provide guidance to staff on how
the searches are to be conducted. There is no evidence of cross-gender searches of
any type occurring at the facility in the last 12 months. Based on the review of the
Pre-audit questionnaire and according to the interviews, no type of cross-gender
search has been conducted at the facility during the past 12 months.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent
circumstances.
Policy does not support staff conducting cross-gender pat-down searches. All
searches must be documented. Responses from staff included that only female staff
conduct searches and there is always a female staff on campus trained to conduct
searches. Staff receives training on how to conduct searches, including cross gender
searches and searches of transgender and intersex youth. Staff interviews
confirmed awareness of how to conduct searches. No residents or staff interviewed
reported the occurrence of any cross-gender searches. The evidence shows cross-
gender pat-down searches have not occurred at the facility during the last 12
months.
Provision (c):
The facility shall document and justify all cross-gender strip searches, cross-gender
visual body cavity searches, and cross-gender pat-down searches.
Cross-gender strip and cross-gender visual body cavity searches are prohibited.
Policy provides for documenting the occurrence of all searches. All interviews
confirmed that no cross-gender searches have occurred at the facility during this
audit period. Staff members are aware of the requirement to document all searches.
There was no evidence documenting any type 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. A
picture is posted in each dorm indicating only one resident at a time are allowed in
the bathroom. No residents interviewed reported ever having been naked in full
view of the opposite gender staff while showering, changing clothes, and performing
bodily functions. During the site review, the Superintendent explained how hygiene
practices are conducted and the bathroom procedures. It was observed that
residents have a reasonable amount of privacy during use of the bathroom.
Residents use the bathroom one at a time; shower curtains are utilized and the
toilets are encased. There is a door leading into the bathroom which is kept closed
when occupied and locked when unoccupied. Staff monitor the use of the bathroom
but are not inside the bathroom.
Staff members of the opposite gender announce their presence when entering the
residents’ housing unit as demonstrated during the comprehensive site review. The
residents and staff stated male staff announce their presence upon entering the
living units. The evidence shows residents shower, perform bodily functions, and
change clothing without non-medical staff of the opposite gender viewing their
buttocks or genitalia. The staff interviews and observations support that viewing of
the camera monitors does not show residents when they are showering, using the
toilet or changing clothes. The bathroom area does not allow staff to get a view of
the resident while performing bodily functions. Hygiene practices are performed
with the expectations of reasonable privacy for each resident.
Provision (e):
The facility shall not search or physically examine a transgender or intersex resident
for the sole purpose of determining the resident’s genital status. If the resident’s
genital status is unknown, it may be determined during conversations with the
resident, by reviewing medical records, or, if necessary, by learning that information
as part of a broader medical examination conducted in private by a medical
practitioner.
Policy and procedures and staff training prohibit the search of transgender or
intersex residents solely for the purpose of determining the residents’ genital status.
Staff interviews verified no such searches have occurred or would occur in this
facility. Staff interviews and training materials provide 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 will be part of a broader medical examination
conducted by a medical practitioner in private.
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. Training materials
indicate the provision of search techniques consistent with the security needs. No
such searches have been conducted during the past 12 months.
Conclusion:
Based on the reviewed documentation and interviews, the Auditor determined
compliance with this standard.
Residents with disabilities and residents who are limited English
115.316
proficient
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Quick Reference Guide to Access an Interpreter
Twin Oaks (TO) Agency Bi-lingual Staff List
Multilingual Posters
Interviews:
Random Staff
TO Agency Head Designee
Provision (a):
The agency shall take appropriate steps to ensure that residents with disabilities
(including, for example, residents who are deaf or hard of hearing, those who are
blind or have low vision, or those who have intellectual, psychiatric, or speech
disabilities), have an equal opportunity to participate in or benefit from all aspects
of the agency’s efforts to prevent, detect, and respond to sexual abuse and sexual
harassment. Such steps shall include, when necessary to ensure effective
communication with residents who are deaf or hard of hearing, providing access to
interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary. In
addition, the agency shall ensure that written materials are provided in formats or
through methods that ensure effective communication with residents with
disabilities, including residents who have intellectual disabilities, limited reading
skills, or who are blind or have low vision. An agency is not required to take actions
that it can demonstrate would result in a fundamental alteration in the nature of a
service, program, or activity, or in undue financial and administrative burdens, as
those terms are used in regulations promulgated under title II of the Americans With
Disabilities Act, 28 CFR 35.164.
Policy and procedures address the provision of support services for disabled
residents by providing these 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. The use of resident interpreters, resident
readers, or other types of resident assistance is prohibited except in limited
circumstances where an extended delay in obtaining an effective interpreter could
compromise the resident’s safety, performance of first responder duties, or the
investigation of the allegations. Staff interviews confirmed this information. The
Disability Rights are posted in each dorm; the poster contains a number for a
resident to call regarding assistance.
The facility has education staff with the background and training and access to
resources to adapt information and provide supportive services to residents with
disabilities or who may be limited English proficient. Mental health staff and Case
Managers may also assist in ensuring residents with disabilities or who may be
limited English proficient receive the benefits of PREA education. The facility and TO
agency has bilingual staff and a list is maintained at the facility identifying the staff
and the contact number.
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.
The facility is a vocational program which includes but is not limited to welding and
carpentry. Facility staff has access to translation and interpreting services with the
professional agency, LanguageLine Solutions, Inc. The evidence shows residents
with disabilities and who may be limited English proficient are provided 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. Staff
interviews revealed residents are not used as interpreters and understand prior
arrangements have been made regarding language interpreters and are aware of
bilingual staff. There are staff who can speak and translate in other languages in an
emergency situation. The evidence shows the facility ensures 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 taking steps to
provide interpreters who can interpret effectively, accurately, and impartially, using
any necessary specialized vocabulary.
Provision (c):
The agency shall not rely on resident interpreters, resident readers, or other types
of resident s 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.
Policy and FOP provide that the facility prohibits the use of resident interpreters,
resident readers or any kind of resident s except when a delay in obtaining
interpreter services could jeopardize a resident’s safety, performance of the first
responder duties, or the investigation of the allegation. Staff interviews confirmed
residents have not been and will not be used to relate PREA information to or from
other residents in the past 12 months. There were no residents in need of an
interpreter during the site visit. Multi-lingual posters in French Creole, Spanish and
English are posted and arrangements exist with a professional agency for
translation and interpreting services. The agency also has bilingual staff.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the
facility is compliant with this standard.
115.317 Hiring and promotion decisions
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Personnel Files
Interview:
Administrative (Human Resources) Staff
Provisions (a) and (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.
Policy and procedures address hiring and promotion processes and decisions,
including the requirement for background checks for new hires. The policy and
interview revealed information regarding the hiring process, completion of
background checks, and the grounds for termination. The policy and procedures are
aligned with the requirements of the standard and provide that background checks
are conducted initially and every five years. Licensed treatment staff also receive an
annual background check
Personnel information reviewed during the onsite audit phases included:
background checks; pre-hire interview questions; new hire application packet;
applications; and results of Diana Screens. The interview with the Human Resources
staff and a review of policy and procedures provide details about the hiring process,
completion of background checks, and the grounds for termination in accordance
with the PREA standard. According to the interview, staff has a continuing duty to
report related misconduct and omission of sexual misconduct or providing false
information will be grounds for termination. The forms completed and included in
the personnel files are in response to the above provisions of this standard.
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 facility considers any incidents of sexual abuse or sexual harassment in
determining whether to hire a person, contract for services, or whether to promote
an employee. Policies FDJJ 1800 and FDJJ 1919 and an interview with the Human
Resource staff provide that staff has a continuing duty to report misconduct and
provide that omissions of misconduct or providing false information will be grounds
for termination. The interview questions for employment also address previous
misconduct. The evidence shows the facility considers 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.
Provisions (c) & (d):
Provision (c): Before hiring new employees or (d) contractors who may have contact
with residents, the agency shall: (1) Perform a criminal background records check;
(2) Consult any child abuse registry maintained by the State or locality in which the
employee would work; and (3) Consistent with Federal, State, and local law, make
its best efforts to contact all prior institutional employers for information on
substantiated allegations of sexual abuse or any resignation during a pending
investigation of an allegation of sexual abuse. Provision (d): The agency shall also
perform a criminal background records check, and consult applicable child abuse
registries, before enlisting the services of anu contractor who may have contact
with residents.
The background check process includes consulting a child abuse registry as
confirmed during the interview and review of documentation. Best efforts would be
made to contact all prior institutional employers for information of incidents or
allegations of sexual abuse. Policy requires background checks to occur prior to
residents receiving services from contractors. The facility has no volunteers at this
time.
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.
The policy is aligned with the requirements of the provisions of the standard and
provides background checks occur prior to employment and every five years
thereafter. Initial background checks and five-year checks were reviewed while
onsite. A review of personnel files for a sample of staff hired in the past 12 months
and beyond revealed that all reviewed had criminal background records checks
completed and a sample review of personnel files of current staff employed for more
than five years revealed that all have had criminal background checks conducted as
required.
Provision (g):
Material omissions regarding such misconduct, or the provision of materially false
information, shall be grounds for termination. misconduct, or the provision of
materially false information, shall be grounds for termination.
Based on the review of the documentation and the interview, the evidence shows
the facility follows this provision of the standard. According to the interview and
policy, the omission of sexual misconduct information or providing false information
is grounds for termination. This information is also covered in new employee
orientation.
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 provide that the request will be sent to the agency's Director of
Human Resources who would respond to the request.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant.
115.318 Upgrades to facilities and technologies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Annual Staffing Plan Assessment
Interview:
Superintendent
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 in 2021,
per the interview and observations..
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 not received an update since the last PREA audit conducted in
2021.
115.321 Evidence protocol and forensic medical examinations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
PREA Compliance Form
Cooperative Agreement (Memorandum of Understanding) - Refuge House, Inc.
Student Handbook & Behavior Motivation System
Interviews:
Superintendent/PREA Compliance Manager
Random Staff
Advocacy Agency Representative- Refuge House, Inc.
Provisions (a) and (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 conducted 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 law enforcement. Agency policy will be
followed regarding investigations of sexual abuse in accordance with the standard.
The PREA training curriculum, random staff members’ interviews and previous
interview with investigative staff confirmed awareness of protocol for contributing to
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, provided by the OIG, is to be shared with 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. Policy and procedures provide for the
uniform protocols to be followed. The protocol includes interviewing; evidence
collection; victim services; notifications; and prosecution of sexual assault cases.
Staff interviews confirmed an understanding of the facility’s protocol for obtaining
usable physical evidence if a resident alleges sexual abuse and knowledge of the
entities responsible for conducting investigations.
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 evidentiary 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 at the hospital by a Sexual Assault
Nurse Examiners (SANE), Sexual Assault Forensic Examiners (SAFE), or other
qualified medical practitioner. The services in response to an allegation of sexual
abuse are free to the victim and confidential. Continuity of care will be provided at
the facility by the onsite medical and mental health staff. Forensic examinations
have not been conducted during this audit period.
Provisions (d) and (e):
Provision (d): The agency shall attempt to make available to the victim a victim
advocate from a rape crisis center. If a rape crisis center is not available to provide
victim advocate services, the agency shall make available to provide these services
a qualified staff member from a community-based organization or a qualified
agency staff member. Agencies shall document efforts to secure services from rape
crisis centers. For the purpose of this standard, a rape crisis center refers to an
entity that provides intervention and related assistance, such as the services
specified in 42 U.S.C. 14043g(b)(2)(C), to victims of sexual assault of all ages. The
agency may utilize a rape crisis center that is part of a governmental unit as long as
the center is not part of the criminal justice system (such as a law enforcement
agency) and offers a comparable level of confidentiality as a nongovernmental
entity that provides similar victim services. Provision (e): As requested by the
victim, the victim advocate, qualified agency staff member, or qualified community-
based organization staff member shall accompany and support the victim through
the forensic medical examination process and investigatory interviews and shall
provide emotional support, crisis intervention, information, and referrals.
Victim advocacy services have been arranged and are detailed in a written
cooperative agreement between the facility's parent agency, Twin Oaks Juvenile
Development, Incorporated and the advocacy agency, Refuge House Incorporated.
The advocacy agency follows all applicable laws and regulations with respect to
confidentiality. The services that will be provided include but are not limited to the
following:
24-hour hotline services to agencies;
Counseling;
Accompaniment;
Client Education; and
Information and Referral
Information regarding victim advocacy services is provided to the residents in
increments beginning during the intake process and again with meetings with Case
Managers and Clinical Coordinators. The advocacy information of services and
contact is provided in the handbook and is posted. The posted information is
consistent and easily read.
Provisions (f), (g) and (h):
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. 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.
All staff members are required to report allegations of sexual abuse that are criminal
in nature to local law enforcement and the Florida Department of Children and
Families and to the Department of Juvenile Justice's Central Communication Center
(CCC). When the law enforcement investigator arrives at the facility to conduct an
investigation, facility staff will provide and request the investigator follow the DJJ
PREA Compliance Form which contains the information that maximizes the potential
for obtaining usable physical evidence for criminal prosecution.
The facility has made arrangements for victim advocacy services with the Refuge
House Incorporated, confirmed through the written Cooperative Agreement and
interviews. A representative from the Gulf Coast Children's Advocacy Center
periodically provides PREA-related education to residents. There is also information
posted regarding the Gulf Coast Children's Advocacy Center.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the provisions of this standard.
115.322 Policies to ensure referrals of allegations for investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
PREA Compliance Form
Investigation Information
Interviews:
Agency Head Designee
PREA Compliance Manager
Provision (a):
The agency shall ensure that an administrative or criminal investigation is
completed for all allegations of sexual abuse and sexual harassment.
Policy and procedures provide that staff report all allegations of sexual abuse and
sexual harassment and to document reports; staff members are aware of the
requirements. Sexual abuse and sexual harassment allegations are referred to the
Florida Department of Juvenile Justice/Office of Inspector General (DJJ/OIG), Florida
Department of Children and Families, and law enforcement where the allegation is
criminal in nature. Policy and interviews provide for investigations of all allegations
of sexual abuse and sexual harassment. The facility reports one allegation of
resident-on-resident sexual abuse and no allegation of sexual harassment. The
investigation for the one allegation is ongoing.
Provisions (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.
Policy and reporting information are located on the DJJ and facility’s parent agency
(Twin Oaks Youth Development Inc.) websites and posted within the facility and
accessible to the public. Policies, documents and interviews confirmed allegations of
sexual abuse and sexual harassment are investigated. Administrative investigations
are conducted by trained DJJ/OIG investigators through the DJJ central office.
Allegations of sexual abuse and sexual harassment that are criminal in nature are
referred to local law enforcement. Allegations are also reported to the Florida
Department of Children and Families. An investigation of an allegation of sexual
abuse is ongoing with DJJ/OIG.
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 governing administrative investigations. The agency utilizes
trained investigators. A previous interview with investigative staff and agency
records confirm that administrative investigations are conducted by a trained
investigator and allegations that are criminal in nature are referred to local law
enforcement.
Provision (e):
Any Department of Justice component responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in juvenile facilities
shall have in place a policy governing the conduct of such investigations.
The Department of Justice is not responsible for conducting administrative or
criminal investigations of sexual abuse or sexual harassment in this facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.331 Employee training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Training Curricula
Course Participant Reports
Interviews:
Random Staff
Superintendent/PREA Compliance Manager
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 (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 policy and procedures address PREA related training for staff. All interviewed
staff members were familiar with the PREA information regarding primary
components of preventing, detecting and responding to sexual abuse or sexual
harassment. PREA training is provided to staff, as indicated by a review of policy
and training documents. The documents and staff interviews support annual
training occurs.
The direct care staff interviewed and the Superintendent/PREA Compliance Manager
reported the training is provided as required. All direct care staff members
interviewed, and document review verified the general topics below are included in
the overall training:
1. Zero-tolerance PREA related policies.
2. Staff responsibilities and how to fulfill them regarding allegations or incidents of
sexual abuse or sexual harassment.
3. Residents’ right to be free from sexual abuse and sexual harassment.
4. The right for staff and residents to be free from retaliation for reporting
allegations or cooperating in an investigation.
5. Dynamics of sexual abuse and sexual harassment in juvenile facilities.
6. Residents and employees rights to be free from retaliation for reporting sexual
abuse and sexual harassment.
7. How to avoid inappropriate relationships with residents.
8. Common reactions of sexual abuse and sexual harassment by juvenile victims.
9. Communicating effectively and professionally with residents, including lesbian,
gay, bisexual, transgender, intersex, or gender non-conforming residents.
10. Mandatory reporting.
11. Relevant laws regarding the applicable age of consent.
Policy, procedures, training materials, staff interviews, and training reports verify
the staff training occurs. Refresher training is provided as needed. Staff interviews
confirmed they have received training on the 11 topics outlined in the standard. The
interviews revealed staff are knowledgeable of PREA standards and were able to
articulate their responsibilities in their PREA roles.
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 the training considers the needs of the population
served as determined by staff interviews and informal conversations during the
comprehensive site review. Agency policy provides that training shall be tailored to
the needs and attributes of the population served. Training is provided annually for
all staff and refresher training is provided as needed. Refresher training may occur
electronically and through staff meetings and shift briefings.
Provision (d):
The agency shall document, through employee signature or electronic verification
that employees understand the training they have received.
The policy and procedures provide all training be documented. Staff members sign
training rosters and electronic records are maintained. A checklist is utilized for
orientation training for all new employees and contains elements of PREA training.
Training records, training materials and interviews verify the training occurs.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the provisions of this standard.
115.332 Volunteer and contractor training
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Training Curriculum/PREA Booklet
Acknowledgement Statements
Interviews:
Contractor
Volunteers (2)
Provision (a):
The agency shall ensure that all volunteers and contractors who have contact with
residents have been trained on their responsibilities under the agency’s sexual
abuse and sexual harassment prevention, detection, and response policies and
procedures.
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 interview with the contractor and volunteers
revealed familiarity with the zero-tolerance policy regarding sexual abuse and
sexual harassment of residents, including how to report. The interviews with the
contractor and volunteers confirmed the review of the zero-tolerance policy is
included in the PREA training.
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 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 a PREA allegation. The training is based on the services provided by the
training participants. The training participants' interviews revealed that the training
includes the tenets of the facility's zero-tolerance policy regarding sexual abuse and
sexual harassment of residents. They recalled signing the acknowledgement
statements.
Provision (c):
The agency shall maintain documentation confirming that volunteers and
contractors understand the training they have received.
The PREA notification and the training booklet contains the information reviewed
with the participants. The providers may be given a downloaded version of the
SkillPro on-line PREA training and they have the opportunity to ask questions during
the review and at any time. The training is documented through the interviews and
the training acknowledgement statements.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with the provisions of this standard.
115.333 Resident education
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Multilingual Brochures
Multilingual Posters
Student Handbook & Behavior Motivation System
Acknowledgement Statements
Orientation Checklists
PREA Education Sign-in Sheets
Interviews:
Residents
Intake Staff
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.
Policy and procedures 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 intake staff who provides PREA education to
residents. Each Case Manager provides PREA education sessions to residents
assigned to their caseload. A review of the education materials indicated the
information provided to the residents is age-appropriate and consistent. The PREA
related information is provided to staff in policies and procedures, training, shift
briefings, and staff meetings.
The intake staff reviewed the education resources used to provide PREA education
to residents including general and safety PREA brochures and posters. The PREA
education sheet which also serves as an acknowledgement of information received
when signed and dated by the resident and the intake staff. The resident gets PREA
education at different junctures in the intake process and within their stay in the
program which include mental health, medical and direct care staff. The interviews
with the residents revealed their general receipt of the information covered in the
PREA education sessions. The intake staff and the residents revealed the initial
PREA education is generally conducted on the first day of admission to the facility
during the intake process; additional information is provided within 10 days.
The facility has a designated agency, Refuge House Incorporated, through a written
agreement that will provide advocacy services to residents. Additionally, a
representative from the Gulf Coast Children's Advocacy Center conducts regular
education sessions regarding sexual safety and sexual health. While half of the
residents interviewed were definitely aware of the role of Refuge House, the other
half did not have a clear uncontradictory understanding of the role of each
advocacy agency. A corrective action was implemented by the Superintendent, as
planned at the conclusion of the onsite audit phase. The Superintendent conducted
community meetings with each dorm. The meeting agenda included PREA refresher
training regarding advocacy agencies and the role of each; the Refuge House and
Gulf Coast Children's Advocacy Center. The Superintendent provided the agenda
and sign-in sheets of the residents confirming attendance. Information from each
agency was reviewed with the residents.
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 documenting the PREA education sessions in Provisions (a)
and (b), and interviews, residents received PREA education. There were 39 residents
in the facility during the comprehensive site review and a sample of 10 were
interviewed. The results of those interviews revealed that residents are involved in
PREA education sessions. Acknowledgement statements, observed posted
information and other printed materials, and the interviews indicate that general
PREA education sessions are provided initially and subsequently to residents.
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. Resources include
education, medical, mental health and direct care staff; professional agency,
LanguageLine Solutions; multilingual posters and other printed materials; and
agency bilingual staff. A representative from LanguageLine Solutions confirmed the
availability of services, including services for the Deaf. The Disability Rights are
posted in each dorm; the poster contains a number for a resident to call regarding
assistance.
Provision (e):
The agency shall maintain documentation of resident participation in these
education sessions.
During a review of a sample of residents' files, the Auditor reviewed a sample of
signed acknowledgement statements and Orientation Checklists which support the
residents’ involvement in PREA education sessions. The residents were aware of
PREA information, including their rights regarding PREA, how to report allegations
and that they would not be punished for reporting allegations of sexual abuse or
sexual harassment. The intake staff ensures residents’ receipt of the information,
including the resident signing the acknowledgement statement of PREA education.
The intake staff completes the Orientation Checklist which also confirms the
introduction to PREA. All of the resident interviews documented that PREA education
occurs in this facility.
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 provides residents information on how to report
allegations of sexual harassment and sexual abuse. A safety brochure provides
safety tips related to the avoidance of sexual abuse and sexual harassment. The
brochure provides educational information regarding sexual abuse and victims. The
residents revealed they can report allegations of sexual abuse or sexual harassment
by telling a staff member; telling a family member or someone else outside of the
facility who may report the allegation for them; using the hotline; or complete a
PREA Form.
Staff present the PREA information in a manner that is accessible to all residents. If
needed, the facility has internal and external resources to provide translation
services through staff, including the professional agency, for residents who may be
limited English proficient or otherwise limited. The PREA information provided in the
facility is easily accessible and the messages are consistent. Signage is specific to
residents regarding how to report allegations and how to request advocacy services.
The prevalent signage also includes areas where residents are not allowed to enter
and areas where they are allowed with staff only.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with the standard.
115.334 Specialized training: Investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Training Curriculum
PREA Compliance Form
Provisions (a) and (b):
Provision (a): In addition to the general training provided to all employees pursuant
to §115.331, the agency shall ensure that, to the extent the agency itself conducts
sexual abuse investigations, its investigators have received training in conducting
such investigations in confinement settings. Provision (b): Specialized training shall
include techniques for interviewing juvenile sexual abuse victims, proper use of
Miranda and Garrity warnings, sexual abuse evidence collection in confinement
settings, and the criteria and evidence required to substantiate a case for
administrative action or prosecution referral.
Agency policy and a previous interview with investigative staff provide for
investigations of allegations of sexual abuse that are criminal in nature to be
conducted by law enforcement. Agency policy provides for the administrative
investigators to be trained. In accordance with policy, administrative investigations
are conducted by the Department of Juvenile Justice (DJJ), Office of Inspector
General (OIG). PREA training is required in addition to the specialized training
regarding conducting administrative investigations. The specialized training
includes but is not limited to interviewing techniques; proper use of Garrity and
Miranda warnings; preserving evidence; and criteria for supporting a finding of
substantiated, unsubstantiated or unfounded. The contract agency or facility staff
does not conduct administrative or criminal investigations into allegations of sexual
abuse or sexual harassment.
Provision (c):
The agency shall maintain documentation that agency investigators have
completed the required specialized training in conducting sexual abuse
investigations.
The DJJ agency policy requires training for the OIG investigators and a training
curriculum exists for the specialized training and as confirmed in a previous
interview with investigative staff. Policy also provides that staff will be trained on
the policies and procedures for the Department related to the handling of sexual
misconduct incidents and reports.
Provision (d):
Any State entity or Department of Justice component that investigates sexual abuse
in juvenile confinement settings shall provide such training to its agents and
investigators who conduct such investigations.
The DJJ provides training to its investigators who conduct administrative
investigations in State-run and contract residential facilities. Law enforcement is
responsible for training their investigators who may conduct sexual abuse
allegations that are criminal in nature. The PREA Compliance Form from the OIG will
be provided to law enforcement that contain the request and the standards to be
followed by law enforcement in conducting an investigation of sexual abuse or
sexual harassment that is criminal in nature. Facility staff does not conduct
administrative nor criminal investigations into allegations of sexual abuse or sexual
harassment.
Conclusion:
Based upon the review and analysis of the available evidence, the auditor
determined the facility is compliant with this standard.
115.335 Specialized training: Medical and mental health care
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Electronic Training Records
PowerPoint Training Modules
Interviews:
Medical Staff
Mental Health Staff
Provision (a):
The agency shall ensure that all full- and part-time medical and mental health care
practitioners who work regularly in its facilities have been trained in: (1) How to
detect and assess signs of sexual abuse and sexual harassment; (2) How to
preserve physical evidence of sexual abuse; (3) How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual harassment; and (4)
How and to whom to report allegations or suspicions of sexual abuse and sexual
harassment.
Medical and mental health staff members receive the regular PREA training as well
as the specialized training provided through the Department of Juvenile Justice (DJJ).
Electronic training logs and interviews document regular PREA training and the
specialized training for medical and mental health staff members. Training records
document specialized training for medical and mental health staff members.
Specialized medical and mental health training is provided through SkillPro, DJJ’s
online training system. Documentation of specialized training was reviewed for
medical and mental health staff and confirmed during interviews. The interviews
with the medical staff and mental health staff and a review of training modules
confirm completion of training which includes this provision of the standard.
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 medical examinations are not conducted by the facility’s medical staff as
verified during the interviews.
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.
The training is documented electronically and through the interviews.
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 staff members as documented electronically and through their verbal
confirmation.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.341 Obtaining information from residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
Superintendent/PREA Compliance Manager
PREA Coordinator
Residents
Provision (a):
Within 72 hours of the resident’s arrival at the facility and periodically throughout a
resident’s confinement, the agency shall obtain and use information about each
resident’s personal history and behavior to reduce the risk of sexual abuse by or
upon a resident.
Policy provides a risk screening occurs within 72 hours upon arrival to the facility.
The staff responsible for risk screening interviews the youth at intake to obtain
information about the residents’ personal history and behavior in order to reduce
the risk of sexual abuse by or upon a resident. The VSAB is administered the same
day of admission according to staff responsible for risk screening, resident
interviews, and review of documentation. The resident’s risk level is reassessed if
new information that is PREA related is received, according to the risk screener
interview and documentation of rescreening.
Policy and procedures require staff to complete the VSAB on all youth admitted to
the facility and the VSAB is used for reassessments. According to the interviews with
the residents and review of documentation, the VSAB is generally administered on
the first day of admission. Staff obtain information from court records and interviews
with the youth, court worker, and parents or guardians. Resident interviews
indicated, among other inquiries, they were asked whether they identify with being
lesbian, gay, bi- sexual, transgender or intersex; if they thought they were in danger
of sexual abuse within the facility; and if they have any disabilities.
Each Case Manager primarily administers the VSAB to the youth assigned to their
caseload. The interviews revealed the practice of the risk screening being
conducted in accordance with policy. The screening instrument and the interview
with the risk screener 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
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 prior to the onsite
audit phase is 18. The risk assessments are accessible to Case Managers,
Therapists, and shift supervisors. The residents' files were observed to be
maintained in a confidential manner in locked cabinets within lockable offices. The
notice of confidential files maintained in the offices are posted on the file cabinets of
treatment team staff.
Provision (b):
Such assessments shall be conducted using an objective screening instrument.
The VSAB is used to obtain the information required by the standard, including but
not limited to prior sexual victimization or abusiveness; self-identification; current
charges; offense history; intellectual or developmental disabilities; and a resident’s
concern regarding his own safety. The interview and review of policy and FOP
revealed how the objective instrument is administered to obtain information to
assist staff in keeping residents safe through the appropriate room assignments.
The responses on the instrument accumulate a score and the risk level is
determined by definition and the corresponding number to that definition. The
process of the administration of the VSAB is rules-based and training on
administering the instrument is provided.
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 VSAB screening instrument and determined all factors
required by this provision of the standard are included. The interview with the risk
screener confirmed awareness of the elements of the risk screening instrument. The
resident interviews confirmed the administration of the screening instrument.
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.
Staff obtain information from court records and interviews with the youth, court
worker, and parents or guardians. The interview with the staff responsible for risk
screening confirmed the information is ascertained through direct questions and
probing and probe as needed. Additionally, she also ask questions and provides
follow-up for clarity of information where needed. Resident interviews also revealed
the VSAB instrument is used. Additional screening instruments for vulnerabilities are
used with the goal of keeping residents safe. The treatment team conducts pre-
admission planning prior to the youth's admission to this residential treatment
facility.
Provision (e):
The agency shall implement appropriate controls on the dissemination within the
facility of responses to questions asked pursuant to this standard in order to ensure
that sensitive information is not exploited to the resident’s detriment by staff or
other residents.
Staff takes appropriate controls to ensure that sensitive information is protected and
not exploited by maintaining the files in a locked and secure manner, in locked file
cabinets in lockable offices with a sign on the file cabinets stating confidential files
are kept there. The online information on computers is password protected and is
only accessible to limited identified staff. The risk screener and Superintendent/
PREA Compliance Manager addressed the management of sensitive information and
the limited and guarded access by treatment staff. Pertinent information is provided
to some staff based on the need to know. Staff training includes information
regarding confidentiality of information concerning residents. The policy and FOP
provides for appropriate controls be taken to ensure that sensitive information is
protected and not exploited.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.342 Placement of residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
PREA Compliance Manager
Superintendent
PREA Coordinator
Residents
Medical Staff
Mental Health Staff
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.
Policy and procedures provide guidance to staff regarding the use of the information
obtained from the screening instrument, VSAB. The interviews indicate the
screening and assessment information and observations are used to inform other
than identified staff of information based on the need to know. Staff members are
informed of housing and program assignments; work assignments; and they assist
in identifying treatment and any special needs as indicated. Policy and procedures
require risk screening information to be used to determine a resident’s room
assignment and room’s proximity to direct care staff to ensure residents' safety. The
facility also utilizes the agency's Classification Alerts to ensure that direct-care staff
are advised if the resident is identified as being at-risk for victimization or posing a
risk to others
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.
Agency policy supports that any use of segregated housing to protect a resident
who is alleged to have suffered sexual abuse shall comply with § 115.342 and the
provision (a). At no time will any client be denied any legally required educational
programs, special education services, daily large-muscle exercise, or medical/
mental health care. Agency policy provides that at-risk residents may only be placed
in isolation in an emergency situation, and only as a last resort if less restrictive
measures are inadequate to keep the resident safe. This facility does not use
isolation.
There weren't any residents at risk of sexual victimization placed in isolation in the
last 12 months. The interview with the staff confirmed the facility has not used
isolation for this purpose. The policy is inclusive of this provision if there were to be
an emergency situation. The use of isolation will be documented if ever used. The
residents’ rights to daily large-muscle exercise and any legally required educational
programming or special education services will be provided.
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.
LGBTI residents are not placed in specific housing solely based on how the residents
identify or their status, in accordance with policy and procedures. Staff members are
prohibited from considering the identification as an indicator that these residents
may be more likely to be sexually abusive. During the comprehensive site review,
there were no rooms or units observed or identified to be reserved for LGBTI youth.
Housing assignments are made on a case-by-case basis as supported by policy and
procedures, interviews and practice. Transgender or intersex resident’s own view
with respect to their safety will be given serious consideration. Informal
conversations with staff and the interviews with the risk screener and other
identified staff revealed there is no special housing based on how a resident
identifies.
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 the resident’s health and safety, and whether the
placement would present management or security problems.
Policy and FOP provide that housing and program assignments for transgender or
intersex residents will be made on a case-by-case basis and these residents will not
be placed in particular or special housing which was evident from staff interviews.
There were no targeted interviewees in this area within the facility during the
comprehensive site review.
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 and procedures state placement and programming assignments for each
transgender or intersex resident shall be reassessed at least twice each year. This
function will be done to review any threats to safety experienced by the resident
and the risk screener is aware of the requirement. The staff responsible for risk
screening confirmed each transgender or intersex resident will be reassessed at
least twice each year to review any threats to safety experienced by the resident.
Provision (f):
A transgender or intersex resident’s own views with respect to his or her own safety
shall be given serious consideration.
The resident’s concern for their own safety is taken into account through the
administration of the VSAB and this applies to every resident. The residents
confirmed in the interviews, they are asked about their safety concerns. A review of
the resident files demonstrated the additional documentation of the screening
assessments and any re-assessments completed for each resident.
Provision (g):
Transgender and intersex residents shall be given the opportunity to shower
separately from other residents.
Transgender and intersex residents are given the opportunity to shower separately
from other residents. All residents shower separately which is posted and the
practice of the facility.
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.
The Policy states if a resident is isolated pursuant to part (b.2.) of this section, the
facility shall document:
a. The basis for the facility’s concern for the resident’s safety; and
b. The reason why no alternative means of separation can be arranged.
No residents at risk of sexual victimization were placed in isolation in the 12 months
preceding the audit. Interviews with the Superintendent/PREA Compliance Manager,
medical staff, and mental health staff confirmed the facility does not use isolation.
The policy is inclusive of this provision if there were to be an emergency situation.
This facility does not utilize isolation as a practice and there are no secure isolation
rooms.
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.
Policy provides for this provision; however, the practice is that 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. Staff interviews confirmed the facility has not
used and does not use isolation.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.351 Resident reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Request to See Staff Form
Sick Call Request Form
PREA Printed Materials
Multilingual Posters
Student Handbook & Behavior Motivation System
Legal Correspondence
Interviews:
Random Staff
Residents
Superintendent/PREA Compliance Manager
Provision (a):
The agency shall provide multiple internal ways for residents to privately report
sexual abuse and sexual harassment, retaliation by other residents or staff for
reporting sexual abuse and sexual harassment, and staff neglect or violation of
responsibilities that may have contributed to such incidents.
Policy, procedures, and practice provide multiple internal ways for residents to
privately report sexual abuse and sexual harassment, retaliation and staff neglect
including telling a trusted staff member or filling out a Request to See Staff Form
and placing it in a secure drop box or giving it to staff. Random resident interviews
confirmed their knowledge of this procedure. Multiple internal ways exist for a
resident to report allegations of sexual abuse and sexual harassment, including how
he can 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 hotline of an agency not a part of the facility as
confirmed by resident interviews, posters, staff, and observations. Residents may
use any telephone to privately report sexual abuse and sexual harassment.
Residents may use the telephone hotline without having to obtain staff permission
and policy mandates staff not to question residents about the reason for the call. A
resident may request writing materials to write and send a letter to one of these
sources. Random residents interviewed were aware of the abuse hotline and were
able to articulate how they could gain access.
The hotline for reporting allegations has been tested and determined to be in
working order. Allegations may be made in English or Spanish. The residents are
aware of the "abuse call" accessibility. Additionally, residents provided that they
may report an allegation by telling a staff member, depositing a PREA Form in the
locked box, or telling a family member who will report it.
The resident receives PREA information, including how to report allegations of
sexual abuse and sexual harassment and how to obtain advocacy services. A
corrective action was implemented which was a refresher on the role of the
advocacy agency, the services provided and how to contact. PREA information is
posted in various areas of the facility with a consistent message which is easily
read. The PREA information is visible to residents, staff, contractors, volunteers and
visitors.
Staff members receive information on how to report allegations of sexual abuse or
sexual harassment through policies and procedures, training, and staff meetings.
File cabinets that store any PREA and other confidential information have labels on
them indicating the presence of confidential information. PREA-related records are
also stored electronically, password protected with limited and identified staff
having access and control.
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.
Residents and staff may use the Florida abuse reporting hotline to report allegations
of sexual abuse and sexual harassment. The interviews revealed familiarity with
policy, Student Handbook, and posted information on how to report allegations.
Telephones are accessible to residents and random staff. The reports of sexual
abuse or sexual harassment will be accepted and forwarded for an investigation.
The facility does not detain residents solely for civil immigration purposes according
to written communication from the Department of Juvenile Justice's legal
department.
Provision (c):
Staff shall accept reports made verbally, in writing, anonymously, and from third
parties and shall promptly document any verbal reports.
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. The resident interviews
demonstrated their familiarity with the various ways they may report either in
person, in writing, by telephone, completing a Request to Speak Form, or through a
third-party. The residents were aware third-party reports may be made and the
majority of residents were aware that reports may be made anonymously. Staff
members interviewed were aware of their duty to receive and document third-party
reports.
Provision (d):
The facility shall provide residents with access to tools necessary to make a written
report.
Interviews revealed writing materials are available for residents to make a
complaint. Forms, paper and pencils are available to residents in each dorm and
school. During the comprehensive site review, the Auditor observed the accessibility
of writing utensils.
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and
sexual harassment of residents.
The collective staff interviews revealed staff can privately report allegations of
sexual abuse and sexual harassment through a call to the Florida abuse reporting
hotline, Department of Juvenile Justice Central Communications Center, or 911/
Sheriff's Office; notify the Superintendent/PREA Compliance Manager or Supervisor;
or write a note to Superintendent.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.352 Exhaustion of administrative remedies
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Interview:
Statewide PREA Coordinator
When a PREA allegation or implication of such is received on a grievance form or
any written form from the grievance box or provided to staff, the policy and
procedures for reporting allegations of sexual abuse or sexual harassment are
initiated and a report is made as required by policy to the Department of Juvenile
Justice (DJJ) Central Communications Center. The written allegation is given to the
Superintendent or designee immediately, in accordance with the FOP, for reporting.
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 according to policy and procedures for an investigation to be
conducted by the DJJ/Office of Inspector General, Florida Department of Children
and Families, and/or law enforcement.
Resident access to outside confidential support services and legal
115.353
representation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Collaborative Agreement, Refuge House, Inc.
Posted Information
Interviews:
Superintendent/PREA Compliance Manager
Residents
Advocacy Agency Representative - Refuge House, Inc.
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.
General information about advocacy services is a part of the initial PREA education
sessions with the residents. Interviews revealed that residents were not clear with
the victim advocacy agency services and refresher education sessions were
conducted by the Superintendent during the post audit phase, which was the
implementation of the corrective action. There is a written agreement between the
facility's parent agency and Refuge House, Incorporated for the specific provision of
advocacy services. Additionally, the Gulf Coast Children's Advocacy Center sponsors
periodic education groups regarding sexual safety and sexual health. Applied
advocacy services by the Refuge House may be accessed by the resident, facility
staff or law enforcement personnel, as determined from the representative of the
Refuge House, Inc. The provision of services that will be provided was also
confirmed by a written Collaborative Agreement.
Residents are provided contact information for the advocacy agency. The
information provided during the PREA education session outlines how the resident
will make contact with the Refuge House, Incorporated for emotional support and
other advocacy services related to sexual abuse. The Refuge House provides
services that include but are not limited to the following: 24/7 hotline services;
certified victim advocate; accompaniment; counselling; and training. The hotline
number for the advocacy agency has been tested. The line was promptly answered
with the concern of whether the caller was in a safe place or not. Residents may use
the telephone to call for advocacy services without interference from staff.
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.
The Collaborative Agreement, policy, procedures, PREA education sessions,
refresher education sessions, and facility staff interviews provide that there will be
adherence to confidentiality measures. The facility has posted information and has a
written agreement outlining the confidential services. Policy and procedures also
address confidentiality of the advocacy support services. The resident receives
information regarding the limitations of confidentiality during the intake process and
receives PREA education in increments. The acknowledgement statement, signed
and dated by the resident and staff, confirm victim advocacy information is
available to residents.
Provision (c):
The agency shall maintain or attempt to enter into memoranda of understanding or
other agreements with community service providers that are able to provide
residents with confidential emotional support services related to sexual abuse. The
agency shall maintain copies of agreements or documentation showing attempts to
enter into such agreements.
The Collaborative Agreement and the advocacy service agency’s representative’s
interview document the availability of advocacy services including but not limited to
emotional support counseling; accompaniment through the forensic medical
examination and investigative interview; and information and referrals. The facility
staff and residents also have access to services through the 24-hour hotline number.
Policy provides that a resident may use the telephone for reporting allegations to
the appropriate entity and also to request advocacy services from the Refuge
House, Inc. Advocacy services may be provided at the facility or offsite.
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 procedures, interviews and the Student Handbook. Residents are
provided the opportunity to receive visitors and to make telephone calls. All
residents interviewed confirmed communication opportunities occur. The
Superintendent confirmed the facility provides residents with reasonable and
confidential access to attorneys, court representatives and Probation Officers. It was
also confirmed that reasonable access to parents/legal guardians and the private
areas and general visitation areas were observed during the comprehensive site
review. The visitation areas included those with a reasonable amount of privacy. All
residents interviewed could state the days and times of visitation and telephone
calls.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.354 Third-party reporting
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Agency Websites
Multilingual Posters
Interviews:
Random Staff
Residents
§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, call law enforcement, and tell a supervisor/management.
The agencies' websites contain the information needed for third-parties to report
allegations of sexual abuse and sexual harassment. Resident interviews revealed
they had contact with someone that did not work at the facility who could make a
report of an allegation for them if needed. Reporting information is posted in the
different buildings in different areas of the facility accessible to residents, staff,
contractors, volunteers, and visitors. There were no third-party reports of sexual
abuse or sexual harassment received during this audit period.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is in compliance with the standard.
115.361 Staff and agency reporting duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Florida Statute Chapter 39, Section 201
Multilingual Posters
Interviews:
Random Staff
Medical Staff
Mental Health Staff
Superintendent/PREA Compliance Manager
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.
All staff members are required to immediately report any allegation of sexual abuse
or sexual harassment to the Department of Juvenile Justice (DJJ) Central
Communications Center (CCC), including the suspicion or receipt of information of
such, in accordance with policy and procedures and confirmed by all interviews.
Policy further states that staff is prohibited from revealing any related information to
anyone other than those persons making treatment, investigation, security, or
management decisions. This sexual misconduct information must be reported to the
CCC, Department of Children and Families, and local law enforcement. All facility
staff members are designated mandated reporters in accordance with State
Statute.
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 and procedures support that after allegations have been appropriately
reported, staff will not be permitted to give out any other information relating to
what was reported except when necessary to obtain treatment for the resident, aid
in the investigation, or help retain the security of the facility. Policy and staff training
address confidentiality of information and the conditions for providing information.
The staff interviews 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. Staff is expected to abide by the confidentiality requirements of the
facility.
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.
According to medical and mental health staff, 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 mandated reporters and required by the State
to report allegations received regarding sexual abuse and sexual harassment, in
accordance with policy. The clinical staff interviewed stated residents are informed
at the initiation of services of the limitations of confidentiality and the duty of the
staff members to report. During the intake process youth have an initial meeting
with medical and mental health staff and get an overview of the respective services
as confirmed by interviews and the orientation checklist, which documents the
meeting as part of the orientation to the facility. Request to Speak to Staff forms are
accessible to residents and a system is in place so they may request to speak with
any staff member. The form provides for the resident to write the reason for the
meeting if they would like to and the form may be placed in the locked box in the
dorm or given directly to a staff member.
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 CCC, and to parents/legal guardians. Policy and interview with the
Superintendent confirmed that a resident’s case worker rather than a parent will be
notified where indicated by the resident being under the guardianship of the Florida
Department of Children and Families (DCF). The resident’s attorney will be notified
within 14 days where applicable. Allegations of sexual abuse will be made by the
Superintendent or designee which includes but is not limited to law enforcement.
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 procedures state that all allegations of sexual abuse and sexual
harassment information to the CCC, DCF. and local law enforcement when the
allegation is criminal in nature. Third-party and anonymous reports received must
be reported and documented by staff as confirmed through random staff interviews
and policy and procedures. The investigation is ongoing regarding the allegation of
sexual abuse. Both agencies' websites contain information regarding reporting
allegations of sexual abuse and sexual harassment. Information is posted
throughout the facility regarding reporting allegations of sexual abuse and sexual
harassment which is visible to residents, staff, contractors, volunteers, and visitors.
Conclusion:
Based on the available evidence, the Auditor determined the facility is compliant
with this standard.
115.362 Agency protection duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Superintendent
Random Staff
Agency Head Designee
§115.362
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 PREA risk screening instrument, VSAB, 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 vulnerability and risk level of
each resident.
The interviews revealed protective measures include but are not limited to
separating youth, single room placement, closer supervision, and informing
supervisors and other staff. The interviews collectively indicated staff's action to
protect a resident would be taken immediately. All staff members are aware of one-
on-one staff supervision and heightened awareness and involvement required
regarding elevated risk levels of residents. During the intake process, residents are
asked about how they feel about their safety as part of the inquiries by staff
completing the VSAB. No resident was identified to be at substantial risk of
imminent sexual abuse in the past 12 months.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.363 Reporting to other confinement facilities
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Interviews:
Superintendent
Agency Head Designee
Provisions (a), (b), (c), and (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.
If an allegation of sexual abuse is received that a resident was sexually abused
while confined at another facility, the Superintendent understands he 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
Superintendent is also required to make a report to the Department of Juvenile
Justice Central Communications Center. Policy and the interviews support
allegations of sexual abuse or sexual harassment from a resident regarding their
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.
115.364 Staff first responder duties
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Coordinated Response Plan
PREA Action Steps
Interviews:
Random Staff
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.
Policy and procedures provide that upon learning of an allegation that a resident
was sexually abused, the first security-level staff member to respond to the report
shall be required to:
a. Separate the alleged victim and abuser;
b. Preserve and protect any crime scene until appropriate steps can be taken to
collect any evidence;
c. 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.
The interviews with random staff confirmed awareness of first responder duties and
the training provided. There was one allegation of youth-on-youth sexual abuse
during this audit period. The allegation did not require physical intervention from
direct care staff. The investigation is ongoing.
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, the Auditor
determined the facility is compliant with this standard.
115.365 Coordinated response
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Coordinated Response Plan
PREA Action Steps
Interviews:
Superintendent
Random Staff
§115.365
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.
Policy and procedures require the development of a written plan to coordinate
actions taken in response to an incident of sexual abuse. The Coordinated Response
Plan outlines the actions of the first responder, supervisors, administrators, medical
and mental health staff and is to be implemented in the event of an allegation or
incident of sexual abuse. The Coordinated Response Plan provides guidance to staff
regarding their identified roles and actions to take when there is an incident of
sexual abuse. Staff members interviewed were familiar with their role regarding the
response to an allegation of sexual abuse.
The PREA Action Steps document serves as a reminder of the steps to take for
reporting allegations of sexual abuse. The document serves as a quick reference to
staff regarding an incident or allegation of sexual abuse regarding ensuring safety of
youth; notifications; and protection of the scene.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility complies with the provisions of the standard.
Preservation of ability to protect residents from contact with
115.366
abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Interview:
Agency Head Designee
Twin Oaks Juvenile Development, Incorporated is not a collective bargaining agency,
as confirmed by the interview.
115.367 Agency protection against retaliation
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Counseling/Therapy Progress Notes
Interviews:
Retaliation Monitor
Superintendent/PREA Compliance Manager
Agency Head Designee
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 and procedures support 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 retaliation monitor in
corroboration with the Superintendent conducts and ensures retaliation monitoring
occurs, including with the assistance of the mental health staff. The Counseling/
Therapy Progress Notes served as documentation of retaliation monitoring
occurring. The agency also has a Retaliation Monitoring Form that may also be used
to document monitoring activities.
The mental health staff, Superintendent and Assistant Superintendent are familiar
with the role of retaliation monitor and the purpose of monitoring. The policy and
procedures require the protection of residents and staff who have reported sexual
abuse or sexual harassment or who have cooperated in a sexual abuse or sexual
harassment investigation. Measures taken to protect residents and staff include
housing changes, shift changes, and emotional support through additional meetings
with mental health staff. There was no targeted interviewee in the facility during the
onsite audit phase.
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 who fear retaliation for reporting sexual abuse or sexual harassment or for
cooperating with investigations.
The policy identifies measures to protect staff and residents including the following:
a. Initiating housing changes or transfers for resident victims or abusers;
b. Removing alleged staff or resident abusers from contact with victims; and
c. Providing emotional support services.
The interviews confirmed the facility will protect residents and staff from retaliation
due to their reporting allegations of sexual abuse and sexual harassment and/or
cooperating with an investigation. The staff interviews identified protection
measures such as housing changes; shift changes; closer monitoring; emotional
support services; transfer; and/or staff termination. The agency head/designee also
emphasized the emotional support involved in the retaliation monitoring process to
include listening to the individual about any concerns they may have. The
retaliation monitor and Superintendent also provided that the goal is to make sure
that all parties involved are kept safe.
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.
The retaliation monitor explained during the interview how he monitors such items
as point cards; interactions; write-ups by staff/disciplinary actions; and any shift re-
assignments. Retaliation monitoring will initially be for 90 days to see if there are
any activities that may suggest possible retaliation by residents or staff. The
monitoring will continue beyond 90 days, if the initial monitoring period indicates a
continuing need. There have been no incidents of retaliation discovered during the
12 months preceding the audit.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
The retaliation monitor and documentation indicated status checks with mental
health staff occurred and initiated by the mental health staff.
Provision (e):
If any other individual who cooperates with an investigation expresses a fear of
retaliation, the facility shall take appropriate measures to protect that individual
against retaliation.
Policy encompasses those who cooperate with an investigation if there is a concern
regarding retaliation. The staff interviews 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 interviews determined familiarity with the
requirements.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.368 Post-allegation protective custody
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Interviews:
Superintendent
Mental Health Staff
Medical Staff
§115.368
Any use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse shall be subject to the requirements of §115.342.
Segregated housing, isolation and protective custody are not used in this facility.
The interviews and observations during the comprehensive site review support that
isolation is not used at this facility. Agency policy provides guidance to staff, aligned
with the standard, for those facilities that use segregated housing/isolation.
Conclusion:
Based upon the review and analysis of Policy, interviews and observations, the
Auditor determined the facility is compliant with this standard.
115.371 Criminal and administrative agency investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ Policy 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
PREA Compliance Form
Incident Report
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinators
Provision (a):
When the agency conducts its own investigations into allegations of sexual abuse
and sexual harassment, it shall do so promptly, thoroughly, and objectively for all
allegations, including third-party and anonymous reports.
The administrative investigations are conducted by the investigators with the
Florida Department of Juvenile Justice (DJJ), Office of Inspector General (OIG). Based
on policy and other documentation and interviews, trained investigators conduct
administrative investigations as prescribed. Allegations that are criminal in nature
are referred to local law enforcement and the Florida Department of Children and
Families and all allegations are reported through the DJJ Central Communications
Center. Each investigative entity is responsible for the training of their
investigators.
Provisions (b) and (c):
Provision (b): Where sexual abuse is alleged, the agency shall use investigators
who have received special training in sexual abuse investigations involving juvenile
victims pursuant to §115.334. Provision (c): Investigators shall gather and
preserve direct and circumstantial evidence, including any available physical and
DNA evidence and any available electronic monitoring data; shall interview alleged
victims, suspected perpetrators, and witnesses; and shall review prior complaints
and reports of sexual abuse involving the suspected perpetrator.
The DJJ investigative staff is trained through the OIG. According to a previous
interview with investigative staff, the DJJ Investigator will turn over any evidence
found to law enforcement investigators since they generally do not handle direct
evidence. The DJJ investigator will assist law enforcement and among other
activities, may review video; gather witness statements; and review logs during the
administrative investigation of the allegation. The law enforcement investigator
and/or qualified medical practitioner are responsible for collecting direct physical
and DNA evidence. The facility staff and DJJ investigators are trained on how to
assist in preserving evidence. The agency, DJJ, provides each facility with the PREA
Form which is provided to law enforcement investigators referencing the PREA
standards regarding conducting investigations in accordance with the standards.
The DJJ investigators follow the OIG guidelines governing PREA related
investigations, in accordance with agency policy.
Provision (d):
The agency shall not terminate an investigation solely because the source of the
allegation recants the allegation.
The interviews, including the previous with investigative staff, and policy confirmed
the provision that an investigation is not terminated if the source recants an
allegation of sexual abuse or sexual harassment.
Provision (e):
When the quality of evidence appears to support criminal prosecution, the agency
shall conduct compelled interviews only after consulting with prosecutors as to
whether compelled interviews may be an obstacle for subsequent criminal
prosecution.
The DJJ agency investigators do not conduct compelled interviews.
Provision (f):
The credibility of an alleged victim, suspect, or witness shall be assessed on an
individual basis and shall not be determined by the person’s status as resident or
staff. No agency shall require a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition for proceeding
with the investigation of such an allegation.
The credibility of an alleged victim, suspect, or witness is assessed on an individual
basis and is not determined by the person’s status as a resident or staff as
supported by the interviews, training, and in accordance with policy. According to
the previous interview with investigative staff, credibility may be influenced by past
history; what can be verified; what other evidence can corroborate the information;
body language; and/or whether or not the person is answering questions or being
dismissive. No resident who alleges sexual abuse will be subjected to a polygraph
examination or other truth telling device as a condition for proceeding with the
investigation of the allegation.
Provisions (g) and (h):
Provision (g): Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act
contributed to the abuse. (2) Shall be documented in written reports that include a
description of the physical and testimonial evidence, the reasoning behind
credibility assessments, and investigative facts and findings. Provision (h):
Criminal investigations shall be documented in a written report that contains a
thorough description of physical, testimonial, and documentary evidence and
attaches copies of all documentary evidence where feasible.
The interviews support that PREA investigations include an effort to determine
whether staff actions or failures to act contributed to the abuse. Investigations in all
facilities are completed with written reports that include a description of the
evidence and investigative facts and findings as gleaned from the previous
interview with the investigative staff. The report contains but is not limited to
information regarding the initial call or allegation; list of interviews; list of exhibits;
logbook information; and critique of any video.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be referred for
prosecution.
The DJJ agency investigators do not conduct criminal investigations. It is the
responsibility of law enforcement personnel to refer cases for prosecution.
Provision (j):
The agency shall retain all written reports referenced in paragraphs (g) and (h) of
this section for as long as the alleged abuser is incarcerated or employed by the
agency, plus five years, unless the abuse was committed by a juvenile resident and
applicable law requires a shorter period of retention.
The written investigative reports are maintained for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years as stated in policy.
Provision (k):
The departure of the alleged abuser or victim from the employment or control of the
facility or agency shall not provide a basis for terminating an investigation.
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, based on policy and
interviews.
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.
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 policy and interviews indicate that staff cooperate with investigators and that
the agency/facility is kept informed of the progress of an investigation. The
Superintendent maintains contact with the investigator from the applicable
investigative entity and also 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.
115.372 Evidentiary standard for administrative investigations
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Agency Policy (FDJJ Policy 1919), Prison Rape Elimination Act (PREA)
Provision (a):
The agency shall impose no standard higher than a preponderance of the evidence
in determining whether allegations of sexual abuse or sexual harassment are
substantiated.
The Florida Department of Juvenile Justice/Office of Inspector General, responsible
for administrative investigations, imposes a standard of a preponderance of the
evidence for determining whether allegations are substantiated, in accordance with
policy and previous interview with investigative staff.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor determined the
facility is compliant with this standard.
115.373 Reporting to residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Document:
Agency Policy (FDJJ Policy 1919), Prison Rape Elimination Act (PREA)
Resident Notification Form
Interviews:
Superintendent
Statewide PREA Coordinator
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 agency has
a dedicated form for this purpose. The results of such investigations will be
documented and provided to the resident. The interviews revealed awareness of the
requirement. There is one allegation of resident-on-resident sexual abuse being
investigated at this time.
Provision (b):
If the agency did not conduct the investigation, it shall request the relevant
information from the investigative agency in order to inform the resident.
The Superintendent remains abreast of an investigation conducted by law
enforcement or the DJJ investigator through direct contact and/or through the
statewide PREA Coordinator and will be provided a copy of completed investigation.
The results of the investigation will be provided to the resident by the
Superintendent or designee, in accordance with policy.
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 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.
There has been one allegation of resident-on-resident sexual abuse and the
investigation is ongoing.
Provision (d):
Following a resident’s allegation that he or she has been sexually abused by another
resident, the agency shall subsequently inform the alleged victim whenever:
(1) The agency learns that the alleged abuser has been indicted on a charge related
to sexual abuse within the facility; or
(2) The agency learns that the alleged abuser has been convicted on a charge
related to sexual abuse within the facility.
Policy provides that following a resident’s allegation of being sexually abused by
another resident the alleged victim shall be informed whenever:
a. The alleged abuser is criminally charged related to the sexual abuse.
b. The alleged abuser is adjudicated on a charge related to sexual abuse within the
facility.
There has been one allegation of resident-on-resident sexual abuse and the
investigation is ongoing.
Provision (e):
All such notifications or attempted notifications shall be documented.
Policy provides for the notification to the resident be documented. There is
familiarity with the requirement by the Superintendent.
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 will
be documented.
Conclusion:
The interviews and review of policy and other documentation confirmed the facility
is compliant with this standard.
115.376 Disciplinary sanctions for staff
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Interview:
Superintendent
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for
violating agency sexual abuse or sexual harassment policies.
Policy, procedures and the interview support that staff be subject to disciplinary
sanctions up to and including termination for violating sexual abuse and sexual
harassment policies.
Provision (b):
Termination shall be the presumptive disciplinary sanction for staff who have
engaged in sexual abuse.
Policy and procedures require staff disciplinary sanctions up to and including
termination for violating sexual abuse policy. The violation must be reported to all
investigative entities, including law enforcement. Termination is the presumptive
disciplinary sanction for staff who engaged in sexual abuse.
Provision (c):
Disciplinary sanctions for violations of agency policies relating to sexual abuse or
sexual harassment (other than actually engaging in sexual abuse) 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.
The agency policy provides that the Department strictly prohibits any type of sexual
activity with a resident and they are not tolerated. Failure to comply with policy may
result in disciplinary actions up to and including dismissal.
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.
Terminations and/or allegations for violations of the facility’s sexual abuse or sexual
harassment policies, or staff resignations related to violations of this policy, are
reported to law enforcement, unless the activity is clearly not criminal, and to
relevant licensing bodies.
Conclusion:
Based upon the review of documentation and the interview, the Auditor determined
the facility is compliant with this standard.
115.377 Corrective action for contractors and volunteers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Acknowledgement Statements
Interviews:
Volunteers (2)
Contractor
Superintendent
Provision (a):
Any contractor or volunteer who engages in sexual abuse shall be prohibited from
contact with residents and shall be reported to law enforcement agencies, unless
the activity was clearly not criminal, and to relevant licensing bodies.
Contractors and volunteers who engage in sexual abuse with a resident are to be
reported to law enforcement and to relevant licensing bodies. The interviews and
acknowledgement statements confirmed that volunteers and contractors 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 and the provision of
services are not utilized pending an investigation, according to the Superintendent.
During this audit period, there have been no allegation of sexual abuse and no
allegation of sexual harassment regarding a contractor or volunteer. The volunteers
and contractor provide social, mental health, and medical services.
Provision (b):
The facility shall take appropriate remedial measures, and shall consider whether to
prohibit further contact with residents, in the case of any other violation of agency
sexual abuse or sexual harassment policies by a contractor or volunteer.
Policy and interviews confirmed 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 contractor or volunteer was reported for allegations of sexual
abuse or sexual harassment.
Conclusion:
Based upon the review of the documentation and interviews, the Auditor
determined the facility is compliant with this standard.
115.378 Interventions and disciplinary sanctions for residents
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Student Handbook & Behavior Motivation System
Interviews:
Superintendent/PREA Compliance Manager
Medical Staff
Mental Health Staff
Provision (a):
A resident may be subject to disciplinary sanctions only pursuant to a formal
disciplinary process following an administrative finding that the resident engaged in
resident-on-resident sexual abuse or following a criminal finding of guilt for resident-
on-resident sexual abuse.
Policy and procedures provide that an administrative process for dealing with
violations of administrative or criminal findings of resident-on-resident sexual abuse.
Residents also may be subject to a transfer hearing due to a rule violation or
charged by law enforcement and placed in a juvenile detention center.
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.
Policy and procedures provide that disciplinary sanctions are 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. Agency policy provides for sanctions and that staff shall not deny
the resident daily large-muscle exercise or access to any legally required
educational programming or special education services if placed in isolation. Policy
also provides for daily visits by mental health and medical personnel if isolation is
used and residents shall have access to other programs and work opportunities to
the extent possible. However, the practice in this facility is that disciplinary isolation
is not used as supported by the interviews and observations.
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.
Policy addresses an administrative process for dealing with rule violations and that
sanctions be directly related to the seriousness of the negative behavior. The
interview with the Superintendent revealed the process regarding allegations of
resident-on-resident sexual abuse which may include the residents involved in the
incident being kept separate; all interactions monitored by staff; regular contact will
be maintained; and the discipline will be based on the outcome of the investigation.
Policy provides that the disciplinary process considers whether a resident’s mental
disabilities or mental illness contributed to the behavior when determining what
type of sanction, if any, should be imposed.
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 interview with clinical staff confirmed that intervention services will be offered
to offending residents and their lack of participation in intervention services will not
interfere with the residents' access to programming, education, or the rewards-
based behavior management system. This situation has not occurred during this
audit period.
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 and procedures provide that the facility may discipline a resident for sexual
contact with staff only upon finding that the staff member did not consent to such
contact. Such contact did not occur during this audit period.
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.
Policy and procedures provide that anyone reporting an allegation of sexual abuse
in good faith will not receive any repercussions. This information is provided to
youth during the intake process during PREA education sessions as confirmed by
residents' interviews.
Provision (g):
An agency may, in its discretion, prohibit all sexual activity between residents and
may discipline residents for such activity. An agency may not, however, deem such
activity to constitute sexual abuse if it determines that the activity is not coerced.
Policy and procedures prohibit any sexual conduct between residents; all such
conduct is subject to disciplinary action. Court processes and/or criminal charges
occur after determination through an investigation that the sexual activity was
coerced.
Conclusion:
Based upon the review and analysis of the available documentation, the Auditor
determined the facility is compliant with this standard.
115.381 Medical and mental health screenings; history of sexual abuse
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Screening for Vulnerability to Victimization and Sexually Aggressive Behavior (VSAB)
Interviews:
Staff Responsible for Risk Screening
Medical Staff
Mental Health Staff
Provisions (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 procedures 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 interview with the risk screener revealed the issues are identified
and the referral is made and addressed the same day. 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. Interviews with the
medical and mental health staff and a review of documentation revealed residents
are generally seen by medical and mental health staff on the same day of admission
as part of the intake process.
Interviews with the medical and mental health staff and observations revealed
documentation of the services provided to each resident is maintained in manual
and electronic files which are maintained in a secure manner. Medical and mental
health staff discussed their knowledge of informed consent, in accordance with
policy. The facility utilizes a consent form regarding treatment services for residents
18 years old and up.
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.
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. The Auditor observed the resident files maintained in a secure manner
in locked cabinets in lockable offices. The file cabinets have signs indicating
confidentiality of files contained in the cabinets. Clinical staff and supervisors have
access to the primary PREA screening instrument, VSAB.
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, procedures and interviews provide that 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. All medical and mental health staff members
are mandated reporters. An Informed Consent form has been developed to
document this type of situation regarding a resident who is 18 years of age or older.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor
determined the facility is compliant with this standard.
115.382 Access to emergency medical and mental health services
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 13HS:01.01), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Coordinated Response Plan
Memorandum of Understanding (MOU), Refuge House, Inc.
Interviews:
Medical Staff
Mental Health Staff
Provision (a):
Resident victims of sexual abuse shall receive timely, unimpeded access to
emergency medical treatment and crisis intervention services, the nature and scope
of which are determined by medical and mental health practitioners according to
their professional judgment.
Medical and mental health staff interviews confirmed emergency medical care and
crisis intervention services will be provided by medical and mental health staff as
required. The interviews, policies, procedures and interviews support the alleged
victim will receive timely and unimpeded access to emergency medical treatment
and crisis intervention services. Residents are informed of clinical services and meet
with those representatives and experience services throughout their stay as
needed.
The alleged victim will be transported to the local hospital for a forensic medical
examination by a qualified medical practitioner, at no cost to the victim, and in
accordance with policy and the MOU. Medical and mental health staff members
maintain secondary materials and documentation of encounters with residents.
Processes and services are in place for a victim to receive timely access to medical
and mental health services based on the professional judgement of the provider.
There has been one allegation of sexual abuse; there is an ongoing investigation.
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 unimpeded access to
emergency services. Policy, procedures and the coordinated response plan provide
guidance to staff in protecting residents and for contacting the appropriate staff
regarding allegations or incidents of sexual abuse, including contacting medical and
mental health staff and/or transporting the resident. The staff has access to a
medical professional 24/7. Review of the coordinated response plan; observations of
the interactions among residents; medical and mental health practitioners; and staff
interviews indicated unimpeded medical and crisis intervention services will be
available to a victim of sexual abuse. The allegations of sexual abuse did not require
medical or mental health emergency intervention services.
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.
The policy, procedures and interview with medical staff confirmed processes and
services are in place for a victim to receive timely information about and timely
access to emergency contraception and sexually transmitted infection (STI)
prophylaxis, where medically appropriate. The services will be provided at the
hospital however the facility also has the capability to conduct STI testing and also
provide treatment.
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, MOU, policies, and procedures 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 cooperates with any investigation arising
from the incident.
Conclusion:
Based on the available evidence and interviews, the Auditor determined the facility
is compliant with this standard.
Ongoing medical and mental health care for sexual abuse victims
115.383
and abusers
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Interviews:
Medical Staff
Mental Health Staff
Provision (a):
The facility shall offer medical and mental health evaluation and, as appropriate,
treatment to all residents who have been victimized by sexual abuse in any prison,
jail, lockup, or juvenile facility.
Policy and procedures require mental health evaluation and treatment, as
determined by medical/mental health staff, be offered to residents who disclose
prior sexual victimization or perpetrated sexual abuse during intake screening. The
interviews support that medical and mental health evaluations 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 following the medical
orders from the hospital and referrals to outside services as needed. Mental health
staff will revise the treatment plan to include a goal of reducing the symptomology
related to the trauma and steps toward attaining that goal. There were no targeted
interviewees in the facility during the onsite audit phase and a forensic examination
was not required.
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 with the clinical staff and observations confirmed on-going medical and
mental health care will be provided as appropriate and will include but not be
limited to following the medical orders from the hospital, increase in mental health
counseling to address additional goal in the treatment plan, and contract and
referral services as needed.
Provision (c):
The facility shall provide such victims with medical and mental health services
consistent with the community level of care.
The policy, procedures, interviews, and observations provide that medical and
mental health services are at least consistent with the community level of care.
Residents are seen by medical and mental health staff on a regular basis routinely
and as needed. Sick call is provided onsite by medical practitioners.
Provision (d):
Resident victims of sexually abusive vaginal penetration while incarcerated shall be
offered pregnancy tests.
Pregnancy tests will be conducted at the hospital. The facility's medical staff also
has the capability of conducting pregnancy tests.
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 medical staff confirms that a victim will be provided timely and comprehensive
information regarding lawful pregnancy-related medical services.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for
sexually transmitted infections as medically appropriate.
Policy and interviews ensure that victims of sexual abuse will be provided tests for
sexually transmitted infections as medically appropriate. Testing will be done at the
hospital and may also be done at the facility.
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, according to policy,
procedures, written cooperative agreement, and staff interviews.
Provision (h):
The facility shall attempt to conduct a mental health evaluation of all known
resident-on-resident abusers within 60 days of learning of such abuse history and
offer treatment when deemed appropriate by mental health practitioners.
Agency policy provides for attempts to be made for a mental health practitioner to
conduct a mental health evaluation within 60 days on all known resident-on-resident
abusers and offer appropriate treatment by mental health staff. Medical and mental
health evaluations and treatment will be offered to resident victims of sexual abuse.
The mental health staff confirmed the resident will get a mental health evaluation
within 30 days.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the facility is compliant with this standard.
115.386 Sexual abuse incident reviews
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Interviews:
Superintendent/PREA Compliance Manager
Incident Review Team Member
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion of every
sexual abuse investigation, including where the allegation has not been
substantiated, unless the allegation has been determined to be unfounded.
Policy and procedures require an incident review team meeting within 30 days of
the conclusion of each investigation, unless the investigation resulted in a
determination of unfounded. Incident review team participation consists of the
Superintendent or other upper level management, PREA Compliance Manager, line
supervisor, medical and mental health staff. The Department of Juvenile Justice (DJJ)
statewide PREA Coordinator facilitates the process and prepares the incident review
team report. Regional staff from DJJ may also participate in the incident review team
meeting.
The interviews and previous interview with the statewide PREA Coordinator indicate
the team considers whether: the allegation or investigation indicates a need to
change policy or practice to better prevent, detect, or respond to sexual abuse; the
incident or allegation was motivated by race, ethnicity, gender identity, gay,
bisexual, transgender, or intersex identification; status or perceived status; gang
affiliation; or other group dynamics. The incident review team will also examine the
area in the facility where the incident occurred to assess whether physical barriers
in the area may enable abuse. The team may also assess the adequacy of staffing
levels in that area during different shifts; and assess whether cameras should be
augmented to further enhance staff supervision. The one allegation during this audit
period is in the process of an ongoing investigation; therefore, an incident review
team meeting has not been held.
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 and knowledge of
the purpose of the incident review process. There is one ongoing administrative
sexual abuse investigations during the onsite audit phase; there were no incident
review team meeting reports to review.
Provision (c):
The review team shall include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners.
Incident review team participation consists of the Superintendent/PREA Compliance
Manager or other upper level management, line supervisor, medical and mental
health staff. The Statewide PREA Coordinator facilitates the process and prepares
the incident review team report. Regional staff from DJJ may also participate in the
incident review team meeting. Investigators may be invited to the meeting if
needed.
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 interviews indicate the team considers whether: the allegation or investigation
indicates a need to change policy or practice to better prevent, detect, or respond
to sexual abuse; the incident or allegation was motivated by race, ethnicity, gender
identity, gay, bisexual, transgender, or intersex identification; status or perceived
status; gang affiliation; or other group dynamics. The incident review team will also
examine the area in the facility where the incident occurred to assess whether
physical barriers in the area may enable abuse. The team may also assess the
adequacy of staffing levels in that area during different shifts; and assess whether
cameras should be augmented to further enhance staff supervision.
A report of findings by the incident review team is prepared by the statewide PREA
Coordinator and provided to the Superintendent/PREA Compliance Manager and DJJ
Regional Director. Any recommendations made by the team for improvement(s) will
be included in the report. An incident review has not been conducted this audit
period.
Provision (e):
The facility shall implement the recommendations for improvement or shall
document its reasons for not doing so.
Policy and procedures provided that any recommendations for improvement
contained in the report of findings will be reviewed and considered for
implementation. Any recommendations not implemented will have written reasons
for not doing so. The Superintendent/PREA Compliance Manager is aware of this
requirement.
Conclusion:
Based upon the review and analysis of the available information, the Auditor
determined the facility is compliant with this standard.
115.387 Data collection
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Agency Policy (FDJJ 2020), Incident Operations Center and Incident Reviews
Facility Operating Procedures (FOP) PREA
PREA Incident Reports Data Sheets
Trendstat Data Comparison Report
Interviews:
Agency PREA Coordinator
Superintendent/PREA Compliance Manager
Provisions (a) and (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 Department of Juvenile Justice (DJJ) and the contractor, Twin Oaks Youth
Development Incorporated, have developed a standardized instrument with
definitions to collect accurate and uniform data for every allegation of sexual abuse.
The instruments include the data necessary to answer all questions from the most
recent version of the Survey of Sexual Violence (currently know as the Survey of
Sexual Victimization) conducted by the Department of Justice. Policy and procedures
require the agencies to collect all data relating to PREA from the facilities required
to adhere to the PREA Standards. Both agencies have a standardized instruments
for collecting data with a set of definitions.
Provision (b):
The agency shall aggregate the incident-based sexual abuse data at least annually.
Policy, procedures, annual reports, data gathering instruments and other documents
confirm the facility collects incident-based, uniform data regarding allegations of
sexual abuse and sexual harassment. A standardized instrument and specific
guidelines and definitions are used to assist in identifying and analyzing the data.
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 facility maintains and collects various types of identified data and related
documents regarding PREA. The facility collects and maintains data in accordance
with policy directives and DJJ aggregates the data which culminates into an annual
report. Policy and procedures require 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 annual reports
including State and private agencies.
The facility's parent agency uses Trendstat, a quality improvement process. The
Trendstat system provides for data to be collected, analyzed and submitted monthly
to the corporate office's leadership team. Data is collected from various service and
operations areas including but not limited to sexual abuse allegations, incidents,
abuse calls, medication areas, risk management, and the status of any corrective
actions. Part of the review process is to compare the data sets from year to year to
identify any trends or opportunities for improvement.
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 Twin Oaks Juvenile Development, Incorporated does not contract with outside
facilities for confinement of its residents. The DJJ contracts with the agency for the
provision of residential services for the juveniles committed to the State. Incident-
based and aggregated data is obtained by DJJ from the State-run juvenile detention
centers and private providers contracted to provide residential treatment services.
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.
Policy and procedures provide that upon request, the facility will provide all such
data from the previous calendar year to the Department of Justice no later than June
30. A request was not made for the previous calendar year by the Department of
Justice.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the facility is compliant with this standard.
115.388 Data review for corrective action
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Facility Operating Procedures (FOP) PREA
Annual Reports
Interviews:
Superintendent/PREA Compliance Manager
PREA Coordinator
Agency Head Designee
Provision (a):
The agency shall review data collected and aggregated pursuant to §115.387 in
order to assess and improve the effectiveness of its sexual abuse prevention,
detection, and response policies, practices, and training, including: (1) Identifying
problem areas; (2) Taking corrective action on an ongoing basis; and (3) Preparing
an annual report of its findings and corrective actions for each facility, as well as
this agency as a whole.
The interviews support the review of data and that it is used to improve the PREA
efforts of the agencies. 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/facility, in accordance with policy and procedures. The
practice allows staff to identify trends and or problem areas and to develop
corrective actions where indicated. The facility collects data monthly for onsite and
corporate review including to identify opportunities for improvement. 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
contract agency also has an annual report. The annual reports are approved by the
agency head/designee of each agency. There are no personal identifiers in the
reports. 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 DJJ website, accessible to the public.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor determined
the agency is compliant with this standard.
115.389 Data storage, publication, and destruction
Auditor Overall Determination: Meets Standard
Auditor Discussion
Documents:
Agency Policy (FDJJ 1919), Prison Rape Elimination Act (PREA)
Agency Policy (FDJJ 1316), Records and Information Management Procedures
Facility Operating Procedures (FOP) PREA
Annual Reports
Interviews:
Superintendent/PREA Compliance Manager
Provisions (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.
All 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
website. A review of the annual report verified there are no personal identifiers.
The Trendstat data which is also presented in annual report format does not contain
any personal identifiers. All facility and agency records are securely stored in locked
cabinets behind locked doors within the key control system and electronic records
are password protected with identified and limited access. The file cabinets and/or
office doors contain signs indicating confidential files are maintained in the area.
Conclusion:
Based upon the review and analysis of the documentation, interviews and
observations, the Auditor determined the facility is compliant with this standard.
115.401 Frequency and scope of audits
Auditor Overall Determination: Meets Standard
Auditor Discussion
The last PREA audit was conducted in 2021; during the prior three-year audit period
the agency ensured each required facility was reviewed at least once. The PREA Pre-
Audit Questionnaire and supporting documentation was completed in the online
audit system. The Auditor was provided additional information by email and in-
person onsite. During the onsite audit phase, a comprehensive site review was
provided to the Auditor and there was full access to the facility. The Superintendent/
PREA Compliance Manager and PREA Coordinator were cooperative in providing
information and participating in and ensuring the private interviews.
The posted notices regarding the audit were observed posted within the facility. The
interviewed residents were asked about the timeframe of the posting of the notices;
the responses were aligned with the information received by the Auditor. The
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 for the routing of main including confidential
correspondence. There was no correspondence from staff, residents or others
received by the Auditor.
Conclusion:
Based on the available evidence and observations, the facility is compliant with this
standard.
115.403 Audit contents and findings
Auditor Overall Determination: Meets Standard
Auditor Discussion
Interviews:
Superintendent
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 facility leadership/management and
other staff were reviewed regarding compliance with the standards and have been
identified in the reports. The interview with the Superintendent, observation, and
communication with the statewide PREA Coordinator confirm the final audit reports
are posted on the agency website.
The audit findings were based on a review of policies, procedures, supporting
documentation, observations, and interviews. There were no conflicts of interest
regarding the completion of this audit. 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.
Appendix: Provision Findings
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(a) coordinator
Does the agency have a written policy mandating zero tolerance yes
toward all forms of sexual abuse and sexual harassment?
Does the written policy outline the agency’s approach to yes
preventing, detecting, and responding to sexual abuse and sexual
harassment?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(b) coordinator
Has the agency employed or designated an agency-wide PREA yes
Coordinator?
Is the PREA Coordinator position in the upper-level of the agency yes
hierarchy?
Does the PREA Coordinator have sufficient time and authority to yes
develop, implement, and oversee agency efforts to comply with
the PREA standards in all of its facilities?
115.311 Zero tolerance of sexual abuse and sexual harassment; PREA
(c) coordinator
If this agency operates more than one facility, has each facility yes
designated a PREA compliance manager? (N/A if agency operates
only one facility.)
Does the PREA compliance manager have sufficient time and yes
authority to coordinate the facility’s efforts to comply with the
PREA standards? (N/A if agency operates only one facility.)
115.312
Contracting with other entities for the confinement of residents
(a)
If this agency is public and it contracts for the confinement of its yes
residents with private agencies or other entities including other
government agencies, has the agency included the entity’s
obligation to adopt and comply with the PREA standards in any
new contract or contract renewal signed on or after August 20,
2012? (N/A if the agency does not contract with private agencies
or other entities for the confinement of residents.)
115.312
Contracting with other entities for the confinement of residents
(b)
Does any new contract or contract renewal signed on or after yes
August 20, 2012 provide for agency contract monitoring to ensure
that the contractor is complying with the PREA standards? (N/A if
the agency does not contract with private agencies or other
entities for the confinement of residents OR the response to
115.312(a)-1 is "NO".)
115.313
Supervision and monitoring
(a)
Does the agency ensure that each facility has developed a staffing yes
plan that provides for adequate levels of staffing and, where
applicable, video monitoring, to protect residents against sexual
abuse?
Does the agency ensure that each facility has implemented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility has documented a yes
staffing plan that provides for adequate levels of staffing and,
where applicable, video monitoring, to protect residents against
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
prevalence of substantiated and unsubstantiated incidents of
sexual abuse?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Generally accepted juvenile detention and correctional/secure
residential practices?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
judicial findings of inadequacy?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from Federal investigative agencies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
findings of inadequacy from internal or external oversight bodies?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: All
components of the facility’s physical plant (including “blind-spots”
or areas where staff or residents may be isolated)?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
composition of the resident population?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: The
number and placement of supervisory staff?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring:
Institution programs occurring on a particular shift?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
applicable State or local laws, regulations, or standards?
Does the agency ensure that each facility’s staffing plan takes into yes
consideration the 11 criteria below in calculating adequate
staffing levels and determining the need for video monitoring: Any
other relevant factors?
115.313
Supervision and monitoring
(b)
Does the agency comply with the staffing plan except during yes
limited and discrete exigent circumstances?
In circumstances where the staffing plan is not complied with, yes
does the facility fully document all deviations from the plan? (N/A
if no deviations from staffing plan.)
115.313
Supervision and monitoring
(c)
Does the facility maintain staff ratios of a minimum of 1:8 during yes
resident waking hours, except during limited and discrete exigent
circumstances? (N/A only until October 1, 2017.)
Does the facility maintain staff ratios of a minimum of 1:16 during yes
resident sleeping hours, except during limited and discrete
exigent circumstances? (N/A only until October 1, 2017.)
Does the facility fully document any limited and discrete exigent yes
circumstances during which the facility did not maintain staff
ratios? (N/A only until October 1, 2017.)
Does the facility ensure only security staff are included when yes
calculating these ratios? (N/A only until October 1, 2017.)
Is the facility obligated by law, regulation, or judicial consent yes
decree to maintain the staffing ratios set forth in this paragraph?
115.313
Supervision and monitoring
(d)
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The staffing plan established
pursuant to paragraph (a) of this section?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: Prevailing staffing patterns?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The facility’s deployment of
video monitoring systems and other monitoring technologies?
In the past 12 months, has the facility, in consultation with the yes
agency PREA Coordinator, assessed, determined, and documented
whether adjustments are needed to: The resources the facility has
available to commit to ensure adherence to the staffing plan?
115.313
Supervision and monitoring
(e)
Has the facility implemented a policy and practice of having yes
intermediate-level or higher-level supervisors conduct and
document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? (N/A for non-secure facilities )
Is this policy and practice implemented for night shifts as well as yes
day shifts? (N/A for non-secure facilities )
Does the facility have a policy prohibiting staff from alerting other yes
staff members that these supervisory rounds are occurring, unless
such announcement is related to the legitimate operational
functions of the facility? (N/A for non-secure facilities )
115.315
Limits to cross-gender viewing and searches
(a)
Does the facility always refrain from conducting any cross-gender yes
strip or cross-gender visual body cavity searches, except in
exigent circumstances or by medical practitioners?
115.315
Limits to cross-gender viewing and searches
(b)
Does the facility always refrain from conducting cross-gender pat- yes
down searches in non-exigent circumstances?
115.315
Limits to cross-gender viewing and searches
(c)
Does the facility document and justify all cross-gender strip yes
searches and cross-gender visual body cavity searches?
Does the facility document all cross-gender pat-down searches? yes
115.315
Limits to cross-gender viewing and searches
(d)
Does the facility implement policies and procedures that enable yes
residents to shower, perform bodily functions, and change clothing
without nonmedical staff of the opposite gender viewing their
breasts, buttocks, or genitalia, except in exigent circumstances or
when such viewing is incidental to routine cell checks?
Does the facility require staff of the opposite gender to announce yes
their presence when entering a resident housing unit?
In facilities (such as group homes) that do not contain discrete yes
housing units, does the facility require staff of the opposite gender
to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions,
or changing clothing? (N/A for facilities with discrete housing
units)
115.315
Limits to cross-gender viewing and searches
(e)
Does the facility always refrain from searching or physically yes
examining transgender or intersex residents for the sole purpose
of determining the resident’s genital status?
If a resident’s genital status is unknown, does the facility yes
determine genital status during conversations with the resident,
by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted
in private by a medical practitioner?
115.315
Limits to cross-gender viewing and searches
(f)
Does the facility/agency train security staff in how to conduct yes
cross-gender pat down searches in a professional and respectful
manner, and in the least intrusive manner possible, consistent
with security needs?
Does the facility/agency train security staff in how to conduct yes
searches of transgender and intersex residents in a professional
and respectful manner, and in the least intrusive manner possible,
consistent with security needs?
115.316 Residents with disabilities and residents who are limited
(a) English proficient
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are deaf or hard of hearing?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who are blind or have low vision?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have intellectual disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have psychiatric disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Residents who have speech disabilities?
Does the agency take appropriate steps to ensure that residents yes
with disabilities have an equal opportunity to participate in or
benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including:
Other? (if "other," please explain in overall determination notes.)
Do such steps include, when necessary, ensuring effective yes
communication with residents who are deaf or hard of hearing?
Do such steps include, when necessary, providing access to yes
interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any
necessary specialized vocabulary?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
intellectual disabilities?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Have
limited reading skills?
Does the agency ensure that written materials are provided in yes
formats or through methods that ensure effective communication
with residents with disabilities including residents who: Who are
blind or have low vision?
115.316 Residents with disabilities and residents who are limited
(b) English proficient
Does the agency take reasonable steps to ensure meaningful yes
access to all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment to residents
who are limited English proficient?
Do these steps include providing interpreters who can interpret yes
effectively, accurately, and impartially, both receptively and
expressively, using any necessary specialized vocabulary?
115.316 Residents with disabilities and residents who are limited
(c) English proficient
Does the agency always refrain from relying on resident yes
interpreters, resident readers, or other types of resident assistants
except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s
safety, the performance of first-response duties under §115.364,
or the investigation of the resident’s allegations?
115.317
Hiring and promotion decisions
(a)
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has engaged in sexual
abuse in a prison, jail, lockup, community confinement facility,
juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been convicted of
engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or
coercion, or if the victim did not consent or was unable to consent
or refuse?
Does the agency prohibit the hiring or promotion of anyone who yes
may have contact with residents who: Has been civilly or
administratively adjudicated to have engaged in the activity
described in the bullet immediately above?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has
engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as
defined in 42 U.S.C. 1997)?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
convicted of engaging or attempting to engage in sexual activity
in the community facilitated by force, overt or implied threats of
force, or coercion, or if the victim did not consent or was unable to
consent or refuse?
Does the agency prohibit the enlistment of services of any yes
contractor who may have contact with residents who: Has been
civilly or administratively adjudicated to have engaged in the
activity described in the two bullets immediately above?
115.317
Hiring and promotion decisions
(b)
Does the agency consider any incidents of sexual harassment in yes
determining whether to hire or promote anyone, or to enlist the
services of any contractor, who may have contact with residents?
115.317 Hiring and promotion decisions
(c)
Before hiring new employees who may have contact with yes
residents, does the agency: Perform a criminal background records
check?
Before hiring new employees who may have contact with yes
residents, does the agency: Consult any child abuse registry
maintained by the State or locality in which the employee would
work?
Before hiring new employees who may have contact with yes
residents, does the agency: Consistent with Federal, State, and
local law, make its best efforts to contact all prior institutional
employers for information on substantiated allegations of sexual
abuse or any resignation during a pending investigation of an
allegation of sexual abuse?
115.317
Hiring and promotion decisions
(d)
Does the agency perform a criminal background records check yes
before enlisting the services of any contractor who may have
contact with residents?
Does the agency consult applicable child abuse registries before yes
enlisting the services of any contractor who may have contact
with residents?
115.317
Hiring and promotion decisions
(e)
Does the agency either conduct criminal background records yes
checks at least every five years of current employees and
contractors who may have contact with residents or have in place
a system for otherwise capturing such information for current
employees?
115.317
Hiring and promotion decisions
(f)
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in written applications or
interviews for hiring or promotions?
Does the agency ask all applicants and employees who may have yes
contact with residents directly about previous misconduct
described in paragraph (a) of this section in any interviews or
written self-evaluations conducted as part of reviews of current
employees?
Does the agency impose upon employees a continuing affirmative yes
duty to disclose any such misconduct?
115.317
Hiring and promotion decisions
(g)
Does the agency consider material omissions regarding such yes
misconduct, or the provision of materially false information,
grounds for termination?
115.317
Hiring and promotion decisions
(h)
Unless prohibited by law, does the agency provide information on yes
substantiated allegations of sexual abuse or sexual harassment
involving a former employee upon receiving a request from an
institutional employer for whom such employee has applied to
work? (N/A if providing information on substantiated allegations of
sexual abuse or sexual harassment involving a former employee is
prohibited by law.)
115.318
Upgrades to facilities and technologies
(a)
If the agency designed or acquired any new facility or planned any yes
substantial expansion or modification of existing facilities, did the
agency consider the effect of the design, acquisition, expansion,
or modification upon the agency’s ability to protect residents from
sexual abuse? (N/A if agency/facility has not acquired a new
facility or made a substantial expansion to existing facilities since
August 20, 2012, or since the last PREA audit, whichever is later.)
115.318
Upgrades to facilities and technologies
(b)
If the agency installed or updated a video monitoring system, yes
electronic surveillance system, or other monitoring technology,
did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if
agency/facility has not installed or updated a video monitoring
system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit,
whichever is later.)
115.321
Evidence protocol and forensic medical examinations
(a)
If the agency is responsible for investigating allegations of sexual yes
abuse, does the agency follow a uniform evidence protocol that
maximizes the potential for obtaining usable physical evidence for
administrative proceedings and criminal prosecutions? (N/A if the
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
115.321
Evidence protocol and forensic medical examinations
(b)
Is this protocol developmentally appropriate for youth? (N/A if the yes
agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.)
Is this protocol, as appropriate, adapted from or otherwise based yes
on the most recent edition of the U.S. Department of Justice’s
Office on Violence Against Women publication, “A National Protocol
for Sexual Assault Medical Forensic Examinations, Adults/
Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative
sexual abuse investigations. )
115.321
Evidence protocol and forensic medical examinations
(c)
Does the agency offer all residents who experience sexual abuse yes
access to forensic medical examinations, whether on-site or at an
outside facility, without financial cost, where evidentiarily or
medically appropriate?
Are such examinations performed by Sexual Assault Forensic yes
Examiners (SAFEs) or Sexual Assault Nurse Examiners (SANEs)
where possible?
If SAFEs or SANEs cannot be made available, is the examination yes
performed by other qualified medical practitioners (they must
have been specifically trained to conduct sexual assault forensic
exams)?
Has the agency documented its efforts to provide SAFEs or yes
SANEs?
115.321
Evidence protocol and forensic medical examinations
(d)
Does the agency attempt to make available to the victim a victim yes
advocate from a rape crisis center?
If a rape crisis center is not available to provide victim advocate yes
services, does the agency make available to provide these
services a qualified staff member from a community-based
organization, or a qualified agency staff member?
Has the agency documented its efforts to secure services from yes
rape crisis centers?
115.321
Evidence protocol and forensic medical examinations
(e)
As requested by the victim, does the victim advocate, qualified yes
agency staff member, or qualified community-based organization
staff member accompany and support the victim through the
forensic medical examination process and investigatory
interviews?
As requested by the victim, does this person provide emotional yes
support, crisis intervention, information, and referrals?
115.321
Evidence protocol and forensic medical examinations
(f)
If the agency itself is not responsible for investigating allegations yes
of sexual abuse, has the agency requested that the investigating
entity follow the requirements of paragraphs (a) through (e) of this
section? (N/A if the agency is responsible for investigating
allegations of sexual abuse.)
115.321
Evidence protocol and forensic medical examinations
(h)
If the agency uses a qualified agency staff member or a qualified yes
community-based staff member for the purposes of this section,
has the individual been screened for appropriateness to serve in
this role and received education concerning sexual assault and
forensic examination issues in general? (Check N/A if agency
attempts to make a victim advocate from a rape crisis center
available to victims per 115.321(d) above.)
115.322
Policies to ensure referrals of allegations for investigations
(a)
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual abuse?
Does the agency ensure an administrative or criminal yes
investigation is completed for all allegations of sexual
harassment?
115.322
Policies to ensure referrals of allegations for investigations
(b)
Does the agency have a policy in place to ensure that allegations yes
of sexual abuse or sexual harassment are referred for
investigation to an agency with the legal authority to conduct
criminal investigations, unless the allegation does not involve
potentially criminal behavior?
Has the agency published such policy on its website or, if it does yes
not have one, made the policy available through other means?
Does the agency document all such referrals? yes
115.322
Policies to ensure referrals of allegations for investigations
(c)
If a separate entity is responsible for conducting criminal yes
investigations, does such publication describe the responsibilities
of both the agency and the investigating entity? (N/A if the
agency/facility is responsible for criminal investigations. See
115.321(a))
115.331
Employee training
(a)
Does the agency train all employees who may have contact with yes
residents on: Its zero-tolerance policy for sexual abuse and sexual
harassment?
Does the agency train all employees who may have contact with yes
residents on: How to fulfill their responsibilities under agency
sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures?
Does the agency train all employees who may have contact with yes
residents on: Residents’ right to be free from sexual abuse and
sexual harassment
Does the agency train all employees who may have contact with yes
residents on: The right of residents and employees to be free from
retaliation for reporting sexual abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: The dynamics of sexual abuse and sexual
harassment in juvenile facilities?
Does the agency train all employees who may have contact with yes
residents on: The common reactions of juvenile victims of sexual
abuse and sexual harassment?
Does the agency train all employees who may have contact with yes
residents on: How to detect and respond to signs of threatened
and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents?
Does the agency train all employees who may have contact with yes
residents on: How to avoid inappropriate relationships with
residents?
Does the agency train all employees who may have contact with yes
residents on: How to communicate effectively and professionally
with residents, including lesbian, gay, bisexual, transgender,
intersex, or gender nonconforming residents?
Does the agency train all employees who may have contact with yes
residents on: How to comply with relevant laws related to
mandatory reporting of sexual abuse to outside authorities?
Does the agency train all employees who may have contact with yes
residents on: Relevant laws regarding the applicable age of
consent?
115.331
Employee training
(b)
Is such training tailored to the unique needs and attributes of yes
residents of juvenile facilities?
Is such training tailored to the gender of the residents at the yes
employee’s facility?
Have employees received additional training if reassigned from a yes
facility that houses only male residents to a facility that houses
only female residents, or vice versa?
115.331
Employee training
(c)
Have all current employees who may have contact with residents yes
received such training?
Does the agency provide each employee with refresher training yes
every two years to ensure that all employees know the agency’s
current sexual abuse and sexual harassment policies and
procedures?
In years in which an employee does not receive refresher training, yes
does the agency provide refresher information on current sexual
abuse and sexual harassment policies?
115.331
Employee training
(d)
Does the agency document, through employee signature or yes
electronic verification, that employees understand the training
they have received?
115.332
Volunteer and contractor training
(a)
Has the agency ensured that all volunteers and contractors who yes
have contact with residents have been trained on their
responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and
procedures?
115.332
Volunteer and contractor training
(b)
Have all volunteers and contractors who have contact with yes
residents been notified of the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment and informed how
to report such incidents (the level and type of training provided to
volunteers and contractors shall be based on the services they
provide and level of contact they have with residents)?
115.332
Volunteer and contractor training
(c)
Does the agency maintain documentation confirming that yes
volunteers and contractors understand the training they have
received?
115.333
Resident education
(a)
During intake, do residents receive information explaining the yes
agency’s zero-tolerance policy regarding sexual abuse and sexual
harassment?
During intake, do residents receive information explaining how to yes
report incidents or suspicions of sexual abuse or sexual
harassment?
Is this information presented in an age-appropriate fashion? yes
115.333
Resident education
(b)
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from sexual abuse and
sexual harassment?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Their rights to be free from retaliation for
reporting such incidents?
Within 10 days of intake, does the agency provide age-appropriate yes
comprehensive education to residents either in person or through
video regarding: Agency policies and procedures for responding to
such incidents?
115.333
Resident education
(c)
Have all residents received such education? yes
Do residents receive education upon transfer to a different facility yes
to the extent that the policies and procedures of the resident’s
new facility differ from those of the previous facility?
115.333
Resident education
(d)
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are limited English proficient?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are deaf?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are visually impaired?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Are otherwise disabled?
Does the agency provide resident education in formats accessible yes
to all residents including those who: Have limited reading skills?
115.333
Resident education
(e)
Does the agency maintain documentation of resident participation yes
in these education sessions?
115.333
Resident education
(f)
In addition to providing such education, does the agency ensure yes
that key information is continuously and readily available or visible
to residents through posters, resident handbooks, or other written
formats?
115.334
Specialized training: Investigations
(a)
In addition to the general training provided to all employees yes
pursuant to §115.331, does the agency ensure that, to the extent
the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such
investigations in confinement settings? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.334
Specialized training: Investigations
(b)
Does this specialized training include: Techniques for interviewing yes
juvenile sexual abuse victims? (N/A if the agency does not conduct
any form of administrative or criminal sexual abuse investigations.
See 115.321(a).)
Does this specialized training include: Proper use of Miranda and yes
Garrity warnings? (N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See
115.321(a).)
Does this specialized training include: Sexual abuse evidence yes
collection in confinement settings? (N/A if the agency does not
conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
Does this specialized training include: The criteria and evidence yes
required to substantiate a case for administrative action or
prosecution referral? (N/A if the agency does not conduct any form
of administrative or criminal sexual abuse investigations. See
115.321(a).)
115.334
Specialized training: Investigations
(c)
Does the agency maintain documentation that agency yes
investigators have completed the required specialized training in
conducting sexual abuse investigations? (N/A if the agency does
not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).)
115.335
Specialized training: Medical and mental health care
(a)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to detect and assess signs of sexual
abuse and sexual harassment? (N/A if the agency does not have
any full- or part-time medical or mental health care practitioners
who work regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to preserve physical evidence of sexual
abuse? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual
harassment? (N/A if the agency does not have any full- or part-
time medical or mental health care practitioners who work
regularly in its facilities.)
Does the agency ensure that all full- and part-time medical and yes
mental health care practitioners who work regularly in its facilities
have been trained in: How and to whom to report allegations or
suspicions of sexual abuse and sexual harassment? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(b)
If medical staff employed by the agency conduct forensic yes
examinations, do such medical staff receive appropriate training
to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams or the agency does not
employ medical staff.)
115.335
Specialized training: Medical and mental health care
(c)
Does the agency maintain documentation that medical and yes
mental health practitioners have received the training referenced
in this standard either from the agency or elsewhere? (N/A if the
agency does not have any full- or part-time medical or mental
health care practitioners who work regularly in its facilities.)
115.335
Specialized training: Medical and mental health care
(d)
Do medical and mental health care practitioners employed by the yes
agency also receive training mandated for employees by
§115.331? (N/A if the agency does not have any full- or part-time
medical or mental health care practitioners who work regularly in
its facilities.)
Do medical and mental health care practitioners contracted by yes
and volunteering for the agency also receive training mandated
for contractors and volunteers by §115.332? (N/A if the agency
does not have any full- or part-time medical or mental health care
practitioners contracted by or volunteering for the agency.)
115.341
Obtaining information from residents
(a)
Within 72 hours of the resident’s arrival at the facility, does the yes
agency obtain and use information about each resident’s personal
history and behavior to reduce risk of sexual abuse by or upon a
resident?
Does the agency also obtain this information periodically yes
throughout a resident’s confinement?
115.341
Obtaining information from residents
(b)
Are all PREA screening assessments conducted using an objective yes
screening instrument?
115.341
Obtaining information from residents
(c)
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Prior sexual
victimization or abusiveness?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any gender
nonconforming appearance or manner or identification as lesbian,
gay, bisexual, transgender, or intersex, and whether the resident
may therefore be vulnerable to sexual abuse?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Current
charges and offense history?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Age?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Level of
emotional and cognitive development?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical size
and stature?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Mental illness
or mental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Intellectual or
developmental disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Physical
disabilities?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: The resident’s
own perception of vulnerability?
During these PREA screening assessments, at a minimum, does yes
the agency attempt to ascertain information about: Any other
specific information about individual residents that may indicate
heightened needs for supervision, additional safety precautions, or
separation from certain other residents?
115.341
Obtaining information from residents
(d)
Is this information ascertained: Through conversations with the yes
resident during the intake process and medical mental health
screenings?
Is this information ascertained: During classification assessments? yes
Is this information ascertained: By reviewing court records, case yes
files, facility behavioral records, and other relevant documentation
from the resident’s files?
115.341
Obtaining information from residents
(e)
Has the agency implemented appropriate controls on the yes
dissemination within the facility of responses to questions asked
pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or
other residents?
115.342
Placement of residents
(a)
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Housing Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Bed assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Work Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Education
Assignments?
Does the agency use all of the information obtained pursuant to § yes
115.341 and subsequently, with the goal of keeping all residents
safe and free from sexual abuse, to make: Program Assignments?
115.342
Placement of residents
(b)
Are residents isolated from others only as a last resort when less yes
restrictive measures are inadequate to keep them and other
residents safe, and then only until an alternative means of
keeping all residents safe can be arranged?
During any period of isolation, does the agency always refrain yes
from denying residents daily large-muscle exercise?
During any period of isolation, does the agency always refrain yes
from denying residents any legally required educational
programming or special education services?
Do residents in isolation receive daily visits from a medical or yes
mental health care clinician?
Do residents also have access to other programs and work yes
opportunities to the extent possible?
115.342
Placement of residents
(c)
Does the agency always refrain from placing: Lesbian, gay, and yes
bisexual residents in particular housing, bed, or other assignments
solely on the basis of such identification or status?
Does the agency always refrain from placing: Transgender yes
residents in particular housing, bed, or other assignments solely
on the basis of such identification or status?
Does the agency always refrain from placing: Intersex residents in yes
particular housing, bed, or other assignments solely on the basis
of such identification or status?
Does the agency always refrain from considering lesbian, gay, yes
bisexual, transgender, or intersex identification or status as an
indicator or likelihood of being sexually abusive?
115.342
Placement of residents
(d)
When deciding whether to assign a transgender or intersex yes
resident to a facility for male or female residents, does the agency
consider on a case-by-case basis whether a placement would
ensure the resident’s health and safety, and whether a placement
would present management or security problems (NOTE: if an
agency by policy or practice assigns residents to a male or female
facility on the basis of anatomy alone, that agency is not in
compliance with this standard)?
When making housing or other program assignments for yes
transgender or intersex residents, does the agency consider on a
case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would
present management or security problems?
115.342
Placement of residents
(e)
Are placement and programming assignments for each yes
transgender or intersex resident reassessed at least twice each
year to review any threats to safety experienced by the resident?
115.342
Placement of residents
(f)
Are each transgender or intersex resident’s own views with yes
respect to his or her own safety given serious consideration when
making facility and housing placement decisions and
programming assignments?
115.342
Placement of residents
(g)
Are transgender and intersex residents given the opportunity to yes
shower separately from other residents?
115.342
Placement of residents
(h)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The basis for the facility’s
concern for the resident’s safety? (N/A for h and i if facility doesn’t
use isolation?)
If a resident is isolated pursuant to paragraph (b) of this section, na
does the facility clearly document: The reason why no alternative
means of separation can be arranged? (N/A for h and i if facility
doesn’t use isolation?)
115.342
Placement of residents
(i)
In the case of each resident who is isolated as a last resort when yes
less restrictive measures are inadequate to keep them and other
residents safe, does the facility afford a review to determine
whether there is a continuing need for separation from the general
population EVERY 30 DAYS?
115.351
Resident reporting
(a)
Does the agency provide multiple internal ways for residents to yes
privately report: Sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: 2. Retaliation by other residents or staff for
reporting sexual abuse and sexual harassment?
Does the agency provide multiple internal ways for residents to yes
privately report: Staff neglect or violation of responsibilities that
may have contributed to such incidents?
115.351
Resident reporting
(b)
Does the agency also provide at least one way for residents to yes
report sexual abuse or sexual harassment to a public or private
entity or office that is not part of the agency?
Is that private entity or office able to receive and immediately yes
forward resident reports of sexual abuse and sexual harassment to
agency officials?
Does that private entity or office allow the resident to remain yes
anonymous upon request?
Are residents detained solely for civil immigration purposes yes
provided information on how to contact relevant consular officials
and relevant officials at the Department of Homeland Security to
report sexual abuse or harassment?
115.351
Resident reporting
(c)
Do staff members accept reports of sexual abuse and sexual yes
harassment made verbally, in writing, anonymously, and from
third parties?
Do staff members promptly document any verbal reports of sexual yes
abuse and sexual harassment?
115.351
Resident reporting
(d)
Does the facility provide residents with access to tools necessary yes
to make a written report?
115.351
Resident reporting
(e)
Does the agency provide a method for staff to privately report yes
sexual abuse and sexual harassment of residents?
115.352
Exhaustion of administrative remedies
(a)
Is the agency exempt from this standard? yes
NOTE: The agency is exempt ONLY if it does not have
administrative procedures to address resident grievances
regarding sexual abuse. This does not mean the agency is exempt
simply because a resident does not have to or is not ordinarily
expected to submit a grievance to report sexual abuse. This
means that as a matter of explicit policy, the agency does not
have an administrative remedies process to address sexual abuse.
115.352
Exhaustion of administrative remedies
(b)
Does the agency permit residents to submit a grievance regarding na
an allegation of sexual abuse without any type of time limits? (The
agency may apply otherwise-applicable time limits to any portion
of a grievance that does not allege an incident of sexual abuse.)
(N/A if agency is exempt from this standard.)
Does the agency always refrain from requiring an resident to use na
any informal grievance process, or to otherwise attempt to resolve
with staff, an alleged incident of sexual abuse? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(c)
Does the agency ensure that: A resident who alleges sexual abuse na
may submit a grievance without submitting it to a staff member
who is the subject of the complaint? (N/A if agency is exempt from
this standard.)
Does the agency ensure that: Such grievance is not referred to a na
staff member who is the subject of the complaint? (N/A if agency
is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(d)
Does the agency issue a final agency decision on the merits of any na
portion of a grievance alleging sexual abuse within 90 days of the
initial filing of the grievance? (Computation of the 90-day time
period does not include time consumed by residents in preparing
any administrative appeal.) (N/A if agency is exempt from this
standard.)
If the agency determines that the 90 day timeframe is insufficient na
to make an appropriate decision and claims an extension of time
(the maximum allowable extension of time to respond is 70 days
per 115.352(d)(3)) , does the agency notify the resident in writing
of any such extension and provide a date by which a decision will
be made? (N/A if agency is exempt from this standard.)
At any level of the administrative process, including the final level, na
if the resident does not receive a response within the time allotted
for reply, including any properly noticed extension, may a resident
consider the absence of a response to be a denial at that level?
(N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(e)
Are third parties, including fellow residents, staff members, family na
members, attorneys, and outside advocates, permitted to assist
residents in filing requests for administrative remedies relating to
allegations of sexual abuse? (N/A if agency is exempt from this
standard.)
Are those third parties also permitted to file such requests on na
behalf of residents? (If a third party, other than a parent or legal
guardian, files such a request on behalf of a resident, the facility
may require as a condition of processing the request that the
alleged victim agree to have the request filed on his or her behalf,
and may also require the alleged victim to personally pursue any
subsequent steps in the administrative remedy process.) (N/A if
agency is exempt from this standard.)
If the resident declines to have the request processed on his or na
her behalf, does the agency document the resident’s decision?
(N/A if agency is exempt from this standard.)
Is a parent or legal guardian of a juvenile allowed to file a na
grievance regarding allegations of sexual abuse, including
appeals, on behalf of such juvenile? (N/A if agency is exempt from
this standard.)
If a parent or legal guardian of a juvenile files a grievance (or an na
appeal) on behalf of a juvenile regarding allegations of sexual
abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her
behalf? (N/A if agency is exempt from this standard.)
115.352
Exhaustion of administrative remedies
(f)
Has the agency established procedures for the filing of an na
emergency grievance alleging that a resident is subject to a
substantial risk of imminent sexual abuse? (N/A if agency is
exempt from this standard.)
After receiving an emergency grievance alleging a resident is na
subject to a substantial risk of imminent sexual abuse, does the
agency immediately forward the grievance (or any portion thereof
that alleges the substantial risk of imminent sexual abuse) to a
level of review at which immediate corrective action may be
taken? (N/A if agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency provide an initial response within 48 hours? (N/A if
agency is exempt from this standard.)
After receiving an emergency grievance described above, does na
the agency issue a final agency decision within 5 calendar days?
(N/A if agency is exempt from this standard.)
Does the initial response and final agency decision document the na
agency’s determination whether the resident is in substantial risk
of imminent sexual abuse? (N/A if agency is exempt from this
standard.)
Does the initial response document the agency’s action(s) taken in na
response to the emergency grievance? (N/A if agency is exempt
from this standard.)
Does the agency’s final decision document the agency’s action(s) na
taken in response to the emergency grievance? (N/A if agency is
exempt from this standard.)
115.352
Exhaustion of administrative remedies
(g)
If the agency disciplines a resident for filing a grievance related to na
alleged sexual abuse, does it do so ONLY where the agency
demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.)
115.353 Resident access to outside confidential support services and
(a) legal representation
Does the facility provide residents with access to outside victim yes
advocates for emotional support services related to sexual abuse
by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll-free hotline
numbers where available, of local, State, or national victim
advocacy or rape crisis organizations?
Does the facility provide persons detained solely for civil yes
immigration purposes mailing addresses and telephone numbers,
including toll-free hotline numbers where available of local, State,
or national immigrant services agencies?
Does the facility enable reasonable communication between yes
residents and these organizations and agencies, in as confidential
a manner as possible?
115.353 Resident access to outside confidential support services and
(b) legal representation
Does the facility inform residents, prior to giving them access, of yes
the extent to which such communications will be monitored and
the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws?
115.353 Resident access to outside confidential support services and
(c) legal representation
Does the agency maintain or attempt to enter into memoranda of yes
understanding or other agreements with community service
providers that are able to provide residents with confidential
emotional support services related to sexual abuse?
Does the agency maintain copies of agreements or documentation yes
showing attempts to enter into such agreements?
115.353 Resident access to outside confidential support services and
(d) legal representation
Does the facility provide residents with reasonable and yes
confidential access to their attorneys or other legal
representation?
Does the facility provide residents with reasonable access to yes
parents or legal guardians?
115.354
Third-party reporting
(a)
Has the agency established a method to receive third-party yes
reports of sexual abuse and sexual harassment?
Has the agency distributed publicly information on how to report yes
sexual abuse and sexual harassment on behalf of a resident?
115.361
Staff and agency reporting duties
(a)
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding an incident of sexual abuse or
sexual harassment that occurred in a facility, whether or not it is
part of the agency?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding retaliation against residents or
staff who reported an incident of sexual abuse or sexual
harassment?
Does the agency require all staff to report immediately and yes
according to agency policy any knowledge, suspicion, or
information they receive regarding any staff neglect or violation of
responsibilities that may have contributed to an incident of sexual
abuse or sexual harassment or retaliation?
115.361
Staff and agency reporting duties
(b)
Does the agency require all staff to comply with any applicable yes
mandatory child abuse reporting laws?
115.361
Staff and agency reporting duties
(c)
Apart from reporting to designated supervisors or officials and yes
designated State or local services agencies, are staff prohibited
from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency
policy, to make treatment, investigation, and other security and
management decisions?
115.361
Staff and agency reporting duties
(d)
Are medical and mental health practitioners required to report yes
sexual abuse to designated supervisors and officials pursuant to
paragraph (a) of this section as well as to the designated State or
local services agency where required by mandatory reporting
laws?
Are medical and mental health practitioners required to inform yes
residents of their duty to report, and the limitations of
confidentiality, at the initiation of services?
115.361
Staff and agency reporting duties
(e)
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
appropriate office?
Upon receiving any allegation of sexual abuse, does the facility yes
head or his or her designee promptly report the allegation to the
alleged victim’s parents or legal guardians unless the facility has
official documentation showing the parents or legal guardians
should not be notified?
If the alleged victim is under the guardianship of the child welfare na
system, does the facility head or his or her designee promptly
report the allegation to the alleged victim’s caseworker instead of
the parents or legal guardians? (N/A if the alleged victim is not
under the guardianship of the child welfare system.)
If a juvenile court retains jurisdiction over the alleged victim, does yes
the facility head or designee also report the allegation to the
juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation?
115.361
Staff and agency reporting duties
(f)
Does the facility report all allegations of sexual abuse and sexual yes
harassment, including third-party and anonymous reports, to the
facility’s designated investigators?
115.362
Agency protection duties
(a)
When the agency learns that a resident is subject to a substantial yes
risk of imminent sexual abuse, does it take immediate action to
protect the resident?
115.363
Reporting to other confinement facilities
(a)
Upon receiving an allegation that a resident was sexually abused yes
while confined at another facility, does the head of the facility that
received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse
occurred?
Does the head of the facility that received the allegation also yes
notify the appropriate investigative agency?
115.363
Reporting to other confinement facilities
(b)
Is such notification provided as soon as possible, but no later than yes
72 hours after receiving the allegation?
115.363
Reporting to other confinement facilities
(c)
Does the agency document that it has provided such notification? yes
115.363
Reporting to other confinement facilities
(d)
Does the facility head or agency office that receives such yes
notification ensure that the allegation is investigated in
accordance with these standards?
115.364
Staff first responder duties
(a)
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Separate the alleged victim and abuser?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Request that the alleged victim not take any actions
that could destroy physical evidence, including, as appropriate,
washing, brushing teeth, changing clothes, urinating, defecating,
smoking, drinking, or eating, if the abuse occurred within a time
period that still allows for the collection of physical evidence?
Upon learning of an allegation that a resident was sexually yes
abused, is the first security staff member to respond to the report
required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as
appropriate, washing, brushing teeth, changing clothes, urinating,
defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical
evidence?
115.364
Staff first responder duties
(b)
If the first staff responder is not a security staff member, is the yes
responder required to request that the alleged victim not take any
actions that could destroy physical evidence, and then notify
security staff?
115.365
Coordinated response
(a)
Has the facility developed a written institutional plan to coordinate yes
actions among staff first responders, medical and mental health
practitioners, investigators, and facility leadership taken in
response to an incident of sexual abuse?
115.366 Preservation of ability to protect residents from contact with
(a) abusers
Are both the agency and any other governmental entities no
responsible for collective bargaining on the agency’s behalf
prohibited from entering into or renewing any collective
bargaining agreement or other agreement that limits the agency’s
ability to remove alleged staff sexual abusers from contact with
any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is
warranted?
115.367
Agency protection against retaliation
(a)
Has the agency established a policy to protect all residents and yes
staff who report sexual abuse or sexual harassment or cooperate
with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff?
Has the agency designated which staff members or departments yes
are charged with monitoring retaliation?
115.367
Agency protection against retaliation
(b)
Does the agency employ multiple protection measures for yes
residents or staff who fear retaliation for reporting sexual abuse or
sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers,
removal of alleged staff or resident abusers from contact with
victims, and emotional support services?
115.367
Agency protection against retaliation
(c)
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents or staff who reported the sexual abuse to
see if there are changes that may suggest possible retaliation by
residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor the conduct and
treatment of residents who were reported to have suffered sexual
abuse to see if there are changes that may suggest possible
retaliation by residents or staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Act promptly to remedy any
such retaliation?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident housing
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Resident program
changes?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Negative performance
reviews of staff?
Except in instances where the agency determines that a report of yes
sexual abuse is unfounded, for at least 90 days following a report
of sexual abuse, does the agency: Monitor: Reassignments of
staff?
Does the agency continue such monitoring beyond 90 days if the yes
initial monitoring indicates a continuing need?
115.367
Agency protection against retaliation
(d)
In the case of residents, does such monitoring also include yes
periodic status checks?
115.367
Agency protection against retaliation
(e)
If any other individual who cooperates with an investigation yes
expresses a fear of retaliation, does the agency take appropriate
measures to protect that individual against retaliation?
115.368
Post-allegation protective custody
(a)
Is any and all use of segregated housing to protect a resident who yes
is alleged to have suffered sexual abuse subject to the
requirements of § 115.342?
115.371
Criminal and administrative agency investigations
(a)
When the agency conducts its own investigations into allegations yes
of sexual abuse and sexual harassment, does it do so promptly,
thoroughly, and objectively? (N/A if the agency does not conduct
any form of administrative or criminal investigations of sexual
abuse or harassment. See 115.321(a).)
Does the agency conduct such investigations for all allegations, yes
including third party and anonymous reports? (N/A if the agency
does not conduct any form of administrative or criminal
investigations of sexual abuse or harassment. See 115.321(a).)
115.371
Criminal and administrative agency investigations
(b)
Where sexual abuse is alleged, does the agency use investigators yes
who have received specialized training in sexual abuse
investigations involving juvenile victims as required by 115.334?
115.371
Criminal and administrative agency investigations
(c)
Do investigators gather and preserve direct and circumstantial yes
evidence, including any available physical and DNA evidence and
any available electronic monitoring data?
Do investigators interview alleged victims, suspected yes
perpetrators, and witnesses?
Do investigators review prior reports and complaints of sexual yes
abuse involving the suspected perpetrator?
115.371
Criminal and administrative agency investigations
(d)
Does the agency always refrain from terminating an investigation yes
solely because the source of the allegation recants the allegation?
115.371
Criminal and administrative agency investigations
(e)
When the quality of evidence appears to support criminal yes
prosecution, does the agency conduct compelled interviews only
after consulting with prosecutors as to whether compelled
interviews may be an obstacle for subsequent criminal
prosecution?
115.371 Criminal and administrative agency investigations
(f)
Do agency investigators assess the credibility of an alleged victim, yes
suspect, or witness on an individual basis and not on the basis of
that individual’s status as resident or staff?
Does the agency investigate allegations of sexual abuse without yes
requiring a resident who alleges sexual abuse to submit to a
polygraph examination or other truth-telling device as a condition
for proceeding?
115.371
Criminal and administrative agency investigations
(g)
Do administrative investigations include an effort to determine yes
whether staff actions or failures to act contributed to the abuse?
Are administrative investigations documented in written reports yes
that include a description of the physical evidence and testimonial
evidence, the reasoning behind credibility assessments, and
investigative facts and findings?
115.371
Criminal and administrative agency investigations
(h)
Are criminal investigations documented in a written report that yes
contains a thorough description of the physical, testimonial, and
documentary evidence and attaches copies of all documentary
evidence where feasible?
115.371
Criminal and administrative agency investigations
(i)
Are all substantiated allegations of conduct that appears to be yes
criminal referred for prosecution?
115.371
Criminal and administrative agency investigations
(j)
Does the agency retain all written reports referenced in yes
115.371(g) and (h) for as long as the alleged abuser is
incarcerated or employed by the agency, plus five years unless
the abuse was committed by a juvenile resident and applicable
law requires a shorter period of retention?
115.371
Criminal and administrative agency investigations
(k)
Does the agency ensure that the departure of an alleged abuser yes
or victim from the employment or control of the facility or agency
does not provide a basis for terminating an investigation?
115.371
Criminal and administrative agency investigations
(m)
When an outside entity investigates sexual abuse, does the facility yes
cooperate with outside investigators and endeavor to remain
informed about the progress of the investigation? (N/A if an
outside agency does not conduct administrative or criminal sexual
abuse investigations. See 115.321(a).)
115.372
Evidentiary standard for administrative investigations
(a)
Is it true that the agency does not impose a standard higher than yes
a preponderance of the evidence in determining whether
allegations of sexual abuse or sexual harassment are
substantiated?
115.373
Reporting to residents
(a)
Following an investigation into a resident’s allegation of sexual yes
abuse suffered in the facility, does the agency inform the resident
as to whether the allegation has been determined to be
substantiated, unsubstantiated, or unfounded?
115.373
Reporting to residents
(b)
If the agency did not conduct the investigation into a resident’s yes
allegation of sexual abuse in an agency facility, does the agency
request the relevant information from the investigative agency in
order to inform the resident? (N/A if the agency/facility is
responsible for conducting administrative and criminal
investigations.)
115.373
Reporting to residents
(c)
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer posted within the resident’s unit?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The staff member is
no longer employed at the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been indicted on a charge related to
sexual abuse in the facility?
Following a resident’s allegation that a staff member has yes
committed sexual abuse against the resident, unless the agency
has determined that the allegation is unfounded or unless the
resident has been released from custody, does the agency
subsequently inform the resident whenever: The agency learns
that the staff member has been convicted on a charge related to
sexual abuse within the facility?
115.373
Reporting to residents
(d)
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been indicted on a charge related to sexual abuse
within the facility?
Following a resident’s allegation that he or she has been sexually yes
abused by another resident, does the agency subsequently inform
the alleged victim whenever: The agency learns that the alleged
abuser has been convicted on a charge related to sexual abuse
within the facility?
115.373
Reporting to residents
(e)
Does the agency document all such notifications or attempted yes
notifications?
115.376
Disciplinary sanctions for staff
(a)
Are staff subject to disciplinary sanctions up to and including yes
termination for violating agency sexual abuse or sexual
harassment policies?
115.376
Disciplinary sanctions for staff
(b)
Is termination the presumptive disciplinary sanction for staff who yes
have engaged in sexual abuse?
115.376
Disciplinary sanctions for staff
(c)
Are disciplinary sanctions for violations of agency policies relating yes
to sexual abuse or sexual harassment (other than actually
engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s
disciplinary history, and the sanctions imposed for comparable
offenses by other staff with similar histories?
115.376
Disciplinary sanctions for staff
(d)
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to: Law
enforcement agencies, unless the activity was clearly not
criminal?
Are all terminations for violations of agency sexual abuse or yes
sexual harassment policies, or resignations by staff who would
have been terminated if not for their resignation, reported to:
Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(a)
Is any contractor or volunteer who engages in sexual abuse yes
prohibited from contact with residents?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Law enforcement agencies (unless the activity was
clearly not criminal)?
Is any contractor or volunteer who engages in sexual abuse yes
reported to: Relevant licensing bodies?
115.377
Corrective action for contractors and volunteers
(b)
In the case of any other violation of agency sexual abuse or sexual yes
harassment policies by a contractor or volunteer, does the facility
take appropriate remedial measures, and consider whether to
prohibit further contact with residents?
115.378
Interventions and disciplinary sanctions for residents
(a)
Following an administrative finding that a resident engaged in yes
resident-on-resident sexual abuse, or following a criminal finding
of guilt for resident-on-resident sexual abuse, may residents be
subject to disciplinary sanctions only pursuant to a formal
disciplinary process?
115.378
Interventions and disciplinary sanctions for residents
(b)
Are disciplinary sanctions commensurate with the nature and yes
circumstances of the abuse committed, the resident’s disciplinary
history, and the sanctions imposed for comparable offenses by
other residents with similar histories?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied daily
large-muscle exercise?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident is not denied access
to any legally required educational programming or special
education services?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the agency ensure the resident receives daily visits
from a medical or mental health care clinician?
In the event a disciplinary sanction results in the isolation of a yes
resident, does the resident also have access to other programs
and work opportunities to the extent possible?
115.378
Interventions and disciplinary sanctions for residents
(c)
When determining what types of sanction, if any, should be yes
imposed, does the disciplinary process consider whether a
resident’s mental disabilities or mental illness contributed to his or
her behavior?
115.378
Interventions and disciplinary sanctions for residents
(d)
If the facility offers therapy, counseling, or other interventions yes
designed to address and correct underlying reasons or motivations
for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions?
If the agency requires participation in such interventions as a yes
condition of access to any rewards-based behavior management
system or other behavior-based incentives, does it always refrain
from requiring such participation as a condition to accessing
general programming or education?
115.378
Interventions and disciplinary sanctions for residents
(e)
Does the agency discipline a resident for sexual contact with staff yes
only upon a finding that the staff member did not consent to such
contact?
115.378
Interventions and disciplinary sanctions for residents
(f)
For the purpose of disciplinary action, does a report of sexual yes
abuse made in good faith based upon a reasonable belief that the
alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish
evidence sufficient to substantiate the allegation?
115.378
Interventions and disciplinary sanctions for residents
(g)
Does the agency always refrain from considering non-coercive yes
sexual activity between residents to be sexual abuse? (N/A if the
agency does not prohibit all sexual activity between residents.)
115.381
Medical and mental health screenings; history of sexual abuse
(a)
If the screening pursuant to § 115.341 indicates that a resident yes
has experienced prior sexual victimization, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a medical or
mental health practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(b)
If the screening pursuant to § 115.341 indicates that a resident yes
has previously perpetrated sexual abuse, whether it occurred in
an institutional setting or in the community, do staff ensure that
the resident is offered a follow-up meeting with a mental health
practitioner within 14 days of the intake screening?
115.381
Medical and mental health screenings; history of sexual abuse
(c)
Is any information related to sexual victimization or abusiveness yes
that occurred in an institutional setting strictly limited to medical
and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions,
including housing, bed, work, education, and program
assignments, or as otherwise required by Federal, State, or local
law?
115.381
Medical and mental health screenings; history of sexual abuse
(d)
Do medical and mental health practitioners obtain informed yes
consent from residents before reporting information about prior
sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18?
115.382
Access to emergency medical and mental health services
(a)
Do resident victims of sexual abuse receive timely, unimpeded yes
access to emergency medical treatment and crisis intervention
services, the nature and scope of which are determined by
medical and mental health practitioners according to their
professional judgment?
115.382
Access to emergency medical and mental health services
(b)
If no qualified medical or mental health practitioners are on duty yes
at the time a report of recent sexual abuse is made, do staff first
responders take preliminary steps to protect the victim pursuant
to § 115.362?
Do staff first responders immediately notify the appropriate yes
medical and mental health practitioners?
115.382
Access to emergency medical and mental health services
(c)
Are resident victims of sexual abuse offered timely information yes
about and timely access to emergency contraception and sexually
transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically
appropriate?
115.382
Access to emergency medical and mental health services
(d)
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(a) victims and abusers
Does the facility offer medical and mental health evaluation and, yes
as appropriate, treatment to all residents who have been
victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility?
115.383 Ongoing medical and mental health care for sexual abuse
(b) victims and abusers
Does the evaluation and treatment of such victims include, as yes
appropriate, follow-up services, treatment plans, and, when
necessary, referrals for continued care following their transfer to,
or placement in, other facilities, or their release from custody?
115.383 Ongoing medical and mental health care for sexual abuse
(c) victims and abusers
Does the facility provide such victims with medical and mental yes
health services consistent with the community level of care?
115.383 Ongoing medical and mental health care for sexual abuse
(d) victims and abusers
Are resident victims of sexually abusive vaginal penetration while yes
incarcerated offered pregnancy tests? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(e) victims and abusers
If pregnancy results from the conduct described in paragraph § yes
115.383(d), do such victims receive timely and comprehensive
information about and timely access to all lawful pregnancy-
related medical services? (N/A if all-male facility.)
115.383 Ongoing medical and mental health care for sexual abuse
(f) victims and abusers
Are resident victims of sexual abuse while incarcerated offered yes
tests for sexually transmitted infections as medically appropriate?
115.383 Ongoing medical and mental health care for sexual abuse
(g) victims and abusers
Are treatment services provided to the victim without financial yes
cost and regardless of whether the victim names the abuser or
cooperates with any investigation arising out of the incident?
115.383 Ongoing medical and mental health care for sexual abuse
(h) victims and abusers
Does the facility attempt to conduct a mental health evaluation of yes
all known resident-on-resident abusers within 60 days of learning
of such abuse history and offer treatment when deemed
appropriate by mental health practitioners?
115.386
Sexual abuse incident reviews
(a)
Does the facility conduct a sexual abuse incident review at the yes
conclusion of every sexual abuse investigation, including where
the allegation has not been substantiated, unless the allegation
has been determined to be unfounded?
115.386
Sexual abuse incident reviews
(b)
Does such review ordinarily occur within 30 days of the conclusion yes
of the investigation?
115.386
Sexual abuse incident reviews
(c)
Does the review team include upper-level management officials, yes
with input from line supervisors, investigators, and medical or
mental health practitioners?
115.386
Sexual abuse incident reviews
(d)
Does the review team: Consider whether the allegation or yes
investigation indicates a need to change policy or practice to
better prevent, detect, or respond to sexual abuse?
Does the review team: Consider whether the incident or allegation yes
was motivated by race; ethnicity; gender identity; lesbian, gay,
bisexual, transgender, or intersex identification, status, or
perceived status; gang affiliation; or other group dynamics at the
facility?
Does the review team: Examine the area in the facility where the yes
incident allegedly occurred to assess whether physical barriers in
the area may enable abuse?
Does the review team: Assess the adequacy of staffing levels in yes
that area during different shifts?
Does the review team: Assess whether monitoring technology yes
should be deployed or augmented to supplement supervision by
staff?
Does the review team: Prepare a report of its findings, including yes
but not necessarily limited to determinations made pursuant to §§
115.386(d)(1)-(d)(5), and any recommendations for improvement
and submit such report to the facility head and PREA compliance
manager?
115.386
Sexual abuse incident reviews
(e)
Does the facility implement the recommendations for yes
improvement, or document its reasons for not doing so?
115.387
Data collection
(a)
Does the agency collect accurate, uniform data for every yes
allegation of sexual abuse at facilities under its direct control
using a standardized instrument and set of definitions?
115.387
Data collection
(b)
Does the agency aggregate the incident-based sexual abuse data yes
at least annually?
115.387
Data collection
(c)
Does the incident-based data include, at a minimum, the data yes
necessary to answer all questions from the most recent version of
the Survey of Sexual Violence conducted by the Department of
Justice?
115.387
Data collection
(d)
Does the agency maintain, review, and collect data as needed yes
from all available incident-based documents, including reports,
investigation files, and sexual abuse incident reviews?
115.387
Data collection
(e)
Does the agency also obtain incident-based and aggregated data yes
from every private facility with which it contracts for the
confinement of its residents? (N/A if agency does not contract for
the confinement of its residents.)
115.387
Data collection
(f)
Does the agency, upon request, provide all such data from the na
previous calendar year to the Department of Justice no later than
June 30? (N/A if DOJ has not requested agency data.)
115.388
Data review for corrective action
(a)
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Identifying problem areas?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Taking corrective action on an
ongoing basis?
Does the agency review data collected and aggregated pursuant yes
to § 115.387 in order to assess and improve the effectiveness of
its sexual abuse prevention, detection, and response policies,
practices, and training, including by: Preparing an annual report of
its findings and corrective actions for each facility, as well as the
agency as a whole?
115.388
Data review for corrective action
(b)
Does the agency’s annual report include a comparison of the yes
current year’s data and corrective actions with those from prior
years and provide an assessment of the agency’s progress in
addressing sexual abuse?
115.388
Data review for corrective action
(c)
Is the agency’s annual report approved by the agency head and yes
made readily available to the public through its website or, if it
does not have one, through other means?
115.388
Data review for corrective action
(d)
Does the agency indicate the nature of the material redacted yes
where it redacts specific material from the reports when
publication would present a clear and specific threat to the safety
and security of a facility?
115.389
Data storage, publication, and destruction
(a)
Does the agency ensure that data collected pursuant to § 115.387 yes
are securely retained?
115.389
Data storage, publication, and destruction
(b)
Does the agency make all aggregated sexual abuse data, from yes
facilities under its direct control and private facilities with which it
contracts, readily available to the public at least annually through
its website or, if it does not have one, through other means?
115.389
Data storage, publication, and destruction
(c)
Does the agency remove all personal identifiers before making yes
aggregated sexual abuse data publicly available?
115.389
Data storage, publication, and destruction
(d)
Does the agency maintain sexual abuse data collected pursuant to yes
§ 115.387 for at least 10 years after the date of the initial
collection, unless Federal, State, or local law requires otherwise?
115.401
Frequency and scope of audits
(a)
During the prior three-year audit period, did the agency ensure yes
that each facility operated by the agency, or by a private
organization on behalf of the agency, was audited at least once?
(Note: The response here is purely informational. A "no" response
does not impact overall compliance with this standard.)
115.401
Frequency and scope of audits
(b)
Is this the first year of the current audit cycle? (Note: a “no” yes
response does not impact overall compliance with this standard.)
If this is the second year of the current audit cycle, did the agency yes
ensure that at least one-third of each facility type operated by the
agency, or by a private organization on behalf of the agency, was
audited during the first year of the current audit cycle? (N/A if this
is not the second year of the current audit cycle.)
If this is the third year of the current audit cycle, did the agency yes
ensure that at least two-thirds of each facility type operated by
the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle?
(N/A if this is not the third year of the current audit cycle.)
115.401
Frequency and scope of audits
(h)
Did the auditor have access to, and the ability to observe, all yes
areas of the audited facility?
115.401
Frequency and scope of audits
(i)
Was the auditor permitted to request and receive copies of any yes
relevant documents (including electronically stored information)?
115.401
Frequency and scope of audits
(m)
Was the auditor permitted to conduct private interviews with yes
inmates, residents, and detainees?
115.401
Frequency and scope of audits
(n)
Were inmates, residents, and detainees permitted to send yes
confidential information or correspondence to the auditor in the
same manner as if they were communicating with legal counsel?
115.403
Audit contents and findings
(f)
The agency has published on its agency website, if it has one, or yes
has otherwise made publicly available, all Final Audit Reports. The
review period is for prior audits completed during the past three
years PRECEDING THIS AUDIT. The pendency of any agency
appeal pursuant to 28 C.F.R. § 115.405 does not excuse
noncompliance with this provision. (N/A if there have been no Final
Audit Reports issued in the past three years, or, in the case of
single facility agencies, there has never been a Final Audit Report
issued.)

report_type: PREA

file_name: Florida_Dove Academy_Year2Cycle4.pdf

program_name_raw: Dove Academy

cycle: Year 2 Cycle 4