summary: PREA - Year 3 Cycle 2

raw_content:
Prison Rape Elimination Act (PREA) Audit Report
Juvenile Facilities
☐ ☒
Interim Final
Date of Report October 11, 2018
Auditor Information
Name: Shirley L. Turner Email: shirleyturner3199@comcast.net
Company Name: Correctional Management and Communications Group
Mailing Address: P. O. Box 370003 City, State, Zip: Decatur, GA 30037
Telephone: 678-895-2829 Date of Facility Visit: September 4-5, 2018
Agency Information
Name of Agency Governing Authority or Parent Agency (If Applicable)
Youth Opportunity Investments
Physical Address: 12775 Horseferry Rd., Ste. 230 City, State, Zip: Carmel, IN 46032
Mailing Address: Same as Above City, State, Zip:
Telephone: 317-587-8880 Is Agency accredited by any organization? ☐ Yes ☒ No
The Agency Is: ☐ ☒ ☐
Military Private for Profit Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Agency mission: “Youth Opportunity Investments is committed to providing high quality, evidence based, and clinically
based individualized programming for youth entrusted to our care in behavioral health, residential, and secure detention
centers. By using research based programming and providing quality education, our team is dedicated to applying
effective solutions to avoid unnecessary "deep end" consequences for children and families involved in the juvenile
justice and child welfare systems.”
Agency Website with PREA Information: www. djj.state.fl.us/partners/prison-rape-elimination-act-(prea)
Agency Chief Executive Officer
Name: Jim Hill Title: Chief Executive Officer
Email: jim.hill@youthopportunity.com Telephone: 727-800-3511, ext. 1002
Agency-Wide PREA Coordinator
Name: Joseph Nixon Title: Regional Director
1
Email: joseph.nixon@youthopportunity.com Telephone: 386-562-2290
PREA Coordinator Reports to: Number of Compliance Managers who report to the PREA
Brian Neupaver, Senior Vice President Coordinator 3
Facility Information
Name of Facility: Broward Youth Treatment Center
Physical Address: 8301 South Palm Drive, Pembroke Pines, FL 33025
Mailing Address (if different than above):
Telephone Number: 954-962-1088
The Facility Is: ☐ ☒ ☐
Military Private for Profit Private not for Profit
☐ ☐ ☐ ☐
Municipal County State Federal
Facility Type: ☐ ☒ ☐ ☐
Detention Correction Intake Other
Facility Mission: “Youth Opportunity Investments is committed to providing high quality, evidence based, and clinically
based individualized programming for youth entrusted to our care in behavioral health, residential, and secure detention
centers. By using research based programming and providing quality education, our team is dedicated to applying
effective solutions to avoid unnecessary "deep end" consequences for children and families involved in the juvenile
justice and child welfare systems.”
Facility Website with PREA Information: www. djj.state.fl.us/partners/prison-rape-elimination-act-(prea)
☐ ☒
Is this facility accredited by any other organization? Yes No
Facility Administrator/Superintendent
Name: Latoya Singletary Title: Program Director
Email: latoya.singletary@youthopportunity.com Telephone: 954-962-1088
Facility PREA Compliance Manager
Name: Same as Above Title:
Email: Telephone:
Facility Health Service Administrator
Name: Sharmen Hill-Smith Title: Registered Nurse
Email: sharman.hill-smith@youthopportunity.com Telephone: 954-962-1088
Facility Characteristics
Designated Facility Capacity: 40 Current Population of Facility: 40
2
Number of residents admitted to facility during the past 12 months 68
Number of residents admitted to facility during the past 12 months whose length of stay in the 68
facility was for 10 days or more:
Number of residents admitted to facility during the past 12 months whose length of stay in the 68
facility was for 72 hours or more:
Number of residents on date of audit who were admitted to facility prior to August 20, 2012: 0
Age Range of 13-18 Years
Population:
Average length of stay or time under supervision:
4-9 Months
Staff Secure
Facility Security Level:
Staff Secure
Resident Custody Levels:
47
Number of staff currently employed by the facility who may have contact with residents:
Number of staff hired by the facility during the past 12 months who may have contact with 47
residents:
Number of contracts in the past 12 months for services with contractors who may have contact with 3
residents:
Number of Buildings: 1 Number of Single Cell Housing Units: 0
Number of Multiple Occupancy Cell Housing Units: 10 Rooms
Number of Open Bay/Dorm Housing Units: 0
Number of Segregation Cells (Administrative and Disciplinary: 0
Description of any video or electronic monitoring technology (including any relevant information about where cameras are
placed, where the control room is, retention of video, etc.): The camera monitoring system is located in a section of
the area where administrative offices are located and the cameras are routinely monitored by staff. There are
a total of 56 cameras which are located in strategic areas within and outside of the building. The system has
the capability to store data for up to 30 days.
Medical
Type of Medical Facility: Onsite Medical Clinic
Forensic sexual assault medical exams are conducted at: Nancy J. Cotterman Center
Other
Number of volunteers and individual contractors, who may have contact with residents, currently 10
authorized to enter the facility:
Number of investigators the agency currently employs to investigate allegations of sexual abuse: 0
3
Audit Findings
Audit Narrative
The auditor’s description of the audit methodology should include a detailed description of the following
processes during the pre-onsite audit, onsite audit, and post-audit phases: documents and files reviewed,
discussions and types of interviews conducted, number of days spent on-site, observations made during the
site-review, and a detailed description of any follow-up work conducted during the post-audit phase. The
narrative should describe the techniques the auditor used to sample documentation and select interviewees,
and the auditor’s process for the site review.
The Broward Youth Treatment Center is located in Pembroke Pines, Florida and serves male
juvenile offenders. The onsite audit phase of the Prison Rape Elimination Act (PREA) audit
was conducted on September 4-5, 2018 by Shirley Turner, certified U. S. Department of
Justice PREA Auditor. The facility’s initial PREA audit was completed with a written report in
2015 while it was operated by a different contractor. The current audit was attained and
assigned to the Auditor by Correctional Management and Communications Group, LLC
(CMCG) located in Minneola, Florida.
The facility is operated by Youth Opportunity Investments, LLC through a contract with the
Florida Department of Juvenile Justice and is a residential staff secure program. The facility’s
designed capacity is 40 and there were 39 residents in the facility on the first day of the audit.
Residents between the ages of 13-18 years old are served in the facility. There are no known
existing conflicts of interest regarding completion of this audit and there were no barriers in
completing any phase of the audit.
Audit Methodology
Pre-Onsite Audit Phase
The Florida Department of Juvenile Justice (FDJJ) statewide PREA Coordinator provided
assistance to the facility administrators in preparation for the audit, including the onsite phase.
Written and verbal communication was maintained among the Program Director, FDJJ PREA
Coordinator and the PREA Auditor as needed. The Regional Director/PREA Coordinator for
Youth Opportunity Investments, LLC also provided follow-up contact with the Auditor regarding
preparation for the onsite phase of the PREA audit. The contacts provided for information
sharing regarding the site visit, data gathering and submitting documentation. The Program
Director and Assistant Program Director were familiar with the onsite audit phase including the
provision of a comprehensive site review for the Auditor and access to staff for formal and
informal interviews.
The PREA Compliance Manager’s role is served by the Program Director. It was revealed
during communication with the Program Director and FDJJ PREA Coordinator that the facility
staff had knowledge of the role of the Auditor and the PREA audit process. Several members
of the facility staff members, including the administrative staff and the agency’s PREA
Coordinator had previously participated in the PREA audit in 2015 or one conducted at another
facility.
4
The audit notice was posted prior to the onsite audit. The pictures of the posted notices were
taken with the locations identified and emailed to the Auditor. The audit notices were printed on
brightly colored paper using print that was easy to see and read. The pictures and narrative
provided in the email indicated the notices were strategically placed throughout the facility,
accessible to residents, staff, visitors, contractors, and volunteers. The notices were posted at
varying eye levels in the lobby, hallways and common areas. The posted audit notices
contained the Auditor’s contact information and information regarding confidentiality. No
correspondence was received prior to the site visit.
The audit notices were not posted upon arrival to the facility. According to the Program
Director, they were removed by residents during the holiday weekend which had just occurred
prior to the first day of the audit. The Auditor informed the Program Director to replace the
notices and for them to remain posted until a PREA report is received. There has still been no
correspondence from residents or staff at the facility during the writing of this. The original
notice was provided to the facility by the FDJJ PREA Coordinator which was provided to him
by the Auditor.
The completed PREA Pre-Audit Questionnaire, policies and procedures, and supporting
documentation were uploaded to a flash drive and mailed to the Auditor. A package of hard
copies of the information was also mailed to the Auditor. This information was received by the
Auditor prior to the site visit. An initial assessment was conducted of the information provided
and the Auditor provided an initial review or issue log to the Program Director/PREA
Compliance Manager, requesting additional information. The hard copies and the additional
documentation on the flash drive were organized by each standard, including the identified
provisions of each standard. Requested follow-up information was received prior to the site
visit and provided and explained during the site visit.
The Auditor provided the Program Director with a document by CMCG titled, “Information
Requested to Determine Staff and Residents to be Interviewed During the On-Site PREA
Audit.” The document was completed and returned to the Auditor. The document requested
the identification of staff members who served and performed in specific PREA related
specialized roles within the facility, including volunteers and contractors who have contact with
residents. The document requested a list of direct care staff and their shift assignments and a
resident population roster. Additionally, the request included information regarding residents
who may be in vulnerable categories such as disabled; limited English proficient; intersex, gay,
lesbian, bisexual and/or transgender residents; and residents housed in isolation.
The Auditor communicated with the Program Director to confirm schedules and to clarify
specialized PREA roles. As a result of the information received and a review of the resident
rosters, the Auditor developed a skeletal draft interview schedule of specialized staff and time
slots for choosing random staff and residents, including targeted resident interviews. A current
resident roster was provided to the Auditor during the first day of the site visit and an update
regarding the access to direct care staff, contractors and volunteers for interviews was also
provided.
5
The facility provided the PREA lists and information before and during the site visit that
assisted with the following determinations and interview selections:
Lists/Information Comments
Complete Resident Roster Provided during pre-audit phase; current
roster provided during the site visit.
Youthful inmates/detainees Youthful inmates/detainees are not housed
in this facility.
Residents with disabilities 4
Residents who are Limited English Proficient None Identified.
LGBTI Residents None Identified.
Residents in segregated housing No segregated housing in the facility.
Residents in Isolation Isolation is not used.
Residents who reported sexual abuse None were identified.
Residents who reported sexual victimization None Identified
during risk screening.
Staff roster for the time of the site visit. Roster provided during the onsite phase.
Specialized Staff Specialized staff was identified on interview
document sent to the facility.
Contractors who have contact with the Contractors were identified.
residents
Volunteer who has contact with the residents Volunteers identified during onsite phase.
All grievances/allegations made in the 12 No PREA related grievances were
months preceding the audit identified.
All allegations of sexual abuse and sexual There were no allegations identified for the
harassment reported for investigation in the 12 months preceding the audit.
12 months preceding the audit
Hotline calls made during the 12 months There was no indication of hotline calls
preceding the audit during the 12 months preceding the audit.
The Auditor reviewed the lists/documents provided and conferred onsite with the Program
Director/PREA Compliance Manager and Director of Case Management for clarity as needed.
As a result of the information received, the Auditor developed an interview schedule consisting
of specialized and random staff and residents.
General and specific information about the facility and its programs and services are provided
on the agency’s website including a picture of the facility and contact information. The
agency’s and FDJJ’s websites contain PREA information with the agency’s website providing a
link to the FDJJ website regarding PREA. The PREA audit report for the initial audit in 2015 is
located on FDJJ’s website. A general internet search of the facility did not reveal information
related to PREA.
Onsite Audit Phase
On the morning of the first day of the audit, the Auditor was met at the door by a direct care
staff member and instructed to sign in on the appropriate log. The staff member conducted a
search of the Auditor and the car keys were secured in a locked key box. The Auditor was
6
greeted by the Program Director/PREA Compliance Manager and an entrance meeting was
conducted in the conference room. The Auditor provided a review of the audit process, site
visit activities and the itinerary for the two-day audit period.
Upon completion of the entrance conference, a comprehensive site review of the facility was
conducted by the Program Director. The site review included all areas of the facility including
but not limited to living areas; kitchen; day rooms; offices; storage rooms; conference room;
lobby; control room; and outside grounds. Staff members were observed providing direct
supervision to the residents during classroom activities and movement between classes. The
resident population on the first day of the onsite audit was 39. The files of residents were
observed to be maintained in a secure manner, in locked file cabinets, in the locked office
when it is unoccupied.
The Auditor was provided a diagram of the physical plant during the pre-onsite phase of the
audit and was somewhat familiar with the layout of the facility. The program is housed in one
main building which includes two multiple occupancy housing units, located on the main halls
with one hall containing a single room. The remaining nine rooms house 4-5 residents. The
“Hurricane” hall contains offices; two classrooms; education testing/supplies room; laundry
room; kitchen; cafeteria; “Man Cave” where the use is part of the behavior management
system; and multi-purpose area. The “Dolphin” hall contains the medical clinic; offices;
cafeteria/multi-purpose room; control room; two classrooms; and day room area. Located on
the outside grounds is space for recreation and other activities. The recreation space contains
two basketball goals.
During the comprehensive site review, the printed notifications of the PREA site visit were not
observed posted in the areas previously identified in the pictures sent to the Auditor which
were accessible to residents, staff and visitors. The first day of the audit was the day after a
holiday weekend which is when the notices were removed by the residents, according to the
Program Director. The pictures of the notices provided to the Auditor during the pre-onsite
phase contained large enough print to make them accessible and easy to see and read. The
Program Director was informed by the Auditor to post new notices until a PREA report is
provided.
Posted signs regarding PREA information was observed posted in various areas of the facility,
including the lobby and other common areas accessible to residents, staff, visitors, and
contractors. The posted materials contained contact information for reporting allegations of
sexual abuse and sexual harassment. The posted information includes instructions on
accessing the 24/7 hotlines for reporting allegations through the abuse hotline and for
requesting advocacy services through the Nancy J. Cotterman Center located in Ft.
Lauderdale, Florida. Posters about the Nancy J. Cotterman Center are placed in the facility
and contain the advocacy services provided by the agency and information about
confidentiality, in addition to the hotline number. The posted PREA information is in English,
Spanish and Creole.
The Program Director provided documentation of correspondence with a representative of the
Nancy J. Cotterman Center requesting continued accessibility to advocacy services for
7
residents when needed. The Program Director was instructed to continue with the process of
obtaining a Memorandum of Understanding that will outline the specific services to be provided
to residents when requested although the services have been verbally stated.
Informal interviews were conducted with staff regarding resident activities and staff duties as
the site review progressed through the different areas of the facility. The site review included
the living units; classrooms; lobby; multipurpose rooms; cafeteria; offices; conference room;
outside grounds; and all areas described above as reviewed on the facility diagram. During the
comprehensive site review, the intake process was described and the daily scheduled
activities and staff supervision practices were provided by the Program Director. There were
no new admissions to the facility during the site visit.
A telephone, accessible to all residents, was observed in the large cafeteria/multi-purpose
room on the “Dolphin” hall where residents have access to call directly and report allegations
of abuse. The instructions for using the telephone are posted adjacent to it on the wall. The
telephone was tested by the Monitor and there was a lengthy wait time to connect with an
operator. Telephones in clinical staff members’ offices may also be used by residents to
access hotlines to report allegations of sexual abuse and sexual harassment or to request
advocacy services.
Signs are located adjacent to the housing units informing female staff to announce their
presence upon entering the areas. All residents interviewed stated the female staff follow the
directions of the sign and let them know when they are entering the housing unit by
announcing “female on mod/hall.” The facility does not have segregated housing and isolation
is not used.
The comprehensive site review allowed for many observations about the daily activities,
program services and operations. Visibility is enhanced with the strategic use of cameras and
it was recommended to the Program Director to increase the visibility of offices where there
are windows in doors through the removal/adjustments of objects in/on the windows. There are
no cameras in bathrooms and reasonable privacy is provided to residents when they use the
toilet, change clothes and shower. Guidelines have been posted regarding steps for staff to
follow when there are blind spots or residents are in offices where there are no cameras or
mirrors. The guidelines include but are not limited to radio communication with the control
room and other staff and office doors remaining open when a resident is in the office.
Sick Call and Grievance Forms and locked boxes are maintained in the hallway areas,
accessible to all residents. Access to writing tools needed for completing the forms is also
provided to all residents. Recommendations for signage postings were made and received
regarding indicating areas of the facility where residents were not allowed or only allowed with
staff supervision. The doors to closets and storage rooms are kept locked.
Interviews
Forty-seven staff members who may have contact with residents are currently employed at the
facility. A total of 39 residents were in the facility on the first day of the site visit. Ten residents
were interviewed after randomly selecting the names from the facility population report and site
visit inquiries regarding targeted interviews. Residents were randomly selected for interviews
8
from the resident roster, considering the make-up of the population and input by administrative
and specialized staff regarding the identified vulnerable categories. There were four targeted
interviews conducted as a result of requested information through conferring with management
and program staff.
Twelve random staff members were interviewed covering all shifts and 10 individual
specialized staff members were interviewed based on their job duties and PREA roles,
including two contractors and one volunteer. The Program Director was interviewed in the
roles of superintendent and PREA Compliance Manager. The interview in the role of PREA
Compliance Manager is included in the group of specialized staff. Although 10 individuals were
identified for specialized interviews, the specialized interviews conducted totaled 13 due to
staff members in this category serving in more than one PREA related specialized role.
The volunteer interviewed provides religious services. The contractors interviewed provide
educational services through the Broward County School Board. Interviews with residents,
staff, contractors, and the volunteer indicated their receipt of PREA training which was also
verified by a review of documentation, including training materials. Interviews were conducted
in the privacy of the conference room.
The Auditor conducted 10 random resident interviews. There were four targeted interviews
conducted. The Auditor conducted the following number of specialized staff interviews during
the onsite phase of the audit:
Category of Staff Number of Interviews
PREA Compliance Manager 1
Medical Staff 1
Mental Health Staff 1
Administrative (Human Resources) Staff 1
Intermediate or Higher-level Facility Staff (unannounced rounds) 1
Volunteers who have Contact with Residents 1
Contractors who have Contact with Residents 2
Staff who Perform Screening for Risk of Victimization and
1
Abusiveness
Staff on the Incident Review Team 1
Designated Staff Member Charged with Monitoring Retaliation 1
Intake Staff 2
Number of Specialized Staff Interviews 13
Number of Random Staff Interviews 12
Total Random and Specialized Interviews 25
Total Interviews plus Program Director (Superintendent) 26
Investigations
The facility reports no allegations of sexual abuse or sexual harassment during the past 12
months and no administrative or criminal investigations have been conducted. Administrative
investigations are conducted by the FDJJ Office of the Inspector General and there is no
9
facility-based investigator located in the facility. When it is determined an allegation is of a
criminal nature, the case is referred to the Broward County Sheriff’s Office. Allegations of
sexual abuse are also reported to and may be investigated by the Florida Department of
Children and Families.
Onsite Documentation Review
The Auditor received many examples of documentation from resident and staff files as part of
the pre-onsite audit phase. During the pre-onsite audit phase and the onsite audit phase the
Auditor collectively reviewed a sample of personnel files of the staff selected to be interviewed,
including documentation of completed criminal background checks. A sample of documents for
persons not interviewed was also examined. The PREA Pre-Audit Questionnaire, facility
policies, procedures and supporting documentation and FDJJ Policies and procedures were
reviewed prior to the site visit and while onsite
The secondary documentation reviewed included but was not limited to various forms; risk
screening instruments; PREA education and training acknowledgement forms; training
records; training curricula; checklists confirming delivery of services; sexual abuse coordinated
response plan; annual staffing plan assessment; staff schedules; evidence of unannounced
rounds; organization chart; logbook entries; letters confirming services; email correspondence;
and other documentation.
After the completion of the site visit process, an exit meeting was held in the conference room
with the Program Director, Assistant Program Director and Director of Case Management. The
exit meeting served to review the onsite process, share notes and review program strengths.
Additionally, during the exit meeting, the Auditor reviewed the recommendation for continuing
the process of obtaining a Memorandum of Understanding with the Nancy J. Cotterman
Center. The timelines for the submission of PREA reports were also discussed. The
administrators were given the opportunity to ask questions related to the audit process.
Post Onsite Audit Phase
The Auditor interviewed the Crisis Intervention Specialist of the Nancy J. Cotterman Center
and the interview confirmed the available services to residents which include but are not
limited to hotline services; crisis intervention; accompaniment through the investigative
interview; forensic medical examination by a qualified medical practitioner; and community
referrals. This information was also encompassed on the posters in the facility.
During the telephone interview, the Crisis Intervention Specialist indicated the advocacy
services will be provided upon request by the resident, facility staff or law enforcement. The
interview also revealed the provision of services to residents in the facility does not rest on
obtaining a written agreement between the facility and the advocacy agency. The Regional
Director for the facility’s agency, Youth Opportunity Investments, was also contacted regarding
the continual need to obtain a written agreement between the facility and the Nancy J.
Cotterman Center
The Auditor determined the results of the site visit confirmed all the standards were met. The
report was submitted to the FDJJ PREA Coordinator to be subsequently forwarded to the
facility.
10
Facility Characteristics
The auditor’s description of the audited facility should include details about the facility type, demographics
and size of the inmate, resident or detainee population, numbers and type of staff positions, configuration
and layout of the facility, numbers of housing units, description of housing units including any special
housing units, a description of programs and services, including food service and recreation. The auditor
should describe how these details are relevant to PREA implementation and compliance.
The Broward Youth Treatment Center is located in Pembroke Pines, Florida and serves male
juvenile offenders. The facility is a 40-bed staff secure substance abuse treatment program
operated by Youth Opportunity Investments, LLC through a contract with the Florida
Department of Juvenile Justice. The program provides gender-specific programming for
adolescent males with program components and services that address their specific needs.
The average length of stay depends on the youth’s pace of success in completing the
individualized treatment plan and goals.
A behavior management system exists that support holding the residents accountable for their
actions and to assist them in maintaining compliance with the program rules and expectations.
Residents served in the program are from 13 to 18 years old. The program provides behavioral
health services; psycho-educational groups; anger management; victim awareness; social
skills; moral development; and gang intervention. Additionally, each resident is provided
individualized mental health and substance abuse services in a trauma-focused, restraint-free
environment and participation in restorative justice programming.
The program is housed in one main building, contains a total of 10 rooms for residents which
are located on two different halls. There are nine multiple occupancy rooms and one single
room. The two halls are separated by the lobby which is the main entrance. The lobby contains
a reception area, sign-in/out station and seating for visitors. A conference room is located in the
back part of the lobby. Significant enhancements have been made to the facility’s physical plant
since the last PREA audit in 2015. The enhancements included general renovations on each
hall; dining area; resident rooms; showers; recreation area; and basketball court.
One hall or section of the building includes two classrooms; education testing and supply room;
offices; kitchen; four housing rooms; bathrooms; dayroom; and “Man Cave.” The behavior
management based “Man Cave” is used according to the level the resident is on and the items
and activities are advanced according to the level of the resident to include the playing of video
games and listening to music. The other hall or section of the building contains the clinic;
offices; dayroom; control room; cafeteria/multi-purpose room; two classrooms; laundry room; six
housing rooms; and a “Man Cave.”
Each hall has bathrooms and laundry rooms and two classrooms. The bathrooms provide the
residents with a reasonable amount of privacy for changing clothes, using the toilet, taking
showers and addressing other personal hygiene needs. There is no camera access to the
restrooms. Cameras are strategically placed inside and on the outside of the building. The
11
camera system supplements direct supervision provided by direct care staff members.
Isolation is not used at this facility.
PREA reporting information and information regarding advocacy services are posted on each
hall of the building in various spaces and in the lobby. The posters in the lobby are very large
and framed. They are very prominent and easily noticeable to visitors, volunteers and
contractors as well as residents and staff. The number to the Broward County Sheriff’s Office,
along with the other reporting numbers, is posted in the offices of treatment and program staff.
Mental health services address issues through individual and group counseling. The Clinical
Director provides oversight to the mental health section and additional staff consists of three
Therapists. A psychiatrist visits the facility every other week. Basic medical services are
provided and coordinated by the Nurse Clinical Supervisor with services also provided by an
additional Registered Nurse. The medical doctor who serves as the Designated Health
Authority visits the facility weekly. Education and vocational services are provided onsite
through the Broward County School Board. The case management staff includes the Director
of Case Management and Case Managers who are responsible for coordinating the overall
care and services for the residents. The case management section also includes one
Transition Case Manager.
The Case Managers are also primarily responsible for providing PREA education to residents
and administering the risk screening instrument. Direct care staff members are responsible for
the daily and direct supervision of residents and manage them during their daily activities. The
staff to resident ratio was observed to be met in all areas of the facility during the
comprehensive site review. Management, treatment, and supervisory staff members provide
oversite of or participation in processes and activities that contribute to the facility operations.
The resident interviews and documentation confirmed the provision of the programs and
services described. The residents indicated during the interviews, they could communicate
with their parents/guardians through telephone calls and visits. Observations during the
comprehensive site review revealed adequate space for conducting the programs and services
described and visitation. A Youth/Parent Handbook is provided to parents/guardians which
includes information regarding visitation and mail.
Summary of Audit Findings
The summary should include the number of standards exceeded, number of standards met, and number of
standards not met, along with a list of each of the standards in each category. If relevant, provide a
summarized description of the corrective action plan, including deficiencies observed, recommendations
made, actions taken by the agency, relevant timelines, and methods used by the auditor to reassess
compliance.
Auditor Note: No standard should be found to be “Not Applicable” or “NA”. A compliance determination
must be made for each standard.
Number of Standards Exceeded: 0
12
Number of Standards Met: 41
Number of Standards Not Met: 0
Summary of Corrective Action (if any)
PREVENTION PLANNING
Standard 115.311: Zero Tolerance of Sexual Abuse and Sexual Harassment;
PREA Coordinator
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.311 (a)
▪ Does the agency have a written policy mandating zero tolerance toward all forms of sexual
abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the written policy outline the agency’s approach to preventing, detecting, and responding
to sexual abuse and sexual harassment? ☒ Yes ☐ No
115.311 (b)
▪ Has the agency employed or designated an agency-wide PREA Coordinator? ☒ Yes ☐ No
▪ Is the PREA Coordinator position in the upper-level of the agency hierarchy? ☒ Yes ☐ No
▪ Does the PREA Coordinator have sufficient time and authority to develop, implement, and
oversee agency efforts to comply with the PREA standards in all of its facilities? ☒ Yes ☐ No
115.311 (c)
▪ If this agency operates more than one facility, has each facility designated a PREA compliance
manager? (N/A if agency operates only one facility.) ☒ Yes ☐ No ☐ NA
▪ Does the PREA compliance manager have sufficient time and authority to coordinate the
facility’s efforts to comply with the PREA standards? (N/A if agency operates only one facility.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
13
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documentation Reviewed:
Facility Policy 5-19, Prison Rape Elimination Act (PREA); Chapter Five: Safety and Security
FDJJ Policy 1919, Prison Rape Elimination Act (PREA) Standards Compliance
Organizational Chart
PREA Pre-Audit Questionnaire
Interviewed:
Program Director/PREA Compliance Manager
Regional Director/Youth Opportunity Investments PREA Coordinator
Random Staff
Residents
Provision (a):
An agency shall have a written policy mandating zero tolerance toward all forms of sexual abuse and
sexual harassment and outlining the agency’s approach to preventing, detecting, and responding to
such conduct.
The facility and FDJJ Policies mandate a zero-tolerance policy toward all forms of sexual abuse and
sexual harassment. The policies outline the facility’s approach to preventing, detecting, and responding
to such conduct. The policies include definitions of prohibited behaviors regarding sexual abuse and
sexual harassment and include sanctions for those found to have participated in prohibited behaviors.
Detection of sexual abuse and sexual harassment is addressed through resident education, staff
training, and intake screening for risk of sexual victimization and abusiveness. The Policies include but
are not limited to responding to sexual abuse and sexual harassment through reporting, investigations,
assessments, crisis intervention, and disciplinary sanctions for residents and staff. The facility has
additional policies that support the PREA standards, in addition to 5-19. FDJJ Policy 1919 is the
overarching PREA Policy that provides guidance to residential facilities for adhering to the PREA
Standards.
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.
Facility Policy 5-19 provides for the designation of the Program Director as the PREA Compliance
Manager. The facility’s parent agency, Youth Opportunity Investments, has designated the Regional
14
Director as the PREA Coordinator. FDJJ 1919 provides for a statewide PREA Coordinator for the
Florida Department of Juvenile Justice. The facility’s Program Director/PREA Compliance Manager
reports directly to the Regional Director. A prior interview with the Regional Director confirmed
knowledge of the PREA standards and the application of such. The Interview with the Regional
Director/PREA Coordinator confirmed the roles of the PREA Compliance Manager and the PREA
Coordinator. Additionally, the FDJJ PREA Coordinator provides support services to the facility.
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’s agency Policies provide for the designation of a PREA Compliance Manager at each
facility. The PREA Compliance Manager reports to the Regional Director who serves as the agency’s
PREA Coordinator as indicated by the organization Chart and the interviews. The interview with the
Program Director and observations revealed the time and authority to perform PREA duties. The
interview with the Regional Director also revealed the time and the authority to perform PREA duties.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard requiring a zero-tolerance policy toward sexual abuse and sexual
harassment, designation of PREA Coordinator for the agencies and a PREA Compliance Manager for
the facility.
Standard 115.312: Contracting With Other Entities for the Confinement of
Residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.312 (a)
▪ If this agency is public and it contracts for the confinement of its residents with private agencies
or other entities including other government agencies, has the agency included the entity’s
obligation to adopt and comply with the PREA standards in any new contract or contract
renewal signed on or after August 20, 2012? (N/A if the agency does not contract with private
agencies or other entities for the confinement of residents.) ☒ Yes ☐ No ☐ NA
115.312 (b)
▪ Does any new contract or contract renewal signed on or after August 20, 2012 provide for
agency contract monitoring to ensure that the contractor is complying with the PREA standards?
(N/A if the agency does not contract with private agencies or other entities for the confinement
of residents OR the response to 115.312(a)-1 is "NO".) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
15
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The facility does not contract with other entities to house its residents as confirmed by the interview with
the Program Director.
Standard 115.313: Supervision and Monitoring
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.313 (a)
▪ Does the agency ensure that each facility has developed a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility has implemented a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility has documented a staffing plan that provides for
adequate levels of staffing and, where applicable, video monitoring, to protect residents against
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: The
prevalence of substantiated and unsubstantiated incidents of sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring:
Generally accepted juvenile detention and correctional/secure residential practices?
☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
judicial findings of inadequacy? ☒ Yes ☐ No
16
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
findings of inadequacy from Federal investigative agencies? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
findings of inadequacy from internal or external oversight bodies? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: All
components of the facility’s physical plant (including “blind-spots” or areas where staff or
residents may be isolated)? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: The
composition of the resident population? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: The
number and placement of supervisory staff? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring:
Institution programs occurring on a particular shift? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
applicable State or local laws, regulations, or standards? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria
below in calculating adequate staffing levels and determining the need for video monitoring: Any
other relevant factors? ☒ Yes ☐ No
115.313 (b)
▪ Does the agency comply with the staffing plan except during limited and discrete exigent
circumstances? ☒ Yes ☐ No
▪ In circumstances where the staffing plan is not complied with, does the facility document all
deviations from the plan? (N/A if no deviations from staffing plan.) ☐ Yes ☐ No ☒ NA
115.313 (c)
▪ Does the facility maintain staff ratios of a minimum of 1:8 during resident waking hours, except
during limited and discrete exigent circumstances? (N/A only until October 1, 2017.)
☒ Yes ☐ No ☐ NA
17
▪ Does the facility maintain staff ratios of a minimum of 1:16 during resident sleeping hours,
except during limited and discrete exigent circumstances? (N/A only until October 1, 2017.)
☒ Yes ☐ No ☐ NA
▪ Does the facility fully document any limited and discrete exigent circumstances during which the
facility did not maintain staff ratios? (N/A only until October 1, 2017.) ☒ Yes ☐ No ☐ NA
▪ Does the facility ensure only security staff are included when calculating these ratios? (N/A only
until October 1, 2017.) ☒ Yes ☐ No ☐ NA
▪ Is the facility obligated by law, regulation, or judicial consent decree to maintain the staffing
ratios set forth in this paragraph? ☒ Yes ☐ No
115.313 (d)
▪ In the past 12 months, has the facility, in consultation with the agency PREA Compliance Manager,
assessed, determined, and documented whether adjustments are needed to: The staffing plan
established pursuant to paragraph (a) of this section? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Compliance
Manager, assessed, determined, and documented whether adjustments are needed to:
Prevailing staffing patterns? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Compliance
Manager, assessed, determined, and documented whether adjustments are needed to: The
facility’s deployment of video monitoring systems and other monitoring technologies? ☒ Yes
☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Compliance
Manager, assessed, determined, and documented whether adjustments are needed to: The
resources the facility has available to commit to ensure adherence to the staffing plan? ☒ Yes
☐ No
115.313 (e)
▪ Has the facility implemented a policy and practice of having intermediate-level or higher-level
supervisors conduct and document unannounced rounds to identify and deter staff sexual
abuse and sexual harassment? (N/A for non-secure facilities) ☒ Yes ☐ No ☐ NA
▪ Is this policy and practice implemented for night shifts as well as day shifts? (N/A for non-secure
facilities) ☒ Yes ☐ No ☐ NA
▪ Does the facility have a policy prohibiting staff from alerting other staff members that these
supervisory rounds are occurring, unless such announcement is related to the legitimate
operational functions of the facility? (N/A for non-secure facilities) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
18
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19, PREA
Staffing Plan
Staffing Plan Assessment
Work Schedules
Logbook Entries
PREA Pre-Audit Questionnaire
Interviews:
Assistant Program Director/Intermediate or Higher-l Level Staff
Program Director/PREA Compliance Manager
Regional Director/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.
Facility Policy 15-9 provides details for maintaining the contract staffing ratios of 1:8 during the waking
hours and 1:10 during the sleeping hours. The camera system is monitored regularly and the provisions
of the standard are taken into consideration regarding adequate staffing levels as confirmed through
the interview with the Program Director and Assistant Program Director, review of staffing plan, work
19
schedules and observations. The work schedules are based on the staffing plan and facility Policy. The
Regional Director/PREA Coordinator provides an additional review of the staffing plan intermittently and
upon request.
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.
Policy provides that in the event that the staffing ratio is unable to be maintained during exigent
circumstances, the deviation must be documented. The facility documents there have been no
deviations to the staffing plan in the past 12 months. The facility is prepared to document any
deviations from the staffing plan. Interviews and observations revealed that the hold-over system is
used when shortages occur and supports adherence to the required staff coverage.
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 facility’s contract provides for a staff to resident ratio of 1:8 during the waking hours and 1:10
during the sleeping hours which is in accordance with the contract. The ratios are maintained by staff
providing direct care to residents. The staff to resident ratio was in compliance during the site visit as
observed during the comprehensive site review. Since the last PREA audit in 2015 the average daily
number of residents has been 39. Since the last PREA audit, the average daily number of residents on
which the staffing plan was predicated is 40. The facility and FDJJ Policies provide for compliance to
the staffing plan except during limited and exigent circumstances and the deviations be documented.
Provision (d):
Whenever necessary, but no less frequently than once each year, for each facility the agency operates,
in consultation with the PREA Compliance Manager required by §115.311, the agency shall assess,
determine, and document whether adjustments are needed to:
(1) The staffing plan established pursuant to paragraph (a) of this section;
(2) Prevailing staffing patterns;
(3) The facility’s deployment of video monitoring systems and other monitoring technologies; and
(4) The resources the facility has available to commit to ensure adherence to the staffing plan.
The Policy provides that an annual assessment of the staffing plan is conducted. The Staffing Plan
Assessment is conducted annually with the latest being signed on May 22, 2018 by the PREA
Compliance Manager and the FDJJ statewide PREA Coordinator. The document reviews but is not
limited to the following areas, prevailing staffing patterns; deployment of video monitoring system; and
occurrence of unannounced rounds, aligned with this provision of the standard. No corrective actions
were identified in the Staffing Plan Assessment.
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
20
supervisory rounds are occurring, unless such announcement is related to the legitimate operational
functions of the facility.
Facility Policy provides for the occurrence of unannounced rounds conducted by management staff and
for the rounds to be documented. A review of a sample of documented unannounced rounds, support
unannounced rounds are conducted by intermediate level and higher level staff for each shift at various
times. The areas assessed during the unannounced rounds by the management staff at various times
include but are not limited to housing unit and common areas.
The interview with the Assistant Program Director indicated how she ensures that staff does not alert
other staff when she is conducting unannounced rounds, including making rounds at varying times. The
FDJJ Policy indicates staff will not alert other staff regarding the occurrence of unannounced rounds.
Staff members are not informed of the unannounced rounds and staff members are encouraged not to
alert other staff members regarding the unannounced visits.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
in compliance with this standard regarding supervision and monitoring.
Standard 115.315: Limits to Cross-Gender Viewing and Searches
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.315 (a)
▪ Does the facility always refrain from conducting any cross-gender strip or cross-gender visual
body cavity searches, except in exigent circumstances or by medical practitioners?
☒ Yes ☐ No
115.315 (b)
▪ Does the facility always refrain from conducting cross-gender pat-down searches in non-exigent
circumstances? ☒ Yes ☐ No ☐ NA
115.315 (c)
▪ Does the facility document and justify all cross-gender strip searches and cross-gender visual
body cavity searches? ☒ Yes ☐ No
▪ Does the facility document all cross-gender pat-down searches? ☒ Yes ☐ No
115.315 (d)
▪ Does the facility implement policies and procedures that enable residents to shower, perform
bodily functions, and change clothing without nonmedical staff of the opposite gender viewing
their breasts, buttocks, or genitalia, except in exigent circumstances or when such viewing is
incidental to routine cell checks? ☒ Yes ☐ No
21
▪ Does the facility require staff of the opposite gender to announce their presence when entering
a resident housing unit? ☒ Yes ☐ No
▪ In facilities (such as group homes) that do not contain discrete housing units, does the facility
require staff of the opposite gender to announce their presence when entering an area where
residents are likely to be showering, performing bodily functions, or changing clothing? (N/A for
facilities with discrete housing units) ☒ Yes ☐ No ☐ NA
115.315 (e)
▪ Does the facility always refrain from searching or physically examining transgender or intersex
residents for the sole purpose of determining the resident’s genital status? ☒ Yes ☐ No
▪ If a resident’s genital status is unknown, does the facility determine genital status during
conversations with the resident, by reviewing medical records, or, if necessary, by learning that
information as part of a broader medical examination conducted in private by a medical practitioner?
☒ Yes ☐ No
115.315 (f)
▪ Does the facility/agency train security staff in how to conduct cross-gender pat down searches
in a professional and respectful manner, and in the least intrusive manner possible, consistent
with security needs? ☒ Yes ☐ No
▪ Does the facility/agency train security staff in how to conduct searches of transgender and
intersex residents in a professional and respectful manner, and in the least intrusive manner
possible, consistent with security needs? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Facility Policy 5-3, Contraband and Search Practices
22
FDJJ Policy 1919
Training Curricula
Cross-gender and Transgender Pat Searches Training Video
Training Sign-in Sheets
Interviews:
Program Director
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.
The Policies collectively prohibit cross-gender searches of any type except in exigent circumstances or
by a medical practitioner and the exigent circumstances must be documented. There is no evidence of
cross-gender strip searches or cross-gender visual body cavity searches occurring at the facility. Based
on the review of the Pre-audit Questionnaire and according to the interviews, no such searches have
been conducted.
Provision (b):
The agency shall not conduct cross-gender pat-down searches except in exigent circumstances.
The Policy prohibits cross-gender searches except in exigent circumstances or by a medical
practitioner and the exigent circumstances must be documented. The facility provides training on how
to conduct these searches in exigent circumstances using training curricula, including PowerPoint and
video training presentations. Staff participation in the training is recorded with training sign-in sheets.
Staff interviews confirmed they are aware of the restriction of conducting cross-gender pat-down
searches except in exigent circumstances. No residents interviewed reported a female staff member
conducted a pat-down search of their body. The evidence shows cross-gender pat-down searches
have not occurred at the facility, but the facility is prepared for them to be conducted in exigent
circumstances. Staff interviews confirmed cross-gender searches would only be conducted due to
exigent circumstances. The interviews revealed the practice is that females do not perform searches of
the residents.
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.
The Policies prohibit cross-gender strip searches and cross-gender visual body cavity searches. Cross-
gender pat-down searches may be conducted only in exigent circumstances which random staff
interviews summarized as an emergency and there would be no available male staff. The Policy
indicates that in the event a cross-gender search is warranted pursuant to an emergency circumstance,
it must be approved and the justification for the search documented. The evidence shows the facility is
prepared to document and justify all cross-gender pat-down searches however the practice is that
females do not perform searches.
23
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.
Facility Policy supports and procedures have been implemented that enable residents to shower,
perform bodily functions, and change clothes without non-medical staff of the opposite gender viewing
them except in exigent circumstances or during routine room checks. Shower protocols explained by
staff detailed the practice. Staff members of the opposite gender are required to announce their
presence upon the housing units. This practice was confirmed through observation of signage
indicating such and interviews with residents and staff. No residents interviewed reported ever having
been naked in full view of female staff while showering, changing clothing, and performing bodily
functions.
The evidence shows residents shower, perform bodily functions, and change clothing without
nonmedical staff of the opposite gender viewing their breasts, buttocks, or genitalia. Based on the
review of the documentation, staff and resident interviews, and observations, the facility follows this
provision of the standard. Viewing of the cameras and staff and resident interviews confirmed that
residents are not directly viewed by staff when showering, using the toilet or changing clothes.
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.
The Policy prohibits the search of transgender or intersex residents solely for the purpose of
determining the residents’ genital status and staff interviews verified no such searches have occurred in
the past 12 months. The practice would be that if the resident’s genital status is unknown, it may be
determined during conversations with the resident, by reviewing medical records, or by learning that
information as part of a broader medical examination conducted in private by a medical practitioner.
One hundred percent of direct care staff received the training on conducting cross-gender pat-down
searches and searches of transgender and intersex residents. Staff interviews confirmed they are
aware of Policy prohibiting them from conducting a physical examination of transgender or intersex
resident solely for the purpose of determining the resident’s genital status.
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 Policy supports that staff will be trained 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 documentation and staff interviews
support the training is conducted. Training participation is documented with sign-in sheets. The
24
evidence shows staff members are trained 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.
Conclusion:
Based on the reviewed documentation and interviews with staff and residents, the Auditor has
concluded the facility follows this provision of the standard.
Standard 115.316: Residents with Disabilities and Residents who are
Limited English Proficient
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.316 (a)
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who are deaf or hard
of hearing? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who are blind or
have low vision? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who have intellectual
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who have psychiatric
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Residents who have speech
disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal
opportunity to participate in or benefit from all aspects of the agency’s efforts to prevent, detect,
and respond to sexual abuse and sexual harassment, including: Other? (if "other," please
explain in overall determination notes.) ☒ Yes ☐ No
▪ Do such steps include, when necessary, ensuring effective communication with residents who
are deaf or hard of hearing? ☒ Yes ☐ No
25
▪ Do such steps include, when necessary, providing access to interpreters who can interpret
effectively, accurately, and impartially, both receptively and expressively, using any necessary
specialized vocabulary? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Have
intellectual disabilities? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Have
limited reading skills? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that
ensure effective communication with residents with disabilities including residents who: Are
blind or have low vision? ☒ Yes ☐ No
115.316 (b)
▪ Does the agency take reasonable steps to ensure meaningful access to all aspects of the
agency’s efforts to prevent, detect, and respond to sexual abuse and sexual harassment to
residents who are limited English proficient? ☒ Yes ☐ No
▪ Do these steps include providing interpreters who can interpret effectively, accurately, and
impartially, both receptively and expressively, using any necessary specialized vocabulary?
☒ Yes ☐ No
115.316 (c)
▪ Does the agency always refrain from relying on resident interpreters, resident readers, or other
types of resident assistants except in limited circumstances where an extended delay in
obtaining an effective interpreter could compromise the resident’s safety, the performance of
first-response duties under §115.364, or the investigation of the resident’s allegations?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
26
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
Letter, Broward County Public Schools Personnel
Agreement for American Sign Language Interpreting Services
Posted List of Bilingual Staff
Posted PREA Information
Interviews:
Program Director/PREA Compliance Manager
Random Staff
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.
The Policies and a letter from Broward County Public Schools address this standard. Policies and the
letter address the provision of support services for disabled residents. The Program Director has
ensured that residents will receive 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. Policy
prohibits use of resident interpreters, resident readers, or other types of resident assistants except in
limited circumstances where an extended delay in obtaining an effective interpreter could compromise
the resident’s safety, performance of first responder duties, or the investigation of the allegations.
Random staff interviews and an interview with the Program Director confirmed this information.
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.
A Letter from the Intern Principal with Broward County Public Schools indicates assistance with
residents who are limited English proficient. The posting of the bilingual staff reaffirms to staff that
residents are not used to assist other residents. The evidence shows that each resident has an equal
27
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.
Provision (c):
The agency shall not rely on resident interpreters, resident readers, or other types of resident assistants
except in limited circumstances where an extended delay in obtaining an effective interpreter could
compromise the resident’s safety, the performance of first-response duties under § 115.364, or the
investigation of the resident’s allegations.
Policy prohibits the use of resident interpreters, resident readers or any kind of resident assistants
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
are not and have not been used to relate PREA information to or from other residents. There were no
identified residents in need of interpreter or translation services during the site visit. The posting of the
bilingual staff reaffirms to staff that residents are not used to assist other residents.
Conclusion:
Based upon the review and analysis of the evidence, the Auditor has determined the facility is
compliant with this standard regarding residents with disabilities and residents who are limited English
proficient. Residents with disabilities and who are limited English proficient will be 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.
Standard 115.317: Hiring and Promotion Decisions
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.317 (a)
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who: Has engaged in sexual abuse in a prison, jail, lockup, community confinement
facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who: Has been convicted of engaging or attempting to engage in sexual activity in the
community facilitated by force, overt or implied threats of force, or coercion, or if the victim did
not consent or was unable to consent or refuse? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with
residents who: Has been civilly or administratively adjudicated to have engaged in the activity
described in the question immediately above? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact
with residents who: Has engaged in sexual abuse in a prison, jail, lockup, community
confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)?
☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact
with residents who: Has been convicted of engaging or attempting to engage in sexual activity in
28
the community facilitated by force, overt or implied threats of force, or coercion, or if the victim
did not consent or was unable to consent or refuse? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact
with residents who: Has been civilly or administratively adjudicated to have engaged in the
activity described in the question immediately above? ☒ Yes ☐ No
115.317 (b)
▪ Does the agency consider any incidents of sexual harassment in determining whether to hire or
promote anyone, or to enlist the services of any contractor, who may have contact with
residents? ☒ Yes ☐ No
115.317 (c)
▪ Before hiring new employees, who may have contact with residents, does the agency: Perform
a criminal background records check? ☒ Yes ☐ No
▪ Before hiring new employees, who may have contact with residents, does the agency: Consult
any child abuse registry maintained by the State or locality in which the employee would work?
☒ Yes ☐ No
▪ Before hiring new employees, who may have contact with residents, does the agency:
Consistent with Federal, State, and local 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? ☒ Yes ☐ No
115.317 (d)
▪ Does the agency perform a criminal background records check before enlisting the services of
any contractor who may have contact with residents? ☒ Yes ☐ No
▪ Does the agency consult applicable child abuse registries before enlisting the services of any
contractor who may have contact with residents? ☒ Yes ☐ No
115.317 (e)
▪ Does the agency either conduct criminal background records checks at least every five years of
current employees and contractors who may have contact with residents or have in place a
system for otherwise capturing such information for current employees? ☒ Yes ☐ No
115.317 (f)
▪ Does the agency ask all applicants and employees who may have contact with residents directly
about previous misconduct described in paragraph (a) of this section in written applications or
interviews for hiring or promotions? ☒ Yes ☐ No
29
▪ Does the agency ask all applicants and employees who may have contact with residents directly
about previous misconduct described in paragraph (a) of this section in any interviews or written
self-evaluations conducted as part of reviews of current employees? ☒ Yes ☐ No
▪ Does the agency impose upon employees a continuing affirmative duty to disclose any such
misconduct? ☒ Yes ☐ No
115.317 (g)
▪ Does the agency consider material omissions regarding such misconduct, or the provision of
materially false information, grounds for termination? ☒ Yes ☐ No
115.317 (h)
▪ Unless prohibited by law, does the agency provide information on substantiated allegations of
sexual abuse or sexual harassment involving a former employee upon receiving a request from
an institutional employer for whom such employee has applied to work? (N/A if providing
information on substantiated allegations of sexual abuse or sexual harassment involving a
former employee is prohibited by law.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documentation Reviewed:
Facility Policy 5-19
FDJJ Policy, 1800, Background Screening
Personnel Files
Interview:
Assistant Program Director/Human Resources
30
Provision (a) & (f):
(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.
(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.
Facility and FDJJ Policies address hiring and promotion processes and decisions and background
checks. The background checks occur prior to employment and at least every five years thereafter, in
accordance with the standard. Ten personnel files were reviewed onsite and documents and processes
were discussed with the Assistant Program Director. The information was confirmed through a review
of the personnel files and interview with the Assistant Program Director.
The interview and review of Policies provided details about the hiring process, completion of
background checks, and the grounds for termination in accordance with the PREA standard. The forms
completed and included in the personnel files are responsive to the provisions of this standard. All
applicants are asked about any prior misconduct involving any sexual activity and the document must
be completed prior to a background check being conducted. The documentation, interview and Policies
support the facility does not hire anyone who has engaged in sexual abuse in a prison, jail, community
confinement facility, or anyone, who has used or attempted to use force in the community to engage in
sexual abuse.
Provision (b):
The agency shall consider any incidents of sexual harassment in determining whether to hire or
promote anyone, or to enlist the services of any contractor, who may have contact with residents.
The Policies support that the facility does not hire or promote anyone who has been civilly or
administratively adjudicated to have been convicted of engaging in or attempted to engage in sexual
activity by any means. The interview was aligned with the standard and the personnel documents show
the inquiries made during the application process regarding 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. Based on the
review of the personnel files, records provided during the pre-audit phase, and the interview, the facility
follows this provision of the standard.
Provisions (c) & (d):
(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
31
(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.
Policy requires background checks to occur prior to residents receiving services from contractors and
volunteers and confirmed by the interview. Best efforts are made to obtain information on prior
substantiated allegations of sexual abuse or any resignation during a pending investigation of an
allegation of sexual abuse. Based on the review of documentation and interview, the facility follows this
provision of the standard.
Provision (e):
The agency shall either conduct criminal background records checks at least every five years of current
employees and contractors who may have contact with residents or have in place a system for
otherwise capturing such information for current employees.
Initial background checks are conducted and in cooperation with the FDJJ Background Screening Unit
and state and local authorities, a background check is conducted every five years. The interview with
the Assistant Program Director and a review of Policies provide details about the hiring process,
completion of background checks, and the grounds for termination in accordance with the PREA
standard. The Auditor reviewed initial background checks and five-year background checks conducted
on identified employees.
Provision (g):
Material omissions regarding such misconduct, or the provision of materially false information, shall be
grounds for termination.
According to the interview, staff has a continuing duty to report related misconduct. This information is
provided to all new employees during orientation training conducted by the Assistant Program Director.
Policy supports that omission of sexual misconduct or providing false information will be grounds for
termination. The interview also revealed that an electronic alert from the FDJJ Background Screening
Unit is provided regarding the arrest of a staff member
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 with the Assistant Program Director revealed the facility would provide this information,
unless prohibited by law.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility
meets the provisions of the standard regarding hiring and promotion decisions.
Standard 115.318: Upgrades to Facilities and Technologies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.318 (a)
32
▪ If the agency designed or acquired any new facility or planned any substantial expansion or
modification of existing facilities, did the agency consider the effect of the design, acquisition,
expansion, or modification upon the agency’s ability to protect residents from sexual abuse?
(N/A if agency/facility has not acquired a new facility or made a substantial expansion to existing
facilities since August 20, 2012, or since the last PREA audit, whichever is later.)
☐ Yes ☐ No ☒ NA
115.318 (b)
▪ If the agency installed or updated a video monitoring system, electronic surveillance system, or
other monitoring technology, did the agency consider how such technology may enhance the
agency’s ability to protect residents from sexual abuse? (N/A if agency/facility has not installed
or updated a video monitoring system, electronic surveillance system, or other monitoring
technology since August 20, 2012, or since the last PREA audit, whichever is later.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Program Description
Interview:
Program Director
Provision (a):
When designing or acquiring any new facility or in planning any substantial expansion or modification of
existing facilities, the agency shall consider the effect of the design, acquisition, expansion, or
modification upon the agency’s ability to protect residents from sexual abuse.
Significant enhancements have been made to the facility’s physical plant which included renovation of
the living units, dining area, youth bedrooms, showers, recreation area, and basketball court. The
facility renovations combined two different facilities located under the same roof into one facility which
is currently operated as a single program. Observations, review of documentation and the interview
support the modifications considered the increase in the population for the entire building.
33
Provision (b):
When installing or updating a video monitoring system, electronic surveillance system, or other
monitoring technology, the agency shall consider how such technology may enhance the agency’s
ability to protect residents from sexual abuse.
The monitoring system supplements direct supervision provided by staff members. The interviews and
observations revealed an increase in the number of cameras to increase monitoring for the increase of
the population and to monitor movement throughout the facility. The update to the video monitoring
system was conducted since the last PREA audit in 2015 and included an addition of 26 cameras and
two DVRs. The observations and interview confirmed the upgrade to the camera system.
RESPONSIVE PLANNING
Standard 115.321: Evidence Protocol and Forensic Medical Examinations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.321 (a)
▪ If the agency is responsible for investigating allegations of sexual abuse, does the agency follow
a uniform evidence protocol that maximizes the potential for obtaining usable physical evidence
for administrative proceedings and criminal prosecutions? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.)
☒ Yes ☐ No ☐ NA
115.321 (b)
▪ Is this protocol developmentally appropriate for youth where applicable? (N/A if the
agency/facility is not responsible for conducting any form of criminal OR administrative sexual
abuse investigations.) ☒ Yes ☐ No ☐ NA
▪ Is this protocol, as appropriate, adapted from or otherwise based on the most recent edition of
the U.S. Department of Justice’s Office on Violence Against Women publication, “A National
Protocol for Sexual Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly
comprehensive and authoritative protocols developed after 2011? (N/A if the agency/facility is
not responsible for conducting any form of criminal OR administrative sexual abuse
investigations.) ☒ Yes ☐ No ☐ NA
115.321 (c)
▪ Does the agency offer all residents who experience sexual abuse access to forensic medical
examinations, whether on-site or at an outside facility, without financial cost, where evidentiarily
or medically appropriate? ☒ Yes ☐ No
▪ Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual
Assault Nurse Examiners (SANEs) where possible? ☒ Yes ☐ No
34
▪ If SAFEs or SANEs cannot be made available, is the examination performed by other qualified
medical practitioners (they must have been specifically trained to conduct sexual assault
forensic exams)? ☒ Yes ☐ No
▪ Has the agency documented its efforts to provide SAFEs or SANEs? ☒ Yes ☐ No
115.321 (d)
▪ Does the agency attempt to make available to the victim a victim advocate from a rape crisis
center? ☒ Yes ☐ No
▪ If a rape crisis center is not available to provide victim advocate services, does the agency
make available to provide these services a qualified staff member from a community-based
organization, or a qualified agency staff member? ☒ Yes ☐ No
▪ Has the agency documented its efforts to secure services from rape crisis centers?
☒ Yes ☐ No
115.321 (e)
▪ As requested by the victim, does the victim advocate, qualified agency staff member, or
qualified community-based organization staff member accompany and support the victim
through the forensic medical examination process and investigatory interviews? ☒ Yes ☐ No
▪ As requested by the victim, does this person provide emotional support, crisis intervention,
information, and referrals? ☒ Yes ☐ No
115.321 (f)
▪ If the agency itself is not responsible for investigating allegations of sexual abuse, has the
agency requested that the investigating entity follow the requirements of paragraphs (a) through
(e) of this section? (N/A if the agency/facility is responsible for conducting criminal AND
administrative sexual abuse investigations.) ☒ Yes ☐ No ☐ NA
115.321 (g)
▪ Auditor is not required to audit this provision.
115.321 (h)
▪ If the agency uses a qualified agency staff member or a qualified community-based staff
member for the purposes of this section, has the individual been screened for appropriateness
to serve in this role and received education concerning sexual assault and forensic examination
issues in general? (Check N/A if agency attempts to make a victim advocate from a rape crisis
center available to victims per 115.321(d) above.) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
35
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
FDJJ Office of Inspector General Directive 3-05, Prison Rape Elimination Act, (PREA)
FDJJ Office of Inspector General Directive 4-03, Law Enforcement
Correspondence, Nancy J. Cotterman Center
Posters and Brochure
PREA Compliance Form
Interviews:
Random Staff
Program Director
Clinical Director
Provisions (a) & (b):
(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.
(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.
The Policy indicates a uniform evidence protocol will be followed regarding investigations of sexual
abuse in accordance with the standard. The facility has a PREA Compliance Form which is provided to
law enforcement agencies regarding the PREA requirements prior to the agency conducting an
investigation. The facility has no investigators. Administrative investigations are conducted by the FDJJ
Office of Inspector General. Referrals for investigations are made to the Broward County Sheriff’s
Office when they are criminal in nature. The random staff members’ interviews confirmed awareness of
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 evidentiarily or
medically appropriate. Such examinations shall be performed by Sexual Assault Forensic Examiners
36
(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.
The facility Policy states forensic medical examinations will be conducted either onsite or at an outside
facility. The interview with the Program Director, correspondence and interview with staff at the Nancy J.
Cotterman Center indicate that a Sexual Assault Forensic Examiner (SAFE) or Sexual Assault Nurse
Examiner (SANE) will conduct the forensic medical examination. When a SAFE or SANE is not
available, a qualified medical practitioner will conduct the examination according to the facility Policy.
The communication between the Program Director and a representative from the advocacy agency and
those interviews indicate services will be provided to the facility upon request by facility staff, resident or
law enforcement. The literature about the advocacy agency supports forensic examinations will be
provided at no cost to the victim. No forensic exams have been conducted during this audit period. The
Program Director states she will continue to work on a formal written agreement for services as indicated
through the interview.
Provisions (d) & (e):
(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 confirmed to be provided when requested. The services that will be
provided to residents, as verified, include but are not limited to 24-hour hotline access; crisis intervention
services; victim/survivor follow-up; and forensic medical examinations. General information regarding
advocacy services is provided to the residents during the intake process and is posted in various areas
of the facility. Residents revealed during interviews that they are aware of the Nancy J. Cotterman
Center, the services provided and how to access those services.
Provisions (f) & (g):
(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.
The facility and Youth Opportunity Investments do not have investigators. Investigations of allegations
of sexual abuse that are criminal in nature are conducted by the Broward County Sheriff’s Office in
accordance with the agency’s policy and the provisions of the standards. Administrative investigations
37
are conducted by the Florida Department of Juvenile Investigation, Office of the Inspector General.
The Florida Department of Children and Families are also contacted regarding allegations of sexual
abuse and may conduct investigations.
Provision (h):
For the purposes of this standard, a qualified agency staff member or a qualified community-based staff
member shall be an individual who has been screened for appropriateness to serve in this role and has
received education concerning sexual assault and forensic examination issues in general.
The Clinical Director is a qualified facility staff member who may serve as an advocate for a resident
when a community-based organization is unavailable as determined by the interviews.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
in compliance with the provisions of this standard.
Standard 115.322: Policies to Ensure Referrals of Allegations for
Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.322 (a)
▪ Does the agency ensure an administrative or criminal investigation is completed for all
allegations of sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure an administrative or criminal investigation is completed for all
allegations of sexual harassment? ☒ Yes ☐ No
115.322 (b)
▪ Does the agency have a policy and practice in place to ensure that allegations of sexual abuse
or sexual harassment are referred for investigation to an agency with the legal authority to
conduct criminal investigations, unless the allegation does not involve potentially criminal
behavior? ☒ Yes ☐ No
▪ Has the agency published such policy on its website or, if it does not have one, made the policy
available through other means? ☒ Yes ☐ No
▪ Does the agency document all such referrals? ☒ Yes ☐ No
115.322 (c)
▪ If a separate entity is responsible for conducting criminal investigations, does such publication
describe the responsibilities of both the agency and the investigating entity? [N/A if the
agency/facility is responsible for criminal investigations. See 115.321(a).]
☒ Yes ☐ No ☐ NA
115.322 (d)
38
▪ Auditor is not required to audit this provision.
115.322 (e)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Office of Inspector General Directive 3-05
PREA Pre-Audit Questionnaire
Interviews:
Random Staff
Program Director
Provision (a):
The agency shall ensure that an administrative or criminal investigation is completed for all allegations
of sexual abuse and sexual harassment.
The Policy directs staff to report all allegations of sexual abuse and sexual harassment and to
document the reports. Staff members are aware of the Policy requirements as verified through their
interviews. The facility reports there is no allegation of sexual abuse. The Directive provides details
regarding referrals and conducting investigations.
Provision (b) and (c):
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
39
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.
PREA reporting information and policy are located on the both facility’s agency website and the FDJJ
website, accessible to the public. Reporting information is also posted in various areas of the facility
including but not limited to the living units and common areas. The posted information is accessible to
residents, staff, contractors and visitors. The Policy and interviews confirmed allegations of sexual
abuse and sexual harassment are investigated. Administrative investigations are conducted by the
trained agency investigators of the FDJJ Office of Inspector General. Allegations that are criminal in
nature are investigated by the Broward County Sheriff’s Office. The Florida Department of Families and
Children are also notified regarding allegations of sexual abuse. During the past 12 months there were
no allegations of sexual harassment or sexual abuse.
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 facility includes in its PREA Policy information regarding investigations and the Office of Inspector
General has Policy in place regarding conducting investigations in confinement settings.
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 at the facility.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding policies to ensure referrals of allegations for investigations.
TRAINING AND EDUCATION
Standard 115.331: Employee training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.331 (a)
▪ Does the agency train all employees who may have contact with residents on: Its zero-tolerance
policy for sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to fulfill their
responsibilities under agency sexual abuse and sexual harassment prevention, detection,
reporting, and response policies and procedures? ☒ Yes ☐ No
40
▪ Does the agency train all employees who may have contact with residents on: Residents’ right
to be free from sexual abuse and sexual harassment ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The right of
residents and employees to be free from retaliation for reporting sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The dynamics of
sexual abuse and sexual harassment in juvenile facilities? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The common
reactions of juvenile victims of sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to detect
and respond to signs of threatened and actual sexual abuse and how to distinguish between
consensual sexual contact and sexual abuse between residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to avoid
inappropriate relationships with residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to
communicate effectively and professionally with residents, including lesbian, gay, bisexual,
transgender, intersex, or gender nonconforming residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to comply
with relevant laws related to mandatory reporting of sexual abuse to outside authorities?
☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: Relevant laws
regarding the applicable age of consent? ☒ Yes ☐ No
115.331 (b)
▪ Is such training tailored to the unique needs and attributes of residents of juvenile facilities?
☒ Yes ☐ No
▪ Is such training tailored to the gender of the residents at the employee’s facility? ☒ Yes ☐ No
▪ Have employees received additional training if reassigned from a facility that houses only male
residents to a facility that houses only female residents, or vice versa? ☒ Yes ☐ No
115.331 (c)
▪ Have all current employees who may have contact with residents received such training?
☒ Yes ☐ No
▪ Does the agency provide each employee with refresher training every two years to ensure that
all employees know the agency’s current sexual abuse and sexual harassment policies and
procedures? ☒ Yes ☐ No
41
▪ In years in which an employee does not receive refresher training, does the agency provide
refresher information on current sexual abuse and sexual harassment policies? ☒ Yes ☐ No
115.331 (d)
▪ Does the agency document, through employee signature or electronic verification, that
employees understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Training Curricula
Training Video
Training Sign-In Sheets
Electronic Training Records
Training Acknowledgement Statements
Interviews:
Random Staff
Program Director
Provisions (a) and (c):
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;
42
(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.
(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 facility Policy addresses 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 refresher training is also
conducted and is documented. All random staff interviewed and the Program Director reported the
training is provided as required. All direct care staff members interviewed and document review verified
the general topics in this standard provision were included in the training. The training records and
interviews confirm the training occurs.
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 males and the training considers the needs of the population as determined by a
review of training curricula and interviews with random staff.
Provision (d):
The agency shall document, through employee signature or electronic verification that employees
understand the training they have received.
The Policy provides all training be documented. Training is documented in different ways, sign-in
sheets, acknowledgement statements, certificates, and electronic records. The Auditor reviewed
several examples for verification of the training occurring and the training was verified through staff
interviews. The facility follows this provision of the standard.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
in compliance with the provisions of this standard.
Standard 115.332: Volunteer and Contractor Training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.332 (a)
43
▪ Has the agency ensured that all volunteers and contractors who have contact with residents
have been trained on their responsibilities under the agency’s sexual abuse and sexual
harassment prevention, detection, and response policies and procedures? ☒ Yes ☐ No
115.332 (b)
▪ Have all volunteers and contractors who have contact with residents been notified of the
agency’s zero-tolerance policy regarding sexual abuse and sexual harassment and informed
how to report such incidents (the level and type of training provided to volunteers and
contractors shall be based on the services they provide and level of contact they have with
residents)? ☒ Yes ☐ No
115.332 (c)
▪ Does the agency maintain documentation confirming that volunteers and contractors
understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Training Acknowledgement Statements
Training Curriculum
Interviews:
Contractors (2)
Volunteer
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.
44
The facility Policy requires volunteers and contractors who have contact with residents, be trained on
PREA and their responsibilities regarding sexual assault prevention, detection, and response to
allegations of sexual abuse and sexual harassment. Interviews with contractors and a volunteer verified
the training occurs and is based on their job responsibilities. A review of training records and interviews
document the training occurs. A review of the curriculum verified the training exists for volunteers and
contractors.
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.
A review of the training curriculum and interviews with the Program Director, volunteer and contractors
revealed the PREA training informs the participants of their role in reporting allegations of sexual abuse
and sexual harassment. The contractors and volunteers 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 contractors and volunteers. The contractors and volunteer revealed their
awareness of the facility’s zero-tolerance policy regarding sexual abuse and sexual harassment of
residents.
Provision (c):
The agency shall maintain documentation confirming that volunteers and contractors understand the
training they have received.
Acknowledgement statements, training curriculum, and/or interviews document the training occurs for
contractors and volunteers.
Conclusion:
The Auditor has determined the facility is compliant with the provisions of this standard regarding
volunteer and contractor training.
Standard 115.333: Resident Education
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.333 (a)
▪ During intake, do residents receive information explaining the agency’s zero-tolerance policy
regarding sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ During intake, do residents receive information explaining how to report incidents or suspicions
of sexual abuse or sexual harassment? ☒ Yes ☐ No
▪ Is this information presented in an age-appropriate fashion? ☒ Yes ☐ No
115.333 (b)
45
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Their rights to be free from sexual abuse
and sexual harassment? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Their rights to be free from retaliation for
reporting such incidents? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to
residents either in person or through video regarding: Agency policies and procedures for
responding to such incidents? ☒ Yes ☐ No
115.333 (c)
▪ Have all residents received such education? ☒ Yes ☐ No
▪ Do residents receive education upon transfer to a different facility to the extent that the policies
and procedures of the resident’s new facility differ from those of the previous facility?
☒ Yes ☐ No
115.333 (d)
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are limited English proficient? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are deaf? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are visually impaired? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Are otherwise disabled? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including
those who: Have limited reading skills? ☒ Yes ☐ No
115.333 (e)
▪ Does the agency maintain documentation of resident participation in these education sessions?
☒ Yes ☐ No
115.333 (f)
▪ In addition to providing such education, does the agency ensure that key information is
continuously and readily available or visible to residents through posters, resident handbooks,
or other written formats? ☒ Yes ☐ No
46
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
PREA Education Novels
Youth/Parent Handbook
PREA Education Acknowledgement Statements
Town Meeting PREA Education Sessions Sign-In Sheets
Interviews:
Residents
Case Managers/Intake Staff (2)
Program Director
Provisions (a) and (b):
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.
Facility Policy provides that all residents admitted to the facility 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. The Case Managers who provide PREA education to residents
and the residents interviewed confirmed PREA education sessions occur during the intake process and
periodically during the resident’s stay. The orientation and refresher information provided to residents is
age-appropriate, based on staff and resident interviews and review of the material. Documentation of
resident signatures, along with the staff and resident interviews, confirm PREA education is provided to
residents periodically during Town Hall Meetings.
The interviews with the Case Managers revealed they ensure residents are educated regarding their
rights to be free from sexual abuse and sexual harassment and freedom from retaliation for reporting
such incidents. The PREA education sessions include a review of the PREA brochure and general
47
information. The residents sign acknowledgement statements confirming their receipt of the PREA
education. A review of documentation showing dates and indicating residents’ participation in PREA
education sessions and interviews with the Case Managers confirmed the PREA education sessions
occur. The interviews with residents also validated that PREA education sessions occur with residents.
The PREA related information is provided to staff in policies and procedures, training and staff
meetings.
Provision (c):
Current residents who have not received such education shall be educated within one year of the
effective date of the PREA standards, and shall receive education upon transfer to a different facility to
the extent that the policies and procedures of the resident’s new facility differ from those of the previous
facility.
Based on the evidence shown in provisions (a) and (b) and interviews, all residents receive PREA
education during the intake process and during Town Hall Meetings.
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. Resource documentation was reviewed of for the provision of accommodations and
supportive services for residents in the aforementioned areas. PREA information is available in English,
Spanish, Creole, which may be the prominent languages of the facility population at some times. The
agency has arrangements for the use of staff and the education unit for interpreting and translation
services. Staff interviews confirmed residents are not used as translators or readers for other residents.
During the resident interviews, general information about PREA was provided.
Provision (e):
The agency shall maintain documentation of resident participation in these education sessions.
A sample of signed acknowledgement statements were reviewed which supported the residents’
involvement in PREA education sessions and sign-in sheets for Town Hall Meetings were reviewed.
The residents were aware of general 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 Case Managers were interviewed regarding PREA education for residents.
The Case Managers and the Director of Case Management ensure residents’ receipt of the PREA
information.
Provision (f):
In addition to providing such education, the agency shall ensure that key information is continuously
and readily available or visible to residents through posters, resident handbooks, or other written
formats.
The PREA education materials provide residents information on how to report allegations of sexual
harassment and sexual abuse. A brochure is provided to each resident to assist in eliminating incidents
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 in different was such as telling a staff member; telling a family member who may report the
48
allegation for them; access to the hotlines to report allegations of sexual abuse or sexual harassment;
and may complete a grievance form or medical request form. Each resident is provided a handbook
which contains information regarding reporting allegations of sexual abuse and sexual harassment.
Posters were observed placed throughout the facility and were easy to see and read.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with the provision of this standard.
Standard 115.334: Specialized Training: Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.334 (a)
▪ In addition to the general training provided to all employees pursuant to §115.331, does the
agency ensure that, to the extent the agency itself conducts sexual abuse investigations, its
investigators have received training in conducting such investigations in confinement settings?
[N/A if the agency does not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).] ☐ Yes ☐ No ☒ NA
115.334 (b)
▪ Does this specialized training include: Techniques for interviewing juvenile sexual abuse
victims? [N/A if the agency does not conduct any form of administrative or criminal sexual abuse
investigations. See 115.321(a).] ☐ Yes ☐ No ☒ NA
▪ Does this specialized training include: Proper use of Miranda and Garrity warnings? [N/A if the
agency does not conduct any form of administrative or criminal sexual abuse investigations.
See 115.321(a).] ☐ Yes ☐ No ☒ NA
▪ Does this specialized training include: Sexual abuse evidence collection in confinement
settings? [N/A if the agency does not conduct any form of administrative or criminal sexual
abuse investigations. See 115.321(a).] ☐ Yes ☐ No ☒ NA
▪ Does this specialized training include: The criteria and evidence required to substantiate a case
for administrative action or prosecution referral? [N/A if the agency does not conduct any form of
administrative or criminal sexual abuse investigations. See 115.321(a).] ☐ Yes ☐ No ☒ NA
115.334 (c)
▪ Does the agency maintain documentation that agency investigators have completed the
required specialized training in conducting sexual abuse investigations? [N/A if the agency does
not conduct any form of administrative or criminal sexual abuse investigations. See 115.321(a).]
☐ Yes ☐ No ☒ NA
115.334 (d)
▪ Auditor is not required to audit this provision.
49
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documentation Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
Interviews:
Program Director
Provision (a) & (b):
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.
The facility does not have facility-based investigators and there are no investigators within Youth
Opportunity Investments to conduct investigations of allegations of sexual abuse and sexual
harassment. The Policies and interview confirmed this information. Administrative investigations are
conducted by the FDJJ Office of the Inspector General. The Florida Department of Children and
Families are also notified of allegations of sexual abuse. Allegations that are criminal in nature are
investigated by the Broward County Sheriff’s Office.
Provision (c):
The agency shall maintain documentation that agency investigators have completed the required
specialized training in conducting sexual abuse investigations.
The facility nor its parent agency has investigators. Administrative investigations are conducted by the
FDJJ Office of the Inspector General. The Florida Department of Children and Families are also notified
of allegations of sexual abuse. Allegations that are criminal in nature are investigated by the Broward
County Sheriff’s Office.
50
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 facility nor its parent agency has investigators. Administrative investigations are conducted by the
FDJJ Office of the Inspector General. The Florida Department of Children and Families are also notified
of allegations of sexual abuse. Allegations that are criminal in nature are investigated by the Broward
County Sheriff’s Office.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding specialized training for investigations.
Standard 115.335: Specialized Training: Medical and Mental Health Care
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.335 (a)
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How to detect and assess signs of
sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How to preserve physical evidence of
sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How to respond effectively and
professionally to juvenile victims of sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners
who work regularly in its facilities have been trained in: How and to whom to report allegations
or suspicions of sexual abuse and sexual harassment? ☒ Yes ☐ No
115.335 (b)
▪ If medical staff employed by the agency conduct forensic examinations, do such medical staff
receive appropriate training to conduct such examinations? (N/A if agency medical staff at the
facility do not conduct forensic exams.) ☐ Yes ☐ No ☒ NA
115.335 (c)
▪ Does the agency maintain documentation that medical and mental health practitioners have
received the training referenced in this standard either from the agency or elsewhere?
☒ Yes ☐ No
51
115.335 (d)
▪ Do medical and mental health care practitioners employed by the agency also receive training
mandated for employees by §115.331? ☒ Yes ☐ No
▪ Do medical and mental health care practitioners contracted by and volunteering for the agency
also receive training mandated for contractors and volunteers by §115.332? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documentation Reviewed:
Facility Policy 5-19
Electronic Training Records
Interviews:
Nurse Clinical Supervisor
Clinical Director
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.
The Policy and facility practice provide medical and mental health staff members receive the regular
PREA training as well as the specialized training provided through FDJJ SkillPro electronic training
system. Training records document specialized training for medical and mental health staff members.
The interviews with the Nurse Clinical Supervisor and Clinical Director and a review of training records
confirmed completion of training which includes the above provisions.
52
Provision (b):
If medical staff employed by the agency conduct forensic examinations, such medical staff shall receive
the appropriate training to conduct such examinations.
Forensic examinations are not conducted in this facility.
Provision (c):
The agency shall maintain documentation that medical and mental health practitioners have received
the training referenced in this standard either from the agency or elsewhere.
The electronic training records, training curriculum and the interviews with medical and mental health
staff confirmed receipt of the required training.
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 by training documentation and interviews.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding specialized training for medical and mental health care.
SCREENING FOR RISK OF SEXUAL VICTIMIZATION
AND ABUSIVENESS
Standard 115.341: Screening for risk of victimization and abusiveness
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.341 (a)
▪ Within 72 hours of the resident’s arrival at the facility, does the agency obtain and use
information about each resident’s personal history and behavior to reduce risk of sexual abuse
by or upon a resident? ☒ Yes ☐ No
▪ Does the agency also obtain this information periodically throughout a resident’s confinement?
☒ Yes ☐ No
115.341 (b)
▪ Are all PREA screening assessments conducted using an objective screening instrument?
☒ Yes ☐ No
115.341 (c)
53
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Prior sexual victimization or abusiveness? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Any gender nonconforming appearance or manner or identification
as lesbian, gay, bisexual, transgender, or intersex, and whether the resident may therefore be
vulnerable to sexual abuse? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Current charges and offense history? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Age? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Level of emotional and cognitive development? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Physical size and stature? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Mental illness or mental disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Intellectual or developmental disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Physical disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: The resident’s own perception of vulnerability? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to
ascertain information about: Any other specific information about individual residents that may
indicate heightened needs for supervision, additional safety precautions, or separation from
certain other residents? ☒ Yes ☐ No
115.341 (d)
▪ Is this information ascertained: Through conversations with the resident during the intake
process and medical mental health screenings? ☒ Yes ☐ No
▪ Is this information ascertained: During classification assessments? ☒ Yes ☐ No
▪ Is this information ascertained: By reviewing court records, case files, facility behavioral records,
and other relevant documentation from the resident’s files? ☒ Yes ☐ No
115.341 (e)
54
▪ Has the agency implemented appropriate controls on the dissemination within the facility of
responses to questions asked pursuant to this standard in order to ensure that sensitive
information is not exploited to the resident’s detriment by staff or other residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Vulnerability to Victimization and Sexually Aggressive Behavior (risk screening instrument)
Admission Classification Form
Interviews:
Program Director
Case Managers (2)/Staff that Perform Screening for Risk
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.
The Policy provides a risk screening occurs and the practice is that it is conducted within 24 hours upon
the youth’s arrival to the facility, which is most likely the same day of admission. A Case Manager
interviews the youth during the intake process to obtain information about his personal history and
behavior in order to reduce the risk of sexual abuse by or upon a resident. The Vulnerability to
Victimization and Sexually Aggressive Behavior (VSAB) is used as the risk screening instrument. The
Admissions Classification Form is also used to glean related information as well as document the
related information. The resident’s risk level is reassessed based on the initial screening or when new
information is received.
Samples of the screening instruments were reviewed by the Auditor. Interviews with residents
confirmed they were asked questions as outlined below during the intake process:
(1) Have you have ever been sexually abused?
55
(2) Do you identify with being gay, bisexual or transgender?
(3) Do you have any disabilities?
(4) Do you think you might be in danger of sexual abuse at the facility?
Provision (b):
Such assessments shall be conducted using an objective screening instrument.
The objective screening instrument, 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
and offense history; intellectual or developmental disabilities; and a resident’s concern regarding his
own safety. The interview and review of VSABs revealed the initial use of the instrument is conducted
upon admission to this facility’s and again when deemed necessary. Supplemental information is
gleaned from or documented on the Admission Classification Form.
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 resident’s own perception of vulnerability; and
(11) Any other specific information about individual residents that may indicate heightened needs for
supervision, additional safety precautions, or separation from certain other residents.
The Auditor reviewed the screening instrument, VSAB, and determined all factors required by this
provision of the standard are included. The interview with two Case Managers also confirmed the
administration of the screening instrument. The resident interviews also confirmed the administration of
the VSAB.
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.
According to the Case Managers, the information is ascertained through an interview, probing where
indicated. The interview with the Case Managers revealed how they ensure that the resident
understands the questions asked. Additional information is obtained through interviews with
parents/guardians. The staff and resident interviews are aligned with the Policy and this provision of the
standard. The review of the instrument and interviews confirmed the information is ascertained through
the resident interview, parent/guardian interview, and a review of the court packet. Resident interviews
revealed the instrument is used during the intake process.
56
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.
The Policy provides for appropriate controls be taken to ensure that sensitive information is protected
and not exploited. The interview revealed the information is only available to treatment staff. The
Auditor observed the files to be maintained in a secure manner and the online documents are
protected. The files are stored in locked file cabinets in locked offices.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding screening for risk of victimization and abusiveness.
Standard 115.342: Use of Screening Information
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.342 (a)
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Housing
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Bed
assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Work
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Education
Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently,
with the goal of keeping all residents safe and free from sexual abuse, to make: Program
Assignments? ☒ Yes ☐ No
115.342 (b)
▪ Are residents isolated from others only as a last resort when less restrictive measures are
inadequate to keep them and other residents safe, and then only until an alternative means of
keeping all residents safe can be arranged? ☒ Yes ☐ No
▪ During any period of isolation, does the agency always refrain from denying residents daily
large-muscle exercise? ☒ Yes ☐ No
57
▪ During any period of isolation, does the agency always refrain from denying residents any
legally required educational programming or special education services? ☒ Yes ☐ No
▪ Do residents in isolation receive daily visits from a medical or mental health care clinician?
☒ Yes ☐ No
▪ Do residents also have access to other programs and work opportunities to the extent possible?
☒ Yes ☐ No
115.342 (c)
▪ Does the agency always refrain from placing: Lesbian, gay, and bisexual residents in particular
housing, bed, or other assignments solely on the basis of such identification or status?
☒ Yes ☐ No
▪ Does the agency always refrain from placing: Transgender residents in particular housing, bed,
or other assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from placing: Intersex residents in particular housing, bed, or
other assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from considering lesbian, gay, bisexual, transgender, or
intersex identification or status as an indicator or likelihood of being sexually abusive?
☒ Yes ☐ No
115.342 (d)
▪ When deciding whether to assign a transgender or intersex resident to a facility for male or
female residents, does the agency consider on a case-by-case basis whether a placement
would ensure the resident’s health and safety, and whether a placement would present
management or security problems (NOTE: if an agency by policy or practice assigns residents
to a male or female facility on the basis of anatomy alone, that agency is not in compliance with
this standard)? ☒ Yes ☐ No
▪ When making housing or other program assignments for transgender or intersex residents,
does the agency consider on a case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would present management or security
problems? ☒ Yes ☐ No
115.342 (e)
▪ Are placement and programming assignments for each transgender or intersex resident
reassessed at least twice each year to review any threats to safety experienced by the resident?
☒ Yes ☐ No
115.342 (f)
58
▪ Are each transgender or intersex resident’s own views with respect to his or her own safety
given serious consideration when making facility and housing placement decisions and
programming assignments? ☒ Yes ☐ No
115.342 (g)
▪ Are transgender and intersex residents given the opportunity to shower separately from other
residents? ☒ Yes ☐ No
115.342 (h)
▪ If a resident is isolated pursuant to paragraph (b) of this section, does the facility clearly
document: The basis for the facility’s concern for the resident’s safety? (N/A for h and i if facility
doesn’t use isolation?) ☒ Yes ☐ No ☐ NA
▪ If a resident is isolated pursuant to paragraph (b) of this section, does the facility clearly
document: The reason why no alternative means of separation can be arranged? (N/A for h and
i if facility doesn’t use isolation?) ☒ Yes ☐ No ☐ NA
115.342 (i)
▪ In the case of each resident who is isolated as a last resort when less restrictive measures are
inadequate to keep them and other residents safe, does the facility afford a review to determine
whether there is a continuing need for separation from the general population EVERY 30
DAYS? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
VSAB screening instrument
PREA Pre-Audit Questionnaire
59
Interviews:
Residents
Program Director
Case Managers (2)
Random 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.
Facility Policy provides guidance to staff regarding the use of the information obtained from the VSAB
risk screening instrument. The staff interviews and information obtained through the administration of
the screening instrument assist in determining bed, education and other program assignments with the
goal of keeping all residents safe and meeting the needs of each resident. This information was verified
through a review of samples of the completed screening instruments.
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.
Isolation is not used in this facility. The interview with the Program Director and observations confirmed
the facility does not use isolation. According to the interviews, no residents were determined to be at
risk of sexual victimization in the 12 months preceding the audit.
Provision (c):
Lesbian, gay, bisexual, transgender, or intersex residents shall not be placed in particular housing, bed,
or other assignments solely on the basis of such identification or status, nor shall agencies consider
lesbian, gay, bisexual, transgender, or intersex identification or status as an indicator of likelihood of
being sexually abusive.
The Policies prohibit placing lesbian, bisexual, transgender, or intersex residents in specific housing or
making other assignments solely based on how the residents identify or their status. The Policy
prohibits staff 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 observed to be
reserved for transgender or intersex residents. Housing assignments will be made on a case-by-case
basis as determined through staff interviews and the Policies.
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.
The Policy supports housing and program assignments for transgender or intersex residents would be
made on a case-by-case basis and these residents would not be placed in particular or special housing
which was evident from staff interviews. There were no transgender or intersex residents in the facility
during the site visit and this audit period. The staff interviews confirmed the facility would consider on a
60
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. Based on the review of the evidence
and the interview, the evidence shows the facility follows this provision of the standard.
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.
The Policies provide that placement and programming assignments for each transgender or intersex
resident will be reassessed at least twice each year. This function would be done to review any threats
to safety experienced by the resident and the staff is aware of the requirement.
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 his own safety is taken into account through the administration of the
screening instrument and this applies to every resident. The residents confirmed in the interviews, they
are asked about their safety concerns by random and/or specialized staff and during treatment team
meetings. The staff interviews revealed staff members are aware of the related Policies.
Provision (g):
Transgender and intersex residents shall be given the opportunity to shower separately from other
residents.
The Policies support transgender or intersex residents be given the opportunity to shower separately
from other residents which is also supported by staff interviews. There were no transgender and
intersex residents during the site visit.
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.
The facility does not utilize isolation. Interviews with the Program Director/Compliance Manager,
Clinical Director and Nurse Clinical Supervisor confirmed the facility does not use isolation.
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.
Interviews with staff confirmed the facility does not used isolation. No residents were identified as being
at risk of sexual victimization in the 12 months preceding the audit.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding use of screening information. The facility uses information from
61
the risk screening required by §115.341 to inform housing, bed, work, education, and program
assignments with the goal of keeping all residents safe and free from sexual abuse. No residents who
identified as transgender or intersex were present during the audit or in the 12 months preceding the
audit.
REPORTING
Standard 115.351: Resident Reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.351 (a)
▪ Does the agency provide multiple internal ways for residents to privately report: Sexual abuse
and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report: Retaliation by
other residents or staff for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report: Staff neglect or
violation of responsibilities that may have contributed to such incidents? ☒ Yes ☐ No
115.351 (b)
▪ Does the agency also provide at least one way for residents to report sexual abuse or sexual
harassment to a public or private entity or office that is not part of the agency? ☒ Yes ☐ No
▪ Is that private entity or office able to receive and immediately forward resident reports of sexual
abuse and sexual harassment to agency officials? ☒ Yes ☐ No
▪ Does that private entity or office allow the resident to remain anonymous upon request?
☒ Yes ☐ No
▪ Are residents detained solely for civil immigration purposes provided information on how to
contact relevant consular officials and relevant officials at the Department of Homeland Security
to report sexual abuse or harassment? ☒ Yes ☐ No
115.351 (c)
▪ Do staff members accept reports of sexual abuse and sexual harassment made verbally, in
writing, anonymously, and from third parties? ☒ Yes ☐ No
▪ Do staff members promptly document any verbal reports of sexual abuse and sexual
harassment? ☒ Yes ☐ No
115.351 (d)
62
▪ Does the facility provide residents with access to tools necessary to make a written report?
☒ Yes ☐ No
▪ Does the agency provide a method for staff to privately report sexual abuse and sexual
harassment of residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
Youth/Parent Handbook
Grievance Form
Sick Call Form
Interviews:
Random Staff
Residents
Program Director
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.
The Policy addresses this standard and provides for multiple internal ways a resident may 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 reporting hotline, as confirmed by resident and staff interviews and
observations; tell staff; complete a Grievance Form; or complete a Sick Call Form.
63
Random staff interviews revealed residents may use the telephone, located in the cafeteria/multi-
purpose room or the phone in the offices of treatment staff, to report sexual abuse and sexual
harassment. There is a designated locked box and forms posted on each hall for depositing the written
forms and residents have access to writing materials as observed and stated by staff. The reporting
information was supported by the resident interviews. The telephone was tested during the
comprehensive site review and the Auditor was unable to reach an operator due to a lengthy wait
period however the phone was subsequently determined to be in working order.
The resident receives a handbook which provides PREA related information, including how to report
allegations of sexual abuse. Posters are located in the facility, visible to residents, staff, contractors,
volunteers, and visitors. Residents revealed they have contact with someone who does not work at the
facility such as a family member or other person they could report abuse to if needed. Staff members
receive information on how to report allegations of sexual abuse or sexual harassment through policies
and procedures, training, and staff meetings.
Provision (b):
The agency shall also provide at least one way for residents to report abuse or harassment to a public
or private entity or office that is not part of the agency and that is able to receive and immediately
forward resident reports of sexual abuse and sexual harassment to agency officials, allowing the
resident to remain anonymous upon request. Residents detained solely for civil immigration purposes
shall be provided information on how to contact relevant consular officials and relevant officials at the
Department of Homeland Security.
Residents may use of the emergency telephone located in the multi-purpose room to report an
allegation of sexual abuse or sexual harassment. Signs are posted explaining how to access agencies.
Random staff revealed staff could use the emergency phone to report allegations of abuse. There were
no allegations of sexual abuse reported during this audit period. Residents detained solely for civil
immigration purposes are to be provided information on how to contact relevant consular officials and
relevant officials at the Department of Homeland Security.
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 third-party reports and to
immediately document verbal reports. The residents revealed through interview their familiarity with the
provisions of reports being able to be made verbally, written, anonymously, and from third-parties. The
resident interviews demonstrated their familiarity with the various ways they may report either in
person, in writing, by phone, completing a grievance or medical request form, or through a third-party.
The residents were aware third-party reports could be made and that reports can be made
anonymously. Interviewed staff members 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.
Writing materials are readily available for residents to complete the accessible forms as observed and
indicated by the Program Director. During the site visit, the Auditor observed the accessibility of forms
and writing utensils to the residents.
64
Provision (e):
The agency shall provide a method for staff to privately report sexual abuse and sexual harassment of
residents.
The staff interviews revealed staff can privately report allegations of sexual abuse. The interviews
collectively identified the following ways a report can be made privately: use of the telephone hotline;
call 911; talk to the Program Director or Clinical Director.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding resident reporting. The residents have multiple internal ways to
privately report. The Auditor confirmed reports can be made verbally, in writing, anonymously, and from
third parties.
Standard 115.352: Exhaustion of Administrative Remedies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.352 (a)
▪ Is the agency exempt from this standard? NOTE: The agency is exempt ONLY if it does not
have administrative procedures to address resident grievances regarding sexual abuse. This
does not mean the agency is exempt simply because a resident does not have to or is not
ordinarily expected to submit a grievance to report sexual abuse. This means that as a matter of
explicit policy, the agency does not have an administrative remedies process to address sexual
abuse. ☐ Yes ☐ No ☒ NA
115.352 (b)
▪ Does the agency permit residents to submit a grievance regarding an allegation of sexual abuse
without any type of time limits? (The agency may apply otherwise-applicable time limits to any
portion of a grievance that does not allege an incident of sexual abuse.) (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency always refrain from requiring a resident to use any informal grievance process,
or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse? (N/A if agency
is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (c)
▪ Does the agency ensure that: A resident who alleges sexual abuse may submit a grievance
without submitting it to a staff member who is the subject of the complaint? (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency ensure that: Such grievance is not referred to a staff member who is the
subject of the complaint? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (d)
65
▪ Does the agency issue a final agency decision on the merits of any portion of a grievance
alleging sexual abuse within 90 days of the initial filing of the grievance? (Computation of the
90-day time period does not include time consumed by residents in preparing any administrative
appeal.) (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ If the agency determines that the 90-day timeframe is insufficient to make an appropriate
decision and claims an extension of time [the maximum allowable extension of time to respond
is 70 days per 115.352(d)(3)], does the agency notify the resident in writing of any such
extension and provide a date by which a decision will be made? (N/A if agency is exempt from
this standard.) ☐ Yes ☐ No ☒ NA
▪ At any level of the administrative process, including the final level, if the resident does not
receive a response within the time allotted for reply, including any properly noticed extension,
may a resident consider the absence of a response to be a denial at that level? (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (e)
▪ Are third parties, including fellow residents, staff members, family members, attorneys, and
outside advocates, permitted to assist residents in filing requests for administrative remedies
relating to allegations of sexual abuse? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ Are those third parties also permitted to file such requests on behalf of residents? (If a third
party, other than a parent or legal guardian, files such a request on behalf of a resident, the
facility may require as a condition of processing the request that the alleged victim agree to
have the request filed on his or her behalf, and may also require the alleged victim to personally
pursue any subsequent steps in the administrative remedy process.) (N/A if agency is exempt
from this standard.) ☐ Yes ☐ No ☒ NA
▪ If the resident declines to have the request processed on his or her behalf, does the agency
document the resident’s decision? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ Is a parent or legal guardian of a juvenile allowed to file a grievance regarding allegations of
sexual abuse, including appeals, on behalf of such juvenile? (N/A if agency is exempt from this
standard.) ☐ Yes ☐ No ☒ NA
▪ If a parent or legal guardian of a juvenile files a grievance (or an appeal) on behalf of a juvenile
regarding allegations of sexual abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her behalf? (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (f)
▪ Has the agency established procedures for the filing of an emergency grievance alleging that a
resident is subject to a substantial risk of imminent sexual abuse? (N/A if agency is exempt from
this standard.) ☐ Yes ☐ No ☒ NA
66
▪ After receiving an emergency grievance alleging a resident is subject to a substantial risk of
imminent sexual abuse, does the agency immediately forward the grievance (or any portion
thereof that alleges the substantial risk of imminent sexual abuse) to a level of review at which
immediate corrective action may be taken? (N/A if agency is exempt from this standard.).
☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance described above, does the agency provide an initial
response within 48 hours? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance described above, does the agency issue a final agency
decision within 5 calendar days? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ Does the initial response and final agency decision document the agency’s determination
whether the resident is in substantial risk of imminent sexual abuse? (N/A if agency is exempt
from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the initial response document the agency’s action(s) taken in response to the emergency
grievance? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency’s final decision document the agency’s action(s) taken in response to the
emergency grievance? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (g)
▪ If the agency disciplines a resident for filing a grievance related to alleged sexual abuse, does it
do so ONLY where the agency demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Youth/Parent Handbook
67
Interviews:
Random Staff
Program Director
Residents
Provision (a):
An agency shall be exempt from this standard if it does not have administrative procedures to address
resident grievances regarding sexual abuse.
The grievance system does not include a process for facility staff to investigate or resolve allegations of
sexual abuse. Once a grievance form is received, it is reported to the appropriate investigative entities
and an investigation may be conducted by the Florida Department of Juvenile Justice, Office of
Inspector General; Florida Department of Children and Families; or the Broward County Sheriff’s Office
when the allegation is criminal in nature. The purpose of the submission of an allegation of sexual
abuse through the grievance system provides residents and staff another avenue for ensuring the
reporting of allegations and provides staff with the opportunity to protect the resident. During this audit
period, there has not been a grievance submitted alleging sexual abuse.
Provision (b):
(1) The agency shall not impose a time limit on when a resident may submit a grievance regarding an
allegation of sexual abuse.
(2) The agency may apply otherwise-applicable time limits on any portion of a grievance that does not
allege an incident of sexual abuse.
(3) The agency shall not require a resident to use any informal grievance process, or to otherwise
attempt to resolve with staff, an alleged incident of sexual abuse.
(4) Nothing in this section shall restrict the agency’s ability to defend against a lawsuit filed by a
resident on the ground that the applicable statute of limitations has expired.
The grievance system does not include a process for facility staff to investigate or resolve allegations of
sexual abuse. Once the grievance is received, it is reported to the appropriate investigative entities and
an investigation may be conducted by the Florida Department of Juvenile Justice, Office of Inspector
General; Florida Department of Children and Families; or the Broward County Sheriff’s Office when the
allegation is criminal in nature. The purpose of the submission of an allegation of sexual abuse through
the grievance system provides residents and staff another avenue for ensuring the reporting of
allegations and provides staff with the opportunity to protect the resident. During this audit period, there
has not been a grievance submitted alleging sexual abuse.
Provision (c):
The agency shall ensure that—
(1) A resident who alleges sexual abuse may submit a grievance without submitting it to a staff member
who is the subject of the complaint, and
(2) Such grievance is not referred to a staff member who is the subject of the complaint.
The grievance system does not include a process for facility staff to investigate or resolve allegations of
sexual abuse. However, the Grievance Form provides residents with the choice of placing the
completed grievance form in the locked box or give it to staff when there is an allegation of sexual
abuse or sexual harassment. A locked grievance box is located on each hall for the secure deposit of a
resident’s grievance.
68
Provision (d):
(1) The agency shall issue a final agency decision on the merits of any portion of a grievance alleging
sexual abuse within 90 days of the initial filing of the grievance.
(2) Computation of the 90-day time period shall not include time consumed by residents in preparing
any administrative appeal.
(3) The agency may claim an extension of time to respond, of up to 70 days, if the normal time period
for response is insufficient to make an appropriate decision. The agency shall notify the resident in
writing of any such extension and provide a date by which a decision will be made.
(4) At any level of the administrative process, including the final level, if the resident does not receive a
response within the time allotted for reply, including any properly noticed extension, the resident may
consider the absence of a response to be a denial at that level.
The grievance system does not include a process for facility staff to investigate or resolve allegations of
sexual abuse. Once the grievance is received, it is reported to the appropriate investigative entities and
an investigation may be conducted by the Florida Department of Juvenile Justice, Office of Inspector
General; Florida Department of Children and Families; or the Broward County Sheriff’s Office when the
allegation is criminal in nature.
Provision (e):
(1) Third parties, including fellow residents, staff members, family members, attorneys, and outside
advocates, shall be permitted to assist residents in filing requests for administrative remedies relating to
allegations of sexual abuse, and shall also be permitted to file such requests on behalf of residents.
(2) If a third party, other than a parent or legal guardian, files such a request on behalf of a resident, the
facility may require as a condition of processing the request that the alleged victim agree to have the
request filed on his or her behalf, and may also require the alleged victim to personally pursue any
subsequent steps in the administrative remedy process.
(3) If the resident declines to have the request processed on his or her behalf, the agency shall
document the resident’s decision.
(4) A parent or legal guardian of a juvenile shall be allowed to file a grievance regarding allegations of
sexual abuse, including appeals, on behalf of such juvenile. Such a grievance shall not be conditioned
upon the juvenile agreeing to have the request filed on his or her behalf.
The grievance system does not include a process for facility staff to investigate or resolve allegations of
sexual abuse. Once the grievance is received, it is reported to the appropriate investigative entities and
an investigation may be conducted by the Florida Department of Juvenile Justice, Office of Inspector
General; Florida Department of Children and Families; or the Broward County Sheriff’s Office when the
allegation is criminal in nature.
Provision (f):
(1) The agency shall establish procedures for the filing of an emergency grievance alleging that a
resident is subject to a substantial risk of imminent sexual abuse.
(2) After receiving an emergency grievance alleging a resident is subject to a substantial risk of
imminent sexual abuse, the agency shall immediately forward the grievance (or any portion thereof that
alleges the substantial risk of imminent sexual abuse) to a level of review at which immediate corrective
action may be taken, shall provide an initial response within 48 hours, and shall issue a final agency
decision within 5 calendar days. The initial response and final agency decision shall document the
agency’s determination whether the resident is in substantial risk of imminent sexual abuse and the
action taken in response to the emergency grievance.
The resident is informed through written information on the Grievance that an initial response to an
allegation of sexual abuse or sexual harassment will be provided to the resident within 48 hours, which
69
is to inform the resident that the report has been referred for an investigation. The grievance system
does not include a process for facility staff to investigate or resolve allegations of sexual abuse. Once
the grievance is received, it is reported to the appropriate investigative entities and an investigation may
be conducted by the Florida Department of Juvenile Justice, Office of Inspector General; Florida
Department of Children and Families; or the Broward County Sheriff’s Office when the allegation is
criminal in nature.
Provision (g):
The agency may discipline a resident for filing a grievance related to alleged sexual abuse only where
the agency demonstrates that the resident filed the grievance in bad faith.
The grievance system does not include a process for facility staff to investigate or resolve allegations of
sexual abuse. Once the grievance is received, it is reported to the appropriate investigative entities and
an investigation may be conducted by the Florida Department of Juvenile Justice, Office of Inspector
General; Florida Department of Children and Families; or the Broward County Sheriff’s Office when the
allegation is criminal in nature.
Standard 115.353: Resident Access to Outside Confidential Support
Services and Legal Representation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.353 (a)
▪ Does the facility provide residents with access to outside victim advocates for emotional support
services related to sexual abuse by providing, posting, or otherwise making accessible mailing
addresses and telephone numbers, including toll-free hotline numbers where available, of local,
State, or national victim advocacy or rape crisis organizations? ☒ Yes ☐ No
▪ Does the facility provide persons detained solely for civil immigration purposes mailing
addresses and telephone numbers, including toll-free hotline numbers where available of local,
State, or national immigrant services agencies? ☒ Yes ☐ No
▪ Does the facility enable reasonable communication between residents and these organizations
and agencies, in as confidential a manner as possible? ☒ Yes ☐ No
115.353 (b)
▪ Does the facility inform residents, prior to giving them access, of the extent to which such
communications will be monitored and the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws? ☒ Yes ☐ No
115.353 (c)
▪ Does the agency maintain or attempt to enter into memoranda of understanding or other
agreements with community service providers that are able to provide residents with confidential
emotional support services related to sexual abuse? ☒ Yes ☐ No
70
▪ Does the agency maintain copies of agreements or documentation showing attempts to enter
into such agreements? ☒ Yes ☐ No
115.353 (d)
▪ Does the facility provide residents with reasonable and confidential access to their attorneys or
other legal representation? ☒ Yes ☐ No
▪ Does the facility provide residents with reasonable access to parents or legal guardians?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Correspondence Memos
Posted Information
Interviews:
Residents
Program Director
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 for advocacy services is a part of the PREA education sessions. Information is also
provided through signs and posters in various parts of the facility. The resident interviews revealed
71
consistency of information regarding the services that can be provided by the advocacy agency. The
hotline telephone was observed and the contact information for services from the agencies was posted.
The telephone was tested and determined to be in working order; there was just a long wait period to
communicate with an operator.
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.
There are posters on the wall about the advocacy agency which contain information regarding
limitations of confidentiality. The interviews with residents confirmed the review of the limitations of
confidentiality.
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 facility has correspondence with the Nancy J. Cotterman Center and posted information regarding
the advocacy services that are available and will be provided upon request whether or not there is a
written agreement. However, the Program Director and the Regional Director/PREA Coordinator for
Youth Opportunity Investments stated they will continue to follow-up regarding the channels to get a
Memorandum of Understanding completed with the advocacy agency.
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 interviews confirmed residents have access to attorneys and probation officers and reasonable
access to their parents/legal guardians. The site review revealed areas where residents could meet
privately with a legal representative and the visitation area for visits with family members. All residents
interviewed stated family could visit and they provided the days and times of visitation and for phone
calls. A review of documentation revealed parents/guardians are provided a Youth/Parent Handbook
informing them of the details of visitation and it contains the contact information of the facility.
Residents interviewed confirmed the facility would allow them to see or talk with a lawyer lawyer or a
court representative in private. The Program Director confirmed the facility provides residents with
reasonable and confidential access to attorneys or court representatives and reasonable access to
parents/legal guardians.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding resident access to outside confidential support services and
legal representation.
Standard 115.354: Third-Party Reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
72
115.354 (a)
▪ Has the agency established a method to receive third-party reports of sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Has the agency distributed publicly information on how to report sexual abuse and sexual
harassment on behalf of a resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Posted Information
Resident/Parent Handbook
Interviews:
Random Staff
Residents
§115.354The 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.
The Policy addresses third-party reporting and interviews revealed random staff members are aware
third-party reporting of sexual abuse and sexual harassment can be done and stated they will be
accepted and reported. Staff members also stated they are to immediately document all verbal reports
received. The interviews revealed they may report allegations privately through the use of the abuse
reporting hotline or talk to the Program Director or Clinical Director. Third-party reporting information is
accessible on the FDJJ website. Residents confirmed they had someone on the outside to report
allegations of sexual abuse and sexual harassment if they needed to and these persons could make
reports for them and without giving the resident’s name.
73
The interviews with the residents revealed their knowledge of third-party reporting. The residents
identified the methods within the facility in which they may make third-party reports such as complete a
Grievance Form, report to staff or a family member, or utilize the abuse reporting hotline telephone.
Information regarding reporting is provided through observed postings located in various areas of the
facility accessible to visitors, residents, staff, contractors and volunteers and on the FDJJ website. the
Broward County Sheriff’s Office with no charges occurring and closed by the OIG as unfounded.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor determined the facility is in
compliance regarding third-party reporting. The facility provides methods for third-party reports of
sexual abuse or sexual harassment.
OFFICIAL RESPONSE FOLLOWING A RESIDENT REPORT
Standard 115.361: Staff and agency reporting duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.361 (a)
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding an incident of sexual abuse or sexual
harassment that occurred in a facility, whether or not it is part of the agency? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding retaliation against residents or staff who
reported an incident of sexual abuse or sexual harassment? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding any staff neglect or violation of responsibilities
that may have contributed to an incident of sexual abuse or sexual harassment or retaliation?
☒ Yes ☐ No
115.361 (b)
▪ Does the agency require all staff to comply with any applicable mandatory child abuse reporting
laws? ☒ Yes ☐ No
115.361 (c)
▪ Apart from reporting to designated supervisors or officials and designated State or local services
agencies, are staff prohibited from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency policy, to make treatment,
investigation, and other security and management decisions? ☒ Yes ☐ No
115.361 (d)
74
▪ Are medical and mental health practitioners required to report sexual abuse to designated
supervisors and officials pursuant to paragraph (a) of this section as well as to the designated
State or local services agency where required by mandatory reporting laws? ☒ Yes ☐ No
▪ Are medical and mental health practitioners required to inform residents of their duty to report,
and the limitations of confidentiality, at the initiation of services? ☒ Yes ☐ No
115.361 (e)
▪ Upon receiving any allegation of sexual abuse, does the facility head or his or her designee
promptly report the allegation to the appropriate office? ☒ Yes ☐ No
▪ Upon receiving any allegation of sexual abuse, does the facility head or his or her designee
promptly report the allegation to the alleged victim’s parents or legal guardians unless the facility
has official documentation showing the parents or legal guardians should not be notified?
☒ Yes ☐ No
▪ If the alleged victim is under the guardianship of the child welfare system, does the facility head
or his or her designee promptly report the allegation to the alleged victim’s caseworker instead
of the parents or legal guardians? (N/A if the alleged victim is not under the guardianship of the
child welfare system.) ☒ Yes ☐ No ☐ NA
▪ If a juvenile court retains jurisdiction over the alleged victim, does the facility head or designee
also report the allegation to the juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation? ☒ Yes ☐ No
115.361 (f)
▪ Does the facility report all allegations of sexual abuse and sexual harassment, including third-
party and anonymous reports, to the facility’s designated investigators? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
75
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
The 2017 Florida Statutes
Interviews:
Random Staff
Nurse Clinical Supervisor
Clinical Director
Program Director
Provision (a) and (b):
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.
The Policies and Florida Statutes collectively address provisions of the standard including providing all
staff immediately report any knowledge, suspicion, information, or receipt of information regarding an
incident or allegation of sexual abuse, sexual harassment or incidents of retaliation and according to
mandatory reporting laws of the State of Florida. The FDJJ trained investigators conduct administrative
investigations and allegations that are criminal in nature are referred to the Broward County Sheriff’s
Office. Allegations of sexual abuse are also reported to the child welfare agency, Florida Department of
Children and Families. Reporting according to the State’s mandatory reporting laws and the facility and
agency Policies was evident through the staff interviews which support that allegations will be made to
the appropriate authorities.
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.
The Policies 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. Staff is
expected to continue to abide by the confidentiality requirements of the facility. Interviews with staff
indicated their knowledge of the prohibition of revealing any information related to a sexual abuse
report to anyone other than to the extent necessary to make treatment, investigation, and other security
and management decisions.
Provision (d):
(1) Medical and mental health practitioners shall be required to report sexual abuse to designated
supervisors and officials pursuant to paragraph (a) of this section, as well as to the designated State or
local services agency where required by mandatory reporting laws.
(2) Such practitioners shall be required to inform residents at the initiation of services of their duty to
report and the limitations of confidentiality.
76
The medical and mental health 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. The clinical staff
interviewed revealed they are mandated reporters. They also indicated informed consent would be
documented for a resident 18 years old and over regarding reporting allegations of sexual abuse that
did not occur in an institutional setting.
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.
Agency Policy provides that reports of allegations of sexual abuse will be promptly made by the
Program Director/designee. Where there is documentation saying the parents/guardians should not be
notified, the Case Worker at the appropriate child welfare agency will be notified. The interview with the
Program Director confirmed if the resident is under the custody of a child welfare agency, the Case
Worker will be notified. This information was also verified through the review of Policies.
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.
There are no facility-based investigators and no investigators within the company. Policy provides for all
allegations to be reported to the Program Director/PREA Compliance Manager and called in to the
investigative entities. Third-party and anonymous reports received must also be reported and
documented immediately by staff, confirmed by Policy and staff interviews.
Conclusion:
The interviews revealed staff awareness of the requirements regarding the reporting duties. All staff
interviewed acknowledged they are mandated reporters and a written report must immediately follow
reported allegations or incidents. The random staff interviewed provided the reporting requirements
and that staff members are expected to document receipt of verbal reports immediately.
Standard 115.362: Agency Protection Duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.362 (a)
▪ When the agency learns that a resident is subject to a substantial risk of imminent sexual
abuse, does it take immediate action to protect the resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
77
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Grievance Form
Youth/Parent Handbook
Interviews:
Program Director
Random Staff
§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.
Facility Policy requires staff to protect the residents through implementing protective measures.
Administration of the vulnerability screening instrument provides information that assists and guide staff
in keeping residents safe through housing and program assignments. The Youth/Parent Handbook
provides information to residents and parents/guardians regarding how to report allegations and contact
information for agencies that may provide additional assistance. The interviews of the random staff and
the Program Director revealed protective measures include but are not limited to alerting the supervisor
and other staff and separating the residents including moving to a different room or hall. The Program
Director and the random staff indicated the expectation is that any action to protect a resident would be
taken immediately.
The interviews revealed there were no residents identified to be at substantial risk of imminent sexual
abuse in the past 12 months. The interviews with the residents revealed that during the intake process
they are asked about how they feel about their safety as part of the inquiries by staff completing intake
paperwork. A review of a sample of screening instruments (VSAB) supports the information provided by
residents.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding agency protection duties.
Standard 115.363: Reporting to Other Confinement Facilities
78
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.363 (a)
▪ Upon receiving an allegation that a resident was sexually abused while confined at another
facility, does the head of the facility that received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse occurred? ☒ Yes ☐ No
▪ Does the head of the facility that received the allegation also notify the appropriate investigative
agency? ☒ Yes ☐ No
115.363 (b)
▪ Is such notification provided as soon as possible, but no later than 72 hours after receiving the
allegation? ☒ Yes ☐ No
115.363 (c)
▪ Does the agency document that it has provided such notification? ☒ Yes ☐ No
115.363 (d)
▪ Does the facility head or agency office that receives such notification ensure that the allegation
is investigated in accordance with these standards? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
Interviews:
Program Director
Provisions (a), (b), (c), and (d):
79
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. (b) Such notification shall be provided as soon as possible, but no later than 72 hours after
receiving the allegation. (c)The agency shall document that it has provided such notification. (d) The
facility head or agency office that receives such notification shall ensure that the allegation is
investigated in accordance with these standards.
Policies provide that upon receiving an allegation that a resident was sexually abused while confined at
another facility, the Program Director notifies the head of the facility or appropriate office of the agency
where the alleged abuse occurred and the appropriate investigative agency. Notification should be
made as soon as possible but no longer than 72 hours after receiving the information. It must be
documented that the notification was made, as required by Policy. It is the responsibility of the receiving
agency to ensure an investigation is completed. The Program Director is familiar with the Policy and her
responsibilities regarding such.
Conclusion:
Based upon the information received and interviews, the Auditor has determined the facility is compliant
with this standard regarding reporting to other confinement facilities.
Standard 115.364: Staff First Responder Duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.364 (a)
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Separate the alleged victim and abuser?
☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence? ☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Request that the alleged victim not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
115.364 (b)
80
▪ If the first staff responder is not a security staff member, is the responder required to request
that the alleged victim not take any actions that could destroy physical evidence, and then notify
security staff? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
Training Curricula
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.
The Policy and training provide that upon learning of an allegation that a resident has been 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,
81
The interviews with staff confirmed awareness of first responder duties and the training they had been
provided. There were no allegations or incident where staff had to act as a first responder in the last 12
months.
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.
According to the Policies, non-security staff who may act as a first responder must be familiar with their
role and how to respond in that role. The duties would include alerting security or other staff and
requesting the resident not take any actions that could destroy physical evidence. During this audit
period no staff has acted as a first responder.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding staff first responder duties.
Standard 115.365: Coordinated Response
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.365 (a)
▪ Has the facility developed a written institutional plan to coordinate actions among staff first
responders, medical and mental health practitioners, investigators, and facility leadership taken
in response to an incident of sexual abuse? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
82
Facility Coordinated Response Plan
Interviews:
Random Staff
Program Director
§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.
The facility has a written Facility Coordinated Response Plan to be implemented in the event of an
allegation or incident of sexual abuse. The plan outlines the actions of the identified staff members such
as the first responder; supervisors; medical; mental health; and management. This coordinated
response to an incident of sexual abuse is also aligned with facility policy 5-19 and FDJJ 1919. Staff
members interviewed were familiar with their role regarding the response to an allegation of sexual
abuse. The interviews with staff confirmed their knowledge of their responsibilities.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility
complies with the provisions of the standard regarding a coordinated response to an incident of sexual
abuse.
Standard 115.366: Preservation of Ability to Protect Residents from Contact
with Abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.366 (a)
▪ Are both the agency and any other governmental entities responsible for collective bargaining
on the agency’s behalf prohibited from entering into or renewing any collective bargaining
agreement or other agreement that limits the agency’s ability to remove alleged staff sexual
abusers from contact with any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is warranted? ☒ Yes ☐ No
115.366 (b)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
83
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
The facility is not responsible for any collective bargaining as determined by the Pre-Audit
Questionnaire and interview with the Program Director.
Standard 115.367: Agency Protection Against Retaliation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.367 (a)
▪ Has the agency established a policy to protect all residents and staff who report sexual abuse or
sexual harassment or cooperate with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff? ☒ Yes ☐ No
▪ Has the agency designated which staff members or departments are charged with monitoring
retaliation? ☒ Yes ☐ No
115.367 (b)
▪ Does the agency employ multiple protection measures for residents or staff who fears retaliation
for reporting sexual abuse or sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers, removal of alleged staff or resident
abusers from contact with victims, and emotional support services? ☒ Yes ☐ No
115.367 (c)
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
and treatment of residents or staff who reported the sexual abuse to see if there are changes
that may suggest possible retaliation by residents or staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
and treatment of residents who were reported to have suffered sexual abuse to see if there are
changes that may suggest possible retaliation by residents or staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Act promptly to remedy
any such retaliation? ☒ Yes ☐ No
84
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Resident
housing changes? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Resident
program changes? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Negative
performance reviews of staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor:
Reassignments of staff? ☒ Yes ☐ No
▪ Does the agency continue such monitoring beyond 90 days if the initial monitoring indicates a
continuing need? ☒ Yes ☐ No
115.367 (d)
▪ In the case of residents, does such monitoring also include periodic status checks?
☒ Yes ☐ No
115.367 (e)
▪ If any other individual who cooperates with an investigation expresses a fear of retaliation, does
the agency take appropriate measures to protect that individual against retaliation?
☒ Yes ☐ No
115.367 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
85
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
PREA Retaliation Monitoring Sheet
Interviews:
Program Director
Director of Case Management/Designated Staff Member Charged with Monitoring Retaliation
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.
The Policies provide for the facility 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. The Director of Case Management is responsible for retaliation monitoring.
The interview with her confirmed she is charged with monitoring for retaliation and how it is conducted.
There have been no allegations of sexual abuse during this audit period.
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 Policies demonstrate measures to protect staff and residents which are aligned with the measures
in this provision such as the general areas:
a. Initiating housing changes or transfers for resident victims or abusers;
b. Removing alleged staff or resident abusers from contact with victims; and
c. Emotional support services.
The Case Manager’s interview was aligned with Policies and it was confirmed that the facility would
protect residents and staff from retaliation for sexual abuse and sexual harassment allegations.
Protective measures would include housing changes, transfers, shift changes removing alleged
abusers, and emotional support services.
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.
86
The Policies support the monitoring will be conducted of residents or staff who reported the sexual
abuse, and of residents, who were reported to have suffered sexual abuse for at least 90 days to see if
there are any changes that may suggest possible retaliation is occurring. It is the responsibility of the
Director of Case Management to act promptly to remedy the situation. She will also be provided support
by the Assistant Program Director and Program Director when indicated. The monitoring continues
beyond ninety (90) days, if the initial monitoring indicates a continuing need as reported by the Director
of Case Management. There have been no incidents of sexual abuse during the 12 months preceding
the audit.
Provision (d):
In the case of residents, such monitoring shall also include periodic status checks.
The Policy and the interview support that status checks would be initiated with residents where it is
warranted. The PREA Retaliation Monitoring Sheet provides for periodic status checks to be
conducted.
Provision (e):
If any other individual who cooperates with an investigation expresses a fear of retaliation, the agency
shall take appropriate measures to protect that individual against retaliation.
The Policies consider other individuals who cooperate with an investigation. The Director of Case
Management indicated she would also take appropriate measures to protect that individual against
retaliation.
Provision (f):
An agency’s obligation to monitor shall terminate if the agency determines that the allegation is
unfounded.
The policy and practice allows for the facility’s obligation to terminate, if it is determined that the
allegation is unfounded. The interviews revealed that this is understood.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding agency protection against retaliation. It is concluded that if the
facility were to have an incident of retaliation, the Director of Case Management would employ
protection measures and monitor according to the time frames required by the standard.
Standard 115.368: Post-allegation protective custody
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.368 (a)
▪ Is any and all use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse subject to the requirements of § 115.342? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
87
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
PREA Pre-Audit Questionnaire
Interviews:
Program Director
Clinical Director
Nurse Clinical Supervisor
§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.
The facility practice is that segregated housing or isolation is not used at the facility. The Program
Director, clinical staff and observations confirmed segregated housing is not used in this facility.
Conclusion:
Based upon the review and analysis of Policy, interviews, and observations, the Auditor has determined
the facility is compliant with this standard regarding post-allegation protective custody.
INVESTIGATIONS
Standard 115.371: Criminal and Administrative Agency Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.371 (a)
▪ When the agency conducts its own investigations into allegations of sexual abuse and sexual
harassment, does it do so promptly, thoroughly, and objectively? [N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.
See 115.321(a).] ☐ Yes ☐ No ☒ NA
88
▪ Does the agency conduct such investigations for all allegations, including third party and
anonymous reports? [N/A if the agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations. See 115.321(a).]
☐ Yes ☐ No ☒ NA
115.371 (b)
▪ Where sexual abuse is alleged, does the agency use investigators who have received
specialized training in sexual abuse investigations involving juvenile victims as required by
115.334? ☒ Yes ☐ No
115.371 (c)
▪ Do investigators gather and preserve direct and circumstantial evidence, including any available
physical and DNA evidence and any available electronic monitoring data? ☒ Yes ☐ No
▪ Do investigators interview alleged victims, suspected perpetrators, and witnesses?
☒ Yes ☐ No
▪ Do investigators review prior reports and complaints of sexual abuse involving the suspected
perpetrator? ☒ Yes ☐ No
115.371 (d)
▪ Does the agency always refrain from terminating an investigation solely because the source of
the allegation recants the allegation? ☒ Yes ☐ No
115.371 (e)
▪ When the quality of evidence appears to support criminal prosecution, does the agency conduct
compelled interviews only after consulting with prosecutors as to whether compelled interviews
may be an obstacle for subsequent criminal prosecution? ☒ Yes ☐ No
115.371 (f)
▪ Do agency investigators assess the credibility of an alleged victim, suspect, or witness on an
individual basis and not on the basis of that individual’s status as resident or staff?
☐ Yes ☐ No
▪ Does the agency investigate allegations of sexual abuse without requiring a resident who
alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a
condition for proceeding? ☐ Yes ☐ No
115.371 (g)
▪ Do administrative investigations include an effort to determine whether staff actions or failures to
act contributed to the abuse? ☒ Yes ☐ No
89
▪ Are administrative investigations documented in written reports that include a description of the
physical evidence and testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings? ☒ Yes ☐ No
115.371 (h)
▪ Are criminal investigations documented in a written report that contains a thorough description
of the physical, testimonial, and documentary evidence and attaches copies of all documentary
evidence where feasible? ☒ Yes ☐ No
115.371 (i)
▪ Are all substantiated allegations of conduct that appears to be criminal referred for prosecution?
☒ Yes ☐ No
115.371 (j)
▪ Does the agency retain all written reports referenced in 115.371(g) and (h) for as long as the
alleged abuser is incarcerated or employed by the agency, plus five years unless the abuse was
committed by a juvenile resident and applicable law requires a shorter period of retention?
☒ Yes ☐ No
115.371 (k)
▪ Does the agency ensure that the departure of an alleged abuser or victim from the employment
or control of the agency does not provide a basis for terminating an investigation?
☒ Yes ☐ No
115.371 (l)
▪ Auditor is not required to audit this provision.
115.371 (m)
▪ When an outside entity investigates sexual abuse, does the facility cooperate with outside
investigators and endeavor to remain informed about the progress of the investigation? (N/A if
an outside agency does not conduct administrative or criminal sexual abuse investigations. See
115.321(a).) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
90
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
Interviews:
Program Director
Random Staff
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.
There are no facility-based investigators. The facility and its parent agency do not have investigators to
conduct any type of investigations. The Florida Department of Juvenile Justice, Office of Inspector
General (OIG) conducts administrative investigations and allegations that are criminal in nature are
investigated by the Broward County Sheriff’s Office. The Florida Department of Children and Families
are also notified regarding allegations of sexual abuse.
Provision (b) and (c):
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.
There are no facility-based investigators. The facility and its parent agency do not have investigators to
conduct any type of investigations. The Florida Department of Juvenile Justice, Office of Inspector
General (OIG) conducts administrative investigations and allegations that are criminal in nature are
investigated by the Broward County Sheriff’s Office. The Florida Department of Children and Families
are also notified regarding allegations of sexual abuse.
Provision (d):
The agency shall not terminate an investigation solely because the source of the allegation recants the
allegation.
There are no facility-based investigators. The facility and its parent agency do not have investigators to
conduct any type of investigations. The Florida Department of Juvenile Justice, Office of Inspector
General (OIG) conducts administrative investigations and allegations that are criminal in nature are
investigated by the Broward County Sheriff’s Office. The Florida Department of Children and Families
are also notified regarding allegations of sexual abuse.
91
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 facility and its parent agency do not have investigators to conduct any type of investigations.
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 facility and its parent agency do not have investigators to conduct any type of investigations.
Provisions (g) and (h):
Administrative investigations:
(1) Shall include an effort to determine whether staff actions or failures to act contributed to the abuse;
and
(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 facility and its parent agency do not have investigators to conduct any type of investigations.
Provision (i):
Substantiated allegations of conduct that appears to be criminal shall be referred for prosecution.
Policies provide that allegations which appear criminal are referred to the local law enforcement which
has the responsibility to refer 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 facility will retain records while the abuser is incarcerated in, or employed by the facility, plus five
years, according to the FDJJ 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.
The facility and its parent agency do not have investigators to conduct any type of investigations.
Provision (l):
Any State entity or Department of Justice component that conducts such investigations shall do so
pursuant to the above requirements.
92
The investigative agencies, Florida Department of Children and Families and FDJJ OIG, are aware of
the PREA standards requirements. A PREA Compliance Form, information sheet, is provided by the
facility to local law enforcement.
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.
Interviews revealed the Program Director will remain abreast of the progress of an investigation, in
accordance with Policies. Additionally, the Policies provide that staff shall cooperate with investigations.
Standard 115.372: Evidentiary Standard for Administrative Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.372 (a)
▪ Is it true that the agency does not impose a standard higher than a preponderance of the
evidence in determining whether allegations of sexual abuse or sexual harassment are
substantiated? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
FDJJ Policy 1919
Interview:
Program Director
§115.372
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.
According to Policy, no standard higher than a preponderance of the evidence is imposed in
determining whether allegations of sexual abuse or sexual harassment are substantiated.
93
Conclusion:
Based upon the review of the Policy and interview, the Auditor has determined the facility is compliant
with this standard regarding evidentiary standard for administrative investigations.
Standard 115.373: Reporting to Residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.373 (a)
▪ Following an investigation into a resident’s allegation that he or she suffered sexual abuse in an
agency facility, does the agency inform the resident as to whether the allegation has been
determined to be substantiated, unsubstantiated, or unfounded? ☒ Yes ☐ No
115.373 (b)
▪ If the agency did not conduct the investigation into a resident’s allegation of sexual abuse in an
agency facility, does the agency request the relevant information from the investigative agency
in order to inform the resident? (N/A if the agency/facility is responsible for conducting
administrative and criminal investigations.) ☒ Yes ☐ No ☐ NA
115.373 (c)
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The staff member is no longer posted within the resident’s unit? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The staff member is no longer employed at the facility? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The agency learns that the staff member has been indicted on a charge related to
sexual abuse in the facility? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The agency learns that the staff member has been convicted on a charge related to
sexual abuse within the facility? ☒ Yes ☐ No
115.373 (d)
94
▪ Following a resident’s allegation that he or she has been sexually abused by another resident,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been indicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No
▪ Following a resident’s allegation that he or she has been sexually abused by another resident,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been convicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No
115.373 (e)
▪ Does the agency document all such notifications or attempted notifications? ☒ Yes ☐ No
115.373 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
Interviews:
Program Director/PREA Compliance Manager
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.
The Policy addresses the resident being informed when the investigation is completed, informed of the
outcome of the investigation, and the documentation of the notification. The Program Director and the
95
Assistant Program Director remain abreast of an investigation conducted by any of the investigative
entities based on the interview with the Program Director. The Primary contact is the Program Director
with the Assistant Program Director serving as designee. The administrators are familiar with the
Policies regarding notification.
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 Program Director will remain abreast of an investigation and maintain contact with the assigned
investigator, based on the interview.
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.
The Policies require the following information be provided to the resident when a staff member
committed sexual abuse against the resident, unless it has been determined that the allegation is
unfounded, whenever:
a. The staff member is no longer assigned 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 within the facility; or
d. The staff member has been convicted on a charge related to sexual abuse within the facility.
The Program Director is familiar with the requirements of the Policy and PREA Standard.
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.
The Policies provide that following a resident’s allegation that he has been sexually abused by another
resident, the alleged victim shall be subsequently informed whenever:
a. The alleged abuser is criminally charged related to the sexual abuse; or
b. The alleged abuser is adjudicated on a charge related to sexual abuse.
The Program Director is familiar with the requirements of the Policy and PREA Standard.
Provision (e):
All such notifications or attempted notifications shall be documented.
The Policies provide all such notifications or attempted notifications be documented. The Program
Director is familiar with the requirements of the Policy and PREA Standard. There have been no
allegations of sexual abuse during this audit period.
96
Provision (f):
An agency’s obligation to report under this standard shall terminate if the resident is released from the
agency’s custody.
The FDJJ Policy provides the facility’s obligation to report under this standard terminates if the resident
is released from the facility’s custody.
Conclusion:
The interview with the Program Director confirmed the requirements of Policies and knowledge of the
process of reporting to a resident regarding the outcome of an allegation of sexual abuse. Based on the
review and analysis of the available documentation, the current interview and a previous interview with
the FDJJ PREA Coordinator, the Auditor has determined the facility is compliant with this standard
regarding reporting to residents.
DISCIPLINE
Standard 115.376: Disciplinary Sanctions for Staff
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.376 (a)
▪ Are staff subject to disciplinary sanctions up to and including termination for violating agency
sexual abuse or sexual harassment policies? ☒ Yes ☐ No
115.376 (b)
▪ Is termination the presumptive disciplinary sanction for staff who have engaged in sexual
abuse? ☐ Yes ☐ No
115.376 (c)
▪ Are disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual
harassment (other than actually engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s disciplinary history, and the sanctions
imposed for comparable offenses by other staff with similar histories? ☒ Yes ☐ No
115.376 (d)
▪ Are all terminations for violations of agency sexual abuse or sexual harassment policies, or
resignations by staff who would have been terminated if not for their resignation, reported to:
Law enforcement agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Are all terminations for violations of agency sexual abuse or sexual harassment policies, or
resignations by staff who would have been terminated if not for their resignation, reported to:
Relevant licensing bodies? ☒ Yes ☐ No
97
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Employee Handbook
Interview:
Program Director
Provision (a):
Staff shall be subject to disciplinary sanctions up to and including termination for violating agency
sexual abuse or sexual harassment policies.
The Policy and Employee Handbook provide that staff be subject to disciplinary sanctions up to and
including termination for violating facility sexual abuse or sexual harassment policies. The Policy states
that termination is the presumptive disciplinary sanction for staff who engaged in sexual abuse.
Provision (b):
Termination shall be the presumptive disciplinary sanction for staff who has engaged in sexual abuse.
The facility Policy provides that termination shall be the presumptive disciplinary sanction for staff who
has 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.
Policy and practice support disciplinary sanctions for violations of policies relating to sexual abuse or
sexual harassment (other than actually engaging in sexual abuse) 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.
98
Provision (d):
All terminations for violations of agency sexual abuse or sexual harassment policies, or resignations by
staff who would have been terminated if not for their resignation, shall be reported to law enforcement
agencies, unless the activity was clearly not criminal, and to any relevant licensing bodies.
Policy provides that terminations for violations of the facility’s sexual abuse or sexual harassment
policies, or staff resignations related to violations of this policy, shall be reported to law enforcement,
unless the activity is clearly not criminal. In addition, it shall be reported to relevant licensing bodies.
According to the Program Director, no staff member has been terminated for violating agency sexual
abuse or sexual harassment policies.
Conclusion:
Based upon the review of Policy and interviews, the Auditor has determined the facility is compliant with
this standard regarding disciplinary sanctions for staff.
Standard 115.377: Corrective Action for Contractors and Volunteers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.377 (a)
▪ Is any contractor or volunteer who engages in sexual abuse prohibited from contact with
residents? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Law enforcement
agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Relevant licensing
bodies? ☒ Yes ☐ No
115.377 (b)
▪ In the case of any other violation of agency sexual abuse or sexual harassment policies by a
contractor or volunteer, does the facility take appropriate remedial measures, and consider
whether to prohibit further contact with residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
99
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ-1919
Training Acknowledgement Statements
Training Curriculum
Interviews:
Assistant Program Director
Program Director
Contractors (2)
Volunteer
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.
The Policies provide for contractors and volunteers who engage in sexual abuse to be reported to law
enforcement and to relevant licensing bodies. Training materials and interviews with a volunteer and
two contractors revealed the facility provides volunteers and contractors a clear understanding that
sexual misconduct with a resident is prohibited. During this audit period, there have been no allegations
of sexual abuse or sexual harassment regarding a contractor or volunteer.
Provision (b):
The facility shall take appropriate remedial measures, and shall consider whether to prohibit further
contact with residents, in the case of any other violation of agency sexual abuse or sexual harassment
policies by a contractor or volunteer.
The facility will take the appropriate remedial measures, and consider whether to prohibit further
contact with residents in the case of any other violation of the sexual abuse and sexual harassment
policies by a contractor or volunteer, as inferred by interviews and Policy.
Conclusion:
Based upon the review and analysis of the available documentation, the Auditor has determined the
facility is compliant with this standard regarding corrective action for contractors and volunteers.
Standard 115.378: Interventions and Disciplinary Sanctions for Residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.378 (a)
▪ Following an administrative finding that a resident engaged in resident-on-resident sexual
abuse, or following a criminal finding of guilt for resident-on-resident sexual abuse, may
100
residents be subject to disciplinary sanctions only pursuant to a formal disciplinary process?
☒ Yes ☐ No
115.378 (b)
▪ Are disciplinary sanctions commensurate with the nature and circumstances of the abuse
committed, the resident’s disciplinary history, and the sanctions imposed for comparable
offenses by other residents with similar histories? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident is not denied daily large-muscle exercise? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident is not denied access to any legally required educational programming or special
education services? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident receives daily visits from a medical or mental health care clinician? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the resident also
have access to other programs and work opportunities to the extent possible? ☒ Yes ☐ No
115.378 (c)
▪ When determining what types of sanction, if any, should be imposed, does the disciplinary
process consider whether a resident’s mental disabilities or mental illness contributed to his or
her behavior? ☒ Yes ☐ No
115.378 (d)
▪ If the facility offers therapy, counseling, or other interventions designed to address and correct
underlying reasons or motivations for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions? ☒ Yes ☐ No
▪ If the agency requires participation in such interventions as a condition of access to any
rewards-based behavior management system or other behavior-based incentives, does it
always refrain from requiring such participation as a condition to accessing general
programming or education? ☒ Yes ☐ No
115.378 (e)
▪ Does the agency discipline a resident for sexual contact with staff only upon a finding that the
staff member did not consent to such contact? ☒ Yes ☐ No
115.378 (f)
▪ For the purpose of disciplinary action does a report of sexual abuse made in good faith based
upon a reasonable belief that the alleged conduct occurred NOT constitute falsely reporting an
101
incident or lying, even if an investigation does not establish evidence sufficient to substantiate
the allegation? ☒ Yes ☐ No
115.378 (g)
▪ Does the agency always refrain from considering non-coercive sexual activity between residents
to be sexual abuse? (N/A if the agency does not prohibit all sexual activity between residents.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Document Reviewed:
Facility Policy 5-19
Youth/Parent Handbook
Interviews:
Program Director
Clinical Director
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.
The Policy and Youth/Parent Handbook address an administrative process for dealing with rule
violations and disciplinary sanctions pursuant to a hearing. Sanctions are directly related to the
seriousness of the negative behavior. The interview with the Program Director revealed the process
regarding allegations of resident-on-resident abuse. There were no allegations of sexual abuse during
the past 12 months.
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
102
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 considers 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. Isolation is not used in the facility.
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.
The Policy provides that the disciplinary and other processes consider whether a resident’s mental
disabilities or mental illness contributed to the behavior when determining what type of sanction, if any,
should be imposed. This was confirmed by the interviews with the Program Director and Clinical
Director.
Provision (d):
If the facility offers therapy, counseling, or other interventions designed to address and correct
underlying reasons or motivations for the abuse, the facility shall consider whether to offer the offending
resident participation in such interventions. The agency may require participation in such interventions
as a condition of access to any rewards-based behavior management system or other behavior-based
incentives, but not as a condition to access to general programming or education.
The facility would consider whether to offer the offending resident therapy, counseling, or other
interventions designed to address and correct underlying reasons or motivations for the abuse
participation, based on policy and interview with the Clinical Director. The facility may require
participation in such interventions as a condition of access to privileges, but not as a condition to
access to general programming or education.
Provision (e):
The agency may discipline a resident for sexual contact with staff only upon a finding that the staff
member did not consent to such contact.
Policy provides the facility may discipline a resident for sexual contact with staff only upon finding that
the staff member did not consent to such contact.
Provision (f):
For the purpose of disciplinary action, a report of sexual abuse made in good faith based upon a
reasonable belief that the alleged conduct occurred shall not constitute falsely reporting an incident or
lying, even if an investigation does not establish evidence sufficient to substantiate the allegation.
The Policy supports that any resident who knowingly and willfully makes a false report of sexual abuse
or counsels another to do such, is guilty of a third-degree felony. Reports of abuse made in good faith
based upon a reasonable belief that the alleged conduct occurred does not constitute falsely reporting
or an incident of lying.
Provision (g):
103
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.
The facility prohibits any sexual conduct between residents. All such conduct is subject to disciplinary
action. Referrals will be made to the Broward County Sheriff’s Office and court processes occur after
determination that a 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 regarding interventions and disciplinary sanctions for residents.
MEDICAL AND MENTAL CARE
Standard 115.381: Medical and Mental Health Screenings; History of Sexual
Abuse
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.381 (a)
▪ If the screening pursuant to § 115.341 indicates that a resident has experienced prior sexual
victimization, whether it occurred in an institutional setting or in the community, do staff ensure
that the resident is offered a follow-up meeting with a medical or mental health practitioner
within 14 days of the intake screening? ☒ Yes ☐ No
115.381 (b)
▪ If the screening pursuant to § 115.341 indicates that a resident has previously perpetrated
sexual abuse, whether it occurred in an institutional setting or in the community, do staff ensure
that the resident is offered a follow-up meeting with a mental health practitioner within 14 days
of the intake screening? ☒ Yes ☐ No
115.381 (c)
▪ Is any information related to sexual victimization or abusiveness that occurred in an institutional
setting strictly limited to medical and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions, including housing, bed, work,
education, and program assignments, or as otherwise required by Federal, State, or local law?
☒ Yes ☐ No
115.381 (d)
▪ Do medical and mental health practitioners obtain informed consent from residents before
reporting information about prior sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18? ☒ Yes ☐ No
Auditor Overall Compliance Determination
104
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documentation Reviewed:
Facility Policy 5-19
Interviews:
Case Managers/Staff Responsible for Risk Screening
Clinical Director
Nurse Clinical Supervisor
Provision (a) and (b):
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.
The Policy provides that a resident who indicates during initial screening that they were a victim or
perpetrator of sexual abuse will be offered a follow-up visit with medical or mental health staff within 14
days of the intake screening. This information was also confirmed through the interview with the clinical
staff members. The practice is that residents are generally seen by medical and mental health staff on
the same day of admission as a part of the intake process.
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.
The Policy supports that 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
105
law. The Auditor observed the resident files maintained in a secure manner, in locked cabinets
contained in locked offices with access by identified staff.
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.
The medical and mental health staff discussed their knowledge of informed consent during each
interview. They provided that informed consent will be obtained and documented before reporting
information about prior sexual victimization that did not occur in an institutional setting, unless the
resident is under the age of 18.
Conclusion:
Based upon the review and analysis of the available evidence, the Auditor has determined the facility is
compliant with this standard regarding medical and mental health screenings; and history of sexual
abuse.
Standard 115.382: Access to Emergency Medical and Mental Health
Services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.382 (a)
▪ Do resident victims of sexual abuse receive timely, unimpeded access to emergency medical
treatment and crisis intervention services, the nature and scope of which are determined by
medical and mental health practitioners according to their professional judgment? ☒ Yes ☐ No
115.382 (b)
▪ If no qualified medical or mental health practitioners are on duty at the time a report of recent
sexual abuse is made, do staff first responders take preliminary steps to protect the victim
pursuant to § 115.362? ☒ Yes ☐ No
▪ Do staff first responders immediately notify the appropriate medical and mental health
practitioners? ☒ Yes ☐ No
115.382 (c)
▪ Are resident victims of sexual abuse offered timely information about and timely access to
emergency contraception and sexually transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically appropriate? ☒ Yes ☐ No
115.382 (d)
▪ Are treatment services provided to the victim without financial cost and regardless of whether
the victim names the abuser or cooperates with any investigation arising out of the incident?
☒ Yes ☐ No
106
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documentation Reviewed:
Facility Policy 5-19
Facility Coordinated Response Plan
Interviews:
Nurse Clinical Supervisor
Clinical Director
Program Director
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.
Policy provides the victim receives timely and unimpeded access to emergency medical treatment,
crisis intervention services and advocacy services. The victim would be transported to the Nancy J.
Cotterman Center for a forensic examination. According to Policy, services will be provided at no cost
to the victim. The Policy and interviews with the Clinical Director and Nurse Clinical Supervisor revealed
the medical and mental health services are determined according to the professional judgment of the
practitioner.
Residents are informed of clinical services during intake. The residents have access to request
Grievance and Sick Call Forms on their living units. Residents are provided access to an outside victim
advocacy agency for services through the Nancy J. Cotterman Center which includes but is not limited
to emotional support and accompaniment through the forensic examination and investigative
interviews. Observations and a review of documents revealed that medical and mental health staff
members maintain secondary materials and documentation of resident encounters. There have been
no incidents of sexual abuse during this audit period.
Provision (b):
107
If no qualified medical or mental health practitioners are on duty at the time a report of recent abuse is
made, staff first responders shall take preliminary steps to protect the victim pursuant to § 115.362 and
shall immediately notify the appropriate medical and mental health practitioners.
The interviews with clinical staff revealed residents have access to unimpeded access to emergency
services. The Policy and the facility 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. Review of the coordinated 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.
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 and interviews confirmed processes and services are in place for a victim to receive timely
access to sexually transmitted infection prophylaxis, where medically appropriate. Additionally, follow-
up services as needed will be provided by the facility’s medical and mental health staff, according to the
interviews with clinical staff. The facility houses males only.
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 Policy states treatment services shall be provided to the victim without financial cost and
regardless of whether or not the victim cooperates with any investigation arising out of the incident. This
was also confirmed through staff interviews.
Conclusion:
Agency Policy revealed emergency services will be provided by medical and mental health staff. The
medical and mental health staff interviews revealed they are knowledgeable of actions to take
regarding an incident of sexual abuse. It is documented through Based upon the review and analysis of
the available evidence, the Auditor has determined the facility is compliant with this standard regarding
access to emergency medical and mental health services.
Standard 115.383: Ongoing Medical and Mental Health Care for Sexual
abuse Victims and Abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.383 (a)
▪ Does the facility offer medical and mental health evaluation and, as appropriate, treatment to all
residents who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility? ☒ Yes ☐ No
115.383 (b)
108
▪ Does the evaluation and treatment of such victims include, as appropriate, follow-up services,
treatment plans, and, when necessary, referrals for continued care following their transfer to, or
placement in, other facilities, or their release from custody? ☒ Yes ☐ No
115.383 (c)
▪ Does the facility provide such victims with medical and mental health services consistent with
the community level of care? ☒ Yes ☐ No
115.383 (d)
▪ Are resident victims of sexually abusive vaginal penetration while incarcerated offered
pregnancy tests? (N/A if all-male facility.) ☐ Yes ☐ No ☒ NA
115.383 (e)
▪ If pregnancy results from the conduct described in paragraph § 115.383(d), do such victims
receive timely and comprehensive information about and timely access to all lawful pregnancy-
related medical services? (N/A if all-male facility.) ☐ Yes ☐ No ☒ NA
115.383 (f)
▪ Are resident victims of sexual abuse while incarcerated offered tests for sexually transmitted
infections as medically appropriate? ☒ Yes ☐ No
115.383 (g)
▪ Are treatment services provided to the victim without financial cost and regardless of whether
the victim names the abuser or cooperates with any investigation arising out of the incident?
☒ Yes ☐ No
115.383 (h)
▪ Does the facility attempt to conduct a mental health evaluation of all known resident-on-resident
abusers within 60 days of learning of such abuse history and offer treatment when deemed
appropriate by mental health practitioners? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
109
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
Interviews:
Nurse Clinical Supervisor
Clinical Director
Program Director
Provision (a):
The facility shall offer medical and mental health evaluation and, as appropriate, treatment to all
residents who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile facility.
The Policy requires that a medical and mental health evaluation and treatment be offered to resident
victims of sexual abuse. According to the interviews, medical and mental health staff members are
aware of the Policy requirement. The Policy and interviews support medical and mental health
evaluations and treatment will be offered to all residents who have been victimized by sexual abuse.
Interviews with the clinical staff and observations confirmed on-going medical and mental health care
will be provided as appropriate.
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 limited to follow-up services, referrals and
therapy.
Provision (c):
The facility shall provide such victims with medical and mental health services consistent with the
community level of care.
Staff interviews and observations revealed medical and mental health services are consistent with the
community level of care.
Provision (d):
Resident victims of sexually abusive vaginal penetration while incarcerated shall be offered pregnancy
tests.
The facility does not house female residents.
Provision (e):
110
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 facility does not house female residents.
Provision (f):
Resident victims of sexual abuse while incarcerated shall be offered tests for sexually transmitted
infections as medically appropriate.
The Policy and interviews ensure that victims of sexual abuse will be provided tests for sexually
transmitted infections as medically appropriate. Follow-up services will be conducted at the facility, as
needed, based on policies and the interviews.
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 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.
The Policy provides for a mental health practitioner to attempt to conduct a mental health evaluation
within 60 days on all known resident-on-resident abusers and offer treatment when deemed
appropriate. Services may include but not be limited to individual, group and family counseling.
Additionally, an evaluation or reassessment will be administered utilizing the risk screening instrument
when new information is learned. According to the Clinical Director, the practice is that all youth
admitted to the facility receive a mental health status examination during the admission process.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor has determined the facility is
compliant with this standard regarding ongoing medical and mental health care for sexual abuse victims
and abusers.
DATA COLLECTION AND REVIEW
Standard 115.386: Sexual abuse incident reviews
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.386 (a)
▪ Does the facility conduct a sexual abuse incident review at the conclusion of every sexual abuse
investigation, including where the allegation has not been substantiated, unless the allegation
has been determined to be unfounded? ☒ Yes ☐ No
111
115.386 (b)
▪ Does such review ordinarily occur within 30 days of the conclusion of the investigation?
☒ Yes ☐ No
115.386 (c)
▪ Does the review team include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners? ☒ Yes ☐ No
115.386 (d)
▪ Does the review team: Consider whether the allegation or investigation indicates a need to
change policy or practice to better prevent, detect, or respond to sexual abuse? ☒ Yes ☐ No
▪ Does the review team: Consider whether the incident or allegation was motivated by race;
ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or
perceived status; gang affiliation; or other group dynamics at the facility? ☒ Yes ☐ No
▪ Does the review team: Examine the area in the facility where the incident allegedly occurred to
assess whether physical barriers in the area may enable abuse? ☒ Yes ☐ No
▪ Does the review team: Assess the adequacy of staffing levels in that area during different
shifts? ☒ Yes ☐ No
▪ Does the review team: Assess whether monitoring technology should be deployed or
augmented to supplement supervision by staff? ☒ Yes ☐ No
▪ Does the review team: Prepare a report of its findings, including but not necessarily limited to
determinations made pursuant to §§ 115.386 (d) (1) - (d)(5), and any recommendations for
improvement and submit such report to the facility head and PREA compliance manager?
☒ Yes ☐ No
115.386 (e)
▪ Does the facility implement the recommendations for improvement, or document its reasons for
not doing so? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
112
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 1919
Interoffice Memorandum
Interviews:
Program Director
Assistant Program Director
FDJJ PREA Coordinator
Provision (a):
The facility shall conduct a sexual abuse incident review at the conclusion of every sexual abuse
investigation, including where the allegation has not been substantiated, unless the allegation has been
determined to be unfounded.
The facility Policy requires the facility to 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 deemed to be unfounded. A review of the Policy and interviews confirmed
knowledge of the function of the incident review team. There were no allegations of sexual abuse
during this audit period. The November 1, 2014 Interoffice Memorandum from the FDJJ Assistant
Secretary of Residential Services outlines the requirements of the incident review team process and
mandates its occurrence. The FDJJ PREA Coordinator facilitates the incident review team process.
Provision (b):
Such review shall ordinarily occur within 30 days of the conclusion of the investigation.
The Policies require that the reviews occur within 30 days of the conclusion of the investigation which is
also the practice. The administrators confirmed incident reviews would occur within 30 days of the
conclusion of an investigation in accordance with agency Policy and the standard. The interviews
confirmed the Policies.
Provision (c):
The review team shall include upper-level management officials, with input from line supervisors,
investigators, and medical or mental health practitioners.
The facility Policy identifies the incident review team members as Program Director; Assistant Program
Director; medical staff, mental health staff; OIG investigator if indicated; and FDJJ area program staff.
The Regional Director for Youth Opportunity Investments may also participate in the incident review
process. The FDJJ PREA Coordinator facilitates the meetings of the incident review team. The
interviews were aligned with the Policy.
Provision (d):
The review team shall:
113
(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 Policy outlines the requirements of the standard for the areas to be assessed by the incident
review team. The interviews and review of Policies confirmed the incident review team is charged with
considering the factors identified in this standard provision regarding the results of the investigation, to
include:
• considering the make-up and vulnerability of the population such as gang affiliation; whether the
resident identifies as gay, bisexual, transgender, or intersex;
• other group dynamics;
• assessment of the area relative to the allegations; and
• adequacy of staffing.
The Policy requires the meeting to be documented, including recommendations and the document must
be provided to the Program Director, FDJJ PREA Coordinator and the Regional Director. The
interviews with the Program Director and FDJJ PREA Coordinator and review of the Interoffice Memo
confirmed the facility would prepare a report of its findings and any recommendations for improvement
when conducting a sexual abuse incident review. The interviews also confirmed that the team would
consider all factors required by the standard. The incident review team meeting is facilitated by the
FDJJ PREA Coordinator.
Provision (e):
The facility shall implement the recommendations for improvement, or shall document its reasons for
not doing so.
Recommendations for improvement by the team members will be incorporated in the documented
meeting activities as required by Policy. It is also required by Policy that it is the responsibility of the
Program Director to implement the recommendations and/or document where they are not
implemented. The Program Director and Assistant Program Director are familiar with the Policy
requirements. The format of the documented meeting has been developed by the FDJJ PREA
Coordinator and provides for the record keeping of the incident review team meeting. The format allows
for documentation of the considerations of the standard.
Conclusion:
Based upon the review and analysis of the available documentation, the Auditor has determined the
facility is compliant with this standard regarding the sexual abuse incident review team.
Standard 115.387: Data Collection
114
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.387 (a)
▪ Does the agency collect accurate, uniform data for every allegation of sexual abuse at facilities
under its direct control using a standardized instrument and set of definitions? ☒ Yes ☐ No
115.387 (b)
▪ Does the agency aggregate the incident-based sexual abuse data at least annually?
☒ Yes ☐ No
115.387 (c)
▪ Does the incident-based data include, at a minimum, the data necessary to answer all questions
from the most recent version of the Survey of Sexual Violence conducted by the Department of
Justice? ☒ Yes ☐ No
115.387 (d)
▪ Does the agency maintain, review, and collect data as needed from all available incident-based
documents, including reports, investigation files, and sexual abuse incident reviews?
☒ Yes ☐ No
115.387 (e)
▪ Does the agency also obtain incident-based and aggregated data from every private facility with
which it contracts for the confinement of its residents? (N/A if agency does not contract for the
confinement of its residents.) ☒ Yes ☐ No ☐ NA
115.387 (f)
▪ Does the agency, upon request, provide all such data from the previous calendar year to the
Department of Justice no later than June 30? (N/A if DOJ has not requested agency data.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
115
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
Facility Policy 5-19
FDJJ Policy 2020, Incident Operations Center and Management Reviews
PREA Incident Reports (Aggregated Data Reports)
FDJJ Annual Reports
FDJJ Central Communications Center Classification (CCC) Definition Report
Interviews:
Program Director
FDJJ PREA Coordinator
Provisions (a) & (c):
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. The incident-based data
collected shall include, at a minimum, the data necessary to answer all questions from the most recent
version of the Survey of Sexual Violence conducted by the Department of Justice.
The Policies require the use of a standardized instrument with definitions to collect accurate, uniform
data for every allegation of sexual abuse. A review of the resulting reports through the collection of data
per facility and the facility’s data collection and maintenance demonstrates the inclusion of data to
answer the Survey of Sexual Violence conducted by the U. S. Department of Justice.
Provision (b):
The agency shall aggregate the incident-based sexual abuse data at least annually.
The Policies and review of the annual report and data gathering instruments and other documents and
the interviews confirm that FDJJ collects incident-based, uniform data regarding allegations of sexual
abuse and sexual harassment for each facility. A standardized instrument and specific guidelines and
definitions, FDJJ CCC Classification Definition Report, is used to assist in identifying 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 and provides the information to FDJJ. The facility collects and maintains data in accordance with
facility and FDJJ Policy directives. The FDJJ aggregates the data which culminates into an annual
report.
Provision (e):
The agency also shall obtain incident-based and aggregated data from every private facility with which
it contracts for the confinement of its residents.
116
The FDJJ maintains and aggregates data from every state operated facility and private facility it
contracts with for the confinement of its residents as confirmed by the FDJJ PREA Coordinator through
the interview regarding data and the data collection process.
Provision (f):
Upon request, the agency shall provide all such data from the previous calendar year to the
Department of Justice no later than June 30.
Upon request, the facility will provide all such data from the previous calendar year to the Department
of Justice no later than June 30.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor has determined the facility is
compliant with this standard regarding data collection.
Standard 115.388: Data Review for Corrective Action
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.388 (a)
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Identifying problem areas? ☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Taking corrective action on an ongoing basis?
☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Preparing an annual report of its findings and
corrective actions for each facility, as well as the agency as a whole? ☒ Yes ☐ No
115.388 (b)
▪ Does the agency’s annual report include a comparison of the current year’s data and corrective
actions with those from prior years and provide an assessment of the agency’s progress in
addressing sexual abuse ☒ Yes ☐ No
115.388 (c)
▪ Is the agency’s annual report approved by the agency head and made readily available to the
public through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.388 (d)
117
▪ Does the agency indicate the nature of the material redacted where it redacts specific material
from the reports when publication would present a clear and specific threat to the safety and
security of a facility? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
FDJJ Policy 1919
FDJJ Policy 1316, Records and Information Management Procedures
FDJJ PREA Annual Reports
FDJJ Central Communications Center Classification Report
Interviews:
Program Director
FDJJ PREA Coordinator
The Policy supports the review of data collected and aggregated in order to improve the PREA efforts.
The interviews revealed the collected and aggregated data is reviewed to assess and improve the
effectiveness of the PREA related initiatives by identifying problem areas; developing and implementing
corrective actions where needed; and preparing an annual report based on the collected data. The
interviews supported the provisions of the collective Policies and the standard.
The Policies indicate an annual report will be prepared that will provide information regarding corrective
actions in addressing sexual abuse. The annual report, prepared by FDJJ, is approved by the FDJJ
Secretary as required by Policy, per the interviews and a review of the report. The annual report reflects
a comparison of the results of annual data. The annual report has been reviewed and the report is
accessible to the public through the FDJJ website and dissemination. There are no personal identifiers
in the annual report.
Conclusion:
Based upon the review and analysis of the documentation, the Auditor has determined the facility is
compliant with this standard regarding data review for corrective action.
118
Standard 115.389: Data Storage, Publication, and Destruction
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.389 (a)
▪ Does the agency ensure that data collected pursuant to § 115.387 are securely retained?
☒ Yes ☐ No
115.389 (b)
▪ Does the agency make all aggregated sexual abuse data, from facilities under its direct control
and private facilities with which it contracts, readily available to the public at least annually
through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.389 (c)
▪ Does the agency remove all personal identifiers before making aggregated sexual abuse data
publicly available? ☒ Yes ☐ No
115.389 (d)
▪ Does the agency maintain sexual abuse data collected pursuant to § 115.387 for at least 10
years after the date of the initial collection, unless Federal, State, or local law requires
otherwise? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Documents Reviewed:
FDJJ Policy 1919
FDJJ Policy 1316
Annual Report
Interview:
Program Director
119
The Policies support that data collected will be securely stored and maintained for at least 10 years
after the initial collection date, unless State or local statutes require otherwise. The aggregated sexual
abuse data will be readily available to the public through the agency’s website; the practice is that the
report is posted on the FDJJ website. A review of the annual report verified there are no personal
identifiers. Related documentation in the facility was observed to be securely stored.
Conclusion:
Based upon the review and analysis of the documentation, interviews and observations, the Auditor has
determined the facility is compliant with this standard regarding data storage, publication, and
destruction.
AUDITING AND CORRECTIVE ACTION
Standard 115.401: Frequency and Scope of Audits
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.401 (a)
▪ During the prior three-year audit period, did the agency ensure that each facility operated by the
agency, or by a private organization on behalf of the agency, was audited at least once? (Note:
The response here is purely informational. A "no" response does not impact overall compliance
with this standard.) ☒ Yes ☐ No
115.401 (b)
▪ Is this the first year of the current audit cycle? (Note: a “no” response does not impact overall
compliance with this standard.) ☐ Yes ☒ No
▪ If this is the second year of the current audit cycle, did the agency ensure that at least one-third
of each facility type operated by the agency, or by a private organization on behalf of the
agency, was audited during the first year of the current audit cycle? (N/A if this is not the
second year of the current audit cycle.) ☒ Yes ☐ No ☐ NA
▪ If this is the third year of the current audit cycle, did the agency ensure that at least two-thirds of
each facility type operated by the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle? (N/A if this is not the third year
of the current audit cycle.) ☐ Yes ☐ No ☒ NA
115.401 (h)
▪ Did the auditor have access to, and the ability to observe, all areas of the audited facility?
☒ Yes ☐ No
115.401 (i)
▪ Was the auditor permitted to request and receive copies of any relevant documents (including
electronically stored information)? ☒ Yes ☐ No
120
115.401 (m)
▪ Was the auditor permitted to conduct private interviews with inmates, residents, and detainees?
☒ Yes ☐ No
115.401 (n)
▪ Were residents permitted to send confidential information or correspondence to the auditor in
the same manner as if they were communicating with legal counsel? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
PREA audits for the facility have been conducted as required for the initial three-year period. The
agency is fulfilling the auditing requirements for this second three-year period. The facility has provided
the Auditor with the required documentation as required by the standards and the auditing process. A
comprehensive site review was provided to the Auditor during the site visit and additional
documentation was reviewed during the site visit. The staff members were cooperative in providing
additional documentation as requested.
The Program Director provided appropriate work spaces which included conditions for conducting
interviews in private with the residents and staff. The notices were initially posted in conspicuous areas
and the pictures sent to the Auditor. The notices provided directions and contact information informing
those who wanted to contact the Auditor of how to do so. No correspondence was received by the
Auditor.
Standard 115.403: Audit Contents and Findings
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.403 (f)
121
▪ The agency has published on its agency website, if it has one, or has otherwise made publicly
available, all Final Audit Reports within 90 days of issuance by auditor. The review period is for
prior audits completed during the past three years PRECEDING THIS AGENCY AUDIT. In the
case of single facility agencies, the auditor shall ensure that the facility’s last audit report was
published. The pendency of any agency appeal pursuant to 28 C.F.R. § 115.405 does not
excuse noncompliance with this provision. (N/A if there have been no Final Audit Reports issued
in the past three years, or in the case of single facility agencies that there has never been a
Final Audit Report issued.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
This facility was previously audited in 2015 and the Auditor confirmed the audit report was posted on
the FDJJ website as is the practice. The report does not contain any personal identifying information
and there were no conflicts of interest regarding the completion of the audit.
The facility and agency policies and other documentation were reviewed regarding compliance with the
standards and have been identified in the report. The audit findings were based on a review of policies
and procedures and supporting documentation; interviews with staff, residents, volunteers, contractors;
and observations by the Auditor.
122
AUDITOR CERTIFICATION
I certify that:
☒ The contents of this report are accurate to the best of my knowledge.
☒ No conflict of interest exists with respect to my ability to conduct an audit of the
agency under review, and
☒ I have not included in the final report any personally identifiable information (PII)
about any resident or staff member, except where the names of administrative
personnel are specifically requested in the report template.
Auditor Instructions:
Type your full name in the text box below for Auditor Signature. This will function as your official
electronic signature. Auditors must deliver their final report to the PREA Resource Center as a
searchable PDF format to ensure accessibility to people with disabilities. Save this report document
into a PDF format prior to submission.1 Auditors are not permitted to submit audit reports that have
been scanned.2 See the PREA Auditor Handbook for a full discussion of audit report formatting
requirements.
Shirley L. Turner October 11, 2018
Auditor Signature Date
1 See additional instructions here: https://support.office.com/en-us/article/Save-or-convert-to-PDF-d85416c5-7d77-4fd6-
a216-6f4bf7c7c110 .
2 See PREA Auditor Handbook, Version 1.0, August 2017; Pages 68-69.
123

program_name_raw: broward ytc

cycle: Year 3 Cycle 2